https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/12/16/les-personnes-blessees-en-blessent-dautres
A lack of system-level approaches poses grave repercussions for patients
istockphoto.com/FatCamera
Trauma-informed approaches to care have populated scientific literature since the mid-1990s. Since then, many organizations, including those in the health-care sector, have introduced frameworks and policies to guide more responsive, trauma-informed practices for patient care — at least on paper.
Recently, I attended a transformational interdisciplinary conference in Vancouver, titled Justice As Trauma. What distinguished this conference from other similar events is the open-minded exploration of innovative ideas and the discussion of groundbreaking projects taking place across Canada and abroad in the spheres of criminal justice, law advocacy, human rights, restorative justice, neuroscience, education and healing, to name a few. However, one common thread that blurred disciplinary boundaries and united diverse groups of attendees was trauma-informed practices. Acclaimed speakers, trailblazers and various status quo agitators inspired unparalleled learning and seeded my heart and mind with hope. This hope blossomed for me into this article.
As a nurse, I hope for high-quality health care for patients, safe care practices, a supported nursing workforce, and thriving work environments. This aspiration is unlike the current reality of health care in British Columbia and other provinces across the country. I will not enumerate the host of issues that Canadians face when seeking care and the challenges experienced by the organizations and individuals delivering it. These problems are publicized and debated enough. Instead, I will introduce a trauma-informed approach to nursing that might be one of the missing ingredients to a better health-care system.
Trauma-informed approach to care
Trauma-informed approaches to care have populated scientific literature since the mid-1990s. Around that time, the Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States organized the Dare to Vision conference, where the stories of victims illuminated the recognition of trauma and potential for retraumatization. Since then, many organizations, including those in the health-care sector, have introduced frameworks and policies to guide more responsive, trauma-informed practices for patient care — at least on paper.
I implore health-care organizations to take this approach further by including nurses under the umbrella of trauma-informed care. One of the key principles of the SAMHSA trauma-informed framework states that the “organization recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system” (p. 8). As an example, BC Mental Health and Substance Use Services (BCMHSU) follows SAMHSA principles, and although the intent is clearly outlined in the framework, as a practising nurse in this province, I can state with confidence that practical implementation of these principles is yet to be realized.
This idea is not new and was empirically explored by Knaak et al. (2021). The authors were concerned with stress, burnout and secondary traumatic stress in health-care providers, especially in the context of the ongoing opioid crisis and the recent COVID-19 pandemic. They noted how workplace stress negatively affects patient care and leads to compassion fatigue and detachment. To this end, the authors evaluated the Trauma and Resiliency Informed Practice (TRIP) program developed by Fraser Health Authority (2017) in British Columbia.
The TRIP program is aimed at reducing provider stigma toward patients with opioid use disorder and increasing awareness of and skills about trauma, self-compassion and compassion satisfaction. The authors asked three research questions; however, the question most pertinent to this discussion is whether the program “improve[s] resiliency skills, compassion satisfaction, secondary traumatic stress, burnout, or self-compassion among health services staff” (p. 88). The results showed significant improvement in self-perceived resiliency skills.
Although the TRIP program made important steps in the right direction, I criticize its exclusive focus on self-care, self-compassion and stress resiliency skills. To explain my reasoning, let’s step back and clarify some concepts.
What is trauma?
There are many definitions of trauma in the literature. SAMHSA (2014) encapsulates trauma as “an event, a series of events or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening” (p. 7). However, the definition offered by Dr. Gabor Maté during his keynote presentation at the Justice As Trauma conference resonated with me the most. As I recall, he said that trauma is not what happens to you but is how it’s reflected in your body; it’s a wound inside you. In his book The Myth of Normal (Maté & Maté, 2022), Dr. Maté offers a similar explanation of trauma as “an inner injury, a lasting rupture or split within the self due to difficult or hurtful events” (p. 20). Unfortunately, many people experience trauma in their lives, whether from single or repeated offences in childhood or adulthood, living through a traumatic event or exposure to the trauma of others.
