I stood in the doorway of room 630 and observed her staring out the window, consumed by thought. She was a 20-year old young woman who had been admitted to the medical unit due to gastrointestinal bleeding. I walked into the room, introduced myself and told her that I needed to perform my initial physical assessment. I put on my stethoscope and motioned closer, then she raised her hands and said “Please, don’t.” I stepped back, confused, and informed her that I needed to check on her bleeding and to make sure everything was ok. She shook her head as tears filled her eyes. I asked her why she was crying and she stated “because I don’t feel comfortable having a stranger touch me.” I assured her that I wouldn’t hurt her and after several more minutes of silence she stated, “I was sexually abused as a teenager.” I thanked her for sharing that very personal and painful information and asked how I could make her more comfortable. She was grateful and just asked for more time. It was early in my nursing career, and I didn’t have any specific training or experience dealing with trauma victims.

Traumatic events, such as sexual abuse, domestic violence, elder abuse, and combat trauma, can have serious long-term detrimental effects on the physical, emotional, and mental well-being of an individual. These life events may lead to depression, distrust, smoking, substance abuse, shame, and low self-esteem. Traumatic events can also shape an individual’s comfort level and attitude toward health care.¹ Routine preventative health care visits that involve invasive physical exams and close contact with a health care provider could trigger fear and anxiety in the patient.

Trauma-informed care (TIC) is a term that has been used in recent years in a variety of areas, including social services, education, mental health, and corrections to address the needs of people who have experienced traumatic life events. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a methodology to respond to those who are at risk or have experienced trauma.² There are four essential approaches and six principles of trauma-informed care.

The four essential approaches of trauma-informed care can be found in a program, organization, or system that²:

1. Realizes the widespread impact of trauma and understands potential paths for recovery.
2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
4. Seeks to actively resist retraumatization.

The six key principles of trauma-informed care include²:

1. Safety – make sure your patient and family members feel safe, both physically and psychologically.
2. Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
3. Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
4. Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
5. Empowerment, voice, and choice – identify individual strengths and differences and utilize them as the foundation for recovery and healing. Provide the patient with choices and an opportunity to share in the decision-making process, which results in a sense of control.
6. Recognition of cultural, historical, and gender issues – set aside cultural stereotypes and biases.

How do we put these principles into every day practice? For patients who openly share their trauma history, clinicians should be careful when delving into their psychological histories, unless they have specific training in trauma.¹ Many patients, however, feel ashamed and are not comfortable exposing their past. Every member of the health care team should be trained on universal trauma precautions, which is the idea that every person potentially has a history of trauma.² There are several strategies that clinicians can utilize to implement the TIC approach in general patient care. ¹

1. Patient-centered communication:

1. Ask every patient what can be done to make them more comfortable during their appointment.
2. Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
3. Give the patient the option to shift their clothing out of the way instead of putting on a gown.
4. Provide a pillow for back support for patients who are anxious in the supine position.
5. Offer a mirror to see procedures or examinations that a patient cannot see.
6. If a patient seems moderately to highly anxious, offer ways for patients to signal distress either verbally or by raising their hand during a procedure.

2. Understanding the health effects of trauma:      

1. Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
2. Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.

3. Multidisciplinary collaboration: 

1. Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
2. Keep referral and educational material on trauma available in waiting rooms.
3. Engage in inter-professional collaboration to ensure continuity of care.

4. Understanding your own history and reactions:

1. Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
2. Learn the signs of professional burnout and prioritize good self-care.

5. Screening:

1. Decide if your organization will screen for current trauma or a history of traumatic events.
2. Consider if screenings will be face-to-face or self-reported by the patient.
3. Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
4. Ensure your organization has the resources available to properly care for the patient, or have processes in place to refer patients to other resources.

Unfortunately, traumatic events occur more often in our society than we think. Caring for patients with a history of traumatic life events requires a high level of sensitivity and compassion. Health care organizations can assist their staff in navigating delicate and difficult situations by providing educational training, tools and resources on the trauma-informed care approach.
 
Resources for Health Care Providers:
Child Welfare Information Gateway
National Council for Behavioral Health
Substance Abuse and Mental Health Services Administration
The Trauma Informed Care Project
 

References:

1. Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma Informed Care in Medicine: Current Knowledge and Future Research Directions. Family Community Health, 38(3), 216-226.

2. Koetting, C. (2016). Trauma-Informed Care: Helping Patients with a Painful Past. Journal of Christian Nursing, 33 (4), 206-213.