Trauma is a widespread experience that can significantly impact a person’s physical and mental health. Trauma-informed care (TIC) is a framework that recognizes the prevalence of trauma in patients’ lives and integrates this understanding into healthcare practices. This article outlines the fundamental principles of TIC, its significance to nurses, and the essential knowledge nurses need to provide effective, empathetic care to trauma-affected individuals.

Evolving from awareness of the physical, emotional, and psychological trauma experienced by military personnel (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014), TIC has expanded in scope to include various forms of adversity, such as adverse childhood experiences (ACE) (Center for Disease Control, CDC, 2014), sexual violence, physical abuse, threat to life (Goddard, et al., 2022) natural disasters and terrorism (SAMHSA, 2023). The concept of vicarious trauma has also been incorporated into the definition to account for the impact of witnessing or indirectly experiencing trauma (Dowdell & Speck, 2022). Understanding TIC is essential for nurses to create a safe environment,  promote healing, and avoid re-traumatization. 

TIC Framework

TIC is a framework that recognizes the prevalence of trauma and seeks to foster recovery by integrating trauma-informed principles into policies, procedures, and practices. The six core principles of TIC, as outlined by SAMHSA and the CDC’s Office of Public Health Preparedness and Response (OPHPR), are safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, and cultural, historical, and gender issues (SAMHSA, 2023). 

Impact of TIC in Nursing

Although the effects of trauma have been recognized by other professions for several decades, nursing has been slower to adopt TIC (Waddell-Henowitch et al., 2024). The implementation of TIC in nursing practice offers numerous benefits, including empowering patients, reducing anxiety and trauma triggers, improving health outcomes, and increasing resilience, potentially minimizing the likelihood of re-traumatization (Goddard, et al., 2022). Furthermore, TIC positively impacts nurses by enhancing provider confidence, increasing job satisfaction (Wholeben et al., 2023), and mitigating burnout (Dowdell & Speck, 2022). 

Essential Knowledge for Nurses

“Adopting a trauma-informed approach is not accomplished through any single particular technique or checklist. It requires constant attention, caring awareness, sensitivity, and possibly a cultural change at an organizational level” (CDC, 2018). Incorporating TIC principles into care begins by understanding the different types of trauma, the effects on an individual’s health, and early recognition of the symptoms. Nurses can utilize skill sets to provide effective communication techniques, crisis management, and de-escalation skills. Techniques that are sensitive to patients with trauma histories include introducing oneself and explaining one’s role, having awareness of one’s nonverbal communication, asking before touching, and using teach back, active listening, and validation (Fleishman et al., 2019).

Events during the past few decades have increased awareness of structural violence, whereby social structures and institutions perpetuate harm, potentially intensifying personal trauma (Klein et al., 2024). Nurses can play a pivotal role in addressing these issues by advocating for change and working to dismantle discriminatory practices. 

Self-care and reflection are essential for nurses to mitigate the effects of vicarious trauma and optimize patient care. A nurse who is reflective and practices self-care is more likely to optimize the care provided to patients (Fleishman et al., 2019).

Implementation

“Quality nursing care begins with valuing the person seeking care” (Dowdell & Speck, 2022, p. 37). “Nurses are well-positioned to mitigate the risk of re-traumatization by implementing TIC within the healthcare system”. (Dubay et al., 2018; Fleishman et al., 2019). Key strategies for implementation include training and education, policy development, interdisciplinary collaboration, and the creation of a supportive physical environment. Further trauma education should be included in nurse training and professional development (Wholeben et al., 2023). 

Healthcare delivery systems should have policies in place that support TIC principles. Nurse can lead this process but must be educated in health policy and the policy-making process to do so. Nurse leaders are well situated to facilitate policy development and implementation (Smith et al., 2022).

Interdisciplinary collaboration is a critical component of TIC implementation. Healthcare teams should include mental health professionals and facilitate connections between patients and community resources. A robust evaluation plan is essential to measure the effectiveness of TIC and inform quality improvement initiatives (SAMHSA, 2023). Although organizational-level changes may require significant time and effort, nurses can leverage their influence to promote the adoption of TIC principles and strategies. Resources to assist nurses in learning more about TIC and implementing a trauma-informed approach to nursing care can be found in Table 1.

