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Applying the Four Keys of Trauma-Informed Care to Care Planning

F699 of the State Operations Manual (SOM) requires facilities to ensure that residents who have experienced trauma receive culturally competent, trauma-informed care (TIC) to eliminate or mitigate triggers that may cause re-traumatization of the resident. This care must be based upon the resident’s preferences and experiences and align with their goals for health and wellness. This article will present the four keys of TIC and how they can be applied to develop a care plan that eliminates or mitigates the risk of re-traumatization.

Key 1 – Realize that trauma has occurred for a resident

Before a care plan team can develop a care plan to address a resident’s trauma, they must first recognize what trauma is. The 3 E’s, as described by the Substance Abuse and Mental Health Service Administration, explain that for something to be traumatic, there must be an event or aseries of events, or set of circumstances which resulted in actual harm or threat of harm. Next, the individual must have experienced trauma or perceived that the event was traumatic. For some, an event may not result in trauma, but for others it does. For example, many people have been in a car accident. For some, the event causes trauma, while others do not perceive the incident as traumatic. When the care plan team realizes an event has occurred that the resident has experienced in a traumatizing way, the next step is to assess the effect the trauma has on the resident.

Key 2 – Recognize the effect of trauma on the resident

When the care plan team assesses the effect of the trauma, they are exploring how the trauma affects the resident. Some of the questions to facilitate this assessment are as follows:

  • How upset do you feel when something reminds you of a stressful experience from the past?
  • What happens when you feel that you are reliving the experience?
  • What does the trauma prevent you from doing?
  • Are there any triggers that make you feel as if you are reliving the stressful experience?
  • What helps you cope with these stressful situations?

Returning to the car accident example, even residents who share the same traumatic event may experience different effects. One resident may suffer from claustrophobia and be very afraid of the dark, while another resident may occasionally have nightmares and impaired sleep quality. The care plan would be very different for these residents because of how they are affected by the trauma.

Part of recognizing how trauma affects a resident includes identifying what triggers the experience of feeling re-traumatized. When the care plan team has this insight, they can craft interventions that will align with the goal of preventing re-traumatization. For example, the resident who has claustrophobia may be triggered when entering the shower room and when all the lights are off in his room at night. The second resident may be triggered by watching movies with car crashes or looking at pictures of old cars. These triggers are very different, and this knowledge will help the care plan team tailor their approach according to what will benefit each resident.

Key 3 –Respond with an individualized, person-centered care plan

Now that the care plan team recognizes how the trauma affects the resident and what triggers re-traumatization, the team can develop an individualized, person-centered care plan. To achieve individualization and person-centeredness, the care plan must be based on the resident’s preferences for the interventions that will be used to prevent re-traumatization. Additionally, the interventions must correlate with the effects of the trauma, including any behavioral manifestations the resident displays. The triggers for re-traumatization must also be addressed. Compare the interventions below for the two residents who have both experienced trauma from car accidents.

Recognize the effect – Claustrophobia and fear of the dark are triggered when entering the shower room and when all the lights are off in the room at night.Recognize the effect – Nightmares and sleep disturbance are triggered by watching movies with car crashes or looking at pictures of old cars.
Response or interventions –
– Bathe in room or in the large shower room located on A hall. Avoid using all other shower rooms.
– Place night light close to head of bed.
Response or interventions –
– Offer an alternative movie if the group activity includes a movie with car crashes.
– Provide a box of photos to reminisce with and include favorite subjects such as woodworking, animals, and historic homes, but do not include old cars.

Key 4 – Resist re-traumatization and evaluate the success of care plan goals

The overarching goal of TIC is to mitigate the risks of re-traumatization for all people who suffer from trauma. The care team must individualize that overarching goal so that it is personalized to each resident’s situation. Compare the two goals below.

Goal: Prevent re-traumatization for the next 90 days.

Or

Goal: The resident will feel safe and enjoy showering for the next 90 days.

The first goal is generic and could be used for any resident who has trauma. The staff helping the resident at the bedside would read it as medical jargon and may also struggle to connect how what they do helps to achieve the resident’s goal. If the care plan team were to ask the resident “have you been re-traumatized in the last 90 days?” during the care plan meeting, the resident may not understand what they were referring to and not relate to the terms trauma or re-traumatization.

In contrast, the second goal is person-centered and individualized, reflecting the resident’s unique situation and their goal for achieving security from re-traumatization. It also inspires caregivers, because it connects what they do when following the interventions to how it helps the resident. Finally, the second goal facilitates discussion between the resident and the care plan team. When the resident, who has claustrophobia that is triggered by certain shower rooms, is asked “have you felt safe and enjoyed showering since we last met?” he or she can instantly relate, understand, and share feelings. This allows the care plan team to determine whether the care plan is effective at resisting re-traumatization or if adjustments need to be made.

Summary

The nurse assessment coordinator and care plan team can apply the four keys of TIC to care planning practices to craft individualized, person-centered care plans that help residents avoid experiencing further trauma.

For more information on TIC, AAPACN offers the following resources:

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