To the Editor:
The article “Trauma-Informed Care and Practice: Practice Improvement Strategies in an Inpatient Mental Health Ward” by Beckett, Holmes, Phipps, Patton, and Molloy, published in the October 2017 issue of the Journal of Psychosocial Nursing and Mental Health Services, evoked a mixed emotional response from me, as a current RN-to-BSN student and mental health nurse. The article cites many positive changes that the studied unit implemented as part of a trauma-informed care (TIC) initiative for patients and staff. However, TIC is not a topic that I learned about in my primary nursing school education, in my RN-to-BSN program, or even when I began to work in the emergency department (ED). I have heard of TIC as a buzzword, but have yet to see implementation of it in the ED. I believe TIC education is important for all nurses because we come into contact with patients who have experienced trauma or have mental health issues, no matter what setting we work in.
Of course, nurses are not social workers, but we often see patients first and generally interact with patients more than any other individual on the health care team. Stokes, Jacob, Gifford, Squires, and Vandyk (2017) describe how Peplau, a well-known nursing theorist, “reinforced that the common goal of nursing is establishing safety and security for the patient through the therapeutic relationship by attending to the patients' needs, not simply by their actions and behaviors” (p. 8). Nurses are often primarily focused on assessing and treating a patient's current medical needs, but we should be considering a patient's past and future. We need to anticipate patients' needs, which we can do by viewing them holistically. If we recognize in nursing that individuals are the whole culmination of their experiences, why is trauma not considered, especially as the effects of trauma can linger for a lifetime?
Stokes et al. (2017) found that patients with a history of trauma use health care services more than patients who do not have such experiences. According to Wheeler (2018), “adverse childhood experiences are likely to increase early mortality in cardiovascular, pulmonary, and liver diseases; suicide; addictions; and other physical and mental health problems” (p. 20). Traumatic experiences can even occur within the health care setting. According to Johns Hopkins Medicine (2015), “one quarter of patients who survive critical illness and an ICU [intensive care unit]-stay experience PTSD [post-traumatic stress disorder]…. These rates are as high as you might see in combat soldiers or rape victims” (para. 5). TIC is not just for soldiers who return from war. “Researchers suggest a shift towards viewing every patient as though they may have a trauma history, and expanding capacity to care for the effects of trauma into all health services” (Stokes et al., 2017, p. 1).
As nurses, we also need to be aware of how patients' trauma affects us. The effects of hearing their stories or empathizing with patients have numerous names in the literature, including “secondary traumatization, passion fatigue, and vicarious traumatization” (Courtois & Gold, 2009, p. 17). Secondary trauma is one reason why nurses experience burnout, especially in the mental health field. Trauma, especially a misunderstanding of it, is draining to nurses as well as patients (Stokes et al., 2017).
Wheeler (2018) proposes that all undergraduates in nursing be taught about TIC. I believe TIC could be easily integrated into the therapeutic communication section of nursing school education, or at least in the mental health nursing section. Education exists on how to integrate TIC into coursework, as it has finally worked its way into psychologists' education. Courtois and Gold (2009) believe that trauma should be thought of as a normal and frequent part of human development, so it could even go in the “human growth and development” section of nursing school.
TIC often seems like a nebulous topic that educators have little understanding of how to implement. However, it does not have to be. In 2018, the Center for Pediatric Traumatic Stress created a way to extend beyond the typical basic and initial assessment of the “ABCs” (airway, breathing, circulation) to include “DEF”—distress, emotional support, and family needs. This acronym was specifically designed for pediatrics, but the implications can be expanded to all patients. Stokes et al. (2017) also mentioned the idea of “universal trauma precautions,” meaning that we should treat all patients as if they have experienced a traumatic experience. Wheeler (2018) states that panels of experts from the psychiatric fields of nursing, such as the American Psychiatric Nurses Association, would be great resources to help make this idea a reality.
TIC speaks to how we should treat patients as the sum of their experiences and help them cope with their past, current, and future stressors. It is not just about treating the trauma after the fact; it is about increasing coping skills and self-efficacy to prevent future trauma and negative experiences. “Nurses, as direct care providers who work within a holistic perspective, are positioned to play an integral role in the advancement of TIC within heath care services” (Stokes et al., 2017, p. 2). I hope that I, along with other mental health nurses, can be involved in the process of implementing TIC in the standard nursing school education as it rightfully belongs.