How to be Trauma Informed in your Practice

In my last post Working Through Loss, I touched on the concept of Trauma Informed Practice (TIP). This topic has got me passionate about sharing the trauma and loss that nurses face shift-to-shift and how this impacts us as human beings. If we as nurses are not aware of trauma and its effects then it could lead to devastating consequences for ourselves and our profession. In rural health it’s imperative that employers acknowledge this fact and incorporate healthy workplace policy to support nurses. If you don’t keep your rural nurses healthy it will affect an entire community’s health.

Prior to becoming a nurse I worked at a rehab centre for women. I was an Executive Assistant, when off for the semester of college, and during classes I was privileged to work in the research department. This job was one of the greatest opportunities of my life, in so many ways. I worked along side an amazing leader who taught me all I know about leadership and capacity building (I will save that for another post).

I would spend countless hours after nursing school locked away in a little office in the skeleton of an old hospital in Vancouver. And through my data entry and analysis a window opened to the trauma that thousands of women face. I inputted data on sexual abuse, physical abuse, and emotional abuse. I typed thousands of horror stories. I collected stats and as the data flowed a picture of a female addict emerged. I remember typing on the computer and I would have tears rolling down my cheeks. I was a silent invisible bystander to these women’s suffering and it changed how I view trauma and life. It made me an advocate, it humbled my struggles in my personal life, and it built upon my empathy. It would be safe to say I learned more in those four walls of that tiny office than I did in all my years prior.

I can see her now, her hair black as night, boobs out and ready for action, make-up on and a stiff upper lip painted blood red. She was a goddess, a beautiful soul that had been raped at the age of five by her one of her mom’s boyfriends. She struggled with relationships, she struggled to get close to people because of the trauma she suffered. This led to many bad relationships with men, she got raped again at 18, she got beat-up, and she became a closed off shell. She hated her life and she hated herself. She would come into the ED drunk and belligerent. She would swear and call us all bitches. She lied, she cheated, and she rebelled. She was one of my favorite people – this mess of a woman was one of the most resilient and authentic humans I have ever met.

It took time for us to break down her walls and when we did there was an amazing, smart, and funny woman under there. I could see how society would pass her off as a whore, a drug addict, a person only taking from society, or perhaps a burden. She is a person I have met in all areas of nursing that I have worked. She is the story of thousands –  I knew her like the back of my hand. She was the female I created out of hundreds of pieces of data, thousands of clicks on the keyboard that painted a fragmented systemically oppressed woman.

Unfortunately, this isn’t a unique picture and as a nurse you meet many patients just like the image I created. It’s easy to pass them off. It’s easy to pass the physical symptoms off as nothing the effects of drugs and alcohol. It’s easy to roll your eyes, call the RCMP to help when they get disorderly. It’s easy to call them “frequent flyers.” It’s a symptoms of nurse burnout and over capacity ED departments. Because I truly believe most nurses are natural empaths. We want to meet our patients where they are but by being a vicarious bystander it can be too much to bear. Because there isn’t just one patient with a traumatic background, trauma is in every life we touch and that’s a big deal for a practitioner.

So how can we be more sensitive to our patients’ trauma? And how can we incorporate that into our practice in a way that gives patients dignity and respect while keeping ourselves sane?

There is a way and more and more health authorities and organizations are getting better and promoting Trauma Informed Practice. The purpose of this post is to give nurses the Coles Notes of TIP and provided nurses with practical tools to be better trauma informed.

So what is TIP?

I found the below definition on the American Academy of Pediatrics website and it illustrates how TIP can be a part of every domain of nursing practice all around the world.

“A trauma informed practice is defined as an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma. Trauma Informed Practice also emphasizes physical, psychological and emotional safety for both patients and providers, and helps survivors rebuild a sense of control and empowerment.”

I love this definition’s connection between not only being sensitive to your patients/clients’ trauma but also that of the workers. That’s the key aspect of being Trauma Informed. Trauma specific however, is where you look exclusively at trauma and it’s effects on patients.

The other key aspect of being trauma informed is understanding what trauma is and the various forms it takes.

Single Incident	Complex and Repetitive	Developmental	Intergenerational	Historical and Multigenerational
One single overwhelming incident as defined by the person experiencing the incident.	Ongoing trauma, like domestic violence.	Trauma experienced early in the life, as a baby or child.	This is the effects of living with a trauma survivor.	Trauma that has happened to a large group of people, like genocide, war etc.

Information taken from the Trauma Informed Practice Guide (2013) and adapted to make this table.

Let’s take a closer look at multigenerational trauma because that links to cultural competency and is a fascinating example of the power of trauma.

