Hospitals and COVID-19 Repercussions: Tips for Integrating Trauma-Informed Care

It’s pretty easy to see that we are all experiencing trauma on some level right now. While the coronavirus spreads, people are becoming seriously ill, some are dying, many are recovering, and supplies are critically short. Clinicians are in the middle of it all.

In addition, restrictions limit where we can go and what we can do, some jobs are on hold or evaporating, and income and retirement accounts are threatened. As we endure separation from family and friends, our fears can percolate.

These factors are challenging for all of us. But healthcare workers in all roles—physicians, nurses, aides, and staff—are facing even bigger challenges as you interact with people who are confirmed to have COVID-19 or have symptoms.

Yes, this is what nurses, doctors, and other healthcare providers do. You accept risks to your own personal health to provide care for others.

But that doesn’t mean you aren’t afraid, that the experience isn’t traumatic. You are just brave enough to lean into your vulnerability. As researcher Brené Brown says, there is no courage without vulnerability.

Awareness of Heightened Fears and Trauma Triggers

For people who have experienced trauma previously in their lives, the fear they are experiencing these days is heightened. All the factors swirling around the COVID-19 health threat, social distancing measures, and societal impact carry the possibility of retriggering people who have already experienced traumatic events.

That goes for you as a clinician as well as for your patients. Most of you are feeling vulnerable right now, to say the least. To do your job well, you have to tap into your well of courage and step up to the difficult tasks at hand every time you come to work.

Recognizing the distressing feelings you and your patients are experiencing is an important part of providing excellent care. Behavioral health practitioners are well educated in trauma-informed care, and clinicians and staff in hospitals and primary care settings can benefit from their expertise.

Although trauma is ultimately defined by the individual experiencing it, guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA) identifies trauma in the following way:

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

Acknowledging the potential effects of those harmful experiences, trauma-informed care aims to promote resilience in patients and staff.

Principles of Trauma-Informed Care

SAMHSA and the Centers for Disease Control and Prevention (CDC) developed a training program designed for trauma-informed care during public health emergencies. Designed for the CDC’s Office of Public Health Preparedness and Response, the training outlines the six principles to consider with a trauma-informed approach:

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment and choice
• Cultural, historical, and gender issues

The approach can be helpful in any part of the healthcare system, and it can be especially effective in the emergency department. As an article by the Institute for Healthcare Improvement notes, the ED’s physical environment and policies can unintentionally retrigger people who have experienced trauma, especially if a behavioral health emergency is involved.

The Center for Healthcare Strategies asserts that the approach should go beyond clinical practices and extend to organizational structures. “Organizational practices that recognize the impact of trauma reorient the culture of a healthcare setting to address the potential for trauma in patients and staff, while trauma-informed clinical practices address the impact of trauma on individual patients,” the center notes.

To move forward in promoting trauma-informed care in hospitals and other healthcare settings, consider adapting SAMHSA’s four-pronged approach to fit your acute-care organization:

• Realize the impact of the trauma and potential routes for recovery.
• Recognize the signs and symptoms of trauma in clinicians, patients, families, and other healthcare staff.
• Respond by integrating trauma knowledge into policies, procedures, and practices.
• Resist retraumatizing patients and healthcare workers.

Repercussions From the Pandemic

While recognizing the effects of past trauma is important, the new trauma invoked by the COVID-19 pandemic involves unusual and difficult situations for clinicians and their patients. The care you can provide amid this public health crisis is often less comfortable for everyone involved.

As hospitals deal with the pandemic, clinicians may be encountering some of the following situations:

• Healthcare workers and other staff may be reusing personal protective equipment (PPE) to prolong the limited PPE available. Such compromises go against clinicians’ years of training in infection control and prevention.
• Triage of ventilators and other equipment may leave some patients without the care you would provide in other circumstances.
• Patients may be sequestered in rooms and on equipment where comforting communication is limited.
• Family members are calling about critically ill patients, but you are too busy to respond and communicate as you would like.
• Some patients are dying alone with no family support.

As clinicians, you are deeply affected when you have to watch patients and their families suffer like this and feel that you can’t do your job the way you have been trained. The demands of caring for patients amid the COVID-19 pandemic are exacerbating an ongoing problem, “conflicted allegiances—to patients, to self, and to employers,” as noted in a 2018 STAT news article. As the authors point out, the inability to provide high-quality care and consistently meet patients’ needs can lead to “moral injury” among clinicians.

In terms of specific trauma-related repercussions of COVID-19, trauma surgeon Tanya Zakrison, MD, MPH, FACS, outlines in a video some strategies for addressing healthcare worker wellness, societal issues of equity and inclusion, and structural violence and discrimination affecting patients.

In terms of healthcare worker wellness, Zakrison advocates ensuring that hospital clinicians and staff have adequate PPE, understanding the effects of separation from family and fears about infecting them, and being aware of moral distress that can develop in clinicians after treating patients who are dying at a high rate.

Speaking up against racism and xenophobia in the healthcare system is a clinician’s duty, she asserts, as we strive to deter continuation of trauma. One aspect of that is ensuring equal access to testing and treatment.

Providing Support for Clinicians and Colleagues

Clinicians are clearly conflicted, trying to balance the health and safety of their patients, their own families, and themselves amid so many unknowns with this coronavirus. Personally, you may feel inadequate at times and disappointed in your own ability to communicate and provide compassionate care.

A few more practical steps are advocated in a STAT article on moral injury written by Rachel E. Smith, a physician assistant and former Army nurse in Iraq. Taking lessons from wartime nursing, she suggests pairing clinicians with battle buddies to check in on one another and provide support, and holding end-of-shift debriefings where staff release their emotional burdens and share in a way that normalizes their fear and anxiety. Virtual support groups are another option.

To ease the stress of this crisis, recognize that you are doing your best, reach out to team members in a supportive way when you can, and be open to accepting assistance yourself. As you strive to help colleagues and patients, consider the practical steps outlined by Trauma Informed Oregon, a statewide collaborative:

• Actively demonstrate and promote a calm demeanor.
• Listen to others’ concerns and reflect support.
• Communicate information as frequently and completely as possible.
• Show respect for others’ feelings and views.
• Make efforts to create an environment that feels physically and emotionally safe.
• Solicit input from those affected by decisions—clinicians, patients, staff—and provide choices when possible.
• Maintain cultural sensitivity.
• Collaborate with colleagues and other teams to step in and provide support when needed.