Article contributed by AAPACN Solution Provider MED-PASS
By Bradley Slye, MPH and Stacy Yale, RN, BSN
Nursing homes across the country face persistent challenges, from staffing shortages and budget constraints to evolving regulatory requirements. These pressures can make it feel overwhelming (or even impossible!) to meet surveyors’ standards while ensuring residents feel comfortable and families remain confident in their loved ones’ care. As a result, it may seem difficult to refine and enhance care practices, particularly those that go beyond strict regulatory mandates.
However, as Dr. Martin Luther King Jr. wisely stated, “The time is always right to do what is right.” Today, that means ensuring your entire team is equipped with a trauma-informed approach to care. Unlike many other initiatives, trauma-informed care (TIC) is not just a best practice—it is a necessity to ensure the well-being of residents that speaks to our deep human need for understanding and empathy.
Why Trauma-Informed Care Matters
Federal regulations mandate that “the facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization.”
While compliance with F699 is clearly important, the true motivation for TIC cannot be regulatory adherence alone. Instead, we should all make a concerted effort to focus on the value TIC brings to residents. Especially at a time in which cultural and social policies are constantly shifting, trauma-informed care remains a steadfast approach to compassionate caregiving at all levels.
Understanding Trauma and Its Impact in Long-Term Care
Long-term care facilities serve a diverse population, many of whom have experienced significant trauma—up to 70%, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Given this prevalence, adopting trauma-informed care as a universal approach is best. Much like infection prevention and control, a consistent, facility-wide approach to trauma-informed care can enhance the well-being of all residents, ensuring a safer and more supportive environment.
Considering the vast range of human experiences and the life span of many long-term care residents, it is highly likely that staff will encounter residents with a history of trauma. Knowing the potential sources of trauma in an individual’s past can help guide a more sensitive and compassionate approach to care for all residents. Some of these experiences could include:
- War or displacement
- Military service
- Adverse childhood experiences
- Emotional, physical or sexual abuse
- Neglect
- Interpersonal violence
- Community violence
- Natural disasters
- Hunger, homelessness or extreme poverty
- Traumatic medical experiences (themselves or loved ones)
- Loss of independence
- Bullying, cruelty, or exclusion
- Racism, historical trauma, and health inequities
Any of these situations can profoundly alter a resident’s mental and physical well-being, as well as their response to care. Many carry the weight of trauma without the understanding to identify or the language to express their experiences. Instead, unaddressed trauma can manifest in residents as anxiety, depression, withdrawal, aggression, mistrust of caregivers, or refusal of medical care, often in alarming or disproportionate response to the “trigger” or situation. Triggers are sensory reminders of past trauma that can cause an automatic reaction, as if the traumatic event were happening again. They may be associated with smells, sounds, places, people, or activities.
Stress resulting from periods of profound change can result in an individual being more vulnerable to triggers. Recognizing and mitigating these triggers is essential in creating a safe and reassuring environment for residents.
As caregivers and clinicians, it is essential to recognize these behaviors as potential responses to past trauma rather than seeing the resident’s behavior as “difficult” or “irrational”. By doing so, we can provide truly person-centered care that honors each resident’s unique history and needs—some of which may have gone unaddressed for a lifetime. Your interactions with residents offer a powerful opportunity to break this cycle, fostering healing, trust, and a sense of safety.
The Core Principles of Trauma-Informed Care
Trauma-informed care shifts the focus from “What is wrong with you?” to “What happened to you?” This approach acknowledges trauma’s long-lasting impact and integrates key principles into caregiving:
- Safety – The principle of safety reflects an organizational commitment to promoting physical, social, cultural, and moral safety for residents, visitors, families and staff. The environment and interactions embrace communication, respect, and an overall sense of welcoming. A safe environment rejects bullying, harassment, verbal abuse, and overt or passive-aggressive behaviors.
- Trustworthiness & Transparency – A trustworthy and transparent organization is one in which actions and communications promote trust. Operations, decisions, and policies are clear, consistent and open, and there is a sense of accountability. There is a culture of openness to feedback, questions, concerns, and shared information. Residents have an active voice in decision making with an understanding of their role in the process.
- Peer Support & Mutual Aid – Peer organizations support mentoring, education, and advocacy. They embrace the concept of lived experiences as a tool for providing knowledge and promoting empathy. Peer support among residents, including recovery and twelve-step groups, foster engagement, acceptance, and social support. Peer groups within the organization, in the form of implementation teams and committees, promote teamwork, collaboration, and mutual problem-solving.
- Collaboration & Mutuality – The principle of collaboration and mutuality reflects the sharing of power between the organization, staff, residents, their families and the community. The underlying belief is that healing occurs within relationships and in shared decision-making and power, regardless of positions in the organization. Resident and family groups are valued as a part of this principle.
- Empowerment, Voice, & Choice – This principle reflects the complexity of individuals and recognizes the need to an individualized approach to safety and quality of care. Empowerment and self-advocacy are recognized as a fundamental aspect of healing, as many trauma survivors have experienced a loss of voice and autonomy. In this environment, individuals are provided with clear and appropriate messages about their rights, responsibilities, and care planning. They are given information in language they understand with an opportunity to provide feedback.
