TIC Training Center

Teachers getting Trauma-Informed Care Training in Virginia. When does this roll out nationwide? How about WorldWide?

The blog post: “Why Trauma-Informed Care Needs to be Our Standard” from Women’s Health Today tells us that Trauma-informed care needs to be the standard of care for IBCLCs according to Kathleen Kendall-Tackett, PhD, IBCLC, RLC, FAPA.

Trauma-informed care (TIC) is a movement gaining momentum in health care. It’s been adopted by national health organizations, such as the Substance Abuse and Mental Health Services Administration (SAMHSA). It has not been widely adopted among providers caring for childbearing women, but it’s something we need to seriously consider if we want to increase breastfeeding rates and improve mothers’ mental health.

Just how common is trauma?

Unfortunately, traumatic experiences are remarkably common among women. According to the National Center for PTSD (2015), findings from a large national mental health study show that more than half of women will experience at least one traumatic event in their lives. The most common trauma for women is sexual assault or child sexual abuse, which affects one in three women. Women are also more likely to be neglected or abused in childhood, to experience domestic violence, or to have a loved one suddenly die. One in every nine of these women will develop PTSD.

A trauma-informed approach

Women who have experienced trauma are also at risk for being retraumatized in medical settings, which is why health care providers must be mindful of their needs. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2015) has outlined the principles of trauma-informed care. The trauma-informed care makes sense for every patient, and is especially relevant during the perinatal period, when women are particularly vulnerable.

According to SAMHSA, a trauma-informed approach to care:

1. Realizes the widespread impact of trauma and understands potential paths for recovery. For perinatal women, trauma increases the risk of depression, anxiety disorders, substance abuse, and PTSD. It may also influence birth outcomes, including preterm delivery and birth-related PTSD.
2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system. The perinatal period is a unique opportunity to recognize trauma and its effects. Trauma can be effectively treated, and helping mothers to identify it can be the first step in their healing.
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices.  The effects of trauma are pervasive in the populations we serve. Yet, health care providers often do not recognize its existence or the impact it can have on every area of a patient’s life. IBCLCs can counter this by recognizing trauma and instituting policies and practices that follow the principles of trauma-informed care.
4. Seeks to actively resist re-traumatization.

Read the full blog post here

In this video, Dr Jacob Ham reframes a trauma perspective in terms of learning brain versus survival brain as a way to make it easier for teachers to talk about trauma with students.

This article from the Chillicothe Gazette explains how do survivor advocates cope and avoid “compassion fatigue” while helping sexual assault victims heal.

“The goal of survivor advocates is to provide emotional support, resources, and referrals to individuals who have gone through a sexual assault at the hospital. They also handle a variety of cases from domestic violence to child abuse and elder abuse. On the clinical side, forensic nurses go into the emergency department to complete a sexual assault examination among other things. Both roles can be equally as taxing emotionally.”

“The program reported 80 percent of its victims were females last year and 40 percent reported from a surrounding county. Adena advocate program coordinator Heather Welshimer said they’ve had people travel as far as two hours to have evidence collected because many small ER departments in southern Ohio don’t offer forensic nursing services.”

“In order to become an advocate, Welshimer said people must complete a 40-hour training through community partners, like the Ohio Alliance in Sexual Violence, or an online training program combined with training at Adena, which incorporates role play into training that’s specific to serving special populations. Training covers a range of topics from victim rights and trauma-informed care to male survivors to campus sexual assault and Title IX, she added.”

“Advocates’ training, Welshimer said, specifically focuses on self-care training that talks about building an individualized self-care plan and identifying positive coping mechanisms. The advocate program also processes cases quarterly in a session where they sit and “talk about any boundaries, triumphs they’ve had” or anything bothering them, added Nicole Bullock, another program coordinator, who has extensive volunteer work.”

