IMPLEMENTING TRAUMA-
INFORMED CARE:
A GUIDEBOOK
About LeadingAge Maryland
LeadingAge Maryland is a community of more than not-for-profit organizations and a wide
range of collaborators united to shape the future of aging in Maryland. Our mission is to expand
the world of possibilities for aging through advocacy, education, innovation and collaboration.
LeadingAge Maryland is a state aliate of the national organization LeadingAge. Resilience for All
Ages is an initiative of LeadingAge Maryland dedicated to equipping individuals and organizations
to become more trauma-informed and to advance trauma-informed work with older adults. Learn
more at www.leadingagemaryland.org.
Implementing Trauma-Informed Care: A Guidebook
Published by LeadingAge Maryland
Baltimore, MD
Copyright
Karen Heller Key – Contributor
Karen Key is President and CEO of Heller Key Management
Consulting and serves as a Principal with Resilience for All Ages.
Her career includes management roles in national nonprofit
human services organizations, including six years at the
national level with AARP, where she led the piloting of a model
for engaging volunteers in improving the experiences of family
caregivers and of older people receiving care at home.A lifelong
student of applied neuroscience, Karen has studied the cognitive
dimensions of how trauma and traumatic stress impact the
brain’s executive function. She has worked to apply this kind of
cognitive science in human services settings, and is the co-author
of an April article in the American Public Human Services
Association journal Policy and Practice exploring the application
of trauma-informed approaches to self-care and resilience within
the human services workforce.
Jill Schumann – Contributor
Jill Schumann is the President and CEO of LeadingAge Maryland.
Prior to her work with LeadingAge Maryland she served as
the chief executive of Lutheran Services in America, one of the
largest health and human services networks in the country. She
has created ground-breaking programs in post-acute healthcare
and behavioral health, and has consulted with organizations
on strategy, governance, innovation, and collaboration and is a
frequent presenter at conferences.
Christy Kramer – Contributor
Christy Kramer is the Director of LeadingAge DC. A licensed
nursing home administrator in Maryland for 15 years, Christy
began her career as administrator of a 285 bed nursing home in
Gaithersburg, Maryland. Over the course of ten years, Christy
participated in large scale projects including: leading the selection
and implementation of the electronic medical records system;
the development of a culture change strategic plan; CARF-
CCAC accreditation; Maryland Performance Excellence Award
application; and Annual Licensure and Certification surveys.
Christy then moved to the George Washington University
Master of Health Administration program where she worked
with the long term faculty on curriculum development and NAB
Accreditation. In addition, she counseled students on fellowship,
residency, administrator-in-training and internship programs.
During this time, Christy was appointed to the Board of Long
Term Care Administrators for the District of Columbia. Christy
recieved her Bachelor's degree from Cornell University and her
Master of Health Services Administration from the George
Washington University.
Lisa Schiller – Contributor
Lisa Schiller, LCSW, is Executive Director of MHY Family Services,
a trauma-informed organization. She has served in management
roles in local and national organizations. She is a long-time
student of the practice of trauma-informed care and believes that
trauma-informed organizations benefit both clients and sta
through the development of safe, respectful and healthy cultures.
INTRODUCTION
PRINCIPLES AND PRACTICES OF TRAUMAINFORMED CARE:
A QUICK REVIEW
PREVALENCE AND IMPACT OF TRAUMA
DEFINING KEY TERMS
CORE PRINCIPLES
LEVELS OF IMPLEMENTATION
GETTING STARTED
FORMING A TRAUMAINFORMED CARE IMPLEMENTATION TEAM
CREATING A TRAUMAINFORMED CARE IMPLEMENTATION PLAN
SPECIAL CONSIDERATIONS FOR NURSING HOMES
MAJOR NEUROCOGNITIVE DISORDERSDEMENTIA
PHYSICIANS AND CONTRACTED HEALTH PROFESSIONALS
RELATIONSHIP TO PERSONCENTEREDDIRECTED CARE
BEHAVIORAL HEALTH RESOURCES
IMPLICATIONS FOR SHORT AND LONG STAY RESIDENTS
STAFF AND TRAUMA
FAMILIES AND TRAUMA
POLICIES AND PROCEDURES
RESOURCES
STATEMENT OF INTENT
PRELIMINARY ORGANIZATIONAL ASSESSMENT
TRAUMAINFORMED CARE IMPLEMENTATION TEAM FORMATION
WORKSHEET
IMPLEMENTATION PLAN CHECKLIST
LEADING CHANGE
GETTING THE BOARD 'ON BOARD'
STAFF KNOWLEDGE: PRE AND POST TEST
ENDNOTES
TABLE OF CONTENTS
INTRODUCTION
Implementing Trauma-Informed Care: A Guidebook is the second in a
series of tools and resources from Resilience for All Ages designed
to assist nursing homes seeking to become trauma-informed
organizations.
