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How Can Healthcare Workers Incorporate Trauma Informed Care?

How Can Healthcare Workers Incorporate Trauma Informed Care

  • Joan Fleishman, PsyD 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 Hannah Kamsky, BSN, RN, CCCTM 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 Stephanie Sundborg, PhD 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.

Article

Abstract Trauma-informed care (TIC) is a patient-centered approach to healthcare that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff. TIC is applied universally regardless of trauma disclosure.

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. The TIC framework is being implemented in healthcare and should be incorporated in daily practice, especially in nursing.

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. However, TIC implementation can be challenging if it’s unclear what to do. This article discusses trauma-informed care, and TIC in healthcare and provides strategies for trauma-informed nursing practice, followed by organizational considerations for the nursing workforce,

Key Words: Trauma, trauma-informed care, trauma-informed nursing, nursing workforce, patient experience, universal precautions, nursing practice, patient-centered care, adverse childhood experiences, workforce wellness,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, 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 ).

  1. In fact, uncertainty is associated with both subjective and physiological measures of stress ( De Berker et al., 2016 ).
  2. When a stressor is temporary or manageable, the stress response system is efficient and effective ( McEwen, 2007 ).
  3. 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.

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.

  • 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). 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.

  1. Engagement in healthcare, for both patients and staff, is impacted by trauma ( Marsac et al., 2016 ).
  2. For patients, the findings are mixed.
  3. 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.

  1. Raja, Hasnain, Hoersch, Gove-Yin, and Rajagopalan ( 2015 ) identified two ways medicine is able to focus on trauma in the provision of care.
  2. 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.
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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.

  • 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,

  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 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 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.
  • Nowing 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.

  1. You might say: “I’m going to need to listen to your lungs.
  2. Is it ok if I put my hand on your shoulder?” or “I am going to place my stethoscope here.
  3. It may feel a bit cold.” Protect Patient Privacy Patients may not feel empowered or safe asking others to step out.
  4. 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.

  1. Patients may not feel empowered or safe asking others to step out.
  2. 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.
  3. 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.

  1. Provide Clear and Consistent Messaging About Services and Roles Trust is built when patients experience care providers who are forthright and honest.
  2. Consistent messaging and transparency are important to foster realistic expectations.
  3. 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.

  1. When providing education, information, or instructions, break the information you share into small chunks and check for understanding.
  2. Using clear language and teach back empowers patients with knowledge and understanding about their care.
  3. 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 ).

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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).

  1. In this case, it is not necessary to know if a patient has a bloodborne illness.
  2. 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.
  3. 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.

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 trauma Healthcare 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.

  1. Create Systems for Addressing Trauma Exposure Healthcare settings need to create a mechanism/venue to address trauma exposure as part of nurses’ work.
  2. Healthcare settings need to create a mechanism/venue to address work-related trauma exposure.
  3. 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.

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.

  1. If staff feel safe, respected, and empowered, they will likely more easily provide trauma-informed care for patients.
  2. Implementation of TIC is much like putting on an oxygen mask in an airplane.
  3. You must first put on your mask before assisting others.
  4. 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. Joan Fleishman, PsyD Email: [email protected] 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.

  1. 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.
  2. Fleishman has focused her work on integrating behavioral health services into primary care.
  3. 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: [email protected] 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.

  1. Hannah’s work with Project Nurture focuses on trauma-informed care delivery as well as systems improvement for pregnant people with substance use disorders.
  2. Stephanie Sundborg, PhD Email: [email protected] 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.

What are the 5 key ways to integrate trauma-informed care?

The Guiding Values/Principles of Trauma-Informed Care – Trauma-Informed Care follows five Guiding Values/Principles that serve as a framework for how service providers and systems of care can work to reduce the likelihood of re-traumatization. These principles are generalizable across a variety of service settings.

Rather than providing a set of practices and procedures, the principles can be interpreted and applied in ways that are appropriate for a specific type of service setting. The Five Guiding Principles are; safety, choice, collaboration, trustworthiness and empowerment. Ensuring that the physical and emotional safety of an individual is addressed is the first important step to providing Trauma-Informed Care.

Next, the individual needs to know that the provider is trustworthy. Trustworthiness can be evident in the establishment and consistency of boundaries and the clarity of what is expected in regards to tasks. Additionally, the more choice an individual has and the more control they have over their service experience through a collaborative effort with service providers, the more likely the individual will participate in services and the more effective the services may be.

What are trauma-informed strategies in the workplace?

For the past few years, we’ve been experiencing collective trauma. But trauma is not new in our organizations, and it’s not going away, either. Estimates are that six in 10 men and five in 10 women experience at least one trauma, and approximately 6% of the population will experience PTSD at some point in their lives.

  • As we’ve seen the lines between work and home blur and a fundamental shift in our expectations of the places we work, organizations have struggled to provide the support and leadership that their employees and customers need.
  • That’s why it’s so important that they take steps now to build the cultures that can see them through this crisis and the ones we’ll all inevitably face in the future.

To do that, we need to build trauma-informed organizations. A trauma-informed organization is one that operates with an understanding of trauma and its negative effects on the organization’s employees and the communities it serves and works to mitigate those effects.