“You have to have an outlet, you know, a way to cope,” Andrea Crace, a sexual assault nurse examiner, said of their roles. “And then we also have each other. We’re a tight-knit group. We lean on each other a lot. If we’ve had a case that’s really bothering us, or we just need somebody to listen to us for five minutes or to just listen to us cry, we’ve all been there and we all do a great job of being there for each other.”

Read the full article here.

Laurie Barkin, who worked in psychiatry for 22 years as a staff nurse, head nurse, educator, and psych liaison nurse, tells this story:

“Many years ago, when I was working on an in-patient psychiatric unit, one of our patients was a woman in her 30s who cut herself frequently.

At the time, “Marjorie” carried the pejorative label “Borderline Personality Disorder.” These days she would be given the diagnosis of a person afflicted with Complex PTSD.

Back then, we hadn’t figured out that many of our BPD patients had been sexually abused as children, their symptoms reflecting the horrors of their traumas.

On many occasions, Marjorie’s behavior escalated into yelling and threatening to hurt herself. At times, she banged her head or cut herself superficially. When she refused to go voluntarily to the “quiet room,” the male mental health staff would do a “takedown,” carry her into the quiet room and put her into leather restraints.

I shudder thinking about this practice, given what we know now about the high incidence of childhood sexual abuse. Although we didn’t have the term for it back then, we finally figured out that Marjorie was “re-enacting” something from her past. ”

Incorporating a trauma-informed care approach

“Eventually, someone on the treatment team came up with an idea:
We should change the way we respond to Marjorie’s behavior. Instead of using male staff to restrain Marjorie, we decided to use a female staff.”

“The plan worked. It took one episode with female staff carrying out the restraint for Marjorie to curtail her behavior.”

It is important for healthcare and crisis workers to be aware that the body remembers somatic and other sensory experiences of trauma.

“When a previously traumatized person is in a situation that evokes the past, somatosensory memories can roar back, hijacking a person’s ability to be present, to think clearly, to listen, and to calm down.”

“This is why crisis workers should take whatever measures they can to de-escalate the situation, create a calm environment, assure the person of his/her safety, and orient the person to the present reality versus the past while being respectful and sensitive—especially when the person is touched.”

Read the full article here.

It all starts asking the right questions.

Unhealthy childhood habits become unhealthy lifelong habits.

When a patient displays troubled behaviors, caregivers may only see the tip of the iceberg and if the system doesn’t find a way to address all the stuff under the surface, probably there won’t be any real improvements.

Trauma-informed care propose a shift in paradigm, instead of asking: What´s the matter with you? start asking: What happened to you?

A qualitative study: “Exploring Nurses’ Knowledge and Experiences Related to Trauma-Informed Care”, which explored nurses’ understandings and experiences related to trauma-informed care, was presented at the NCBI (National Center for Biotechnology Information, U.S. National Library of Medicine, National Institutes of Health).

“Trauma-informed care is an emerging concept that acknowledges the lasting effects of trauma. Nurses are uniquely positioned to play an integral role in the advancement of trauma-informed care. However, knowledge related to trauma-informed care in nursing practice remains limited. The purpose of this article is to present the results of a qualitative study which explored nurses’ understandings and experiences related to trauma-informed care.”

“Seven semi-structured interviews were conducted with nurses and four categories emerged from the analysis: (a) Conceptualizing Trauma and Trauma-Informed Care, (b) Nursing Care and Trauma, (c) Context of Trauma-Informed Care, and (d) Dynamics of the Nurse-Patient Relationship in the Face of Trauma. These findings highlight important considerations for trauma-informed care including the complex dynamics of trauma that affect care, the need to push knowledge about trauma beyond mental health care, and noteworthy parallels between nursing care and trauma-informed care.”

Conceptualizing Trauma and TIC

“This category captured the participants’ understandings of trauma and its effects on their practice. Most participants reported not receiving formal trauma-informed education as part of their schooling and, as a result, very few stated that they were familiar with the actual concept of TIC. Instead, participants described what trauma and trauma-sensitive care meant to them. Furthermore, participants described how their motivation to learn about trauma stemmed from their own experiences, from their patients’ experiences, or from family and friends who experienced trauma. Learning about trauma and its effects on patients was more of an inductive process where they saw a need to better understand trauma in practice, thus prompting them to explore it in more detail.”

