Trauma and adverse childhood experiences can have lifelong effects on emotional, behavioral, and physical health. Healthcare providers, along with state and federal policy makers, are expanding trauma-informed care (TIC) and trauma-informed approaches across health, social service, and education sectors. In this article, the authors discuss what is TIC and its importance, operationalizing TIC to include: appropriate language, the physical space and exam in a trauma-informed organization, as well as organizational and clinical strategies for implementing it.
Key words: trauma-informed care, organizational, clinical, client-centered care, people who have experienced trauma
Trauma can have lifelong effects on emotional, behavioral, and physical health. Healthcare providers (HCPs), along with state and federal policy makers, are expanding trauma-informed care (TIC) approaches across health, social service, and education sectors. HCPs are likely to work with individuals with a history of trauma across many settings. It is imperative to have a working knowledge of ways to support these individuals. The information gleaned in this article will also build on the information in the article published in the August 2020 issue of Women’s Healthcare.1 In that article “Trauma-informed care for the primary care provider,” the author provided an overview of trauma, universal screening, and TIC and discussed the four R’s and six key principles HCPs can use to implement TIC.1 In this article, the authors discuss strategies HCPs can use to implement a trauma-informed approach at the clinical level and steps to creating a trauma-informed framework at the organizational level. Understanding core principles related to trauma-informed approaches may assist HCPs in providing TIC in the clinical setting and leading initiatives to make necessary changes at the organizational level.1
What is trauma?
A universal definition of trauma does not clearly exist, but overall, trauma refers to any experience that causes an intense psychological or physical stress reaction.2 It may occur as a result of violence, abuse, neglect, loss, disaster, war, and other emotionally harmful experiences. Trauma may occur as the result of a single event, a series of events, or a set of circumstances. The extent to which an event is traumatic depends on how an individual interprets, applies meaning to, and is disrupted by that event.2,3
What is trauma-informed care?
A TIC approach acknowledges that many people have experienced or witnessed traumatic events and that this can continue to affect many aspects of their lives and how they access and experience healthcare. Individuals who have experienced trauma attempting to engage with their healthcare team find themselves in settings that too often re-traumatize them. Learning to interact with those who have experienced trauma in ways that encourage their resiliency and growth is imperative.
Trauma-informed care acknowledges the need to understand a patient’s life experiences to deliver effective, quality care. It has the potential to improve patient engagement, treatment adherence, health outcomes, as well as providing wellness for HCPs and staff.2–4 A TIC approach aims to be sensitive to peoples’ experiences of trauma and how their trauma may affect their healthcare. This approach encourages interaction with patients in a manner that promotes choices, education, and empowerment.2,5 This creates opportunities for those who have experienced trauma to rebuild a sense of control. However, more needs to be done to develop an integrated, comprehensive TIC framework across both clinical and organizational levels.2,5 Key strategies for adopting TIC principles at the clinical level involve engaging patients in their treatment processes, screening for trauma, training staff in trauma-specific approaches, and engaging referral sources and partner organizations.1,6–9
Language and the meaning of words can impact the dynamics of the patient–provider relationship. The use of certain trigger words and phrases may cause a person to have a strong negative reaction because they evoke the memories and emotions of previous traumatic experiences. The goal of using trauma-sensitive language is to move from labeling and pathologizing to understanding. Understanding does not necessarily mean that one agrees with or endorses something, it simply means that one understands it.
