It seems a sad irony — or perhaps fortuitous — that requirements for the provision of trauma-informed care (TIC) were initiated just as the nation and the world were caught in the throes of the COVID-19 pandemic. Considering the SAMHSA definition of trauma, as resulting from events that are experienced 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,” there is no doubt that the pandemic, defined by isolation, loss, uncertainty, and disconnection, has been traumatic for us all.
The implementation of TIC practices, which aim to promote “a culture of safety, empowerment, and healing,” is critical to our ability to navigate the continuing insults and aftermath of the pandemic. Yet our current discussions of TIC are often limited to applying this model to our care for patients and residents. The pervasiveness of the impact of the pandemic and the characteristics of health care work require that we turn the lens of TIC toward our staff as well.
The Stress First Aid Model
The health care workforce is generally susceptible to stress illness and the psychological repercussions of trauma. Chronic exposure to death, illness, trauma, and heavy workloads combined with a “service before self” culture produces an environment of enormous risk under normal circumstances (Int J Environ Res Public Health 2020;17:4267). With the additional impact of the pandemic superimposed over already existing risk, health care workers are increasingly likely to experience psychological morbidities.
Prevalence reports indicate that nearly one quarter of healthcare workers have experienced depression, one quarter have experienced anxiety disorder, and nearly half have experienced some form of psychological distress as a result of stress during the pandemic (Psychiatry Res 2020;293:113382). If we hope to sustain our workforce through such dire times, it becomes critical to implement a TIC approach to support our caregivers so that they can continue to support those who rely on their care.
Implementing new programs and changing the organizational culture, of course, require time. Long-term strategies for responding to the staff’s psychological safety are vital to overall organizational success. However, to respond to acute needs, short-term strategies need to be assessed and implemented in tandem. The Stress First Aid program, a peer-to-peer psychological support model originally developed for the military, can serve as a useful framework for planning short-term interventions and creating the foundation of a long-term strategy.
The foundational research for the Stress First Aid program identifies five key factors for trauma intervention: promoting a sense of safety, of self-efficacy, of calm, of connectedness, and of hope (Psychiatry 2007;70:283–315). Although there are numerous interventions that can serve to support these elements, this model offers tangible short-term strategies to address the experience of acute stress and to proactively reduce the risk of psychological morbidity.
Creating an Environment of Perceived Safety
It likely comes as no surprise that the experience of psychological stress is directly related to the perception of the safety of the environment and — more specific to the pandemic — the risk of infection and exposure (Front Psychiatry 2020;11:583971). Three interventions have been shown to mitigate the experience of perceived environmental risk by limiting uncertainty and enhancing staff sense of control (Psychiatry Res 2020;292:113312; J Emerg Trauma Shock, 2020;13(2):116–123):
Having staff work in organized, structured units where work is as consistent as possible.
Providing communication from teams and supervisors that is clear, direct, and frequent.
Ensuring personal protective equipment is available when necessary.
Enhancing Staff Competence
Multiple studies have identified the positive impact of providing staff education and training. Providing teams with up-to-date information and proactively preparing them with training enhances the staff’s sense of self- and team-efficacy and was identified as a protective factor with regard to the development of posttraumatic stress syndrome (Int J Environ Res Public Health 2021;18:601). Although this factor pertains to more than one type of education and training, amid the COVID-19 pandemic education targeted at understanding the virus and proper infection control protocols was noted to be particularly effective at accomplishing this goal.
Giving Permission to Pause
In health care, it is not uncommon for staff to neglect self-care or fail to take a moment to assess and debrief after an incident or loss. This lack of assessment and reflection results in not only physical exhaustion but also heightened anxiety and a failure to acknowledge or cope with negative emotions. In turn, staff become increasingly susceptible to developing maladaptive coping mechanisms and more vulnerable to the experience of psychological morbidities.
Mitigation strategies for such challenges include:
Instituting formal, scripted pauses at set times or debriefing after incidents.
Using moments of pause and huddles to acknowledge and verbalize difficulties. This normalizes the experience of stress for staff and further promotes the safe discussion of stress responses.
Giving permission for individual team members to take breaks. Introducing models such as the Stress Continuum Model or the S.T.O.P. (Stop, Think, Observe, Proceed) for use during pauses encourages individuals to build self-awareness of their own stress reactions.
Building Personal Connections
Humans are inherently social beings, so it is understandable that we find significant protection from stress through social supports. Two specific strategies for enhancing this sense of connection have shown benefits in health care settings:
Having leaders who are physically present, are outwardly supportive of their teams, and engage teams in joint decision-making.
Encouraging the development of “battle buddy” relationships among team members. Such connections give staff a go-to person to approach for support or encouragement
The foundational research for the Stress First Aid Program is not the only study to have identified hope as a factor that enables individuals to overcome adversity and protect against reactions to trauma (Psychiatry, 2007;70:283-315; J Emerg Trauma Shock, 2020;13(2):116–123.). Fortifying such positive sensations can be supported in health care teams through numerous small acts — which may be as simple as acknowledging team members for their work contributions, celebrating patient recoveries, and highlighting recognition from patients and families. Taking the time to infuse each day with doses of hope fortifies staff morale and boosts engagement.
The application of short-term strategies to support the staff’s psychological safety serves as a starting point for larger programs that can shift organizational culture. To achieve long-term success, organizations must commit to investing in supportive programming, such as Stress First Aid, and to creating a culture that eliminates the stigma of acknowledging stress and fosters an environment where it is okay to not be okay and to seek support.
As with any successful venture, it must be remembered that a TIC approach for our staff is not a destination or box to be checked. Rather, it is a long-term commitment and a continuous process that will allow us to sustain, strengthen, and care for those who spend each day caring for others.
Sarah Sjostrom is the Associate Chief Nursing Officer at Hebrew Rehabilitation Center, Dedham, MA.