Using a Trauma-Informed Approach to Address Burnout in Nursing

What an Organization Can Accomplish

Carol Dawson-Rose, RN, PhD, FAAN; Yvette P. Cuca, PhD, MPH, MIA; Shanil Kumar, MPH; Angela Barbetta Collins, MPH, BSN, RN

Disclosures

Online J Issues Nurs. 2023;28(1)

Abstract and Introduction

Abstract

Burnout among nurses is prevalent and has worsened during the COVID-19 pandemic. Trauma-informed care (TIC) is an approach that can bring healing to people and systems who have been impacted by trauma and traumatic events. Nurses working in hospitals experience vicarious trauma and secondary traumatic stress as they witness what their individual patients experience; however, nurses themselves experience traumatic events and that has only escalated with the current pandemic. Working from a model of Trauma-Informed Healthcare (TIHC) and SAMSHA foundations of a trauma-informed approach (TIA) we identify opportunities for organizations such as hospitals to integrate TIA towards altering the system to better provide for nursing staff who are suffering from burnout and exhaustion. We offer an exemplar of an organizational-level approach to supporting nursing staff through TIA.

Introduction

Nurses and the organizations where they work prioritize care not only for individuals, but also for communities and populations that experience illness or the threat of illness. While high rates of stress, exhaustion, and burnout existed prior to COVID-19, the additional workload of the ongoing pandemic has increased harm and stressful events for nurses working at the bedside in hospitals (Chan et al., 2021). Although interventions to address the impact of stress, exhaustion, and burnout among nurses (e.g., prioritizing self-care; training on delivery of trauma-informed care (TIC), coping with stress, or self-recognizing and preventing burnout) do exist, many focus on supporting nurses only at the individual level.

We provide an overview about how using a trauma-informed approach (TIA) at the organizational or systems level could be implemented as an alternative to or concurrently with individual approaches to address burnout in nurses. A systems level TIA has potential to provide support for nurses who have been exposed to traumatic events during the pandemic and to prevent further harm to them. We present the Substance Abuse and Mental Health Services Administration (SAMHSA) principles of TIA and describe a model for trauma-informed healthcare (TIHC). Further, we suggest a systems-level perspective of the TIHC model that acknowledges the importance of nurses and the obligation of the organization to support them. Finally, we present an exemplar of nursing leadership from TIA.

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Table 1. Six Key Principles of a Trauma-Informed Approach
Principle	Key Organizational Description
Safety	"Throughout the organization, staff [nurses and other health workers] and the people they serve… [hospitalized patients] feel physically and psychologically safe."
Trustworthiness and Transparency	"Organizational operations and decisions are conducted with transparency with the goal of building and maintaining trust with clients and family members, among staff, and others involved in the organization."
Peer Support	"Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collaboration, and utilizing their stories and lived experience to promote recovery and healing."
Collaboration and Mutuality	"Importance is placed on partnering and the leveling of power differences … among organization staff from clerical and housekeeping personnel to professional staff to administrators, demonstrating that healing happens in relationships and in the meaningful sharing of power and decision-making."
Empowerment, Voice, and Choice	"Throughout the organization… individuals' strengths and experiences are recognized and built upon…. Organizations understand the importance of power differentials and ways in which clients [and staff], historically, have been diminished in voice and choice and are often recipients of coercive treatment."
Cultural, Historical, and Gender Issues	"The organization actively moves past cultural stereotypes and biases…; offers access to gender responsive services; leverages the healing value of traditional cultural connections; incorporates policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma."

Table 2. Process Inputs and Outcomes of a Trauma-Informed ICU Nurse Management Model
Process Inputs	Process Outcomes
Monthly updates on staffing status and opportunities to participate in peer panel interviews.	• Transparency on adequate staffing in numbers and skill.
Staff education on implicit bias, ladder of inference, and closed loop social-emotional communication.	• A supportive team that allows for inquiry, safety nets for errors, and educational opportunity.
Office Hours: Dedicated time for staff to use 30-minute increments for anything they want offered twice a week. The focus of the time is to allow the team to be heard, offer support, and allow for opportunity to contribute to necessary change as needed.	• Emotional and ethical guidance to process morbidity and mortality. • Transparency on expectations and professional status.
Quarterly community building events to establish and then model appropriate supportive conversations.	• Emotional and ethical guidance to process morbidity and mortality. • A supportive team that allows for inquiry, safety nets for errors, and educational opportunity.
Modeling, encouragement, and opportunity for transparency regarding personal impact of emotionally charged conversations and experiences while caring for the pediatric cardiac population in the form of complex care experience debriefings held monthly.	• Emotional and ethical guidance to process morbidity and mortality. • A supportive team that allows for inquiry, safety nets for errors, and educational opportunities.
Staff education on the Strategic Plan, transparency of challenges, and opportunity to share responsibility for problem solving.	• Shared governance.
Establishment of Communication Standards and reparative pathways.	• Transparency of expectations and professional status. • A supportive team that allows inquiry, safety nets for errors, and educational opportunity.

Authors and Disclosures

Carol Dawson-Rose, RN, PhD, FAAN
Carol Dawson-Rose is Professor and Chair in the Department of Community Health Systems at University of California, San Francisco (UCSF) School of Nursing. Her research is centered on improving equity in care for people living with HIV who use drugs. Dr. Dawson-Rose's current projects consider how to implement trauma-informed approaches in HIV primary care settings, substance use services, community-based HIV services for sexual and gender minority transitional age youth, and public health nursing practice. She participated in the development of the model of Trauma Informed Healthcare. Email: carol.dawson-rose@ucsf.edu

Yvette Cuca, PhD, MPH, MIA
Yvette Cuca is a sociologist in the UCSF School of Nursing Department of Community Health Systems. She has over 20 years of experience in domestic and international research and program evaluation. Her recent research has focused on the impact of trauma on patients and on the providers and staff who care for them. Dr. Cuca also investigates the ways that trauma-informed approaches may improve health and social outcomes for patients and improve work life for healthcare staff. Email: yvette.cuca@ucsf.edu

Shanil Kumar, MPH
Shanil Kumar is an analyst in the UCSF School of Nursing Department of Community Health Systems. He has 6 years of experience studying health sciences and public health specifically examining factors affecting vaccine uptake. Shanil has experience in policy, prevention, and planning with the Merced Department of Public Health as well as tobacco cessation efforts in the Central Valley with the American Cancer Society. More recently, Shanil has been involved in the recruitment, planning, and coordinating of focus groups investigating trauma, resiliency, and cultural and social influences of Indo-Fijians in the Central Valley. Email: shanil.kumar@ucsf.edu

Angela Collins, MPH, BSN, RN
Angela Barbetta Collins has been a pediatric ICU nurse for 18 years and a Nurse Manager for 5 years. She is currently the Unit Director of the Pediatric Cardiac ICU and CTCU at UCSF Benioff Children's Hospital. She also held clinical positions at Lurie Children's Hospital of Chicago. Angela is completing a MPH at the University of California Berkeley. Her primary patient population of focus is Pediatric Congenital Heart Defects and Pediatric Cardiac Surgery. She is a UCSF DEI Champion, trained in Trauma Informed Care, and developed the Trauma Informed ICU Nurse Management Model. Email: angela.collins@ucsf.edu