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Psychiatric-Mental Health Nursing

6.5 Trauma-Informed Care

Psychiatric-Mental Health Nursing6.5 Trauma-Informed Care

Learning Objectives

By the end of this section, you will be able to:

  • Apply and define trauma-informed care in child/adolescent populations
  • Select nursing interventions incorporating trauma-informed concepts
  • Evaluate psychiatric-mental health nursing trauma-informed outcomes of care

In trauma-informed care (TIC), health-care providers acknowledge all past and present parts of a person’s life situation, including any trauma they have endured (Center for Health Care Strategies, 2021) in an effort to provide treatment that supports the client’s autonomy, strength, and control over making health-care decisions. Trauma encompasses three areas: the event, how the individual experiences the event, and the way the event affects the individual’s life into the future (Patterson & Troy, 2022). A person who has experienced trauma can develop mental health problems, such as anxiety, depression, and addiction.

The Substance Abuse and Mental Health Services Administration (SAMHSA) (2021) has defined six core principles of TIC:

  • Safety: Throughout the organization, clients and staff feel physically and psychologically safe.
  • Trustworthiness and transparency: Decisions are made with transparency and with the goal of building and maintaining trust.
  • Peer support: Individuals with shared experiences are integrated into the organization and viewed as integral to service delivery.
  • Collaboration and mutuality: Power differences between staff and clients and among organizational staff are leveled to support shared decision-making.
  • Empowerment voice and choice: Client and staff strengths are recognized, built on, and validated, including a belief in resilience and the ability to heal from trauma.
  • Cultural, historical, and gender issues: Biases, stereotypes (e.g., based on race, ethnicity, sexual orientation, age, geography), and historical trauma are recognized and addressed.

Organizations focused on providing TIC should consider the addition of trained peer-support workers, individuals who have lived trauma experiences, to the treatment team in an effort to promote a higher level of trust and engagement from the client (Menschner & Maul, 2016). By adopting a trauma-informed care approach, health-care providers and care settings can ensure that clients feel safe and cared for in a way that encompasses all of their needs.

Application of TIC to Child Development

According to Forkey et al. (2021), more than half of all U.S children under the age of eighteen have experienced some type of trauma in their lifetimes. The American Psychological Association (2023) describes trauma as an emotional reaction to a disturbing, distressing, and painful experience. While there is a wide range of events that can be considered traumatic or adverse childhood experiences (ACEs), medical events are high on the list. Keeping this in mind, it is important to point out that pediatric health-care providers are in the spotlight for being able to make a difference in creating safe, stable, and nurturing relationships with their clients.

While all children will experience some type of stress at some point in their lives, it has been found that toxic stress (adverse events that keep activating the stress response) can lead to lifelong impairments “in physical and mental health processes that embed developmental, neurologic, epigenetic, and immunologic changes” (Forkey et al., 2021, p. 3–4). This then leads to a higher risk for having major depressive disorder with a more severe clinical presentation, stress disorders, “feeling sick” due the immunological component, and poor cognitive function. Higher risk populations include children with families living in poverty, a history of child abuse, being an immigrant or refugee, being a victim of bullying, being LGBTQIA+, having obesity, being part of a military family, being born prematurely, and having chronic medical conditions (Forkey et al., 2021).

Toxic stress from ACEs can alter brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse. Children with three or more reported ACEs, compared with children with zero reported ACEs, had higher prevalence of one or more mental, emotional, or behavioral disorders—36.3 percent versus 11.0 percent (Centers for Disease Control and Prevention, 2022, February 24).

Preventing ACEs can help children thrive into adulthood by lowering their risk for chronic health problems and substance misuse, improving their education and employment potential, and stopping ACEs from being passed from one generation to the next (Centers for Disease Control and Prevention, 2022, February 24). Raising awareness about ACEs can help reduce stigma around seeking help for parenting challenges, substance misuse, depression, or suicidal thoughts. Community solutions focus on promoting safe, stable, nurturing relationships and environments where children live, learn, and play. In addition to raising awareness and participating in community solutions, nurses should recognize ACE risk factors and refer clients and their families for effective services and support.

Pediatricians, nurses, and community health-care providers can promote primary prevention through universal screening for such things as poverty, food insecurity, housing needs, language barriers, postpartum depression, and acculturation in immigrant populations (Garner & Yogman, 2021). Using primary prevention techniques is meant to mitigate the stress response by providing interventions to reduce adversity. An example would be that the pediatrician or pediatric nurse screens for food insecurity and finds that the parents do not have adequate funds to provide healthy foods. In response, the pediatrician will educate the parents about community resources that are available.