Multigenerational traumas are significant events that a large group of people have lived through and inevitable pass down to their children, usually on a subconscious level. It also has been proposed that mass trauma, like the cultural genocide or Canada’s indigenous people, the holocaust, and other societal traumas can affect the DNA that is passed down to other generations. That’s a powerful concept for all practitioners to understand. You may be dealing with a patient that hasn’t lived through the trauma per se but is affected by it. Translating in the need for practitioners to be aware of the history attached to our patients and communities.

Therefore, cultural competence is paramount. I live and work on land that belongs to a nation of people that have been systemically killed, ripped of their culture, taken for granted, and oppressed. Those traumas are in each offspring and generation that has followed – that’s not opinion that is fact. If you argue that certain groups need to move on or get over it then you’re not operating from a trauma informed space.

There is a lot of great work going on to promote healing for our indigenous people but sadly more needs to be done. But if you as a practitioner can acknowledge multigenerational trauma and the effects of racism then you will be better able to support our indigenous patients and be a true healer.

Another mass gendercide that isn’t largely talked about but still has effects today are the witch hunts. Sure, the witch hunts happened in the 1400’s but it spanned many generations. And over 3 million lives of women, handicapped, and homosexual people were killed. That’s a huge amount of people and if you flash to the future today how can that not still be creating trauma and defining narratives for women all around the world. History has effects long after the events have finished but the results of those effects lives in each cell of subsequent generations and that’s important to broaden your definition of trauma. Sometimes the trauma is deeply rooted in our society and makes itself visible through sexism, racism, and other forms of oppression. It’s no wonder people have a difficult time healing and moving forward.

Regardless of what form of trauma your patients have suffered it can manifest in many physical and behavioural ways. Unfortunaly too often when these symptoms and or behaviours are challenging we use language that is not trauma informed.

For example: using the below labels are not adequality defining the issues of our patients and are inertly disrespectful.

• Drug seekers
• Non-compliant
• Manipulators
• Personality disordered
• Non-copers
• Frequent flyers

And the list goes on, but the shift to being trauma informed is understanding not what is wrong, but what has happened. Drug seekers are seeking something and perhaps at quick glance it’s drugs. But I would bet under all that “stuff” is a human who has suffered many forms of trauma and needs to numb themselves in order to cope on a daily basis. Maybe the frequently flyers are telling you that they need support and gain a sense of safety by being in hospital. Manipulators are telling you that they can’t ask directly for what they need. When we add disorder to someone’s history, look at it as not a disorder but a response to trauma. Frame these challenging behaviours in a manner that fosters compassion and empathy.

Let me give you a hypothetical scenario. Young girl in foster care gets physically violent when she gets upset. So, one night after getting angry at her foster parents for not letting her watch Youtube she grabs a pair of scissors and tries to hurt her foster dad. RCMP are called and she comes to a local ED. She could clearly tell you why she behaves this way, and if you ask she would tell you it’s because of the things her dad did to her. But all you could find in her history is labels like conduct disorder, attachment disorder, and violent tendencies. I would have an attachment disorder too, if all I knew of people who where to love and care for me was abuse. I wouldn’t want to get too close either. So why don’t we call her a trauma survivor who is attempting to cope with life. Her disorders are a response to her emotional dysregulation that has happened because of sexual abuse. But no, we call the police we lock them up in a room to calm down, we get caught up in the challenging behaviours, and we forget to search for and acknowledge the root cause.

Fast forward this story to thirty years later when this young girl is now a woman who has several kids in foster care herself. No job, teeth rotten out by using meth, combative, and suspicious of anyone who gets too close. She comes into your ED with chronic pain, drug seeking tendencies, and now has other labels. Borderline personality disorder, substance misuse, and fibromyalgia. Our diagnosis may have gotten more sophisticated, but we still aren’t acknowledging the link – how the past affects the future.

How do you get to the root of someone’s trauma?

This is where you need to remember the difference between trauma informed and trauma specific health services.

• Trauma Informed: understanding how trauma affects people.
• Trauma Specific: creating services that attempt to help the person deal with the effects of trauma.

As a rural nurse, there is some over-lap, but most of the time we need to be operating from a trauma informed centre and have the knowledge to refer and advocate for trauma specific services for our patients. Simply by changing your language to be trauma inclusive will help to better treat trauma survivors.

Ways to implement Trauma Informed Practice

• Engaging – ask why with certain challenging behaviours.

Again, symptoms and behaviours can be a response to trauma so when your nursing/medical interventions are not working or you are having difficulties treating a patient, look for the response. Ask questions, trauma victims may not want to initially disclose their personal stories, but at least give them the option. It may over time open the door to discussion.

