What is Trauma Informed Care?
As health care providers, we encounter many individuals who have experienced adverse life events and traumatic experiences. A trauma can be a result from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening.”1 Trauma may adversely impact an individual’s psychological, emotional, physical, social, and spiritual health. Trauma informed care is an important framework that addresses the pervasive impacts of trauma and promotes healing and resilience. By addressing physical and psychological safety in the context of a provider-patient relationship, it helps survivors regain a sense of control and agency. Trauma informed care enhances a patient’s health outcomes and engagement.2
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Trauma Informed Care Principles and Tips:3
Safety (Emotional, Psychological, Physical)
- Provide respectful and accessible welcome
- Welcoming language on all signage
- Ensure immediate basic needs are addressed
- Orient patients to staff and their roles
- Keep noise levels low in waiting rooms or common shared spaces
- Support patients understanding of the physical space. Provide information on where critical services are located: bathrooms, receptionists, etc. Keep parking lots, common areas, bathrooms, entrances, and exits well lit. Offer guidance on exiting at the completion of a visit.
- Offer provider responses that are consistent, predictable, respectful, and maintain healthy boundaries. If changes or delays occur, provide sufficient information, notice, and preparation.
- Speak to patients at eye level whenever possible. Crouch down or sit in a chair when appropriate.
- Be aware of your body language with a patient – don’t tower over patients or visitors, allow a patient an option of where to sit in the room so that they may access the door.
- Ask patients if they prefer to talk with the door open or closed. Consider who else is in the room when discussing information with a patient.
- Be aware that patients may not always be able to verbalize distress. Consider talking with a patient about different ways to let staff know if s/he/they are uncomfortable, scared, anxious, etc.
- Provide flexibility so that staff members are able to interact with people in distress without telling them what to do or immediately giving consequences.
- Ask permission to touch the patient or move patient’s belongs. This can help patients regain their personal autonomy and control.
Trustworthiness and Transparency
- Provide transparency whenever possible – this builds trust and allows the patient to anticipate what may be difficult.
- Inform patients of expectations before, during, and after exams or procedures.
- Let patients know which parts of the body may be impacted before beginning or proceeding with an exam.
- Narrate tasks or procedures for patients - even for small tasks.
- Focus on the patient interaction and make eye contact. Limit the amount of computer-based documentation during the visit when possible.
Collaboration and Mutuality
- Establish a nurturing and supportive relationship that minimizes power imbalances by being respectful, empathic, non-shaming, and non-blaming.
- Provide opportunities for patients to make decisions about their goals and care where they are active participants in their care. Allow flexibility for those goals to shift depending on circumstance.
- Invite patient questions in a genuine and authentic way.
- Learn about patient strengths and resources to manage challenging situations. Ask “what has worked for you in the past?”
Empowerment, Voice, Choice
- Keep patients well informed about all aspects of their care.
- Maintain awareness and respect for basic human rights and freedoms, including the option to decline treatment as appropriate.
- Offer alternative explanations to patients who may be having a hard time with treatment options or expectations. Allow patients the option to include others in their plan of care when appropriate.
- Provide options wherever possible:
- Doors, curtains, shades – can the patient decide if s/he/they wants those open or closed?
- If a patient has to be woken up for meds or vitals, ask how s/he/they would prefer to be woken up.
- Can a patient keep his/her/their own clothes on rather than changing.
Recognition of Cultural, Historical and Gender Issues
- Understand how cultural and social factors impact one’s response to a trauma event and how they perceive privacy and safety.
- Use interventions that respect of diverse cultural backgrounds and create opportunities for patients to engage in cultural sensitive interventions and practices that promote trauma healing and recovery.
- Listen to and validate a wide range of emotions (i.e. grief, sadness, anger, and fear) from patients.
- Ask patients upon arrival what is their preferred language in which to communicate.
- Ask patients how they identify and/or which pronouns they prefer to use. Communicate this to other team members. If a patient is mis-pronouned, apologize and move on.
- Utilize your colleagues for group support to reduce isolation and “worrying alone.” Spend 5-20 minutes anticipating challenges, or reflecting on what went well and what improvements you would like to make
- Educate self and other staff about compassion fatigue and stress symptoms. Encourage and promote wellness. Build resiliency skills to mitigate burnout and vicarious trauma.
- Encourage self and staff to take a 10 minute break. Go outside, engage in a self-care or mindfulness technique, walk up and down stairs – these activities encourage a reset.
Trauma Informed Care Tips for Medical Exam or Intervention:
- Meet with patient fully clothed first to review the care procedure step by step.
- Leave the room to allow patient to change in private.
- Wait for approval from the patient before touching and proceeding with each step.
- If exam or intervention cannot be completed, normalize this experience and agree to reschedule the appointment.
- Give the patient the option of getting dressed before discussing next steps
- Provide written follow up information to patients.
Inpatient Trauma Informed Care Tips:
- Come up with a plan for the shift when possible – what are the windows for meds or vitals or other procedures. Involve the patient when possible in setting expectations and a plan.
- If patient has an upcoming procedure, even routine ones, be transparent with what it will involve from start to finish (sometimes patients are told only what the procedure looks like but not the after-care such as you will return and feel groggy and you won’t be able to eat right away).
- Ask a patient what would make them more comfortable before a procedure whenever possible – some patients want to be awake and alert and others would prefer sedation. Some patients may want a warm blanket.
- Let patients know who is on their care team and why they are involved. It may be obvious to providers why a consult was called but not to a patient.
- Consider a huddle or more formal care coordination with team members for patients experiencing distress at being hospitalized.
- Be proactive in managing escalating behavior. Understand that it may be due to a trauma reaction and reframe behavior to understand it in response to a stimuli or experiences.
1SAMHSA Trauma and Justice Strategic Initiative, “SAMHSA Concept of Trauma and Guidance for Trauma Informed Approach,” https://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf, (2014).
2Christopher Menschner and Alexander Maul, Center for Health Care Strateiges, “Key Ingredients for Successful Trauma-Informed Care Implementation, ” Advanced Trauma Informed Care, https://www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/ (April 2016).
3American Institutes for Research’s National Center on Family Homelessness, “Trauma-Informed Care,” Trauma Informed Organizational Toolkit, https://www.air.org/resource/trauma-informed-organizational-toolkit, (Sept 2009).
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