Pediatric health-care providers who use the relational approach, helping to strengthen relationships, should provide plenty of time to clients and their families, practice cultural competence, and provide interpreter services as needed. Pediatric health-care providers must also be able to recognize barriers to creating safe, stable, nurturing relationships. In some cases, health-care providers will need to work with other community stakeholders in order to educate and train families about how to build strong relationships that provide nurturing environments for child development.


Ultimately, practitioners must provide care in a manner that does not cause re-traumatization, feeling like the past trauma is reoccurring or that the person is in an unsafe situation as they were when the trauma occurred (Substance Abuse and Mental Health Services Administration, 2014). Creating a safe environment is a top priority for organizational client care practices.

There are two areas in which organizations can focus: physical environment and social-emotional environment (Menschner & Maul, 2016). The physical environment encompasses things such as providing good lighting in parking areas, hallways, waiting rooms, and all treatment areas; reducing noise and distractions; separated seating in waiting areas; welcoming signage throughout the facility; visibility of security; monitoring who enters and exits the building; not allowing people to loiter at the entrance or in the parking lot; and giving clients clear access to exits from examination rooms. The social-emotional environment encompasses providing a welcoming and understanding care environment, giving plenty of notice if scheduling changes, handling conflict appropriately, and acknowledging the role of culturally competent care in reducing the trauma response.

Working with children and adolescents is very different from working with adults. Young people are often reluctant participants who have been brought for care they did not seek on their own. Additionally, their communication skills are limited based on their developmental stage. In addition to gathering information from the child, information must also be obtained from the parent or caregiver (Hilt & Nussbaum, 2016).

The first step to successful care is to create a therapeutic nurse-client relationship. A therapeutic alliance can typically form if the young person feels noticed, heard, and appreciated. It is often helpful to start the conversation with a relatively neutral question like, “Your mom said that you go to [name of school]. What is that school like?” School, friends, family, and favorite activities are low-stress conversation starters. For a very young child, a conversation starter could be a simple observation like what they are wearing. For example, “I see you are wearing blue tennis shoes; did you pick those out yourself?” (Hilt & Nussbaum, 2016).

For young people who seem reluctant to start talking, it may be helpful to describe something you saw that shows you have been paying attention to them. For example, “It looked as though it was hard for you to sit and do nothing while your dad and I were talking. Am I right about that?” (Hilt & Nussbaum, 2016).

When caring for adolescents, it is helpful to gather data from the parent or caregiver, and then ask to speak with the adolescent alone. Reinforce that the conversation is “conditionally confidential” (discussion will remain confidential unless laws require that the provider disclose it, as with, for example, suicidal ideation) and invite the adolescent to sit alone with you to talk. A one-on-one conversation with an adolescent typically creates a better, more honest therapeutic alliance (Hilt & Nussbaum, 2016).

A subtler strategy to build a therapeutic nurse relationship with children and adolescents is to shape how you speak so you are perceived as a responsive problem-solving partner rather than a judgmental authority figure. Building a therapeutic nurse-client relationship with a young person should lead to learning their true chief complaint because the chief complaint of an adolescent may be different from their parents’ complaints (Hilt & Nussbaum, 2016).

Family interaction adds another layer of complexity to the care for children or adolescents who have experienced trauma. Family dynamics refers to the patterns of interactions among family members, their roles and relationships, and the various factors that shape their interactions. Because family members typically rely on each other for emotional, physical, and economic support, they are one of the primary sources of relationship security or stress. Secure and supportive family relationships provide love, advice, and care, whereas stressful family relationships may include frequent arguments, critical feedback, and unreasonable demands (Jabbari et al., 2023).

Interpersonal interactions among family members, as a component of safety, have lasting impacts and influence the development and well-being of children. Unhealthy family dynamics can cause children to experience trauma and stress as they grow up. Conflict between parents and adolescents is associated with adolescent aggression, whereas mutuality (cohesion and warmth) is shown to be a protective factor against aggressive behavior (Jabbari et al., 2023). Effectively assessing and addressing a client’s family dynamics and its role in a child’s or adolescent’s mental health disorder requires an interprofessional team of health professionals, including nurses, physicians, social workers, and therapists. Nurses are in a unique position to observe interaction patterns, assess family relationships, and attend to family concerns in clinical settings because they are in frequent contact with family members. Collaboration among interprofessional team members promotes family-centered care and provides clients and families with the necessary resources to develop and maintain healthy family dynamics (Jabbari et al., 2023).