Nursing Care and Trauma

“In this category, the participants’ views of providing nursing care in the context of trauma are described. Participants emphasized that TIC is pertinent to all patients regardless of setting, not just in psychiatric/mental health care, where trauma care is traditionally considered relevant. According to participants, nursing care from a trauma-informed perspective was related to (2.1) basic nursing practice, (2.2) labels and preconceptions, and (2.3) safety and control.”

Context of TIC

“Further to discussing the role of trauma in nursing care, participants suggested specific contextual factors that influence the application of TIC in practice. Participants commented on the nursing profession as becoming more methodological and quantified, particularly with advances in technology. Participants questioned the effects of quantification on nursing care and fostering approaches that support TIC.”

Dynamics of the Nurse-Patient Relationship in the Face of Trauma

“In this category, the participants’ recounts of how trauma can complicate the nurse-patient relationship along several dimensions are explained. These included the aspects of how care can traumatize (or re-traumatize) patients, how nurses might vicariously and/or directly be traumatized by their patients, and how trauma is a dynamic process that affects nurses beyond the individual nurse-patient relationship.”

TIC: Beyond Mental Health Care

“Given that TIC is an emerging concept within nursing, we recruited nurses from diverse practice areas and purposefully did not specify nursing specialty. Interestingly, through this strategy, our sample consisted entirely of participants who identified primarily as mental health nurses, suggesting that mental health nurses overall are more attuned to and familiar with TIC. Yet, most participants in this study acknowledged a need for TIC within all areas of nursing. This need to push the boundaries of TIC beyond mental health is also reflected in the literature (e.g., Kassam-Adams et al., 2015; Ko et al., 2008; Reeves, 2015).”

Conclusion

“In this study, we explored nurses’ understandings and experiences with TIC. While the participants were not familiar with the term TIC, their understandings of trauma and what it means to care from a trauma-sensitive perspective closely resembled existing definitions of the concept. Interestingly, the participants did not describe TIC as a unique philosophy of care but instead emphasized how TIC is fundamentally part of nursing care, with an emphasis on holism and the therapeutic relationship. An important finding of this study, which is not yet described in existing literature, is the complex dynamics of the nurse–patient interaction in the context of trauma. (Re)traumatization is possible for both the patient and the nurse and trauma may perpetuate more trauma through these interactions. More work is needed in this area to fully understand this complex interplay. Finally, several contextual elements complicating the implementation of TIC in practice are explored. These elements need to be addressed if efforts aimed at improving TIC are to be successful.”

Read the full article: Exploring Nurses’ Knowledge and Experiences Related to Trauma-Informed Care.

Trauma is an “emotional response or experience that overwhelms an individual’s capacity to cope”
(TIP Guide, 2013, p. 5)

What is Trauma-Informed Care?

• Includes a basic understanding of how trauma impacts individuals seeking care
• Being aware and recognizing that patients may have experienced some form of trauma throughout their lives
• Changing our approach to care to avoid triggers
• Approach vs. specific skills/techniques

Principles and Practices of Trauma-Informed Practice

1. Trauma Awareness
2. Emphasis on safety and trustworthiness
3. Creating an opportunity for choice, collaboration, and connection
4. Strengths-based and skill building

Why is Trauma-Informed Care/Practice Important?