The first, Foundations of Trauma-Informed Care, is a toolkit that
includes:
• Foundation of Trauma-Informed Care: A Primer
• Six one-page lessons for sta
• Two slide presentations with notes to be used for
presentations and training
• A User Guide
It will be helpful to become familiar with the Foundations before
moving to implementation planning.
This Guidebook focuses on trauma-informed care implementation.
It contains:
• A quick review of the basics of trauma and trauma-informed
care
• An explanation of the levels of implementation and the
Guidebook focus on Level One
• Steps to create an implementation plan and form an
implementation team
• Special considerations for nursing homes
• A variety of resources for implementation
Training and webinar resources are available from Resilience for All
Ages and additional tools will be available in the months to come.
While this section will summarize basic information
regarding trauma-informed care, it is important
that those using this guidebook will first have read
the Resilience For All Ages publication, Foundations
of Trauma-Informated Care: An Introductory
Primer.
1
In the Center for Medicare and Medicaid
Services issued a set of changes to the requirements
for nursing home communities that participate
in Medicare and Medicaid programs.
Among the
many changes finalized in this rule are policies
designed to strengthen the provision of person-
centered care to residents.
Person-centered care
takes a holistic approach to meeting the needs of
each individual resident, and considers psychosocial
and spiritual aspects of well-being in addition to
physical health. While the term “person-centered”
mirrors CMS language, many nursing home leaders
aspire to what might better be described as person-
directed services and supports, characterized by
a recognition of residents’ rights to care that is
shaped to meet their preferences and goals to the
greatest extent possible.
In order to provide this kind of care to all residents,
nursing home communities must be equipped
to understand and work with the circumstances,
needs, and wishes of people who bring with them a
wide variety of backgrounds and lived experiences.
Accordingly, the new Requirements of Participation
include an emphasis on providing services that
are culturally competent — reflecting cultural
awareness and humility — and that are sensitive
and responsive to the special needs of residents
who have experienced trauma.
The inclusion of a focus on trauma-informed care
reflects increasing recognition that the experience
of trauma is widespread across the population and
PRINCIPLES AND PRACTICES OF
TRAUMAINFORMED CARE
A Quick Review
has significant long term consequences for health
and well-being. This recognition has led to the
development of approaches addressing the impact
of trauma, some of them involving trauma-specific
treatment, and others involving creating conditions
that are sensitive to the impact of trauma and to
avoiding re-traumatization.
While children’s services, behavioral health, violence
reduction initiatives, and programs for people who
are veterans and Holocaust survivors have been
practicing trauma-informed work for more than a
decade, the field of aging services has come to the
work of treating trauma only recently. The goal is to
create safe environments for older people (and sta
members) so that all services, supports and care
oered — including all medical care, enrichment
and socialization services —factor in the reality that
some residents (and sta members) will respond
dierently because of trauma histories, and will
benefit from having those oerings provided in
trauma-informed ways.
Prevalence and Impact of Trauma
While Americans once considered trauma to be a
relatively infrequent occurrence, most research
finds that a majority of us — somewhere between
55% and 90% by some measures —have experienced
at least one traumatic event.
,
Potentially traumatic
experiences include: experiencing or witnessing
childhood adverse events (e.g. experiencing or
witnessing emotional, physical or sexual abuse or
neglect, living with a parent with mental illness or
substance misuse disorder, death or absence of a
parent because of imprisonment); domestic and
sexual violence; natural disasters; car, train and
airplane crashes; combat; becoming a refugee;
homelessness; medical trauma; violent crime;
bias and discrimination; and hate crimes and hate
speech.
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
A majority of us —
somewhere between
55% and 90% by some
measures — have
experienced trauma.
Prevalence and Impact of Trauma Continued.
A potentially traumatic event is any powerful event
that aects a person’s daily life. While not all people
will experience these events as traumatic, the reality
that these kinds of events can be traumatizing is
essential to bear in mind, given the impact that
traumatic stress has on human health and well-
being.
Stress vs. Traumatic Stress
All human beings react to some external stimuli
with a stress response, ranging from the physical to
the emotional and to the cognitive and behavioral.
Traumatic stress refers to “the emotional, cognitive,
behavioral and psychological experiences of
individuals who are exposed to, or who witness,
events that overwhelm their coping and problem
solving abilities.”
6
In other words, a trauma, which
produces traumatic stress, occurs when our coping
mechanisms are overwhelmed by outside events.
Over the course of their lives, many older people
have experienced one or more of the potentially
traumatic events and experiences described above
— and the impact of that earlier trauma does not
disappear with age. Of course older people are
subject to these events in the present as well as
the past, and so may have more recent or current
traumas of these kinds with which to contend.
Older people may also experience traumas related
to the aging process itself, including the loss of
loved ones, of their own capacities (physical and
mental), loss of roles and identity and of their
home, and increased dependence on caregivers.