Strengths-Based Care and Client Empowerment

Care provided should be person-centered, meaning it focuses on the individual needs and desires of that client (Perrelle et al., 2022). Care should focus on a person’s strengths rather than their deficits (UNC School of Medicine, Department of Psychiatry, 2023). Focusing on the client’s strengths instead of just looking at what is “wrong” with them should be at the core of trauma-informed care. This approach includes applauding the client for small steps that they take toward their own treatment (Guevara et al., 2021). It helps to empower the client while giving them hope that they can accomplish bigger treatment goals.

Nursing and Trauma-Informed Care

Individuals who have a history of trauma may become triggered by engagement with the health-care system. They may experience arousal and reactivity symptoms. As a result of the stimulation of the “fight, flight, or freeze” stress response, the parts of the brain involved in memory, planning, decision-making, and regulation are not engaged. This can impact the client’s involvement with health-care services and affect their ability to adhere to treatment plans (Fleishman et al., 2019). Nurses must understand this potential impact of previous trauma and incorporate client-centered, trauma-informed care. Nurses can incorporate trauma-informed care by routinely implementing the following practices with all clients (Fleishman et al., 2019):

  • Introduce yourself and your role in every client interaction: Clients might recognize you, but they might not remember your role. This can lead to confusion and misunderstanding. When a client understands who you are and your role in their care, they feel empowered to be actively engaged in their own care. They also feel less threatened because they know your name and why you are interacting with them. When one party is nameless, there can be an automatic power differential in the interaction.
  • Use open and nonthreatening body positioning: Be aware of your body position when working with clients. Open body language conveys trust and a sense of value. Trauma survivors often feel powerless and trapped. Health-care situations can trigger past experiences of lack of control or feeling trapped. Using nonthreatening body positioning helps prevent the threat detection areas of the client’s brain from taking over and helps clients stay regulated. A trauma-informed approach to body position includes attempting to have your body on the same level as the client, often sitting at or below the client. Additionally, it is important to think about where you and the client are positioned in the room in relation to the door or exit. Both nurse and client should have access to the exit.
  • Provide anticipatory guidance: Verbalize what the client can expect during a visit or procedure or what paperwork will cover. Knowing what to expect can reassure clients even if it is something that may cause discomfort. Past trauma is often associated with unexpected and unpredictable events. Knowing what to expect reduces the opportunity for surprises and activation of the sympathetic nervous system symptoms. It also helps clients feel more empowered in the care planning process.
  • Ask before touching: For many trauma survivors, inappropriate or unpleasant touch was part of a traumatic experience. Touch, even when appropriate and necessary for providing care, can trigger a “fight, flight, or freeze” response and bring up difficult feelings or memories. This may lead to the individual experiencing increased anxiety and activation of the stress response, resulting in disruptive behaviors and possible dissociation. Nurses are often required to touch clients, and sometimes this touch occurs in sensitive areas. Any touch can be interpreted as unwanted or threatening, so it is important to ask all clients permission to touch them. Asking permission before you touch clients gives them a choice and empowers them to have control over their body and physical space. Be alert to nonverbal signs, such as eye tearing, flinching, shrinking away, or other body language indicating the person is feeling uncomfortable.
  • Protect client privacy: Family members and other members of the medical team may be present when you care for a client. Clients may not feel empowered or safe in asking others to step out. It is crucial that nurses do not put the responsibility on the client to ask others to leave. It is the nurse’s role to ask the client (in private) whom they would like to be present during care and ask others to leave the room.
  • Provide clear and consistent messaging about services and roles: Care providers who are forthright and honest build trust with their clients. Dependability, reliability, and consistency are important when working with trauma survivors because previous trauma was often unexpected or unpredictable. Providing consistency from the nursing team regarding expectations and/or hospital rules can help clients feel secure and decrease opportunities for unmet expectations that might lead to triggering disruptive behavior. When clients are feeling triggered (i.e., their “fight, flight, or freeze” system is engaged), information processing and learning parts of the brain do not function optimally, and it is hard to remember new information. When providing education, information, or instructions, break information into small chunks and check for understanding. Offer to write important details down so they can accurately recall the information at a later time. Use clear language and “teach back” methods that empower clients with knowledge and understanding about their care.
  • Practice universal precaution: Universal precaution means providing TIC to all clients regardless of a trauma history. We cannot know what each person has experienced in their lifetime. Approach every interaction with the understanding that trauma may have occurred and will influence the reaction and emotions of the client. Unless a trauma-focused intervention is needed to amend the impact of trauma, many TIC experts propose universal precaution rather than direct screening.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Nursing Sensitivity During Assessment

When assessing a client, the nurse must always be conscious of the fact that the interaction with the client may in itself be upsetting for the client and could lead to re-traumatization. Therefore, the organization has to be purposive in working with staff in providing trauma-informed care from the time when the client is initially assessed through their period of care and treatment.