The first step in changing language to be more trauma-sensitive is to separate trauma from the person’s identity. This is not the same as ignoring their trauma and how it impacts their life. Instead of saying “victim” or “survivor,” say “someone who experienced trauma.”10 When HCPs change language in this way, they also are more likely to move away from assumptions and biases that negatively impact patient care.11
In the theme of avoiding labels, focus on the person’s behavior rather than labeling them with a characteristic. For example, noncompliant has been used to describe a person who did not satisfy the care plan that was created for them. When HCPs use the label of noncompliant, it can lead to the assumption that the person is a lost cause or feeling they need to make them compliant. When the focus is changed to the behavior rather than a broad statement attached to character, the HCP can change their perspective and how they approach patient care.2,11 In TIC, providers never make patients do anything. They try to find the root cause or motivation, and create change from there, thus building a therapeutic relationship.2,12 An example of changing language and changing perspective: If a person is not taking their medication, rather than labeling them as noncompliant, say “the person is not taking their medication as recommended.” Now, the HCP can try to understand why this may be occurring and what barriers are impeding actualization of the plan of care.11
As well, the use of empathetic language fosters the therapeutic relationship. Utilizing active listening, clarification, and reflection of what the patient says lays the groundwork for empathetic language. The use of empathetic language allows the HCP to express understanding rather than pity toward the patient and their experience. Using phrases such as “I can understand why” creates a space where the patient does not feel judgment.10,13–15
Person-centered care involves putting the person at the center of their healthcare. To be person centered, the HCP uses a shared decision-making model to develop the plan of care with the person instead of dictating what should or will be done. The goal of the HCP is to provide the person information in an understandable way, assist them in understanding their options, and allow them to choose what is best for them. This may not be the choice the HCP would make and may even be something with which the provider personally disagrees. The person’s choice may not be the most efficacious of options presented. However, having an efficacious option that a person does not utilize is not efficacious at all.10,13,16
When a patient seems to be resistant to care or is engaging in high-risk behaviors, think and ask, “what happened to you?” instead of “what is wrong with you?”13 Being able to understand the circumstances that led the person to choose the behaviors they are exhibiting can create empathy. It can assist the HCP in identifying barriers to care and addressing them. This change in perspective may also decrease HCP burnout as it takes the burden off the provider and gives responsibility back to the person.17–19
The physical exam
Creating a space and exam that is trauma informed is a continuation of the concept of person-centered care. The goal is to create a calm, quiet space where the person feels safe, respected, and heard.20,21 Extreme anxiety and re-traumatization can occur when a person who has experienced trauma feels physically, socially, or emotionally unsafe.
Consider power dynamics when creating a therapeutic space and work to provide the person as much control as possible. The person should be able to sit or stand where they please. If possible, meet and discuss care with the person while they are clothed, rather than in a gown. Avoid standing over the person while discussing care with them. Sitting on the exam stool while talking with a patient on the exam table places the provider lower than them, a physical representation of a shift in power. The HCP should use their first name, last name, and then credentials when introducing themselves to patients and then ask the patient how they would like to be addressed.
Asking the patient about triggers they have experienced shows consideration and assists the HCP to avoid triggering adverse emotional or physical reactions.20,21 The provider should let the patient know they are in control and have full bodily autonomy. If the patient says to stop, the provider must stop. Allow the patient to move and expose their body rather than the provider doing it for them. For example, ask a patient to move up or open their own gown or the provider can ask if they can move the patient or open up the gown. When positioning the patient, allow them to move their own body and give them verbal cues to do so. For example, if the patient needs to abduct their legs for a pelvic exam, ask the patient to bring their knees to the side. If they need a physical cue, instead of putting their hands on the patient’s thighs, the provider can put their hands on the outside of the patient’s knees and ask them to bring their knees to the provider’s hands.
Trauma-informed clinical strategies can prevent re-traumatization of individuals who have experienced trauma. These strategies also foster a therapeutic patient–provider relationship and support the use of patients’ strengths to promote resilience and empowerment in their pathway to care (Table 1).
Table 1. Clinical strategies to operationalize a TIC approach
- Train staff in trauma-specific treatment approaches
- universal screening to assess for trauma
- Provide person-centered care with shared decision making
- Use trauma-sensitive language
- Create an environment in which the patient feels safe, respected, and heard
- Ask the patient about a trauma history to avoid triggers during the physical exam
- Use referral sources and partnering organizations
Beyond specific clinical strategies, changes to organizational policy and culture need to be implemented for a healthcare setting to become truly trauma-informed.21–24 Maximizing collaboration among organization leadership, healthcare and other staff, patients, and their families in all components is key in establishing a trauma-informed healthcare setting. The organization must also work to develop community partnerships to ensure a robust trauma-informed referral network.2,6–9
From the organizational perspective, changing practices to fit TIC principles will transform the culture of a healthcare setting by building a TIC framework. Experts recommend that organizational reform precede the adoption of TIC practices.2 Developing a TIC framework requires a commitment from organization leaders and staff. Readiness of the organization, in terms of attitudes, values, and beliefs is crucial. It is imperative to have leaders and staff with skills and knowledge, and to consider structural factors (ie, infrastructure, policies, procedures) if organization-wide TIC approaches are to be sustainable. Integrating TIC approaches at the organizational level takes time and requires commitment and dedication from all parties.2,4,21–23 The following steps can help ensure that organizational changes are adopted and sustained for a TIC framework (Table 2).