Experiences of neglect and of elder abuse are also
important to consider. These losses may look like
"normal" grieving, or may result in a traumatic
stress response.
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
Defining Key Terms
While it is anticipated that CMS will be providing
more detailed guidance, currently CMS is pointing
nursing home leaders to the principles set forth
in a SAMHSA resource entitled SAMHSA’s
Concept of Trauma and Guidance for a Trauma-
Informed Approach.
7
Accordingly, while there are
many definitions of key terms oered throughout
the literature on trauma, traumatic stress and
trauma-informed care, those oered here are based
on the SAMHSA resource. Please note that in order
to make the SAMHSA guidance relevant to older
people and to long term care settings, we have
made minor modifications to terms used in the
original publication.
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 eects
on the individual’s functioning and
mental, physical, social, emotional, or
spiritual well-being.
The Three E’s of Trauma
The Three E’s of Trauma are event(s), experience of
event(s), and eect.
EVENTS — can include actual or extreme threat of
harm, or severe, life-threatening neglect for a child.
Events can occur once or repeatedly over time.
Traumatic events can occur throughout a lifetime.
EXPERIENCE — how the individual experiences an
event helps determine if it is a traumatic event.
Factors include:
How an individual assigns meaning to the
event
How the individual is disrupted physically
and psychologically by the event
The individual’s experience of powerlessness
over the traumatic event, which can trigger
feelings of humiliation, shame, guilt, betrayal
and/or silencing, isolation, shattering of
trust, and fear of reaching out for help
Cultural beliefs (e.g. about the role of
women), availability of social supports,
and age and developmental stage of the
individual at the time of the event
EFFECT — adverse eects can occur immediately
or after a delay, and can have a range of duration.
Individuals may not recognize the connection
between traumatic events and their eects.
Adverse eects include:
Inability to cope with normal
stresses of daily living
Inability to trust and benefit from
relationships
Cognitive diculties — memory,
attention, thinking, self-regulation,
controlling the expression of emotions
TRAUMAINFORMED
A program, organization or system that is trauma-informed realizes the widespread impact of trauma
and understands potential paths to recovery; recognizes the signs and symptoms of trauma in clients,
families, sta and others involved with the system; and responds by fully integrating knowledge about
trauma into policies, procedures and practices to actively resist re-traumatization.
Other ways this response is manifest include:
Ensuring that the materials used in your
organization — from your mission statement
to manuals to policies and procedures —
reflect your commitment to creating a
culture of resilience, recovery and healing
from trauma
Formalizing ways for people who have
experienced trauma to advise and guide the
organization
Providing sta training and guidance for
supervisors on secondary traumatic stress
Articulating your commitment to a physically
and psychologically safe environment
- including employees and supervisors -
fairness and transparency (others would
include a culture of social and moral safety)
Adopting a universal precautions approach
that assumes the presence of trauma in the
lives of residents and employees and takes
steps to not replicate trauma
RESISTING — re-traumatization of residents and
sta members by ensuring that practices do
not create a toxic environment — for example,
understanding the impact of using restraints or
seclusion on a resident with a trauma history.
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
The Four R’s of a Trauma-Informed
Approach
A trauma-informed approach can be understood
through the terms realization, recognition,
responding, and resisting.
REALIZATION — all those involved in your
organization at all levels realize that:
Trauma can aect individuals, families,
organizations and communities
People’s behavior can be understood
as coping strategies designed to
survive adversity and overwhelming
circumstances (past or present)
RECOGNITION — all those involved in your
organization are able to recognize the signs of
trauma and have access to trauma screening and
assessment tools.
RESPONDING — your organization responds by
applying a trauma-informed approach to all aspects
of your work. Specifically, everyone on sta in every
role has changed their behaviors, language and
policies to take into consideration the experiences
of trauma among residents, their families and sta.
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
The Ten Domains for Implementing a
Trauma-Informed Approach
SAMHSA has outlined ten domains of organizational
functioning that should be addressed when
implementing trauma-informed care. As is evident,
they involve the entire organization. Those domains
are:
Governance and Leadership
Policy
Physical Environment
Engagement and Involvement — of people
in recovery, trauma survivors, residents and
family members, and sta at all levels
Cross-Sector Collaboration — all levels,
departments, and teams
Screening, Assessment, Treatment Services
Training and Workforce Development
Process Monitoring and Quality Assurance
Financing
Evaluation
KEY PRINCIPLES OF A TRAUMA
INFORMED APPROACH
Safety
Trustworthiness & Transparency
Peer Support
Collaboration & Mutuality
Empowerment, Voice, & Choice
Cultural, Historical, & Gender Issues
The Six Key Principles of a Trauma-
Informed Approach
SAFETY — all people associated with the
organization feel safe. This includes the safety of
the physical setting and the nature of interpersonal
interactions.
