Patient Safety for Nursing Students: How to Use Trauma-Informed Care & SBAR

It’s the veteran who can have flashbacks when he wakes up from a deep sleep. It’s the schoolteacher who was assaulted by a man after a dinner party late last year. An estimated 70% of adults and 60% of children across the U.S. have experienced a traumatic event at least once in their lives. And while less than 10% are diagnosed with Post-Traumatic Stress Disorder (PTSD), trauma can lead to headaches, anxiety, depression, mood swings, and more.

If you’re a nurse or an allied health professional, the prevalence of trauma means viewing your patients through a more holistic lens. If you’re a nursing student, it means learning the importance of trauma-informed care (TIC) now. But what is TIC in action? For our veteran, it’s having his wife in the recovery room to keep him calm post-anesthesia. For our schoolteacher, it’s scheduling her with female doctors and nurses to maximize her comfort and increase the chances of routine follow-ups. Trauma-informed care may not be second nature, but in many cases, it needs to be. Learn the core values of TIC, the dangers of re-traumatization, and read examples and scenarios so you can better understand how TIC improves both patient safety and patient outcomes.

Trauma-Informed Care: the Basics

Trauma-Informed Care (TIC) was developed to bring support and services to people coping with past or current traumatic events. TIC recognizes that the trauma experience is pervasive in society and should be addressed by promoting a healing environment unique to the individual for recovery. With TIC, it is assumed that an individual is more likely than not to have experienced trauma that continues to reside within them. It acknowledges the presence of trauma symptoms and the powerful role trauma can play in a person’s life, while calling for organizational change to prevent, address, and treat the trauma. TIC goes beyond treating symptoms and aims to provide accessible support services that are appropriate to the type of trauma being treated. The use of TIC helps to reduce possible triggers and prevent re-traumatization.

Understanding Re-traumatization

Re-traumatization occurs when difficult feelings and reactions are triggered that are associated with the original trauma. The re-traumatizing event can be literal or symbolic and is often unintentional.

Re-traumatization can happen in large or small ways after initial trauma is experienced. Examples of a person being re-traumatized include having to tell their trauma story over and over to numerous people or to be labeled in a way that causes more trauma. Even smells and sounds can trigger re-traumatization. Telling someone to get over their experience is also a form of personal re-traumatization.

Steps should be taken to prevent accidental re-traumatization from traditional practices and services intending to help heal. The potential for re-traumatization exists with individuals and staff at all levels of care within the organization. Common forms of re-traumatization include but are not limited to personal trauma, community trauma, and social trauma.

Examples of Unintentional Re-traumatization

• Personal re-trauma – A woman in labor has experienced sexual trauma in her past. During labor, a young male resident enters the room and performs a cervical check with little warning or explanation to the woman. The resident is unaware of the woman’s history and does not receive informed consent prior to performing the cervical check, triggering the woman’s traumatic prior experience.
• Community re-trauma – A community is rebuilding after a severe storm came through causing injury, home destruction, widespread flooding, and loss of power for weeks. Many community buildings, such as the community center and churches, were damaged. Now, another storm warning goes into effect that is expected to be just as severe, if not more so, than the previous storm. Even if the storm ends up not causing damage, re-traumatization may occur.
• Social re-trauma example – A patient that speaks limited English overhears medical staff talking about him out in the hallway of the clinic. They are mocking his accent and laughing about his word choices when trying to communicate. He is scheduled to follow up in several weeks. At his follow up appointment, he recognizes one of the staff members as one of the personnel making fun of him during his previous visit and decides to leave the appointment early to avoid interacting with the staff.