Challenges to TIC 

The implementation of TIC within a health system may be subject to various challenges, including resource constraints, insufficient training, resistance to change, and the complexity of trauma. Healthcare professionals may feel underprepared to support patients who have experienced specific types of trauma or feel vulnerable based on their own traumatic experiences.

Conclusion

TIC is a critical component of effective nursing practice. By understanding and applying TIC principles, nurses can create a supportive environment that fosters healing and recovery for trauma-affected patients. Further, nurses are uniquely positioned to drive institutional and social policy change that limits vicarious trauma and re-traumatization. Ongoing education and institutional support are essential to successfully integrate TIC into nursing practice. n

References

Centers for Disease Control and Prevention (U.S.). (2024). About adverse childhood experiences. https://cdc.gov/aces/about/index.html 

Centers for Disease Control and Prevention (U.S.). (2018). Office of Public Health Preparedness and Response. 6 guiding principles to a trauma-informed approach. https://stacks.cdc.gov/view/cdc/56843 

Dowdell, E. B., Speck, P. M. (2022). CE: Trauma-Informed Care in Nursing Practice. AJN, American Journal of Nursing 122(4):p 30-38. http://doi.org/10.1097/01.NAJ.0000827328.25341.1f 

Dubay, L., Burton, R. A., Epstein, M. (2018). Early adopters of trauma informed care: An implementation analysis of the advancing trauma informed care grantees. Center for Health Care Strategies. https://www.chcs.org/resource/early-adopters-of-trauma-informed-care-an-implementation-analysis-of-the-advancing-trauma-informed-care-grantees/ 

Fleishman, J., Kamsky, H., Sundborg, S., (2019). Trauma-informed nursing practice. OJIN: The Online Journal of Issues in Nursing, 24,(2), Manuscript 3. https://ojin.nursingworld.org/table-of-contents/volume-24-2019/number-2-may-2019/trauma-informed-nursing-practice/ 

Goddard, A., Jones, R., & Etcher. L., (2022). Trauma informed care in nursing: A concept analysis. Nursing Outlook, 70(2022), 429-439. https://doi.org/10.1016/j.outlook.2021.12.010

Klein, L. B., Melnik, J., Curran, K., Luebke, J., Moore, K. M., Ruiz, A. M., Brown, C., Parker, D., Hernandez-White, I., & Walsh, K. (2024). Trauma- and violence-informed empowering care for sexual assault survivors. Journal of Forensic Nursing, 20(3), 166-173. https://doi.org/10.1097/JFN.0000000000000483 

Smith, Y. M., & Cleveland, K. A. & Kleman, C. (October 28, 2021). Understanding Nurses’ Experiences and Contributions to GoverningBoards. OJIN: The Online Journal of Issues in Nursing, 27(1). https://doi.org/10.3912/OJIN.Vol27No01PPT32 

Substance Abuse and Mental Health Services Administration (SAMHSA) (2023). Practical Guide for Implementing a Trauma-Informed Approach. SAMHSA Publication No. PEP23-06-05-005. https://store.samhsa.gov/sites/default/files/pep23-06-05-005.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA) (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. . SAMHSA Publication No. SMA14-4884. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf 

Waddell-Henowitch, C., McPhail, D., Kelly, C., & Ferris, S. (2024). Method matters: Integrating trauma-informed principles into psychiatric and mental health nursing research. Issues in Mental health Nursing, 45(9), 917-926. https://doi.org/10.1080/01612840.2024.2367756 Epub 2024 Aug 7. PMID: 39110850 .

Wholeben, M., Castro, Y., Salazar, G. & Field, C. (2023). Impact of trauma-informed care training on attitudes among emergency department personnel, staff advocates, and nursing students. Journal of Trauma Nursing, 30(5), 261-270. https://doi.org/10.1097/JTN.0000000000000740