TRUSTWORTHINESS AND TRANSPARENCY —
your organization is run with the goal of building
trust with all those involved.
PEER SUPPORT — support from other trauma
survivors is a key to establishing safety and hope.
Peer support may be from others in the community.
COLLABORATION AND MUTUALITY —
recognition that everyone at every level can
play a therapeutic role through healing and safe
relationships. Your organization emphasizes
the leveling of power dierences and taking a
partnership approach with sta.
EMPOWERMENT, VOICE, AND CHOICE — your
organization recognizes and builds on the strengths
of people — sta members and residents. You
recognize the ways in which nursing home residents
and sta members may have been diminished in
voice and choice and have at times been subject to
coercive treatment. You support and cultivate skills
in self-advocacy, and seek to empower residents
and sta members to function or work as well as
possible with adequate organizational support.
CULTURAL, HISTORICAL, AND GENDER
ISSUES — your organization actively moves past
cultural biases and stereotypes (gender, region,
sexual orientation, race, age, religion), leverages
the healing value of cultural traditions, incorporates
processes and policies that are culturally aware, and
recognizes and addresses historical trauma.
However, the capacity to assess the meaning
of behavior is incomplete without the addition
of a consideration of prior adversity. A trauma-
informed approach to assessing behavior does not
take precedence over other rubrics — it adds an
essential missing piece to the puzzle that can help
make sense out of puzzling behavior and informs
our understanding about why our interventions
sometimes are ineective or even backfire.
PRINCIPLE : PRIOR ADVERSITY IS NOT
DESTINY.
In an environment of safety and support, change,
healing and better lives are possible.
There are two key dimensions to emphasize
regarding the potential for older people who
have experienced adversity to thrive: the role
of individual human potential and the role of a
supportive environment.
Human potential for healing across the lifespan:
Beyond the evidence and practice wisdom from
multiple fields that focus on the physical, mental
and spiritual health of individuals, there exists data
on the impact of psychological interventions with
older adults. This includes the kinds of trauma-
specific interventions that may be oered through
behavioral health services, along with insights
from neurobiology that help explain how greater
resilience and healing is possible even after the
brain is impacted by traumatic stress.
The role of a safe and supportive environment:
Because adverse or traumatic experiences, by
definition, are the result of a lack of safety and
make individuals susceptible to feeling unsafe,
subsequent environments have the potential to
either exacerbate the feeling of threat and danger
or mitigate it. A safe environment creates a setting
in which manifestations of traumatic stress are
minimized and individuals experience greater
comfort and opportunity for well-being and healing.
IMPLEMENTING TRAUMAINFORMED CARE: A QUICK REVIEW
Core Principles
There are three core principles that guide trauma-
informed care:
1. The impact of adversity is not a choice.
2. Understanding adversity helps us make
sense out of behavior.
3. Prior adversity is not destiny.
PRINCIPLE : THE IMPACT OF
ADVERSITY IS NOT A CHOICE.
Adverse or dicult life experiences aect all of us in
ways that are more about neurophysiology and less
about character than most of us have supposed.
Despite the commonly shared belief that ‘what
doesn’t kill us makes us stronger,’ the evidence
from neurobiology and public health increasingly
demonstrates that adversity causes changes in the
brain and body that occur outside our awareness
and are not subject to being overridden by ‘grit’ or
toughness.
PRINCIPLE : UNDERSTANDING
ADVERSITY HELPS US MAKE SENSE OUT
OF BEHAVIOR.
We cannot fully understand behavior or respond to
it eectively without understanding prior adverse
experiences.
In working with older adults, clinical and non-clinical
sta members are continuously — consciously
and deliberately or unconsciously — observing
behavior and interpreting what that behavior
means. Some of this is an ongoing process with all
human interactions. Some of this observation and
meaning-making comes from the training that sta
members receive in their professional disciplines.
When considering what observed behavior might
mean, we use a number of dierent rubrics, among
them considerations about possible medical
reasons, psychosocial causes, and environmental
factors.
LEVELS OF IMPLEMENTATION
IMPLEMENTING TRAUMAINFORMED CARE: LEVELS OF IMPLEMENTATION
When an organization makes a commitment to
implement trauma-informed care, it is beginning
a multi-year, multi-dimensional process of change.
For nursing homes participating in the Medicare
and/or Medicaid programs, CMS has mandated
trauma-informed care in the Phase (November
) Requirements of Participation.
The research and practice of trauma-informed care in
settings that provide supports and services to older
adults is still in its infancy. Very few organizations
in this field are familiar with the concepts, let alone
how they can be translated into the daily life of the
organization. Therefore, it is likely that even the most
committed organizations will move through levels
of implementation, deepening their understanding
and application over a period of years. Hopefully,
a community of research and practice will develop
to build shared learning about eective approaches
and evidence-based resources.