• Create a safe environment – remember the hierarchy of needs.

It is easy to get caught up in the medicine and we as practitioners can forget about the simple things in life. Food, shelter, safety, and belonging. Often when these needs are not met we can develop physical symptoms. Treating the physical symptoms isn’t going to solve the problem. However, engaging in dialogue about patient needs can give valuable insight and help us better aim our treatment plan and allows the opportunity for health promotion.

• Provide Choice – limit barriers

People want choice. Often trauma is associated with a loss of control so if you can provide your patients with choice and truly let them be the decision makers of their care, you will get better by-in. And better response to treatment.

• Look for a trauma cause of physical problems – making links.

If you are not successful in identify a diagnosis, or treatment plans are not helping, it is time to open your differential to include trauma sources. Keep the list of all the different types of trauma close by and don’t forget the concept of multigenerational trauma.

• Highlight strengths and resiliency – skills building.

Every human has their strengths and all you need to do as a nurse is identify and praise them for it. Listen to their narrative and pull out the things that have kept them going and share this with them. Often, we forget how strong we are. And it can be beneficial to have someone remind you of your resilience and strength. Be that cheerleader for your patients that are challenging and you will see them rise to the praise.

• Remember patient/client rights – it’s not about you.

This is simple but in a work environment where its go-go we forget it’s not about our time management and organization. It’s about the person – the entity behind the title of patient. Let’s remember that patients have rights, they can refuse care, or challenge decisions, and deserve our time to explore their motivation and reach a mutual agreement that is focused on them.

In my last post I go into detail on how being a vicarious bystander to trauma and suffering can affect nurses. This leads to organizational changes that need to be made in order to support trauma informed practice. Because it’s not just about the patients it is a continuum that spans all aspects of care.

Ways to Support Organizational Change to address Trauma:

• Create healthy policy that includes and acknowledges employees experience with trauma, be it personal or the effects of the job.
• Incorporate debriefing and offer support for workplace trauma experiences.
• Have staff have a voice in safety.
• Hold staff meetings that include opportunities to talk about trauma and ethical issues, in order, to share and exchange knowledge with colleagues.
• Provide education to workforce on trauma and its’ effects.
• Create links with other organizations to support cultural competence.

Ways to Support your Colleagues:

• Open communication of trauma – if you know your colleague worked a difficult case ask them about it. Not the details but how they feel about it and what strategies they have utilized to move forward.
• Watch Sliming – sliming is an interesting phenomenon. It’s the process of a person who has borne witness to a traumatic event and in the means of coping, they tell their colleagues and or friends and family all about the horrid and gory details. You slime them in other words. This often leaves the listener disturbed and in some cases equally as traumatized. Try to spare the details of an experience and share the feelings that were brought up, the challenge for you to move forward, or the ethical implications.
• Be aware of language and personal bias – it is easy to get carried away, to label patients etc. But watch your language you may unbeknownst to you be giving others the right to be disrespectful and not patient centred.
• Support colleague’s wellness and self-care – your colleague looks tired or is showing symptoms of burnout try and engage them in a dialogue and promote their health and wellness. Allow them the opportunity to say no to overtime, working late, or taking more than they can handle. Sometimes all we need is a reminder that it’s ok to have time off, it’s ok to put yourself first.
• Be aware of your triggers and the triggers of your colleagues – I can be triggered by young males who are suffering from mental illness and or drug addiction, it reminds me of my brother. It sneaks up on me and I can feel the trigger being pulled. All the sudden this articulate competent nurse gets frustrated, can barley put two words together, overly emotional, and lastly, disengaged. Not a good place to be in when your trying to care for someone. But I have gotten smarter over the years and I know the feeling of being triggered and that’s when I utilize my strategies.
• Lead by example – I think that’s self explanatory.

Change doesn’t happen overnight for anybody. It took years of trauma and self-neglect for some of our most challenging patients to get to where they are and the same goes for us as nurses. By being aware of trauma and the effects you can make the first step in being trauma informed. My hope is that I have brought some light to this topic and personified the trauma victim in a way that leads to empathy and compassion. My wish is that you as the reader take inventory of your skills as a trauma informed practitioner and take some of my suggestions back to your workplace and start the dialogue and process of becoming trauma informed.

Educational Links

Trauma Informed Practice Guide (2013)

Dr. Dan Siegal – Video on the Effect’s of Trauma

Website with info on trauma and resiliency – Dr. Siegal Triangle of Wellbeing

https://trauma-recovery.ca/resiliency/triangle-of-well-being/

Dr. Veronica Mead – Look at chronic illness and trauma

Canadian Centre for Occupational Health and Safety