MSN, BSN, RN
Consider this patient scenario: Mr. Singh*, a 65-year-old male, is frequently admitted to the hospital for atypical chest pain episodes. While he has a history of coronary artery disease, the physicians have ruled out any new myocardial infarction or pericarditis. After multiple cardiac imaging and diagnostic procedures, there is still no explanation for his sudden chest pain.
Mr. Singh needs an interpreter to discuss medical treatments as English is not his first language. Many hospital staff considered Mr. Singh “difficult” due to his outward frustration and pain management demands.
The day I took care of Mr. Singh, the physicians decided to wean him off intravenous opiates and planned to discharge him with outpatient cardiology follow-up.
This patient scenario left me feeling morally distressed, wondering what more we could have done. Were the physicians and nurses asking the right questions, trying to reveal the root cause of these sudden, terrifying episodes of pain? What if something else was driving Mr. Singh’s perception of pain?
During my interactions with this patient, I noticed his chest pain would abruptly wake him from his sleep with accompanying symptoms like shortness of breath and tachycardia. What I was seeing looked like a panic attack triggered by post-traumatic stress disorder. While it is vital to rule out a life-threatening coronary event, further investigation into his past trauma history was warranted. Unfortunately, no psychological interview or evaluation was mentioned in his medical records.
I saw staff members downplay this man’s real pain experiences. Several times during interdisciplinary rounds, no interpreter service was offered
Imagine fearing for your life, not understanding what is wrong with your body, and having no way to express yourself in your native language. To provide quality care to Mr. Singh, we must provide holistic and empathetic treatment through trauma-informed care.
Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as adverse life events that cause long-lasting harm to a person’s mental health, functionality, and well-being.
Trauma can present in various levels of abuse, poverty, racism, oppression, and through witnessing or being a survivor of violence or assault. Trauma can be passed down through generations, cultures, and communities A traumatic experience is highly individualized for the person experiencing the trauma; two people could experience the same adverse event and have different psychological and physical reactions.
Post-traumatic stress disorder (PTSD) is a common anxiety disorder with physical and psychological manifestations triggered by the recall of a traumatic event. PTSD is often misdiagnosed since the primary focus is on the somatic symptoms instead of the underlying psychological cause. Anxiety, depression, substance abuse, chest pain, headache, GI irritation, and fatigue are commonly present with PTSD. Since PTSD often goes under-reported and underdiagnosed, healthcare professionals should engage in universal trauma precautions and ask what life events influenced the patient’s current condition.
Trauma-informed care (TIC) is a systematic framework that uses the following principles: realization, recognition, response, and resisting re-traumatization. By practicing these principles, healthcare professionals can foster a safe, trusting, and empowering relationship with our patients. As we explore these principles further, we will examine trauma-informed care in Mr. Singh’s treatment context.
Healthcare professionals and medical institutions are responsible for creating a culture of widespread trauma awareness in every sector of the healthcare community. The first pillar of TIC is understanding that, more often than not, every person you interact with has experienced some form of trauma that shapes their behavior and coping mechanisms. You never know if the “difficult” patient has experienced racial discrimination or childhood abuse.
Mr. Singh was not just a man with episodic chest pain; he had a childhood, lived life in a different country, moved to America, had a family, and experienced loss and hardship. Instead of asking, “What’s the matter with you?” we should ask, “What happened to you?” Once we accept that everyone experiences trauma to some degree, we can move on to recognizing the signs and symptoms.
Not only should healthcare workers recognize how trauma manifests in behaviors, but they should also screen and assess trauma occurrences. Any patient who seeks care in a clinic or hospital should be screened for potential trauma-related history and symptom presentation. The initial screening should flag events that need further treatment, follow-up, or other resources. Physicians and social workers should interview and thoroughly assess patients with a trauma history to determine how best to meet their needs during and after their hospitalization.
Trauma history and PTSD assessment should have been part of Mr. Singh’s treatment plan from the moment he was admitted to the hospital. If Mr. Singh had been diagnosed with PTSD and the staff had been able to identify his triggers, then perhaps he would have had fewer recurring hospitalizations. In addition to treating his chest pain symptoms, we could have provided non-pharmaceutical options for anxiety management. Instead, Mr. Singh remained frustrated and misunderstood, constantly fighting with staff and suffering from unresolved pain.
“Response” is how we show up for our patients and staff by integrating TIC into policies, procedures, structures, language, education, and practices. From the top down, the organization’s leadership must create a culture that embodies the TIC principles and advocates for safety, collaboration, and empowerment. Examples of TIC response are mandatory training, implementation of universal trauma precautions, trauma screenings, hiring psychological support for staff, and increasing resource accessibility.
Once we ruled out myocardial infarction, we could have sat with Mr. Singh, asking more questions about how he was feeling and investigating triggers causing the symptom onset. Could he have been having night terrors that triggered his chest pain? Could waking up in an unfamiliar environment signal to his brain that the body must guard itself against a threat? Did he need someone to sit with him through the episode? By responding with compassion and empathy, we build trusting relationships with our patients, supporting them through the complex healthcare system.
The last principle of TIC is resisting the re-traumatization of our patients. In nursing, we must ask ourselves if we promote a safe and healing environment or provoke patients’ painful memories. Maintaining a calm and quiet atmosphere, building a trusting partnership with our patients, and assisting them in finding their voice are essential tactics to avoid re-traumatization. If we end up triggering a traumatic memory, we can learn from the experience, share awareness, and avoid future re-traumatization.
Mr. Singh needed support to use his voice and advocate for himself during his pain crisis. Downplaying his symptoms and denying him therapeutic resources was only making his episodes more frequent and severe. He needed interpreter services during every interaction to express his needs fully. In addition, the care team needed to identify Mr. Singh’s triggers and create an action plan to execute during the episodes. If we were to ask the patient what he needed most during his episodes, he might have required interventions other than opioid pain management. Unfortunately, in this example, we did not approach his care through a trauma-informed lens, and he suffered physical and emotional distress.
Mr. Singh is just one of many patients who go underdiagnosed and undertreated, falling through the cracks of the vast healthcare system. To provide quality patient care, we must strive to shift the culture to embracing the four TIC principles and implement universal trauma precautions.
As nurses, we should look deeper into symptom presentation and ask our patients more questions about their life experiences and exposure to trauma. Patient health outcomes will improve when we advocate for patient safety, empowerment, and collaboration.
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