First Steps: Turning on Your TIC Mindset

There is a growing investment in resources, tools, training, and support for health professionals working on the front lines to help the process of recovery. One helpful method to deal with trauma is to keep the TIC approach mindset at the forefront of care. It can be difficult to practice TIC due to the natural desire to try and avoid and forget traumatic experiences, but that approach rarely works. While it takes time to make TIC second nature, you can start by implementing these three viewpoint changes:

• Acknowledge that trauma is common: Trauma is part of the human condition and affects people of all ages, races, orientations, and socioeconomic stations. Acknowledging trauma starts by adopting a mindset that starts with looking at trauma through the lens of “what happened to this person?” instead of “what’s wrong with this person?” The TIC approach centers around a holistic process of healing by addressing a person’s stressors instead of dwelling on brokenness and pain. It allows a person to recognize that trauma is present, but it does not define who they are.
• Actively look for symptoms: Trauma is unique to the individual and can present in a variety of ways. Some emotional warning signs to be aware of when looking for signs of trauma in others include withdrawal, sadness or anger, fear, anxiety, guilt, shame, and denial. It’s possible a person may also demonstrate physical warning signs such as fatigue, insomnia, muscle aches and pains, agitation, startling easily, and difficulty focusing. A victim of trauma may display several symptoms or very few symptoms. How each person handles and copes with trauma is unique to them, and their choices should be respected at all times. Symptoms of trauma are normal reactions to abnormal events. Healthcare professionals have a responsibility in providing holistic care that includes watching for signs and symptoms of possible trauma and offering support and services as needed to help patients process and heal from it.
• Keep re-traumatization triggers top of mind: Tt can be difficult for a healthcare provider to know a person’s triggers or to always avoid them. Developing a trusting relationship with the patient can help them feel more at ease and safe while in your care. Over time, they will be more likely to open up and you will get to know more about their history, including any possible triggers related to traumatic experiences. Re-traumatization triggers are like other signs of trauma, but they can become more severe over time. The more often a person is re-traumatized, the more likely they are to have profound and severe effects from the initial trauma. If a trigger is known, it should be well documented and communicated to other care staff to help avoid the trigger and provide the best care possible to the patient. If a trigger cannot be avoided, the risk or benefit must be explained to the patient and support services should be offered so they can receive the care they need. It’s crucial to receive informed consent and ask permission before touching or doing any sort of procedure to another person. Ensuring they understand what will happen and why will give them time to prepare and avoid re-traumatization.

Practice Your TIC: Examples & Scenarios

One of the best ways to begin using TIC is to work through examples and scenarios. Consider how a patient might react in a difficult situation or when anxious about receiving a necessary medical procedure. Once the concerns are acknowledged, the care team can develop a plan of action that involves the patient and provides the most holistic approach possible. Holistic care results in better outcomes for patients and helps healthcare personnel meet the needs of those they serve.

• Example: John is a 34-year-old combat veteran who must undergo anesthesia to have a necessary surgery performed. John experiences post-traumatic S=stress disorder (PTSD) and relives some of his traumatic experiences when coming out of anesthesia. He has had problems in the past in the recovery room and is concerned about undergoing the procedure because of his known reaction with anesthesia. In the past, he has flashbacks to when he was in a war zone and has a difficult time being reoriented by strangers. He states that his spouse is able to comfort and reorient him the best. The nurse knows that John will need specialty care in the recovery room and makes arrangements to allow John’s spouse to be present to help orient him. She also makes a note on the chart about his history and pads the side rails of his bed.
• Scenario: A young woman with anxiety presents to the women’s health clinic and is due for a routine vaginal examination. She states that she has a history of being sexually abused and does not want to have the exam done without a support person with her and that she does not want to see a male doctor. On this particular day, only male doctors are available in the clinic and a chaperone is offered but the patient declines. If you were the nurse, what are some symptoms and triggers you feel the patient is demonstrating? What kind of solutions could you offer to help her feel more comfortable?

