Trauma-informed care

For example, the Office for Health Improvement & Disparities identifies 6 fundamental principles for trauma-informed practice. They are safety, trust, choice, collaboration, empowerment and cultural consideration.

The Scottish Government defines trauma-informed practice as ‘A model that is grounded in and directed by a complete understanding of how trauma exposure affects service user's neurological, biological, psychological and social development’.

The Wales Trauma Framework defines a trauma-informed approach that addresses Adverse Childhood Experiences (ACEs) through 5 principles and 4 practice levels. It aims to help Welsh society understand that behaviour is a form of communication and recognise the impact of historical inequalities and social injustice on trauma. The ultimate goal is to promote the implementation of a trauma-informed approach across various levels of society.

A concept analysis using Walker and Avant’s model identifies four defining attributes: recognition, knowledge, concern and respect. Another concept analysis using the same model proposes a working definition of trauma-informed care in nursing to provide a framework for clinical care and research. 

This paper argues that a comprehensive, multi-disciplinary approach to trauma through trauma-informed care requires universal recognition and screening. Targeted interventions create a system of healing through empowerment, relationship building and a reduction in trauma triggers.

A conversation between Vanessa Garrity and Zoe Dodd, where they share their thoughts on trauma-informed care. At the time of recording this podcast, Vanessa worked as the national head of mental health for health in justice and this reflects some of the thoughts shared. 

Research highlights that the experience of trauma is unequally distributed in society. The Scottish Government's Trauma-informed practice toolkit cites evidence that traumatic events are more frequently experienced by people in low socio-economic groups and from black and minority ethnic communities. 

Additionally, people who are homeless are more likely to have experienced trauma than the general population. Trauma-informed care and Psychologically Informed Environments align with the goals of the homeless sector and move towards long-term solutions that support an individual’s needs. 

Evidence also suggests that the development of trauma-informed care within learning disabilities services would ‘allow the use of interventions that consider the importance of trauma in clinical presentations and limit diagnostic overshadowing’.

Several reviews have found limited evidence for the effectiveness of the trauma-informed approach framework. There is a need for the development of an evidence base around the treatment of traumatic stress in people with learning disabilities. 

Various studies show that ACEs have a connection to negative health outcomes. Research on ACEs has been and remains a crucial driver of trauma-informed approaches.

The advantages of trauma-informed practice for the NHS include successful preventative intervention and support. These reduce the financial and social impact of late intervention, cost to society and social exclusion. 

Tim and Hannah first worked together on the parity of esteem project at the Royal College of Nursing and now together in this podcast they explore the perspectives on trauma-informed care, including the origins of trauma, impact of adverse childhood experience, social inequalities, and perspectives on nurse supervision. 

Tim and Hannah are keen to work in a co-produced way so that different perspectives of nurse and patient are explored. In part two of this podcast the themes are emotional intelligence, retraumatised experiences with mental health care, reparative and restorative practice, peer support, woman’s trauma, male trauma, recognising and addressing inequalities.  

Regardless of the lack of a standard definition, professionals have different understandings of trauma-informed approaches. Here at the RCN, we believe that there needs to be more clarity about trauma-informed approaches and potential pitfalls. Additionally, studies highlight a need for training or education for health professionals.

Staff involved in providing trauma-informed care should also receive better support. For example, studies have revealed elevated ACE scores for direct care staff working in settings for people with learning disabilities. 

An organisational and systems-level change is necessary to achieve trauma-informed care. The former United States based agency SAMHSA developed evidence-based guidance for implementing a trauma-informed approach which includes 10 domains for organisational change:

1. Governance and leadership
2. Policy 
3. Physical environment 
4. Engagement and involvement
5. Cross-sector collaboration 
6. Screening, assessment, treatment services 
7. Training and workforce development 
8. Progress monitoring and quality assurance 
9. Financing 
10. Evaluation.

There is a risk of mental health service users being re-traumatised if services fail to identify and recognise their systemic traumas. To achieve trauma-informed care, we need to fund reflective practice and rotate mental health nurses out of acute inpatient environments more frequently. 

Initial steps for health care organisations interested in adopting a trauma-informed approach include supporting a culture of staff wellness. Organisations without safeguards in place to allow staff to process their emotions safely may be exposing employees to secondary traumatic stress, vicarious trauma and burnout. These may inhibit their ability to provide high-quality care and increase staff turnover. 

In the UK, trauma-informed care has been implemented inconsistently, with visible national strategy and leadership Scotland and Wales. However, things are more disjointed in England. 

NHS Education for Scotland has developed a range of learning resources, including a knowledge and skills framework for transforming psychological trauma (PDF) and an associated training plan. A coordinated central strategy and increased funding for evaluation and education would contribute to implementing evidence-based trauma-informed approaches in the UK.

Dr Stephen Jones interviews Dr Liz Walsh and Jess Davidson MBE to explore how an understanding of a trauma informed approach can provide nurses with a universal language to promote mental wellbeing within the context of moral distress.

Liz’s video: Dr Liz Walsh gets us to think about the impact of patient trauma and some of challenging patient interactions with nurses, while also helping us to reflect on our own views, assumptions, and emotions in response.

Hannah’s video: Through her lived experience of mental illness and academic foundations, Hannah Cadogan helps us to explore psychological trauma and what nursing staff can do to support those in distress.

Rachel’s video: Rachel Boddy shares her personal experience of trauma as an A&E nurse and then patient, through the story of overcoming stigma with compassion. 

Rachel’s Poem: Rachel Boddy encapsulates her lived experience of trauma and mental health stigma through the telling of her self-written poem.

Girl with the brown paper bag
How selfish can’t she see
There are people who are dying
She’s really not in need

Girl with the brown paper bag
What’s the big deal
It’s all in her head
Is she being for real

Girl with the brown paper bag
Now I feel like I’m dying
Not sure what’s happening
Can’t think although I’m trying

Girl with the brown paper bag
Struggling to breath
Why is my throat squeezing
Is this how it feels

Girl with the brown paper bag
I know how you felt
To feel so scared
Just wanting some help

Girl with the brown paper bag
I know how life changes in an instant
To feel so alone
But we’re no longer so distant

Girl with the brown paper bag
I’m so sorry I didn’t see
The trauma you carried
So now I plea

Girl with the brown paper bag
Although you’re long gone
I’m here to tell you
You did nothing wrong

Girl with the brown paper bag
I never got to hear your story
So I’m here sharing mine
To restore your glory

Rachel Boddy