Table 2. Organizational strategies to operationalize a TIC approach
- Identify TIC practices already in place
- Involve patients in planning
- Train clinical as well as nonclinical staff members
- Create a safe physical and emotional environment
- Prevent secondary traumatic stress in staff
- Hire a trauma-informed workforce
The first step for the organization is to conduct an assessment to identify trauma-informed practices already being used and opportunities for additional TIC approaches. Leading and communicating about the new pathway to TIC is key, and this can be done by creating a plan that empowers everyone in the healthcare setting to be part of the transformation process. This in turn will help generate buy-in throughout the organization. It is important for everyone to understand why there will be changes and how it will benefit the entire organization.2,7–9
The second step is to engage patients in each stage of organizational planning. When a healthcare organization implements the process to becoming trauma informed, it is important to include those with lived experience of trauma. People who have experienced trauma are able to provide different perspectives to inform organizational changes. They have an essential role on stakeholder committees, patient advisory boards, and boards of trustees.2
The third step is to train all staff members. Everyone working in the organization can benefit from having fundamental knowledge of TIC approaches. Staff members include clinical as well as nonclinical staff, such as security guards and front-desk workers. An organization-wide approach to TIC training helps to develop cohesiveness and a common language. This organization-wide training approach also establishes that it is everyone’s responsibility to create a sensitive, safe, welcoming, trusting, and nonjudgmental environment.
Another step is to prevent vicarious traumatic stress in staff. Working with people who have experienced trauma puts both clinical and nonclinical staff at risk of vicarious trauma. This comes about through listening to the patients’ trauma stories and becoming witnesses to the pain, fear, and terror that the trauma has caused.
HCPs and other staff may have their own personal trauma histories, which may be exacerbated by providing care for patients who have experienced trauma. Organizations must ensure the physical and emotional safety of staff as well as patients. It is imperative to invest in staff wellness and support through trainings, mental health days, and a focus on self-care to reduce the potential for staff burnout.2,6–9
A final step for the organization is to hire a trauma-informed workforce. Hiring staff that are well informed and ready to work in a TIC environment is pivotal. Previous experience with relevant patient populations and training are key for employing a trauma-informed framework. It is also imperative to have a workforce that embodies empathy and is team centric and collaborative in approaches to care. These attributes form the core principles of a TIC health organization. Every organization is different, and some may require modifying their mission statements, changing human resource policies, amending bylaws, allocating resources, and updating clinical manuals.2,6–9 Each organization should seek to implement core TIC principles using an evidence-based model of care that best meets the needs of the population they serve (Box).
Box. Resources for operationalizing a TIC framework
- Center for Health Care Strategies: Robert Wood Johnson FoundationA
- Substance Abuse and Mental Health Services AdministrationB
- United States Agency for Healthcare Research and QualityC
- Blue Knot Foundation: National Centre for Excellence for Complex TraumaD
There is an increase in interest to use TIC to address physical health, behavioral health, and social impacts of trauma in the clinical setting and at the organizational level. Several strategies for a TIC approach that can be used by HCPs and staff at the clinical level have been described. Operationalizing a TIC framework at the organizational level requires more widespread efforts and cultural change. The organization must embrace core TIC principles to support change that is both patient and staff centric. Evidence-based models are emerging to guide better care for patients and further the field of being a trauma-
informed organization .
Heather C. Quaile is CEO, Founder, and Clinical Director of the Sexual Health Optimization and Wellness (SHOW) Center in Kennesaw, Georgia. Jenna Benyounes-Ulrich is a women’s health nurse practitioner with expertise in midwifery and gynecology in private practice in Alexandria, Virginia. The authors have no actual or potential conflicts of interest in relation to the contents of this article.
