Introduction
Traumatic events such as abuse, domestic violence, sexual abuse, and combat trauma can have long-term psychological and physical effects. According to Butler et al. (2019), trauma negatively affects ordinary coping systems that give people control and meaning in their life, rendering them helpless. Healthcare organizations which provide services to individuals who have experienced trauma need to comply with trauma informed care (TIC) principles. The Hudson Valley Health care system (HVHCS) provides care to elderly veterans with mental conditions such as post-traumatic stress disorder (PTSD) and dementia (“Post-traumatic stress disorder,” 2015). Other healthcare services offered at the health center include twenty-four-hour care services in home settings, reproductive treatment related to military sexual violence, providing home caregivers to elderly veterans, telehealth, hospice and palliative care, family support, and patient education.
The target patient population is veterans between the age of 50 and 97. PTSD patients experience distressing thoughts, flashbacks, and intrusive reminders of their experiences with adverse events. Given that veterans are the target population in HVHCS, they are likely to have witnessed terrorist acts, war/combat, or death threats that can be debilitating to their mental health. These events (warfare, political and personal violence, and oppressive social conditions) most often involve grave human rights violations that cause human suffering. Trauma-informed care (TIC) can create approaches to intervene in human suffering. Social work at the organization involves identifying patients’ psychosocial, mental, and emotional needs and helping them access appropriate care.
Trauma
Training
Despite TIC’s value being appreciated by the healthcare system, it has not been widely implemented because of healthcare practitioners’ unfamiliarity with its principles. According to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA), many healthcare providers lack understanding of individual actions needed to support effective trauma care (Menschner & Maul, 2016) Additionally, traditional treatments are inconsistent with contemporary TIC principles, increasing the need for training. Therefore, training is a prerequisite for the effective adoption of TIC principles. However, HVHCS does not train staff, including new employees, on trauma-informed care. Without training, healthcare providers may not have the required skills to effectively address patients’ needs. All clients have unique experiences and challenging behaviors and their elimination represents the cornerstone of mental health treatment.
However, a significant variation exists between trauma-informed care and trauma-focused therapy. TIC involves creating a safe environment that enables collaboration, trust, choice, and empowerment in healthcare settings. On the contrary, trauma-focused therapy concentrates on providing cognitive-behavioral interventions that can help patients reduce trauma symptoms to a tolerable level. Through trauma-focused therapy, healthcare providers can improve patients’ ability to regulate negative emotions and behaviors (Levenson, 2017). While healthcare providers may possess the knowledge, competency, and skills in trauma-focused therapy, they may not have the necessary trauma-informed care skills sensitive to patients’ traumatic needs. According to Menschner and Maul (2016), an organization needs to align its workforce development with TIC principles and values to embrace the TIC model fully. To this end, for HVHCS to fully adopt the TIC model, it needs to train staff appropriately.
Unfortunately, training staff on TIC is not enough; organizations need to ensure that the implemented strategies are sustained until they are part of the organizational culture. Therefore, HVHCS needs to commit resources in training and staff supervision to enhance compliance with TIC principles and practices. With adequate knowledge, healthcare providers can create environments that facilitate positive health outcomes, especially for trauma patients.
Procedures, Mission and Policy Statements
The organization’s mission and policy statement do not include explicit statements about trauma or trauma-informed care. Its mission is to “honor America’s Veterans by providing exceptional health care that improves their health and well-being” (“Post-traumatic stress disorder,” 2015). While the mission statement connotes patient-centered care, it does not directly inform practices specific to trauma care. The policy statements delineate the company’s role in always striving to address all patients’ needs comprehensively. By addressing patients’ demands extensively the healthcare facility implies that it also addresses trauma for PTSD patients.
However, PTSD and psychological units in the organization mainly focus on trauma-informed care. The PTSD department’s mission statement highlights the unit’s objective which is to provide behavioral, emotional, and relational care to veterans who have experienced traumatic events in combat or military-related experience (“Post-traumatic stress disorder,” 2015). Organization-wide procedures have not been reviewed for consistency with TIC principles. Although clinical procedures in most units are general instead of specialized, conducting trauma history is mandatory. The trauma history assessment is done during biopsychosocial assessments to determine the patient’s treatment plan. Through the assessment, healthcare providers can identify problem areas and plan interventions to address the identified problem.
Trauma-Specific Areas and Referrals
HVHCS provides trauma-specific treatment to patients who have experienced trauma. Healthcare practitioners help patients develop effective strategies, behaviors, and relationships to cope with traumatic events. Based on the concept that adverse experiences can shape a patient’s fundamental belief, clients are helped to construct healthy perceptions and feelings and eliminate irrational and self-destructive coping behaviors acquired from traumatic events. Other trauma-informed care includes domiciliary treatment and individual and group psychotherapy.
