MDS Alert

Understand how trauma impacts residents and the care they receive.

Individual facilities and larger institutions are recognizing how trauma experienced in different parts of life impact people once they become residents in nursing facilities. With the Centers for Medicare & Medicaid (CMS) implementing a requirement for trauma-informed care as part of Phase 3 of the Requirements of Participation (RoP) beginning Nov. 28, 2019, your facility and staff should be ready to understand different types of trauma and how those experiences impact both residents and staff.

Recognizing the experience of trauma — and the ways in which the physical and intimate care necessitated by a resident’s bodily condition may trigger memories or reactions — is important in delivering truly person-centered care. Appreciating the reality that many residents have experienced trauma before reaching your facility means considering adjusting some go-to protocols and procedures to avoid both triggering and retraumatizing the people in your care.

Understand What Constitutes Trauma

The Substance and Mental Health Services Administration (SAMHSA), a branch of the U.S. Department of Health and Human Services, published a guide, “Concept of Trauma and Guidance for a Trauma-Informed Approach” to help medical service providers provide care that is better attuned to individual needs.

SAMHSA provides this definition of trauma: “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.”

With an understanding of what constitutes trauma, you can begin to imagine the immensity of the effects — and experiences and practices today can trigger memories of reactions of past experiences, and even cause more harm. SAMHSA points to the reality of how past “business-as-usual” practices in delivering care probably did not ease the effects of individuals’ trauma and may even have contributed to it.

You can think of trauma as being represented by these three “E” words: the event, the experience of the event, and the effect, SAMHSA says. Understanding this layered definition of trauma will help your staff appreciate the significance of helping to put residents at ease and not triggering any of those elements.

Know How Trauma Impacts Care

Understanding how the acknowledgement of trauma should be incorporated into the delivery of care is crucial — and such awareness should not be directed toward residents alone.

Remember that power dynamics in relationships are often a central point of trauma, and the intimacy of care necessitated by the physical state of many residents can be especially triggering.

“Traumatic events by their very nature set up a power differential where one entity (whether an individual, an event, or a force of nature) has power over another. They elicit a profound question of ‘why me?’ The individual’s experience of these events or circumstances is shaped in the context of this powerlessness and questioning. Feelings of humiliation, guilt, shame, betrayal, or silencing often shape the experience of the event,” SAMHSA says.

Many residents may already be battling “why me” feelings due to the loss of their respective independence, and the power dynamics inherent to caregiving (or being the recipient of care) only underlines the differential.

Trauma is extremely individualized: A situation that one person finds traumatic may not evoke trauma for another. So “unlocking” what works for one traumatized resident may not work be the best workaround for another resident, underscoring the significance of designing and delivering truly person-centered care.

Train Staff Accordingly

Remember that your facility may need to adjust staff training in terms of skills, not just knowledge — and CMS will be looking out, via staff competency assessment tools that are part of another program launch: the Civil Money Penalty Reinvestment Program.

With this in mind, make sure your staff have the hard skills to provide behavioral healthcare services, including caring for residents with mental and psychosocial illnesses by implementing nonpharmacological interventions, says Kris Mastrangelo, president and CEO of Harmony Healthcare International Inc. in Topsfield, Massachusetts.

From a whole-facility perspective, your entire workplace and residence, respectively, should prioritize the integration of trauma-informed care into the myriad systems.

“A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization,” SAMHSA says.

Focus on These Areas Specifically

There are six key points to consider when figuring out how to incorporate trauma awareness into your facility’s delivery of care, SAMHSA says. All are centered on creating and maintaining a certain level of awareness for the resident or staff member who has experienced trauma, by focusing on establishing environments and relationships that are safe, trustworthy, and supportive. Specifically, SAMHSA recommends a multipronged approach, built on:

            1. Safety;
            2. Trustworthiness and transparency;
            3. Peer support,
            4. Collaboration and mutuality;
            5. Empowerment, voice, and choice; and
            6. Cultural, historical, and gender issues.

“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 in order to eliminate or mitigate triggers that may cause retraumatization of the resident,” SAMHSA says.

The best way to provide this kind of person-centered care may lie in simply knowing residents as well as possible. Seeing each resident as an individual person with a history of lived experiences and as a point in a web or network of various relationships and power dynamics opens the avenues for providing better care.

Similarly, appreciating that individual staff members have had myriad experiences before arriving at the facility — circumstances that may affect how they approach particular residents or situations — allows for a more open and honest accounting of how to maintain a happy and safe workplace.

Create opportunities to keep conversations open, to make spaces safe, and to keep relationships supportive.

“Know the individuals you care for, including information about their mental health, trauma history, coping, and resilience,” say Gigi Amateau, MSG, and Tracey Gendron, PhD, members of the department of gerontology at Virginia Commonwealth University, in a presentation for Health Insight. Identify and utilize the inherent strengths of your facility’s staff members.

Remember that there are outside resources that are useful, too. Enlist support with community mental health professionals and other resources, Amateau and Gendron say.

Beware: Facilities that are not providing trauma-informed care for their residents are subject to citation F699 by surveyors.