Implementing trauma-informed care: A tool to prevent violence in healthcare

Kathryn Merkeley, MHSA, RN, PMP, CPPS
Vizient Program Director, Performance Improvement Programs

With incidences of violence and injuries to healthcare workers on the rise, organizations are faced with addressing environmental risks, providing workforce training and protective equipment and implementing policies and procedures for managing aggressive behaviors. Drivers of violence are multifaceted and catalysts for aggressive behavior vary by individual. Trauma-informed care (TIC) can be a successful strategy for preventing violence by integrating person-centered strategies that prioritize safety, minimize triggers and promote empathy and mutual respect.

What is trauma?

The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as an event or long-term pattern of events experienced by an individual as harmful or life threatening and the resulting adverse effects may be temporary or cause extended physical and psychological disturbances. Types of trauma include:

• Primary: Directly experiencing injury or illness, witnessing human suffering or exposure to hazardous conditions such as violence, infectious disease and toxins.
• Secondary: Repeated exposure to another person's trauma.
• Collective: Events that impact entire groups or communities such as natural disasters, epidemics, mass casualty incidents, acts of violence, and societal and historical trauma.

More than 70% of adults report experiencing at least one traumatic event in their lifetime. Long-term toxic stress caused by trauma — especially trauma from adverse childhood experiences that happen during development — can "rewire" the part of the brain that regulates emotions and controls impulses, leaving the individual in a constant state of hypervigilance. Danger becomes the lens through which they view the world, and even mundane situations can activate a fight (overreaction), freeze (underreaction) or flight response. Without appropriate support, individuals often adopt maladaptive coping mechanisms, develop physical and mental illnesses and experience impaired functioning. Even when controlling for lifestyle choices, the adverse effects of toxic stress persist and can pass on from generation to generation (epigenetic).

In conversations with Vizient providers, I'm reminded that trauma is pervasive in healthcare. Loss of autonomy or control over one's health, unexpected diagnosis or injury, exposure to human suffering and death, workplace demands and hazardous conditions and other stressors within the healthcare environment can be traumatic or cause re-traumatization. Trauma contributes to poor health outcomes, decreased productivity, compassion fatigue, burnout, turnover and loss of trust in the healthcare system.

Trauma-informed care

TIC provides organizations with the framework to deliver safe, effective care that's respectful of the impact of trauma. SAMHSA uses four "Rs" to describe key assumptions of TIC below.

Everyone, regardless of role:

• Realizes the widespread impact of trauma
• Recognizes the signs and symptoms of trauma
• Responds by applying trauma-informed principles in all aspects of functioning
• Actively resists re-traumatization

Just because someone has a history of trauma doesn't mean they'll exhibit violent behavior. TIC avoids biases on what trauma "looks like" and shifts the narrative from asking, "What's wrong with you?" to "What happened to you?" This invites a deeper understanding of the individual's unique history and expressions of trauma. An understanding of the psychological, biological and social impacts of trauma and the importance of safety, trust, agency and connection in empowering individuals to heal directs interventions. TIC positions organizations to provide proactive, safe and effective services by recognizing and addressing the underlying factors that increase the risk for negative behaviors and outcomes. In the words of Bishop Desmond Tutu, "There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they are falling in."

Becoming a trauma-informed organization is an ongoing process that begins with organizational change. Embedding TIC principles into organizational culture and all aspects of administration and operations is the foundation for lasting success. Strategies for implementing TIC include:

• Build awareness: Engage champions for TIC to increase buy-in.
• Perform a baseline assessment: It's important to understand existing practices, determine capacity for change and identify opportunities for improvement.
• Engage individuals: Involve those with lived trauma experiences in all phases of the process.
• Identify strategies for implementation at the organizational level:
  • Incorporate TIC principles into policies, procedures and the organization's mission, vision and values.
  • Integrate TIC into workforce development including recruiting, hiring, training and retention.
  • Promote workforce wellness by training staff on the signs of secondary trauma, incorporating wellness activities into daily operations and offering forums/services that remove the stigma of seeking help.
  • Create a physically safe environment that's warm, welcoming, inclusive and minimizes potential trauma cues (e.g., noise, crowding, lack of privacy, etc.).
  • Create a psychologically safe environment by training staff in effective communication to foster mutual respect, facilitate collaboration, display empathy, maintain appropriate boundaries and manage conflict.
  • Use a strength-based approach to focus on positive attributes that supports a growth mindset, positive relationships and resilience in patients, staff and organizations.
• Recognize contributing factors: Understand the impact of historical, societal, generational and cultural factors that contribute to trauma and re-traumatization. Engage community partners to improve population health, reduce adverse effects and address underlying roots of trauma.
• Identify strategies for implementation at the clinical level:
  • Recognize the prevalence of trauma and apply principles of TIC universally in all patient interactions.
  • Develop standard work for screening and assessment by a trained provider that are appropriate for the treatment setting.
  • Engage in shared decision-making and allow patients to have voice and choice in their treatment planning.
  • Collaborate with patients on how to support their individual needs and respond if they become unable to control their emotional responses.
  • Identify resources for trauma-specific treatment by a trained provider.
  • Cross-collaborate with other human services organizations to provide consistent care and establish a referral network for treatment and support services.
  • Use a strength-based approach that empowers patients, builds on existing skills and promotes resilience and recovery as defined by the patient's individual goals.
  • Use peer support to promote healing through relationships and shared experiences.
• Promote continuous learning and sustainability: Regularly evaluate initiatives, use visual management to track outcomes, observe daily work and solicit feedback to identify opportunities for improvement and highlight exemplary performance.

Incorporating TIC has the potential to address the upstream causes of behavior and minimize the likelihood that healthcare services inadvertently contribute to violent events. In doing so, organizations can successfully prioritize physical and psychological safety and improve their ability to deliver effective, compassionate and empowering care for everyone they serve.

Learn more about the Vizient Framework for High Reliability Healthcare and the Vizient Patient Safety Organization.

Author

Kathryn Merkeley is a program director for the Vizient Patient Safety Organization, supporting organizations as a subject matter expert and resource for safety and performance improvement. Prior to joining Vizient, Merkeley served as the director of patient safety at Children's National Hospital in Washington, D.C., where she oversaw strategic safety and systems improvement initiatives for clinical and non-clinical service lines. Merkeley's clinical background is in emergency department and trauma nursing, where she worked in a variety of frontline and operational leadership roles in rural, community and urban hospitals. She holds a Bachelor of Science in nursing from Widener University in Chester, Pa., and a Master of Science in health systems administration from Georgetown University in Washington, D.C.