How SBAR Keeps Patients Safe

SBAR (Situation-Background-Assessment-Recommendation) is a communication framework used by healthcare professionals to facilitate communication regarding a patient’s condition.. It helps healthcare providers stay organized when communicating with each other and is aimed at preventing crucial aspects of patient information being missed. When a patient is moved from the care of one team to another, for example from a nursing provider to an X-ray provider, SBAR ensures continuity of care. Communication is a key component of patient safety because it allows for important information to be conveyed in a timely manner, resulting in appropriate care for the patient. For SBAR to truly be successful, all four components must be included during every handoff.

#1: Organizes Communication with PCP

An SBAR report provides a focused communication framework between a primary care physician (PCP) and other providers that is easy to use. It enables care-team members to prioritize patient safety. SBAR is designed to concisely communicate crucial patient information without getting into extraneous details, saving both the PCP and the person giving the report time and presenting a focused reason for the patient’s visit. Let’s take a look at the following example of a nurse giving SBAR to a PCP.

• S – Situation: Mr. Abel is a 55-year-old male patient that came to the clinic today reporting a sore throat, fever, and cough that started two days ago.
• B – Background: Mr. Abel reports he watched his grandson last week who was diagnosed with strep throat the day after he cared for him.
• A – Assessment: Upon examination Mr. Abel appears to have redness and foul-smelling breath. He states it is painful to swallow. Lungs are clear to auscultation and his current temperature is 100.1 F with a heart rate of 95 and a pain score of 4/10.
• R – Recommendation: I recommend that Mr. Abel be swabbed for strep throat and receives a dose of Tylenol to reduce his current fever and discomfort.

#2: Streamlines Communication in Critical Situations

Healthcare is a fast-paced environment, and stressful situations can increase the odds that patient information is omitted due to the pressure of the moment and time constraints. Communicating using SBAR during emergency situations is critical to help maintain a calm, controlled environment for the patient. When communication fails, the patient is at increased risk for adverse outcomes. Emergency physicians must be able to act fast so they will need to know the important information quickly to initiate care and give appropriate orders.

• S – Situation: Ms. Jenkins is a 68-year-old female patient that presents to the emergency room with high blood pressure and a severe headache.
• B – Background: Ms. Jenkins denies feeling symptoms like this before today but states she recently lost her husband and has not been sleeping well.
• A – Assessment: Upon assessment the patient is found to have serial blood pressure readings of 169/105, 172/99, and 189/100, taken five minutes apart. The patient states the headache is constant but worsens with movement.
• R – Recommendation: I recommend that Ms. Jenkins receive a dose of intravenous blood pressure medication, such as hydralazine, to help quickly lower her blood pressure and some Tylenol for her headache. I further recommend that Ms. Jenkins remains on the monitor for evaluation of her blood pressure and a reassessment in 15-minute intervals to see how she responds and if her symptoms improve.

Patient Safety: Further Research & Reading

Patient safety relies on developing trust and being able to clearly and concisely communicate vital information. Providing a safe environment where the patient feels comfortable to express themselves will help facilitate holistic, high quality care. If you’re interested in additional information on patient safety consider the following resources:

• What is Trauma-Informed Care? A CHCS guide that discusses the principles and benefits of providing TIC including organizational benefits.
• Getting Started with a Trauma-Informed Checklist: A downloadable guide to review the principles of TIC to help identify areas of growth.
• Emotional and Psychological Trauma: A guide to approaches often used by therapists that may be implemented to help address and deal with trauma,
• SBAR Tool: Situation-Background-Assessment-Recommendation: A guideline and tool that will walk you through building and using the SBAR framework.
• SBAR (Situation-Background-Assessment-Recommendation): Procedure for building SBAR including examples to review.
• Trauma-Informed Nursing Practice: Presented by the American Nurses Association, this resource provides information on the importance of TIC in the nursing profession.
• What Are the 6 Principles of Trauma-Informed Care?Presented by Duquesne University School of Nursing to cover the six principles of TIC and why it is important for those desiring to pursue a career in nursing.
• Trauma-Informed Care: Presented by the American Academy of Pediatrics on a TIC approach to treating pediatric patients with a history of trauma.