Trauma-informed care a professional obligation for nurses

Katie Owen, Senior Lecturer in the Bachelor of Nursing Programme at Whitireia, says nurses and others in mental health and addiction have long known there is a clear relationship between trauma and mental health.

“But what has been new over the last five years or so,” she says, “is the research linking health outcomes with trauma. This has led to a much more explicit acknowledgement of the importance of nurses being trauma-informed in their training and eventually in their practice.” 

Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012–2017 (Ministry of Health) and Let’s get real (Ministry of Health, 2008) are also clear about the importance of trauma-informed care as a priority and competency for those working in mental health and addiction. This, along with the emerging evidence base, has led to intensified teaching of trauma-informed care at Whitireia.

Its approach is based on the four Rs of trauma-informed care as developed by Substance Abuse and Mental Health Services Administration (SAMHSA, 2014). These are: 

1. Realising the widespread impact of trauma and understanding how trauma can affect families, groups, organisations, and communities as well as individuals 
2. Recognising the signs and symptoms of trauma in the health care system
3. Responding by fully integrating knowledge about a trauma-informed approach to all areas of functioning (policies, procedures and practices)
4. Actively seeking to Resist re-traumatisation of clients as well as staff.

Coordinator of the Post-Graduate Certificate in Nursing (Mental Health) Catherine Fuller says there’s now a professional obligation for nurses to demonstrate trauma-informed care because it is part of reducing harm and is more likely to promote recovery, health and wellbeing.

“This is exactly what we want the therapeutic relationships with the people we work with to look like,” she says.

Both Katie and Catherine stress that trauma-informed care is not something that can be taught in isolation and that it is firmly embedded across both the Bachelor of Nursing and Post-graduate Certificate teaching.

“Everything is integrated, so we teach trauma-informed care in assessment scenarios, context-based learning and flipped classrooms. It’s part of seeing the big picture; students recognising the interventions they need to be providing; how they’re going to communicate with people; and their role in resilience, recovery and strengths-based person-centred care,” Catherine says.

In Year 2 of the Bachelor of Nursing Programme the semesters are based on an overarching theme underpinning everything that is taught in relation to mental health. In the first semester the theme is recovery and stigma. In the second it is trauma-informed care.

“So, for the whole second semester, when we talk about sensory modulation, co-existing problems, suicide or whatever, it’s all underpinned by trauma-informed care,” Katie says.

In fact, the second semester starts with a session on trauma and trauma-informed care which includes a focus on the ongoing Adverse Childhood Experiences (ACEs) Study in the US, which has demonstrated direct links between childhood trauma and physical and mental health outcomes.

And trauma-informed care is not just about understanding how past trauma could be affecting a person’s mental and physical health in adulthood.

“What’s better understood now is that services themselves can be traumatising,” Katie says.

“The obvious issues here are seclusion and restraint, but there’s also being aware of the power relationships nurses have with people and trying to minimise the impacts of power in how you speak to people. It’s about self-determination and allowing people to determine their own health outcomes.”

Other aspects of service that can be traumatising include privacy, physical examination, issues around gender and mixed wards, and whether the environment is gender-appropriate. And Katie says intergenerational trauma is particularly relevant to Māori and Pasifika.

“So, making sure services are culturally appropriate is important because when they’re not it can be traumatising.

“The other thing is that we’re not just talking about the relationship between trauma and mental health, but about all health outcomes. Whether you’re going to be a mental health nurse or work in primary care, ED or as a surgical nurse, all these areas need to be trauma-informed.

“This is particularly so at the under-graduate level, and it fits with what we teach about social justice, the social determinants of health, colonisation, racism and stigma. It fits with everything else students learn about how to respond to people, and it all links to caring and working with people holistically. It makes perfect sense to them.”

Catherine says it’s also important that nurses are aware of their own trauma. 

“People who have experienced trauma are sharing their stories with you as a nurse, so you need to be able to keep yourself safe and not become burnt out. That’s why reflective practice is so important, and when that’s occurring properly you’re likely to be more trauma informed.” 

She says students certainly see the value in the self-reflective aspects of trauma-informed care.

“We’re not trying to educate nurses who can’t relate to people or recognise there’s an inter-relationship going on. We want them to understand that sometimes they will have reactions to people’s stories, and that this is being human. But how do you respond to this and look after yourself?

“An example of this is that students reflect using Te Whare Tapa Whā as a model, so they understand how part of their role is keeping themselves well (and when that’s not occurring how they can rebuild) so they can work with people effectively.”

There hasn’t yet been any formal evaluation around trauma-informed care training at Whitireia, but both Katie and Catherine say it’s very clear the students find it valuable and understand how the stories people come with are important to their care and recovery. 

Catherine says Whitireia will continue embedding trauma-informed care into its curricula into the future, and an important aspect of that will be research to support what has been done so far.

“We have no doubt this will come back positive because the evidence informing our practice and what our students are saying suggests that’s the case.

“We are already doing some research into how well students are able to apply what they have learned in the workplace. Sometimes they find there are barriers to practising the way they believe they should because ideas like trauma-informed care have not yet become part of the organisation’s culture.”

Katie says this is one of the most confronting things many graduates find once they begin work.

“So, we have to change the wider culture around things like stigma, values-based practice and trauma-informed care, and find ways to support our new graduates where they’re not always able to be the kind of nurse they want to be. 

“All this starts in education. It takes time, but change is happening, and we want our graduates to be at the forefront of bringing that about.”