Each organization will need to tailor
implementation to its particular circumstances
and resources. The first level of implementation
will likely involve:
Engaging in basic education regarding trauma-
informed care
Establishing a multi-disciplinary team to guide
implementation
Conducting a preliminary organizational
assessment and setting priorities
Making basic changes to policies and procedures
to reflect a trauma-informed approach
Identifying mental/behavioral health experts in
trauma to whom older adults, family members
and sta members may be referred as needed
Identifying ways to create a sense of safety for
clients and sta
Beginning to grasp what a truly trauma-informed
organization might look like
As organizations progress to a greater
integration of a trauma-informed approach,
the second level of implementation will likely
involve:
Recognizing the need for significant culture
change that reflects a greater degree of
transparency, respect and empowerment for
clients, families and sta members
Translating the principles of trauma-informed
care to the work of each department and sta
member
Identifying and addressing overt and covert
barriers to a more robust trauma-informed
approach
Communicating the implications of trauma-
informed care: to firms who provide related
services such as therapy and pharmacy; to
clients and family members; and to the wider
public
Becoming more deeply aware of the eects
of primary and secondary trauma for sta
members and increasingly engaging with people
with lived experience of trauma
And, moving forward, organizations truly
committed to trauma-informed care may:
Become part of learning communities that
engage in applied research and share best
practices
Identify measures of progress and continually
stretch themselves
Increase sta training and learning about
trauma-informed care
Strengthen behavioral health and peer support
networks
Connect to trauma issues in the wider
community
GETTING STARTED
IMPLEMENTING TRAUMAINFORMED CARE: GETTING STARTED
As your organization begins to implement trauma-informed care, the senior team must make it clear that they
are invested in, and committed to, trauma-informed care.
The Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that implementing
trauma-informed care requires change at many levels of an organization and, therefore, has identified ten
domains that should be addressed:
SAMHSA has outlined a series of questions organizations can use to stimulate their thinking in each of the
domains as they implement trauma-informed care.
8
This document is available at: https://store.samhsa.gov/
system/files/sma14-4884.pdf
Getting Started Checklist:
Senior leaders can take the following steps to get started with trauma-informed care implementation:
Read and discuss:
Foundations of Trauma-Informed Care: A Primer
Relevant sections of the CMS Requirements of Participation
SAMHSA Guiding Principles of Trauma-Informed Care
Any updated guidance from CMS
Senior Team (and relevant others such as the Board of Directors) discuss and commit to a Statement
of Intent (page 8)
Form a Trauma-Informed Care Implementation Team page and page
Establish the Trauma-Informed Care Team’s Scope of Work and Budget (page )
Conduct a Preliminary Organizational Assessment (page )
Create a plan to address the results of the Preliminary Organizational Assessment (in conjunction
with the Trauma-Informed Care Implementation Team)
Identify local behavioral health resources and Employee Assistance Program resources. Share your
organization’s commitment to trauma-informed care and the ways in which they may support it
(page )
Review relevant local and state mandated abuse reporting requirements
Develop and implement policies and procedures to support trauma-informed care (in conjunction
with the Trauma-Informed Care Implementation Team) (page )
Educate all sta members regarding the basics of trauma-informed care (page )
. Governance and Leadership
. Policy
. Physical Environment
. Engagement and Involvement
. Cross-Sector Collaboration
. Screening, Assessment, Treatment Services
. Training and Workforce Development
. Process Monitoring and Quality Assurance
. Financing
. Evaluation
As with any significant change, implementing
trauma-informed care will require a group of well-
informed and enthusiastic champions. A Trauma-
Informed Care Team will work together to plan for
implementation and then guide the roll-out and
ongoing development and periodic evaluation.
While the Team might be led from someone from
social work, nursing, or special projects, it will be
important to have the nursing home administrator
on the team to ensure that all departments are
engaged and involved. The Executive Director,
CEO, or other end-point decision maker for the
community will likely not participate directly in
the implementation team, but it is critical that this
person be knowledgeable about trauma-informed
care and send the clear and consistent message that
they are committed to creating a trauma-informed
organization.
The Trauma-Informed Care Team needs to be
small enough to be able to learn together, meet
regularly and act nimbly. It must be large enough to
involve the perspectives of individuals from various
disciplines and levels of the organization. A range
of seven to ten people on the team generally works
FORMING A TRAUMAINFORMED CARE
IMPLEMENTATION TEAM
well. In a nursing home setting, you will want to
have people on the Team from:
It is wise to invite a Certified Nursing Assistant
or other direct service worker and to consider
individuals from other departments as well – and
to include employees from dierent levels of the
organization. Experiential work has shown that it is
best to form a separate team rather than assigning
the implementation of trauma-informed care to
an existing group such as quality improvement or
safety committees.