This can be achieved by:

  • building a workforce that is trauma informed
  • communicating with staff about using a trauma-informed approach to the client
  • training staff in trauma-specific treatments
  • creating a physical and emotional environment that is safe for the client
  • preventing secondary traumatic stress in staff
  • involving clients in organizational planning
  • including clients in the treatment process
  • screening for trauma
  • engaging referral sources and partner organizations (Center for Health Care Strategies, 2017)

Complexity and Diversity Considerations

A complex trauma occurs when an individual is exposed over time to multiple recurring traumatic events (Cenat, 2022). This type of trauma can be sexual, physical, or psychological in nature. Because these traumas reoccur, they have a major impact on an individual’s physical and mental health, especially if they begin in childhood. Individuals who have experienced complex traumas are more likely to develop depression, PTSD, anxiety, sleep disorders, suicidal ideation and substance misuse, as well as physical conditions, such as diabetes, hypertension, obesity, and digestive disorders (Cenat, 2022).

Another aspect of complex trauma is racial trauma. This type of trauma is related to racial discrimination that results in threats, humiliation, prejudice, and verbal/physical attacks on an individual. “According to a national survey in the United States, 50% to 70% of Black, Hispanic, and Asian people stated they had been victims of racial discrimination” (Cenat, 2022, para 3). This type of trauma occurs in neighborhoods, work environments, schools, and health-care environments. If an individual experiences racial trauma as a child or an adolescent, it has the potential to follow them into their adult life, impacting both mental and physical health.

Cognitive Behavioral Therapy

One type of therapy that has been found to help clients (adolescents and older) with PTSD is cognitive behavioral therapy. CBT, combined with exposure therapy, helps people face and control their fear by gradually exposing them to the trauma they experienced in a safe way. It uses imagining, writing, or visiting the place where the event happened to help reduce the intensity of trauma symptoms.

CBT follows several steps (Mayo Clinic, 2019). The first is that the individual identifies the problem areas in their life, and they focus on the emotions and beliefs attached to those problems. The provider helps the individual recognize the thinking patterns that may be contributing to the emotions and beliefs. The individual is encouraged to reshape those thinking patterns in order to reduce negativity associated with them. CBT is a short-term therapy that usually lasts between five to twenty sessions (Mayo, Clinic, 2019).

Outcomes of Care

The overall goal for anyone experiencing trauma-related anxiety is to reduce the frequency and intensity of the anxiety symptoms. SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) outcomes are individualized to the client’s diagnosed conditions, situational factors, and current status. Planning outcomes in small, attainable steps can help a client gain a sense of control over their anxiety (SAMHSA, 2021). Examples of SMART outcomes include:

  • The client’s vital signs will return to baseline within one hour.
  • The client will identify and verbalize symptoms of anxiety by the end of the shift.
  • The client will verbalize three preferred stress management and coping strategies for controlling their anxiety by the end of week one.

In addition to keeping the client and others safe, priority nursing interventions for a client experiencing severe anxiety focus on the client’s physical needs, such as fluids to prevent dehydration, blankets for warmth, and rest to prevent exhaustion.

Support During Recovery and Post-Traumatic Growth

It is very important to get support during the recovery process. Support can be found in a variety of ways/places, including friends, family, coworkers, mental health professionals, religious professionals, and support groups (Patterson & Troy, 2022). Support can be as simple as an individual asking a friend to sit with them when they are feeling anxious. For some people, taking the step to ask for help is the most difficult part of the process.

Positive changes in a person’s outlook after experiencing a trauma is called post-traumatic growth (Mehraban et al., 2022). Trauma can cause a person to ruminate on the traumatic event. That rumination can cause the person to have an increase in stress. It can also make them take a look at how they react to things and become able to reframe their thoughts (Shin et al., 2023). One thing that has a significant effect on post-traumatic growth is a person’s perception of social support from their friends and family (Mehraban et al., 2022). A person who has the support of others is more likely able to adapt to stressful situations and improve their coping mechanisms.


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