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Creating Trauma-Informed Long-Term Care Organizations

      Trauma-informed long-term care organizations recognize that residents, patients, family members, and staff may have histories of adversity and trauma that impact their experiences within the dailiness of the organization. Similar to how health care professionals put on gloves as a universal precaution when there is a chance that they may be exposed to pathogens, being trauma-informed involves metaphorically putting on gloves by being intentional about how we do our work.
      When we recognize that those who have experienced trauma may perceive ill intentions or threatening interactions in practices that may be commonplace in health care, we are able to choose to intentionally respond to everyone with universal precautions by ensuring the five trauma-informed values and principles of safety, trustworthiness, choice, collaboration, and empowerment, while also promoting diversity, equity, inclusion, and accessibility.

      Self and World View

      Self and world view reflect how we think and feel about ourselves, others, and the world — the lens through which all of us experience the here and now. This lens is shaped early on by our individual and community experiences. It can also continue to shift later in life when impacted by what are called significant emotional events. Such events could be as simple as a meaningful conversation or as complex as living through the COVID-19 pandemic, civil and social unrest, and economic instability. Significant emotional events in the present often replicate themes that have shaped an individual’s self and world view; this is especially true for individuals who have experienced prior trauma.
      When individuals have experienced trauma, especially when it was prolonged, the brain learns that it needs to remain in survival mode — also referred to as the fight, flight, or freeze response. The overactivation of the survival response in the brain combined with a self-view that reflects ideas such as “I’m not good enough,” “People will hurt me,” and “I can’t trust anyone,” causes individuals to be more likely to experience threats in the present, whether they are real or perceived.
      We cannot change what has happened to someone in the past, but potential activation of the survival response is something we do have control over in our roles when we respond in ways that “neutralize the environment” or prevent retraumatization (see Figure 1).
      Image 1

      Retraumatization: What Hurts

      What we continue to see in our work is that the way organizations and systems function can unintentionally hurt people. Retraumatization is when interactions (e.g., tone or language use), procedures (e.g., having a resident in a room by themselves), the physical environment (e.g., poor lighting or close seating), or even current events (e.g., COVID-19 or acts of racism or discrimination) replicate someone’s history of trauma literally or symbolically. Consequently, these may result in the activation of an individual’s survival response.
      We may not know the exact details of someone’s history of adversity or trauma. However, there are common themes or dynamics that are generally experienced as retraumatizing, even though they are usually unintentional. Some of these themes are listed in the System/Relationship chart in Figure 2 (you can view the full chart of examples at https://www.pacesconnection.com/blog/new-re-traumatization-chart). For example, consider a resident who has told the same health information to multiple providers before finally receiving care and now has a history of feeling unheard; or staff members who now believe they are failures after their overwhelmed supervisor fixed something for them because there was no time to coach them on how to address it.
      Image 2
      We cannot change the fact that trauma has happened, and it is not necessarily our role to treat trauma. However, by intentionally reviewing the way we and our organizations do our work for the potential of these trauma themes/dynamics, we can do our part in engaging in universal precautions for all involved.

      Making a Commitment

      Long-term care organizations looking to be trauma-informed need to make a commitment to ensuring universal precaution at all levels of the organization to prevent retraumatization of residents, patients, family members, and the workforce. As illustrated in Figure 3, this requires organizations to:
      • (1)
        Recognize and reflect on self and world view.
        • All workforce members are aware of how their own self and world view impact the work they do, and that the self and world view of their patients or residents and colleagues is different than their own — acknowledging that past individual, historical, and systemic narratives influence the present moment.
        • Individuals and the organization recognize racist beliefs, oppressive thoughts, and discriminatory behaviors that often occur in organizations and systems.
      • (2)
        Maintain a basic understanding of trauma and adversity.
        • Everyone in the organization has a common language to describe trauma, adversity, and their impacts on others and themselves.
        • The organization provides training to workforce at all levels as well as psychoeducation to patients, residents, and families as needed.
      • (3)
        Consider the workforce.
        • The organization prioritizes workforce wellness and resilience. Like the oxygen mask guidance on airplanes, staff members need to be supported and taken care of so that they can provide trauma-informed care to those they work with.
        • The organization intentionally ensures the trauma-informed values and principles of the workforce and provides structures and supports such as supervision, debriefing, and regular check-ins to address the possibility of what we call the negative impacts of the work (e.g., burnout, compassion fatigue, moral distress, vicarious trauma, etc.).
      • (4)
        Plan and facilitate organizational strategy.
        • A trauma-informed organization is one that uses the filter of the values and principles in everything that it does, from direct interactions and relationship building, to considering the physical environment, to revising policies, procedures, and protocols.
      Image 3
      The difference between staff having awareness of trauma and trauma-informed care and being a trauma-informed organization is intentionality and strategy. This is a process that on average takes a minimum of two to three years to be at a point of sustainability, depending on the size of the organization. Because of this, we decided to write our Trauma-Informed Organizational Change Manual to provide guidance, tools, and examples from our work for organizations to plan for, implement, and sustain an intentional trauma-informed strategy. The manual can be requested for free at the Institute on Trauma and Trauma-Informed Care website (http://socialwork.buffalo.edu/trauma-manual).
      Images reproduced from the Trauma-Informed Organizational Change Manual with permission of The Institute on Trauma and Trauma-Informed Care.
      Samantha Koury is a licensed social worker and co-director of the Institute on Trauma and Trauma-Informed Care, part of the University at Buffalo School of Social Work and Buffalo Center for Social Research. Susan Green is a licensed clinical social worker, co-director of the Institute on Trauma and Trauma-Informed Care, and clinical professor at the University at Buffalo School of Social Work.