In 2016, the Centers for Medicare and Medicaid Services revised their conditions of participation for nursing homes. In their Final Rule, outlining their plans for regulation they stated, “Trauma survivors, including veterans, survivors of large-scale natural and human-caused disasters, Holocaust survivors and survivors of abuse, are among those who may be residents of long-term care facilities. For these individuals, the utilization of trauma-informed approaches is an essential part of person-centered care.”
Defining Trauma and Trauma-Informed Care
To understand the importance of trauma-informed care and begin to put it into practice, providers and their organizations must first understand trauma. The definition of trauma varies depending on the source referenced. According to the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders, trauma includes events or experiences that expose individuals to “actual or threatened death, serious injury or sexual violence…” The Substance Abuse and Mental Health Services Administration defines trauma as “result[ing] from an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”
What all this means is that many people have experienced bad things in their lives, and some of those people experience long-lasting negative effects from those experiences. Trauma-informed care recognizes that healthcare providers sometimes cannot know when someone has a history of trauma. While serving patients who have experienced trauma, the types of care offered and the way care is offered can worsen the negative effects of trauma. And of course, employees at organizations in the health field should work to avoid inflicting this type of unintended harm.
To do this, people working in health facilities have worked to develop trauma-informed practices. Trauma-informed care requires organizations and individual providers realize that their patients may have had a host of bad things happen to them in their lives, and further recognize that such patients may be coping with those issues in ways that are not obviously connected to those bad things. According to SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach, trauma-informed approaches should include six main characteristics, paraphrased below:
Safety – Throughout the organization, staff and the people they serve of all ages should feel physically and psychologically safe. The physical setting should be safe and interpersonal interactions promote a sense of safety. Understanding safety as defined by those served is a high priority. This is a parallel process as staff need to feel safe, as much as people receiving services.
Trustworthiness and Transparency – Organizational operations and decisions are conducted with transparency with the goal of building and maintaining trust with clients and family members, among staff, and others involved in the organization.
Peer Support – Individuals with lived experiences of trauma are encouraged to support and provide mutual self-help as key vehicles for establishing safety and hope, building trust, enhancing collaboration, and utilizing their stories and lived experience to promote recovery and healing.
Collaboration and Mutuality – Attention should be placed on partnering with clients to achieve goals, and leveling power differences between staff and clients and between staff across the organization from clerical and housekeeping personnel, to professional staff to administrators, demonstrating that meaningful sharing of power and decision-making can occur. Trauma-informed organizations must recognize that everyone has a role to play in a trauma-informed approach.
Empowerment, Voice, and Choice – Throughout the organization clients’ strengths and experiences are recognized and built upon. To accomplish this, operations, workforce development, and services are should be organized to foster empowerment for both staff and clients. Organizations should understand the role of power differentials between staff and clients, and between levels of staff and the ways these can impact how services are delivered and received. Services must acknowledge ways in which clients, historically, received sometimes coercive treatments as a result of diminished voice and choice. Clients are supported in shared decision-making, choice, and goal setting to determine their plan of action to heal and move forward. Self-advocacy skills must be cultivated in both clients and staff.
Cultural, Historical, and Gender issues – Trauma-informed organizations actively move past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, religion, gender-identity, geography, etc.); offers access to gender responsive services; helps clients leverage the healing value of traditional cultural connections; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma.
These parameters give organizations a framework with which they can update practices to avoid unintentionally harming patients who have experienced trauma of some kind.
Trauma-Informed Care in Nursing Homes
Nursing homes should begin integrating trauma-informed practices into their work even before the Centers for Medicare and Medicaid Services guidelines are released. Below are suggestions for organizational leaders and staff to consider:
Post the trauma-informed care principles in high traffic staff areas and host meetings to discuss core principles with staff
Create opportunities for all staff to think about the ways in which their services are or are not trauma-informed
Review and ensure that policies are trauma-informed for staff, maximizing these principles in staff–organization interactions as well as staff–resident interactions.
Set aside time for staff to learn about and integrate trauma-informed care in all aspects of their care by giving them access to resources that will help them understand the impacts of trauma and those impacts implications for trauma-informed care. The resources below may be useful:
- Adverse Childhood Experiences Study
- Trauma-Informed Care in Residential Long-Term Care for Older Adults. (inSocialWork® Podcast Series, Episode 263)
- Impacts of Trauma in Later Life (inSocialWork® Podcast Series, Episode 208)
- “Concept of Trauma and Guidance for a Trauma-Informed Approach”
- The Institute on Trauma and Trauma-Informed Care
- Training and Technical Assistance on Trauma
- Key Ingredients for Successful Trauma-Informed Care Implementation
- World Health Organization International Adverse Childhood Experiences Scale
- Original Adverse Childhood Experiences tools
- Trauma Exposure Measures
- Provider Self Care Toolkit
- Post-Traumatic Stress Disorder Toolkit for Nurses
- Vicarious Trauma Toolkit
- Trauma informed Care 101