Quaile HC. Trauma-informed care for the primary care provider.
Women’s Healthcare. 2020;8(4):6-12.
Menschner C, Maul A. Center for Health Care Strategies. Key Ingredients for Successful Trauma-Informed Care Implementation. April 2016. https://www.traumainformedcare.chcs.org/wp-content/uploads/2018/11/Brief-Key-Ingredients-for-TIC-Implementation.pdf.
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf.
Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.
Menschner C, Maul A. Center for Health Care Strategies. Strategies for Encouraging Staff Wellness in Trauma-Informed Organizations. December 2016. https://www.traumainformedcare.chcs.org/wp-content/uploads/2018/11/Brief-Trauma-Informed-Care-Staff-Wellness.pdf.
United States Agency for Healthcare Research and Quality. Trauma-informed care. April 2016. https://www.ahrq.gov/professionals/prevention-chronic-care/healthier-pregnancy/preventive/trauma.html.
Knight C. Trauma informed practice and care: implications for field instruction. Clin Soc Work J. 2019;47:79-89.
Wilder Research. Creating a Trauma-Informed Organization: Literature Review for Volunteers of America. January 2017. https://www.wilder.org/sites/default/files/imports/VOA_TraumaReport_1-17.pdf.
Ades V, Wu SX, Rabinowitz E, et al. An integrated, trauma-informed care model for female survivors of sexual violence: the Engage, Motivate, Protect, Organize, Self-Worth, Educate, Respect (EMPOWER) clinic. Obstet Gynecol. 2019;133(4):803-809.
Hamberger LK, Barry C, Franco Z. Implementing trauma-informed care in primary medical settings: evidence-based rationale and approaches. J Aggression Maltreatment Trauma. 2019;28(4):425-444.
Godbold L. How to be Trauma-Informed–for Real! Aces Connection. January 20, 2017. acesconnection.com/blog/how-to-be-trauma-informed-for-real.
Raja S, Hasnain M, Hoersch M, et al. Trauma informed care in medicine: current knowledge and future research directions. Fam Community Health. 2015;38(3):216-226.
Gerber MR, ed. Trauma-Informed Healthcare Approaches: A Guide for Primary Care. Cham, Switzerland: Springer Nature; 2019.
Purkey E, Patel R, Phillips SP. Trauma-informed care: better care for everyone. Can Fam Physician. 2018;64(3):170-172.
Yatchmenoff DK, Sundborg SA, Davis MA. Implementing trauma-informed care: recommendations on the process. Adv Soc Work. 2017;18(1):167-185.
Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698-709.
Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. J Gen Intern Med. 2017;32(4):475-482.
Kusmaul N, Wilson B, Nochajski TH. The infusion of trauma-informed care in organizations: experience of agency staff. Human Service Organizations Management. 2015;39(1):25-37.
Ginwright S. The future of healing: Shifting from trauma informed care to healing centered engagement. May 31, 2018. https://medium.com/@ginwright/the-future-of-healing-shifting-from-trauma-informed-care-to-healing-centered-engagement-634f557ce69c.
Sperlich M, Seng JS, Li Y, et al. Integrating trauma‐informed care into maternity care practice: conceptual and practical issues. J Midwifery Womens Health. 2017;62(6):661-672.
Elliott DE, Bjelajac P, Fallot RD, et al. Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. J Comm Psychol. 2005;33(4):461-477.
Shah P, Thornton I, Turrin D, Hipskind JE. Informed Consent. Treasure Island, FL: StatPearls Publishing; 2020.
Lockert L. Center for Health Care Strategies. Building a trauma-informed mindset: Lessons from CareOregon’s Health Resilience Program. June 10, 2015. http://www.chcs.org/building-trauma-informed-mindset-lessons-careoregons-health-resilience-program/.
Davis R, Maul A. Center for Health Care Strategies. Trauma-Informed Care: Opportunities for High-Need, High-Cost Medicaid Populations. March 2015. http://www.chcs.org/resource/trauma-informed-care-opportunities-high-need-high-cost-medicaid-populations/.