Over decades of practice-informed research, clinical support, and advocacy, a gradual embrace of trauma-informed care as a fundamental component to quality health service delivery has emerged. Every patient has a story – a context, and a set of experiences- that impact their health and wellbeing, including their interactions in healthcare. When trauma, and particularly adverse childhood experiences, are a component of our patients’ stories, we see a correlation with worse health outcomes and greater barriers to overall wellbeing. The healthcare delivery system must and can account for this awareness through provision of trauma-informed care.
Primary Care Development Corporation (PCDC), a national nonprofit based in New York, is dedicated to enhancing health equity through advocacy, investment, and technical assistance. After training hundreds of healthcare professionals across the country about addressing the impact of trauma on patients and communities, we have observed consistent patterns in what may help or hinder organizations as they become trauma informed.
- Trauma-informed care uniquely ‘hits home’ for healthcare staff. Like anyone, healthcare professionals may have experienced some form of trauma themselves. A key difference, however, lies in the frequency of responding to the needs of patients with trauma, and the significant potential for experiencing vicarious traumatization. This experience, be it in working with clients in processing traumatic memories or responding to medical emergencies amidst the anguishing circumstances of the COVID-19 pandemic, is uniquely persistent in healthcare service.
Calling out clinicians and other staff engaged in these experiences superheroes has perhaps ignored the humanness of being a caregiver, but there does seem to be value in recognizing staff experiences with trauma. For staff that bear witness to the impacts of trauma, understanding the phenomenon of trauma and appreciation for incorporating trauma-informed principles like safety and trustworthiness are almost innate. Most health professionals still need training and support in operationalizing trauma-informed care, but we have seen powerful motivation to implement trauma-informed principles activated when we recognize existing awareness of trauma. With this experience, however, it was not uncommon in both national webinars and in-person trainings, for care managers, therapists, nurses and others to acknowledge personal trauma during training discussions. While not the goal of trauma-informed care trainings, sharing revealed that many healthcare workers need and crave safe spaces to discuss their clinical cases, but also to process their own experiences including trauma.
- Trauma-informed care begins with trauma-informed organizational practice. Trauma-informed care needs to flow from leadership and throughout the healthcare organization to consistently reach clients or patients. In even the most well-resourced organizations employing incredibly talented and dedicated staff, we have seen healthcare professionals that are burning out and struggling to stay afloat. Most often, this has not been due to a lack of self-care by employees, but a combination of demanding work with insufficient support.
It is unrealistic for organizations to expect their staff to practice trauma-informed care if they are not working in a trauma-informed organization where they experience emotional support, realistic caseloads, and policies that enable wellbeing (employee assistance programs, adequate paid time off, good health benefits including mental health, etc.). This is equally if not more the case for behavioral health professionals, who are increasingly called upon to provide local support for their peers (while themselves often lacking the same benefit). Too often trauma-informed care training participants share implementation barriers not about their patients or workspaces, but about their management and leadership. Trauma-informed organizations begin with trauma-informed leaders.
- Many healthcare professionals just learning about trauma-informed care are often not starting from ‘zero’. Trauma-informed care is not dissimilar from other approaches to good care that are sometimes already familiar to staff, including person-centered care and culturally-competent care. As trainers of healthcare professionals, we develop trainings on each of these topics and frequently find the discussions touching on similar themes. For example, when taking a patient or person-centered approach to care, healthcare staff consider the whole-person and their unique goals instead of their singular diagnosis or illness. The practitioner’s job is not always to ‘fix’ an identified problem as much as it is to incorporate a person’s goals into a broader care plan, facilitate open conversation and create context for safe discussions in present and future episodes of care. If an organization has already worked to incorporate cultural humility, taking an open and curious stance in learning about patients’ backgrounds, cultures and values, they have already begun to embrace trauma-informed principles of collaboration and empowerment. Capitalizing on existing efforts around enhancing care can be a significant boon to any new trauma-informed initiative.
- Leadership take note: it starts with you but lives with your staff. While leadership buy-in and support is essential, the sustainability of trauma-informed care implementation typically resides with staff. Recognizing and including key members of the team in preparation and implementation of trauma-informed care can support the ultimate viability of the work. In the case of screening for adverse childhood experiences and trauma, daily practice of these efforts is often not as simple as it may seem. Staff that play a part in screening- from the front desk team to the clinicians, need to be involved in the roll-out of any new practices to troubleshoot the process and develop a sense of ownership in the work. When planning for a new trauma-informed patient flow, screening process, or treatment space, no one knows better how it will go than the staff involved in the daily practice. If staff feel they were not consulted or considered in a new initiative, especially related to trauma-informed care, they may feel caught off guard, devalued, and generally start off already experiencing a lack of choice contrary to trauma-informed care itself.
- Trauma-informed care can be practiced just about anywhere (even in small exam rooms or dated clinics). We’ve assisted in planning and financing beautiful facility renovations for trauma-informed redesign, but completing a recent year-long training series for small practices implementing trauma-informed screening for adverse childhood experiences revealed that trauma-informed care can happen in even some of the tightest corners. Staff in small practices and clinics- those with fewer than about six providers (and sometimes just one)- and agencies practicing in older or cramped spaces- sometimes share that they feel their workspaces make trauma-informed care impossible. Leadership may also feel that without a major overhaul or a new building, it’s not worth incorporating trauma-informed care.
It is a fair question: “how could anyone feel safe and empowered in this kind of place?” A tiny clinical room barely big enough for the exam table or an old office in the shadow of a decaying industrial area may seem impossibly unforgiving, but we have witnessed training participants find ways to incorporate trauma-informed principles in their care no matter the space. Sometimes creating safe and welcoming spaces is as simple as replacing a flickering white florescent bulb with a new warm-colored replacement, but most trauma-informed care really occurs in the client and staff interactions. Offering clients some choice about where they sit or even how they position their chair (we’ve even shared stories of providers offering to sit on the exam table if patients felt more comfortable on their stool!) can be a meaningful gesture towards empowerment. Listening carefully to patients wishes and needs, respecting personal boundaries and asking permission before making physical contact or asking invasive questions can all send important messages that enhance safety, trust, and confidence in the practice of trauma-informed care.
Every agency, organization, and clinic is unique in their steps toward navigating the best implementation of trauma-informed care. After training and learning from hundreds of healthcare professionals from mental health, substance use, social service, and primary care systems, it is increasingly clear how valuable trauma-informed care is for both clients and staff. As much as we must focus on reducing unnecessarily healthcare costs and improving key outcomes and metrics, to get there we must begin by focusing on the humanity inherent in the practice of care. Healthcare practitioners bring powerful personal and professional experiences to the table, and with strong leadership support and thoughtful execution of trauma-informed principles, we are seeing a nation of dedicated caregivers ready to rise to the occasion of trauma-informed care.
Yael Lipton, MPH, MCHES, is Curriculum Development Specialist and Trainer, and Andrew Philip, PhD, is Clinical Lead and Senior Director at Primary Care Development Corporation.
The Primary Care Development Corporation is a nationally recognized nonprofit providing strategic investment and technical assistance to support and expand health care – primarily in low-income, underinvested communities – to achieve health equity. For more information visit pcdc.org or call (212) 437-3900.