- Cultural, Historical, & Gender Issues – Trauma-informed, resilience-oriented organizations prioritize diversity, equity, and engagement while actively resisting cultural stereotypes and biases related to race, ethnicity, religion, gender, gender identity/expression, age, disability, and sexual orientation. Respect and inclusion are not just values but foundational commitments. This principle recognizes the lasting impact of racism, sexism, ageism, and ethnocentric attitudes on individuals, families, and communities. These effects that are even more pronounced for those with intersecting marginalized identities.
Incorporating Trauma-Informed Approaches
To integrate trauma-informed care into your care, a 2019 article by Dr. Joan Fleishman and her colleagues suggests asking three key questions:
- Safety: Does this cultivate a sense of safety?
- Respect: Am I, and others, showing respect?
- Trust: Does this build trust?
Of course, principles are only as effective as their implementation. Without addressing deeply rooted biases, attitudes, and behaviors, meaningful change is unlikely. Embracing trauma-informed care requires a paradigm shift—one that prioritizes mindfulness and intentionality in everyday interactions. Consider these strategies to put trauma-informed principles into practice:
- Avoid assumptions. Demonstrate genuine respect by being mindful of language related to family structure, gender, race, and religion. When appropriate, ask open-ended questions to clarify individual preferences. Always respect personal space and privacy.
- Listen. Taking the time to understand residents’ personal histories and needs fosters stronger, more fulfilling relationships and improves the quality of care.
- Validate and affirm feelings. Let residents lead conversations about their experiences. Avoid language that minimizes, infantilizes, or judges their trauma.
- Follow through. Honor commitments and promises. If circumstances prevent this, be transparent about why.
- Emphasize personal control. Whenever possible, offer choices and support residents in their decisions, including what treatments or services they receive and who provides them.
By incorporating these strategies, caregivers can create a more compassionate, respectful, and supportive environment in which residents feel safe.
Culturally Competent and Trauma-Informed Care Planning
Culturally competent and trauma-informed care are explicitly mandated under F656, which requires a comprehensive, individualized care plan for each resident. As caregivers, we share the responsibility of collaborating with trauma survivors, as well as their families, friends, and other healthcare professionals (e.g., psychologists, mental health specialists) to develop and implement personalized interventions. In facilities with multiple trauma survivors, it may also be beneficial to establish a support group led by a qualified professional or to provide space for an existing support group to meet.
As previously mentioned, it is essential to remain mindful of potential triggering events, even when a survivor is hesitant to share their history. The goal should always be to minimize harm and prevent re-traumatization by fostering a safe, supportive environment.
Examples of trauma-informed care planning may include:
- Offering alternatives to showering, such as tubs or sponge baths
- Providing individual or small-group activities instead of large gatherings
- Reducing or eliminating exposure to loud noises during events
- Lowering or eliminating overhead paging volume
- Keeping phone or pager volume low when caring for the resident
- Ensuring consistent staff assignments or offering same-sex caregivers for dressing and personal care
- Asking for explicit permission before touching the resident or handling personal items (e.g., clothing, assistive devices)
- Explaining each step of a procedure in clear, simple language, avoiding medical jargon and ensuring the resident understands its purpose
Cultural preferences play a crucial role in a resident’s comfort and well-being. These preferences vary widely and should be respected, even if they differ from our personal beliefs or practices. Culturally responsive care prioritizes the resident’s values and traditions over our own.
Cultural factors that may influence care include:
- Food choices and dietary preferences
- Clothing norms, including hair and skin coverings
- Comfort with physical touch or care from caregivers of the opposite sex
- Expectations around eye contact, tone of voice, and personal space
- Participation in culturally meaningful activities
- End-of-life rituals and practices
- Attitudes toward medications, treatments, and procedures
Both trauma-informed and culturally competent care must be tailored to the individual. The best way to ensure respectful and effective care is to engage directly with residents about their preferences and needs.
The Benefits of Trauma-Informed Care in LTC
- Implementing trauma-informed care in long-term care settings offers profound benefits for residents. When supported by trauma-informed caregivers, residents often experience reduced stress, anxiety, and behavioral symptoms. Strengthened trust and cooperation enhance the caregiver-resident relationship, leading to better adherence to treatment plans and fewer hospitalizations.
- When you and your team are prepared for sensitive situations, your confidence in applying these strategies will grow significantly. Take pride in providing respectful, equitable, and affirming care; helping trauma survivors and other marginalized groups feel truly seen, heard, and supported.
Conclusion
Trauma-informed care is not an optional enhancement, but a fundamental necessity in long-term care settings. By recognizing and addressing the lasting effects of trauma, LTC facilities can create environments where residents feel safe, respected, and empowered.
Prioritizing TIC leads to better resident outcomes, improved caregiver satisfaction, and a culture of compassion and dignity. As the LTC community continues striving for excellence, embracing trauma-informed principles will be a transformative step toward holistic, high-quality care.
By fostering a culture of education, empathy, and thoughtful implementation, LTC providers can ensure that every resident receives care that honors their past while nurturing their present and future well-being.
Further Reading
- Fleishman, J., Kamsky, H., Sundborg, S., (May 31, 2019) “Trauma-Informed Nursing Practice” OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 2, Manuscript 3.
- Trauma-Informed Care Toolkit from Virginia Commonwealth University, accessible at www.tictoolkit.vcu.edu
- Trauma-Informed Care Self-Study Packet from MED-PASS, accessible at www.med-pass.com/is410pck
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