As you think about specific people to involve,
identify individuals who are natural leaders and
who are respected by their peers. People who have
already proven themselves supportive of person-
centered care and who are open to change make
good candidates for the Team. As you speak with
potential Trauma-Informed Care Team members,
be aware that sta members may bring their own
trauma histories. You do not need to delve into
people’s personal lives, but do make sure to be
clear that it is fine to decline the invitation with no
repercussions.
Initial commitments of Team members should be
for a minimum of six months to assure continuity
and eective team work. Later, other individuals
may be identified as natural champions for trauma-
informed care, or some Team members may need
or choose to leave the Team. As sta members are
educated about trauma-informed care the Team will
want to develop a clear and transparent process for
identifying new Team members.
As you think about
specic people to involve,
identify individuals who
are natural leaders and
who are respected by their
peers.
Nursing/Clinical
Social Work
Human Resources
Direct Care
Spiritual life/Chaplaincy
Environmental Services
IMPLEMENTING TRAUMAINFORMED CARE: FORMING A TRAUMAINFORMED CARE TEAM
The Trauma-Informed Care Team
Charter
The Team will design and guide the implementation
of trauma-informed care.
Specific responsibilities may include:
Perform a preliminary organizational
assessment
Create an implementation plan to include
tasks, timelines, responsibilities and
milestones
Consider what resources will be required
Identify and address barriers to
implementation
Ensure that all sta members have a basic
knowledge of trauma-informed care
Develop and implement policies and
procedures to support trauma-informed care
Create communication vehicles to spread
the word
See that communication regarding the
organization’s commitment to trauma-
informed care is transmitted to patients/
residents/ clients, family members, other key
stakeholders (keep in mind that actions will
speak louder than words)
Consult with and engage others in support
of trauma-informed care, including:
medical director, other physicians, nurse
practitioners or physician assistants who
work with your patients/ residents/ clients;
your Employee Assistance Program; mental
health professionals in the area experienced
in treating people with trauma; and people
with lived experience of the issue
Identify and implement practices that
create a culture of safety, respect, openness,
empowerment, and collaboration
IMPLEMENTING TRAUMAINFORMED CARE: FORMING A TRAUMAINFORMED CARE TEAM
Consider how re-traumatization and
secondary trauma for sta members and
patients/ residents/ clients can be avoided
Establish and monitor measures of success in
implementation
Commit to ongoing training, and sustaining
and deepening the trauma-informed culture
Some Things to Consider
It may be important to address power/ rank/
culture dierentials on the Team to assure
that all Team members can participate
actively.
While there are a variety of approaches to
implementing trauma-informed care, few
have a significant research evidence base
and most have not addressed the specifics of
nursing home settings.
The Team will benefit from someone who
can play a coordinating role - scheduling
meetings, creating meeting agendas, taking
and distributing notes, and assuring good
communication.
In its early work and planning, the Team
may benefit from the help of an external
consultant or facilitator.
Implementing trauma-informed care is not a
rapid process, so patience and perseverance
will be required.
Spiritual Direct Care
Environmental
Services
Nursing/
Clinical
Social Work
Human
Resources
CREATING A TRAUMAINFORMED CARE
IMPLEMENTATION PLAN
IMPLEMENTING TRAUMAINFORMED CARE: CREATING A TRAUMAINFORMED CARE PLAN
KEY PRINCIPLES OF A TRAUMA
INFORMED APPROACH
Safety
Trustworthiness & Transparency
Peer Support
Collaboration & Mutuality
Empowerment, Voice, & Choice
Cultural, Historical, & Gender Issues
As with all multi-disciplinary, multi-departmental
projects, implementing trauma-informed care will
proceed more smoothly if a plan is created before
implementation is begun. The resources in this
Guidebook will be helpful in developing the plan. Be
sure to become familiar with them before beginning.
Remember that trauma-informed organizations
benefit residents, sta and families by practicing
these six core principles and so they must be kept
front of mind in planning:
SAFETY — physically, socially, and
psychologically safe communities
TRUSTWORTHINESS AND TRANSPARENCY
— above board, straightforward communication
PEER SUPPORT — being able to count on others
in an open and caring way; that means asking for
and oering help
COLLABORATION AND MUTUALITY — an
emphasis on leveling power dierences and
valuing all
EMPOWERMENT, VOICE, AND CHOICE
— recognizes, encourages and builds on the
strengths of everyone
CULTURAL, HISTORICAL, AND GENDER
ISSUES — moves beyond stereotypes and is
culturally aware
Sketch out the overall scope of work, then assign
responsibilities and timelines. The Implementation
Plan Checklist can serve as a basic tool and the
Getting Started section will be useful. Key elements
of an implementation plan are:
Commitment — Creating a trauma-informed
organization requires commitment at all levels of
the organization. Board and sta leadership must
send a clear message and must commit sta and
financial resources to implementation. (Statement
of Intent, Getting the Board ‘on Board’)
Education — Because trauma-informed care is
a new concept for most nursing homes education
will be critical. All sta should be trained in the
basics. Discussions about the implications of
trauma-informed care and about possible real-time
applications of this approach should be part of sta
and team meetings. (Foundations Toolkit, Pre-and
Post-Test)
Implementation Team Formation — The
Implementation Team will be drawn from all levels
of the organization and will serve as champions and
planners to move trauma-informed care forward.