Trauma is more prevalent than we think. For example, let’s consider a health-care system. Usually, people seek and access health care when they are ill, injured, suffering, giving birth or dying. In other words, individuals enter health-care settings during stressful and turbulent life events with high-stakes outcomes. As front-line care providers, nurses have a front-row seat to the suffering of human beings. Thus, nurses not only bring their own traumas into the workplace, but they also repeatedly experience vicarious trauma. Unhealed and unresolved trauma often leads to a host of adverse personal and professional outcomes. In the case of nursing practice, trauma can contribute to burnout, moral distress, attrition, negative self-perception, loss of empathy and avoidance, among many other symptoms. Certain organizational practices and toxic work environments can further contribute to retraumatization.
However, having a workforce of vicariously (and possibly personally) traumatized and retraumatized nurses is not inconsequential. Despite profound personal consequences, trauma among nurses can have an exorbitant effect on patient safety, care and health outcomes. Hurt people hurt people. This phrase was frequently repeated during the conference and often in the context of justice-involved individuals, yet it is true for all of us. Hurt people hurt people, and whether the act is intentional or subconscious, the aftermath remains unchanged. Unaddressed nursing trauma and a lack of system-level approaches to stopping organizational harm, creating healing work environments and reducing the risk of retraumatizing already have and will continue to have grave repercussions for the entire country. We are the living witnesses to this statement.
We need to nurse the nurses
Now let’s return to where I criticize the exclusive focus on self-care and self-compassion. As I discussed, trauma is prevalent, persistent and cascading, and although self-healing practices are among crucial elements of well-being and buffering negative experiences, they are not sufficient. Imagine trying to heal or reduce the risk of trauma through personal resilience and self-compassion in an environment that is not conducive to healing and is often harmful. It is akin to drying the ocean with a mop. Instead, we need to nurse the nurses.
Patients need nursing care, just as nurses need care from the organizations they work for. We do not tell patients to self-care when they arrive at a hospital door, and our nurses deserve similar courtesy. Trauma does not occur in a silo, so neither should the healing. A systemic approach to trauma-informed health care is required to foster a thriving nursing force. The key stakeholders across federal and provincial governments and health-care organizations need to do the following:
- Provide trauma-informed training to their leaders and employees to help them recognize, understand and respond appropriately to trauma-related issues
- Minimize the risk of harm and retraumatization through comprehensive organizational policies and practices
- Enable nurses to participate effectively in creating healing physical and mental environments
- Incorporate healing elements into build design such as exposure to natural light, soothing colours, nature or art with nature views
- Offer flexible work schedules, mental health days and on-site wellness programs
- Support the well-being and resilience of the workforce through allocation of organizational fiscal and human resources
- Promote trauma-informed leadership
As informed by the SAMHSA framework, a trauma-informed approach to care must encompass diverse human and non-human actors within the health-care systems to achieve the desired outcomes. In other words, trauma-informed care requires a wide lens that embraces patients, families, nurses, physicians, allied health and other supporting staff, as well as the elements of material, physical and architectural environments, where harm, healing and health find embodiment.
References
Knaak, S., Sandrelli, M. & Patten, S. (2021). How a shared humanity model can improve provider well-being and client care: An evaluation of Fraser Health’s Trauma and Resiliency Informed Practice (TRIP) training program. Healthcare Management Forum, 34(2), 87–92. doi:10.1177/0840470420970
Maté, G. & Maté, D. (2022). The myth of normal: Trauma, illness & healing in a toxic culture. Knopf Canada.
Substance Abuse and Mental Health Administration (SAMHSA). (2014, July). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf
Mar’yana Fisher, RN, PhD(c), LLB, BA (psychology), BSN, works in palliative care at Vancouver General Hospital.
#opinions
#covid-19
#mental-health
#nurse-patient-relationship
#nurses-health-and-well-being