The healthcare facility also provides referral services to its patients. For example, veterans with behavioral problems are referred to the mental acute psychological unit for treatment. The mental psych unit provides holistic and highly-specialized care to the veterans (“Post-traumatic stress disorder,” 2015). Patients can also be referred to the after-care program such as feeling/emotion regulation, dream/relaxation therapy, anger management, medication management, and trauma exposure therapy. (“Post-traumatic stress disorder,” 2015). Other referral programs at the healthcare facility include vocational rehabilitation, referrals for chemical dependency disorders, and referrals for traumatic brain injury assessment and interventions.
Areas of Improvement
The healthcare center needs to increase the number of activities that stimulate cognitive functioning and engage veterans in recreational activities. The above-mentioned practices represent an important aspect of psychological self-care. Considering that traumatic conditions affect internal belief systems, self-care should be imperative in treatment. Recreational activities such as participating in social activities and nature walks can provide beneficial emotional support to the patients. The organization also needs to provide institution-wide training on TIC to hone the knowledge, skills, and competencies of healthcare providers on effective TIC practices.
Safety
The healthcare facility has taken adequate measures to ensure the physical and emotional safety of patients. It provides shuttle services that transport patients between 3 locations in the community (“Post-traumatic stress disorder,” 2015). Given that some patients have dementia, the shuttle services help ensure their physical safety by transporting patients to and from designated areas. Through collaboration with family and friends, the healthcare center reduces the risk of patients getting lost. According to Purkey et al. (2018), ensuring patients’ physical and emotional safety involves two components; first, the structure and delivery of healthcare, and second, recognizing the physical and emotional safety needs of patients. Appropriate measures have been taken to ensure that the parking lots, common areas, and washrooms are safe. Noise levels at the healthcare facility are kept as low as possible, and only soft music and entertainment are allowed in the wards and common areas. There is clear access to the facility’s entrance and exits.
Healthcare providers can also experience secondary trauma when they hear disturbing thoughts, events, and experiences of their patients. Besides, front-line and non-clinical staff could have personal traumatic experiences. To promote staff safety, the healthcare facility offers staff opportunities to explore their own traumas through supportive activities such as supervised meditation, yoga, and mindfulness practice. However, it does not provide trauma-informed care training to staff, especially to those working in nursing home units. According to Menschner and Maul (2016), TIC training is an essential safety component that can protect staff from secondary traumatic experiences. Training increases staff awareness of the risks of traumatic stress that can emanate from patient care and interaction.
Inconsistent and unpredictable healthcare delivery is harmful to traumatic patients. Survivors of adverse experiences may be sensitive to nonverbal communication and unpredictable events, and, therefore, ensuring that healthcare delivery is always consistent can be helpful for patients (Purkey et al., 2018). To that end, HVHCS is highly patient-centered and responsive to the needs of the patients. All healthcare providers are mandated to stick to appointment schedules, and last-minute cancellations are highly discouraged. If an appointment cancellation is inevitable, patients have to be prepared in advance for the changes.
Trustworthiness
Trustworthiness involves transparently conducting organizational operations in a bid to build and maintain trust with key organizational stakeholders. HVHCS has undertaken adequate measures to improve stakeholder trust with the organization. All stakeholders, including patients, are included in organizational planning practices. The stakeholder committee comprises patient representatives, staff, organizational leaders, and external stakeholders who inform major organization change initiatives. The members of the committee are involved in all organizational initiatives such as practice change, modifications, or improvements. Individuals who have experienced first-hand trauma are consulted on issues affecting traumatized patients. Through such consultations, the organization is able to promote transparency.
Patients’ rights are fully communicated to the patients to empower them to make informed decisions. The healthcare center informs patients of their right to privacy and confidentially to build boundaries and trust between healthcare providers and patients. Apart from patient rights, the healthcare center strives to inform all stakeholders on rules, procedures, and organizational activities to promote transparency. For example, during orientation, patients and families are provided with the program’s health and safety policies and informed on who will be responsible for their care and financial obligations.
Appropriate measures have also been taken to reduce power differentials between staff, clients, and organizational leaders. The organization has a strong code of ethics that prohibits healthcare providers from exploiting or manipulating their patients, promoting trust. The organization’s reporting structure is horizontal, i.e., employees at the organization have the autonomy to make decisions within their rights and competencies. Patients have the opportunity to promote feedback on health services, as well.
Concerning task clarity, unit leaders are tasked with designing and allocating tasks to members working within their units. However, trauma care always involves a multidisciplinary team working from different specialties across different departments. Since referrals are part of the treatment routine, coupled with the fact that HVHCS runs multiple community clinics, collaboration with healthcare providers outside the health setting is inevitable. To prevent fragmented healthcare and role ambiguity, each multidisciplinary team has a team leader that acts as the care coordinator. The multidisciplinary team leader’s responsibilities include briefing the team on each member’s role, establishing effective communication with members, and resolving conflicts. Through the multidisciplinary team leader, the organization is able to establish task clarity. HVHCS adequately satisfies the TIC principle of trustworthiness and transparency.