They must be empowered to work across disciplines
to create a trauma-informed culture. (Forming an
Implementation Team, Forming a Team Worksheet,
Team Charter, Leading Change)
Preliminary Assessment — This preliminary
assessment will provide an initial view of things in
place to build on and gaps that need to be filled. It
can provide insights into priorities and sequencing
of implementation. (Preliminary Organizational
Assessment)
IMPLEMENTING TRAUMAINFORMED CARE: CREATING A TRAUMAINFORMED CARE PLAN
Communication — All stakeholders need to
know of the organization’s commitment to trauma-
informed care. Open, transparent, straightforward
communication is a hallmark of a trauma-informed
organization, so communicate early and often,
and oer opportunities to listen closely to all
stakeholders. (Sta and Trauma-Informed Care,
Families and Trauma, Quick Review)
Action Plan — The Implementation Team in
concert with others will create an action plan and
will assign responsibilities and timelines. (Special
Considerations for Nursing Homes, Resources)
Departmental Responsibilities — While the
goal is to create a trauma-informed culture across
the organization, each department will need to pay
attention to the implications for their specific work
and create a plan for implementation. (SAMHSA
Domains/questions, Sta and Trauma-Informed Care,
Physicians and Contracted Health Professionals,
Relationship to Person-Centered/ Person-Directed
Care, Major Neurocognitive Disorders/ Dementia,
Implications for Short and Long-Stay Residents,
Families and Trauma)
Policies and Procedures — Many policies
and procedures will need to be revised to reflect
trauma-informed care. Using a transparent and
collaborative approach to the development of these
will be an important part of the trauma-informed
journey. (Quick Review, Policies and Procedures)
Measurements of Success — As with other
aspects of the organization’s functioning, it will be
important to identify measures of success and areas
of challenge as the implementation of trauma-
informed care proceeds. Results of the preliminary
organizational assessment will help point toward
possible measures. Using the Quality Assurance
Performance Improvement approach integrates
trauma-informed care measures into those of the
overall organization.
Resources — As trauma-informed care becomes
more widely adopted in nursing homes and other
settings that provide supports and services to older
adults, the research literature and evidence-based
practice will grow. Onsite training and consultation
can be valuable; attendance at webinars, workshops
and conferences will deepen understanding; and
regular review of articles and web resources will
keep the organization abreast of new knowledge.
(Resilience for All Ages website)
Going Deeper — This Guidebook, in concert with
the Foundations of Trauma-Informed Care Toolkit,
provides the basics for early implementation of
trauma-informed care. To create a truly trauma-
informed culture will require going beyond that. So,
be sure the plan includes a commitment to going
deeper over time.
Creating a Trauma-Informed Care Implementation Plan Continued.
SPECIAL CONSIDERATIONS
FOR NURSING HOMES
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Trauma-informed principles and practices apply in many, many
settings. Since the CMS Requirements of Participation Phase
specifically require nursing homes to implement trauma-
informed care, this section of the Guidebook will highlight
some of the special issues nursing homes will need to address.
They include:
Major Neurocognitive Disorders/ Dementia
Physicians and Contracted Health Professionals
Relationship to Person-Centered/ Person-Directed Care
Behavioral Health Resources
Implications for Short and Long-Stay Residents
Sta and Trauma- Informed Care
Families and Trauma
Policies and Procedures
Taking a trauma-
informed approach
when caring for
patients ensures we
don’t inadvertently
re-traumatize
them, and results in
tailored interventions
likely to improve
the overall patient
experience.
- Dr. Mark Lachman
Major Neurocognitive Disorders/
Dementia
Implementing trauma-informed care in nursing
home settings can be complicated by the presence
of many individuals with various types and stages
of neurocognitive disorders.
According to Dr. Mark Lachman, a geriatric
psychiatrist, “For those with dementia who have
also endured traumatic experiences, the disease
often impacts their ability to protect themselves
against traumatic memories and this may result in
certain behavioural presentations. Taking a trauma-
informed approach when caring for patients ensures
we don’t inadvertently re-traumatize them, and
results in tailored interventions likely to improve
the overall patient experience.
10
"
In an article in Social Work Today, T. Scott Janssen
has outlined the complexities of trauma-informed
dementia care.
11
There are studies indicating that
people who have experienced post-traumatic
stress may have a higher incidence of developing
dementia, perhaps related to the eects of toxic
stress on the brain. There are also studies that
suggest that dementia may be a risk factor in
developing delayed onset PTSD.