• Providing an open environment enables survivors to feel safe
• Feeling safe and supported will impact patients’ willingness to discuss their personal history of trauma
• Feeling threatened or unsafe impacts patients’ willingness to seek help and comply with interventions, leading to poor outcomes

* Disclosure of trauma is not necessary to be trauma-informed

Ways to Engage in Trauma-Informed Care

• Open and honest communication to reduce stigma
• Acknowledge personal bias and triggers to reduce burnout and trauma exposure response
• Adequate assessment (assess all domains of health), and identify when trauma may be an unacknowledged factor
• Understand that trauma survivors’ mechanisms of coping have been altered; demonstrate empathy
• Awareness of the language used to describe the people served
• Be compassionate and strength-focused in interactions
• Work together to identify how TIC can be enacted in healthcare

Trauma Informed Care Vs. Trauma Specific

Trauma-informed

• Taking into account the possibility of trauma when providing care
• Can use this approach without knowing the history of a patient
• Helps to establish rapport and trust
• Specific communication and behavior techniques to help reduce anxiety

Trauma-Specific

• Health care provider knows the patient has a history of trauma
• Understand the effects of Trauma
• Inter-professional collaboration
• Understanding personal history and reactions
• Specific interventions

Click here to download the full slideshow: “Trauma Informed Care and Nursing Practice”

Presenter:
Tess Kroeker, ADPN, BHS(PN), MBA, RPN Vice-President, ARPNBC
October 26th, 2017

In collaboration with the Association of Registered Nurses of British Columbia.

In the last years, it’s becoming clearer worldwide that trauma-informed care for nurses is of vital importance when being trained and also when dealing with patients, as stated by Katie Owen, Senior Lecturer in the Bachelor of Nursing Programme at Whitireia, New Zeland:

“But what has been new over the last five years or so,” she says, “is the research linking health outcomes with trauma. This has led to a much more explicit acknowledgment of the importance of nurses being trauma-informed in their training and eventually in their practice.”

Similarly, the Coordinator of the Post-Graduate Certificate in Nursing (Mental Health) Catherine Fuller says:  “there’s now a professional obligation for nurses to demonstrate trauma-informed care because it is part of reducing harm and is more likely to promote recovery, health, and well-being.”

Further Considerations

And trauma-informed care is not just about understanding how past trauma could be affecting a person’s mental and physical health in adulthood. “What’s better understood now is that services themselves can be traumatizing,” Catherine says.

“The obvious issues here are seclusion and restraint, but there’s also being aware of the power relationships nurses have with people and trying to minimize the impacts of power in how you speak to people. It’s about self-determination and allowing people to determine their own health outcomes.”

“The other thing is that we’re not just talking about the relationship between trauma and mental health, but about all health outcomes. Whether you’re going to be a mental health nurse or work in primary care, ED or as a surgical nurse, all these areas need to be trauma-informed.

Catherine says it’s also important that nurses are aware of their own trauma.

“People who have experienced trauma are sharing their stories with you as a nurse, so you need to be able to keep yourself safe and not become burnt out. That’s why reflective practice is so important, and when that’s occurring properly you’re likely to be more trauma-informed.”

Read the full article here.

Christie Alminde, RN, CPN, who served as an outreach coordinator for the Center for Pediatric Traumatic Stress, talks about nursing and trauma-informed care online training available:

” When we know better, we do better. We never wore seat belts, never had car seats, and never wore bike helmets while growing up. Now, my family ALWAYS wears seat belts and bike helmets and are optimally restrained while riding in cars.”

“In the same vein, we can apply this to our professional lives as nurses. While not available when I was in Nursing School, nurses can now use evidence-based trauma-informed care to optimize patient experience and improve health outcomes.”

Trauma-informed Care Online Training

Christie Alminde comments the following about training:

“Free online courses for CE credit developed by the Center for Pediatric Stress at The Children’s Hospital of Philadelphia (CHOP) are now available at HealthCareToolBox.org. Having this training has allowed me to improve how I deliver clinical care to my pediatric patients and their families, some of whom are in desperate situations. It also has helped me cope better with my own secondary stress from working with traumatized patients.”

“Today, I practice with a trauma-informed approach, every patient, every time. Providing trauma-informed care means taking emotional and psychological aspects of children’s experiences into account when you interact with patients and families. It also means trying to reduce the potentially traumatic aspects of medical and nursing care.”

Read the full article here.