Choice
The healthcare center has taken adequate measures to promote consumer choice and control. One of the trauma care objectives is to prevent the re-traumatization of patients. However, patients can experience re-traumatization when retelling their stories, which may exacerbate symptoms. To this end, healthcare providers dealing with traumatized patients at the setting are mandated to create environments that minimize re-traumatization risk. For example, psychoeducation is given to eligible patients to build resilience or normalize presenting symptoms as the first step towards comprehensive care. Importantly, patients are given the autonomy to decide whether to disclose information or participate in activities. For example, during group psychotherapy, patients can only share their experiences if they are willing. Also, patients have the autonomy to choose treatments that best suits their preferences. Often, patients are given several treatment options and encouraged to make choices without coercion. Patients are informed of the positives and negatives of each treatment option to help them make informed decisions. Professional ethics mandate that healthcare providers should always give the patient all available treatment options.
A key challenge facing the shared decision-making model at the organization concerns the eligibility or patient’s capacity to make decisions. Given that the healthcare setting provides care to veterans aged 50 to 97, mental health conditions can be two-fold for any given patient: PTSD and dementia. As cognitive deficits increase, the patient’s ability to make decisions may become difficult. In such situations, family members are allowed to make decisions for such patients. Healthcare providers at the facility can also reject a patient’s decision if the patient’s choice is not cost-effective for the healthcare center.
Collaboration
Collaboration principles are similar to shared decision-making principles. It involves partnering with patients during the healing process. According to Levenson (2017), effective collaboration involves eliminating power differential between healthcare providers and clients/patients. The organization maximizes shared power by providing patients with the autonomy to consent to treatments, information disclosure, and activity participation. Healthcare providers at the organization are mandated to create collaborative relationships characterized by mutual interaction. Patients can contribute to their healthcare by giving feedback on the quality and effectiveness of the implemented interventions. While the healthcare provider has clinical expertise in managing symptoms, the patient has clinical expertise on subjective symptoms. Through mutual participation, the patient and healthcare provider’s knowledge is combined to identify the underlying problems and interventions. According to Purkey et al. (2018), collaborative relationships help patients become engaged with their care, reducing dependence. Additionally, therapeutic relationships help patients connect with others and expose them to an emotionally corrective experience (Levenson, 2017). Helping a patient evolve from a passive victim into an active participant is a major treatment milestone. HVHCS has maximized collaboration and power-sharing by promoting participation, two-way feedback, and active clinical interactions.
Empowerment
Empowerment involves recognizing the strengths of the patient and applying these strengths to treatment. It is an approach where symptoms are reframed, and resilience is emphasized. Often, trauma survivors have a sense of powerlessness in their daily existence. A major treatment goal at the organization is to improve the patient’s self-efficacy. Self-efficacy refers to an individual’s capacity to perform a target behavior (Williams & Rhodes, 2016). Building a patient’s self-efficacy involves identifying how the patient’s strengths and skills can be used as a resource to promote health outcomes. According to Williams and Rhodes (2016), a key benefit of self-efficacy is that it informs healthcare providers why individuals are motivated to perform target behaviors. Self-efficacy also directly influences behaviors; therefore, it can be used as a strategy to achieve target behaviors (Williams & Rhodes, 2016). By making self-efficacy a treatment goal for trauma patients, the healthcare facility is promoting patient empowerment.
Conclusion
Hudson Valley Health Care System has taken the necessary measures to promote trauma-informed care. It has succeeded in promoting safety, trust, empowerment, collaboration, physical and emotional safety of staff and patients, patient control & choice. The organization capitalizes trustworthiness by including key stakeholders, including patients, in all healthcare initiatives. It also builds trust by adequately sharing information on organizational practices, policies, and procedures. Patients are given the autonomy to choose treatments and participate in treatment through collaborative interactions. Although it provides trauma-specific treatments, HVHCS has failed to establish itself as a trauma-focused institution effectively. Policy statements do not explicitly state the organization’s mission to provide trauma-informed care. Additionally, no training on trauma-related issues is conducted at the organization. The organization also needs to improve choice and control by giving veterans with dementia more decision-making autonomy. HVHCS can improve its TIC by training and supervising to improve staff competency in providing trauma-focused care and to enhance compliance with TIC principles and practices.
References
Butler, D. L., Critelli, M. F., & Carell, J. (2019). Trauma and human rights: Integrating approaches to address human suffering. Palgrave Macmillan
Levenson, J. (2017). Trauma-informed social work practice.Social Work, 62(2), 105–113. Web.
Menschner, C., & Maul, A. (2016). Key ingredients for successful trauma-informed care implementation. SAMHSA. Web.
Post-traumatic stress disorder (PTSD) program: VA Hudson Valley health care system (2015). U.S Department of Veterans Affairs. Web.
Purkey, E., Patel, R., & Phillips, S. P. (2018). Trauma-informed care: Better care for everyone.Canadian Family Physician, 64(3), 170–172. Web.
Williams, D., & Rhodes, R. E. (2016). The confounded self-efficacy construct: Review, conceptual analysis, and recommendations for future research. Health Psychology Review, 10(2), 113–128. Web.