Integrating Trauma-Informed Care in Home Health: COVID-19 Considerations

Seniors receiving healthcare at home have a better chance of social distancing than those in skilled nursing facilities, yet the stress of the coronavirus pandemic and the potential for traumatic effects is creeping into the home care environment.

Most of us are experiencing trauma to some degree right now. While the coronavirus spreads, people are becoming seriously ill, some are dying, many are recovering, and some supplies are scarce. Meanwhile, nurses must continue to visit patients and provide care in their homes.

Tensions have been building as we all deal with restrictions limiting where we can go and what we can do, concerns about jobs being put on hold or evaporating, and worries about income and retirement accounts dwindling. As we endure separation from family and friends, our fears can percolate.

Especially among seniors already having serious conditions requiring healthcare at home, worries about COVID-19 are warranted. Those over 65 with chronic conditions are more vulnerable to effects of the disease, and the Centers for Disease Control and Prevention (CDC) has recognized that by providing specific guidance.

Besides fears about catching the virus and becoming critically ill, seniors and their families are dealing with a variety of complicating factors that can affect someone who has experienced past trauma. Similarly, the nurses and caregivers visiting their homes are worried about catching the virus themselves and passing it on to their families. Further, those providing care may also have trauma experiences in their personal histories.

As nurses and caregivers in clients’ homes, you are facing life-threatening challenges as you interact with people who are confirmed to have COVID-19 or suspect they may have it.

Yes, this is what healthcare workers do. You know you have some level of risk to your own personal health as you provide care for others.

As you visit clients in their homes, you might feel afraid. The experiences of the past few months might even feel traumatic. Your clients are fortunate that you are brave enough to lean into your vulnerability and come into their homes. As researcher Brené Brown says, “Courage and fear are not mutually exclusive. Most of us feel brave and afraid at the exact same time. We feel vulnerable.”

Mixing New Fears and Old Trauma

For people who have experienced trauma previously in their lives, the fear they are experiencing amid COVID-19 may be strong. Health threats from the coronavirus, social distancing measures, economic fears, and isolation all have the potential to retrigger people who have already experienced traumatic events.

That goes for you as a home health nurse or caregiver as well as for your clients. If you are feeling vulnerable right now, you are not alone. To do your job well, you must tap into your well of courage and enter your clients’ homes with a positive attitude.

Recognizing the extreme concern you and your clients may be feeling is an important part of providing excellent care during this crisis. Take a note from behavioral health practitioners, who are well educated in trauma-informed care.

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 clients and those providing care.

For those who have experienced past trauma, trust is an important pillar of support amid dramatic changes. When you are making your initial visit to a new client’s home, keep in mind the added pressures the pandemic is placing on relationship building with your client and their family.

Understanding Trauma-Informed Care

SAMHSA and the 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 Center for Healthcare Strategies asserts that the approach should go beyond clinical practices and extend to organizational structures.

In terms of care in the home, you can promote collaborative decision-making by providing options for your client to choose from as you discuss care goals. You can also encourage family members providing care to educate themselves on trauma and healing.

As you strive to promote trauma-informed care in home health settings, consider adapting SAMHSA’s four-pronged approach to fit your agency:

• Realize the impact of the trauma and potential routes for recovery.
• Recognize the signs and symptoms of trauma in nurses, caregivers, clients, and family members.
• Respond by integrating trauma knowledge into your agency’s policies, procedures, and practices.
• Resist retraumatizing clients and home health workers you supervise.

Working Through the Pandemic

Before entering a client’s home, educating yourself on the effects of past trauma can inform your approach to care. In addition, the potential for new trauma flowing from all of the COVID-19 restrictions continues to hang over us. The extra protective and preventive measures you have to take can feel uncomfortable for you and depersonalizing for your clients.

Some of these factors may affect you and your clients during this pandemic:

• Donning and doffing personal protective equipment (PPE) adds time and stress to your home visits.
• Your appearance with PPE is less friendly and may feel impersonal to your clients.
• Wearing PPE may confuse clients with dementia and interfere with care.
• Clients with dementia may need written reminders posted to remind them to wash their hands frequently and well.
• Isolation may add to the tension clients and family members feel and may affect the positive outlook you desire in clients to support healing.
• Your team may be short staffed and your longer work hours may influence your own ability to put aside worry and remain positive.

Finding Support Amid the Stress

As you head out to provide care in others’ homes each day, you may feel conflicted, trying to balance the health and safety of your clients, your own family, and yourself amid so many unknowns with this coronavirus. Personally, you may feel inadequate at times and disappointed in your own ability to present a friendly demeanor and provide compassionate care.

You may need extra attention and care from your own team during this time. If you are a manager, consider facilitating mutual support among team members by assigning buddies, so they can check in on each other and talk about concerns. Virtual support groups are another option.

To ease the stress of this crisis, be generous with praise for each person doing their 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 clients, 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—nurses, caregivers, clients, family members—and provide choices when possible.
• Maintain cultural sensitivity.
• Collaborate with colleagues to step in and provide support when needed.