  • It may not be possible to predict or avoid the next crisis our organizations will face.
  • However, with forethought, planning, and commitment, we can be prepared to meet the next challenge — whatever it may be — and come through it stronger.
  • The past two years have been incredibly turbulent, as we’ve faced Covid, racial violence, political upheaval, environmental disasters, war, and more.

Anxiety and depression have skyrocketed, Organizations have had to confront issues they never expected and find new ways to support their employees through repeated traumatic experiences. The reality, though, is that trauma is not new in our organizations.

It’s not going away, either. Estimates are that six in 10 men and five in 10 women experience at least one trauma, and approximately 6% of the population will experience PTSD at some point in their lives. Trauma and distress can arise from a wide array of causes, including domestic violence, sexual assault, racism, bias, harassment, economic uncertainty, political division, and more.

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New challenges arise every day, and conflict and strife anywhere in our globally connected world affect us all, As we’ve seen the lines between work and home blur and a fundamental shift in our expectations of the places we work, organizations have struggled to provide the support and leadership their employees and customers need.

  1. That’s why it’s so important that they take steps now to build the cultures that can see them through this crisis and the ones we’ll all inevitably face in the future.
  2. To do that, we need to build trauma-informed organizations.
  3. In my work with organizations, I use a simplified version of the Substance Abuse and Mental Health Services Administration definition of trauma: Trauma is an emotional injury that affects performance and well-being.

The same incident can affect different people differently, so the goal is to assess each individual and provide the supports they need. A trauma-informed organization is one that operates with an understanding of trauma and its negative effects on the organization’s employees and the communities it serves and works to mitigate those effects.

What is integration of trauma informed care?

Child trauma-informed integrated healthcare is the prevention, recognition, and response to trauma-related difficulties through collaboration of physical and mental health professionals with the child and family.

What are recommended as trauma-informed best practices?

A trauma-informed approach to care includes maximizing physical and psychological safety; identifying and meeting trauma-related needs to enhance child and family well-being, resiliency and permanency; and the incorporation of best practices to avoid re-traumatization.

What are the 3 R’s of trauma-informed care?

The three R’s – Reaching the traumatised brain. Dr Bruce Perry a pioneering neuroscientist in the field of trauma has shown us to help a vulnerable child to learn, think and reflect, we need to intervene in a simple sequence.

What is an example of a trauma-informed environment?

The three basic principles for creating safe, supportive environments are: –

  1. Create an environment that is perceived and felt as safe
  2. Provide an opportunity for individuals in trauma to successfully self-regulate their behaviors in productive ways and create a sense of belonging to communities around them
  3. Install routines, schedules, structures and rules that are predictable and allow the individual to establish a sense of competency and achievement,

A technique used by many practitioners is mindfulness training, which helps an individual to calmly focus on the present while calmly acknowledging their current feelings, thoughts and body sensations with a desired outcome to experience the present in a productive and safe way.

What is trauma-informed care and practice approach?

Check out MHCC’s TICP resources: – Training Publications Resources Trauma Informed Care and Practice (TICP) is an approach which recognises and acknowledges trauma and its prevalence, alongside awareness and sensitivity to its dynamics, in all aspects of service delivery.

TICP is grounded in and directed by a thorough understanding of the neurological, biological, psychological and social effects of trauma and interpersonal violence and the prevalence of these experiences in persons who receive mental health services. It involves not only changing assumptions about how we organise and provide services but creates organisational cultures that are personal, holistic, creative, open and therapeutic.

Implementing Trauma Informed Care into Organizational Culture and Practice

A trauma based approach primarily views the individual as having been harmed by something or someone. TICP is a strengths-based framework that is responsive to the impact of trauma, emphasising physical, psychological, and emotional safety for both service providers and survivors; and creates opportunities for survivors to rebuild a sense of control and empowerment.

TICP is a practice that can be utilised to support service providers in moving from a caretaker to a collaborator role, where services represent a ‘new generation’ of transformed mental health and allied human services organisations and programs which serve people with histories of violence and trauma.

When a human service program seeks to become trauma informed, every part of its organisation, management, and service delivery system is assessed and modified to ensure a basic understanding of how trauma impacts the life of an individual who is seeking services.

What are the five essential elements of trauma interventions?

These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

What are the 5 core trauma-informed principles?

Key principles of trauma-informed practice – There are 6 principles of trauma-informed practice: safety, trust, choice, collaboration, empowerment and cultural consideration.

What are the five essential elements of trauma interventions?

These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

What are the six stages of trauma integration?

Personal reflections by Odelya – I was first introduced to trauma therapy as a student and client trying to live with my own struggles as a trauma survivor. My journey continues as a clinician, scholar, and teacher of sustainable trauma integration therapy.

  • From many years of observing and working on my own dynamics and working with clients on four continents, I’ve come to see how important it is to view mental health symptoms in the context of underlying root causes.
  • Trauma, caused by emotional injury or cognitive, physical, spiritual or social harm, is a root cause of problems for a surprisingly large percentage of clients with mental health symptoms.

​ Clinicians may be technically correct in diagnosing such clients as having Depression, Anxiety, Bipolar disorder, personality disorders, RAD, Addictions, Eating Disorders and so forth. But when trauma lies at the core of symptoms, such a diagnosis can harm more than it helps.

Trauma integration is a complex journey with emotional, cognitive, physical, spiritual and social aspects. A single strategy approach doesn’t go very far in this journey. ​ Diagnostic labels can be deeply misleading to both survivors and clinicians, by riveting attention to a narrow set of issues that deserve consideration but only in the context of a much larger journey.

​ My core training and the primary tools that I use for interaction with clients come from attachment-based psychotherapy, neuroscience and expressive therapies. Responding to the insights above, for the past decade I’ve also invested a great deal of effort and time in wellness and integrative health, including nutritional psychology, to augment my core training.

  1. Goals that I ponder constantly in work with clients and in my writing are sustainability and attaining total wellness.
  2. ​ Trauma integration takes time, and requires in-depth investigation of all root causes.
  3. Some trauma survivors suffer from lingering underlying infections that show up in the form of autoimmune and inflammation disorders, psychological conditions such as depression, anxiety, OCD, self-regulation problems, attention or sensory difficulties, or chronic ill health.

Unless we address these, no trauma treatment will help for long. In this case the mental health symptoms will not improve without addressing underlying root causes. ​ We also know that trauma affects the body and can be an instigator of chronic fatigue, IBS and IBD, chronic nerve and muscle pain, and other conditions.

  1. In this case, such conditions will not improve without addressing the underlying trauma.
  2. By the time they come to me, many clients have tried a variety of modalities with several therapists.
  3. Typically they report temporary good results with one modality or another, that eventually proved unsustainable.

For such clients, targeting all aspects of wellness is essential. Working in a linear way, one modality after another is unlikely to assist them. A comprehensive perspective is essential for progress. That doesn’t mean we have to deal with everything at once. How Can Healthcare Workers Incorporate Trauma Informed Care Expressive Trauma Integration™ (ETI) approach is based on over a decade of research and clinical work with traumatized populations in the Middle East, United States, Africa, and Asia by Dr. Odelya Gertel Kraybill, an integrative trauma psychotherapist, and consultant.

A modular approach suitable for both psychosocial and trauma therapy interventions, ETI is an integrative framework that draws on recent research and practice from the fields of neuroscience, attachment and developmental psychology, expressive therapies, experiential and body-oriented therapies, cognitive processing, behavioral modifications, mindfulness, and nutritional psychology.

ETI has been field-tested and revised in trainings provided to social and community workers, therapists, first responders, and students, in Lesotho, S. Africa, S. Korea, Philippines, US, Canada, Israel, Japan and China. The ETI training model was formally accepted by the Philippines Department of Health in 2014 as one of their key modules of response to communal trauma after crisis.

  1. ETI Pillars Psychoeducation about trauma is education about the cognitive, physical, emotional, spiritual and social effects of trauma on survivors and families (individual trauma) and communities (communal trauma).
  2. The Six Stage Trauma Integration Roadmap provides a clear conceptual framework for understanding and responding to trauma.

The ETI approach helps survivors describe their experience in stages of: 1-Routine, 2-Event, 3-Withdrawal, 4-Awareness, 5-Action, 6-Integration. Survivors locate what they are experiencing on this map and in the safety of a therapeutic setting, use it to guide exploration of further steps towards trauma integration.

​ Attunement Based Psychotherapy. Attunement is a nonverbal process of being with another person in a way that attends fully and responsively to that person. A key aspect of attunement is that it is a joint activity, experienced in interaction with a caregiver. In therapy, the therapist attunes to the client with a goal to become a “co-regulator” with the client’s responses.

Over time, the client is able to transfer the sense of being co-regulated, to self-regulation outside of the therapy room, in everyday life. Through attuned relationship, clients lean to expand their capacity to endure the pain and loss of trauma and its aftermath.

  1. ​ Self-Regulation refers to the ability to maintain control over one’s sensory reactions and expand one’s capacity to respond emotionally and cognitively.
  2. Studies show that traumatic memories are stored in locations in the brain that can’t be accessed by cognitive approaches.
  3. Engagement with these memories must come via lower parts of the brain.

Whereas talk-based and cognitive approaches work top-down and enlist higher parts of the brain in calming the more primordial functions of the lower brain, nonverbal approaches work bottom-upwards. They engage directly with the lower parts of the brain and expand from there until the client is ready to engage in top-down narrative processing and trauma integration.

In the ETI approach, we use tools and techniques that facilitate body-awareness (grounding and embodiment), improve sensory and bilateral integration, strengthen the vagal tone, and promote neuroplasticity (reorganization and formation of brain responses). Individualized Sustainability Plan (ISP). Setbacks are common for trauma survivors, often after encouraging progress.

An ISP is an individual plan designed to assist the continuity of progress. It contains techniques and practices tailored to a client’s unique situation and preferences and addresses all aspects of wellness, including emotional, cognitive, physical, spiritual, and social aspects.

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