These intersections between trauma and dementia
are further complicated by:
The challenges and losses people face when
entering the new and unfamiliar environment of
a care setting
The diculty of getting accurate personal
histories
Similarities between behaviors associated with
dementia and with post-traumatic stress
The likelihood that frightening memories
of trauma may be exacerbated by cognitive
impairment
Clearly, creating a safe, supportive and respectful
environment is important in addressing both post-
traumatic stress and dementia. In helping people
with cognitive impairment to feel calm and safe
and to address behaviors that may or may not
be associated with previous trauma, the general
approach is to assume previous trauma. While it
may not be possible to learn the specifics of the
trauma, asking general questions of the person and
the family may provide helpful information about
previous trauma that will help to solve a behavioral
puzzle. Noting and documenting specific triggers of
aggressive or frightened behaviors may also provide
clues. Conversely, noting and documenting the
specifics of times when the individual seems calm
may also provide insight and ideas for providing
support and safety when emotional dysregulation
or behavioral issues arise. These practices are
consistent with person-centered and person-
directed care that respects people as unique
individuals.
In sum, while the intersections of trauma and major
neurocognitive disorders are complex and the
study of these intersections is in the early stages,
sta with a knowledge of trauma-informed care and
an organization committed to its practice will be of
great benefit to both sta members and individuals
in their care. For sta members working closely
with persons with major neurocognitive disorders,
worries about safety and eectiveness can lead
to frustration, burn-out, secondary or vicarious
trauma, and even job changes. Care providers who
use a trauma-informed lens and practices trauma-
informed principles may find themselves feeling
greater safety and competence in managing and
minimizing challenging behavior.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Care providers who use
a trauma-informed lens
and practices trauma-
informed principles may nd
themselves feeling greater
safety and competence in
managing and minimizing
challenging behavior.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Physicians and Contracted Health
Professionals
People who receive healthcare and services in
nursing homes interact regularly with a variety
of health professionals. These include physicians,
nurses, pharmacists, therapists (occupational,
physical, respiratory, speech), and diagnostic
technicians. In many organizations, at least some
of these roles may be contractual rather than
employed-sta relationships. In the same way that
sta members at every level of the organization
must contribute to building a trauma-informed
organization, so too, must contracted health
professionals.
Suggested steps include:
Make explicit expectations regarding trauma-informed care part of written agreements.
Include some elements of trauma-informed practice in any ongoing evaluation of the contracting
health professional.
Provide and document basic education about trauma-informed care for all health professionals
working within your organization.
Identify information and resources regarding trauma-informed care targeted to specific professions.
Many professional associations such as the American Physical Therapy Association and American
Academy of Family Physicians have published such information.
Ensure that all health professionals are familiar with universal trauma precautions and make use of
them in their practices.
12
Establish documentation processes that inform the health care professional of known trauma
histories taken by other professionals and the history of successful and unsuccessful strategies that
had been used to avoid re-traumatization.
Share these and other articles/resources with health professionals:
http://brsstacs.center4si.com/TICinMedicine.pdf
https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-
important-2018101613562
https://www.aafp.org/afp/2017/0515/p655.html
These professionals often must ask sensitive
questions, conduct medical examinations, or
administer hands-on treatments that may be
painful or frightening. Such actions can trigger
strong reactions in individuals with prior histories of
abuse or other adverse experiences. Therefore, it is
important that health care professionals are aware
that many of the individuals they see have histories
of trauma, given the prevalence of trauma in the
general population. The organization must educate
health professionals about trauma-informed care
and hold them accountable for practicing in ways
that promote a culture of safety, empowerment and
healing.
Relationship to Person-Centered/
Directed Care
The movement toward person-centered care began
slowly more than two decades ago, but is advancing
more rapidly with reinforcement from the CMS
Requirements of Participation for nursing homes.
Person-centered care (increasingly referred to as
person-directed supports and services) is based
upon the needs and preferences of each unique
individual. It stands in contrast to some more
traditional medical approaches that emphasized
eciency, schedules and standardized processes
that worked well for the organization.
Person-centered care values the individual and
seeks to know and partner with each person to
provide what is needed in ways that are shaped
by the individual. Rather than seeing the person
as a series of diagnoses or challenges to be solved
by the experts, this approach seeks to know and
understand the person, and care provision is guided
by the choices and priorities of the person. This can
be manifest in everything from food and schedule
preferences to respecting end of life wishes. Person-
centered care requires meaningful interpersonal
relationships. Even in situations where late-stage
dementia is involved, close attention is paid to what
works best for the individual.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Trauma-informed care is an important puzzle
piece in providing person-centered care. Trauma-
informed care emphasizes these six principles.
SAFETY
TRUSTWORTHINESS AND
TRANSPARENCY
PEER SUPPORT
COLLABORATION AND MUTUALITY
EMPOWERMENT, VOICE, AND CHOICE,
CULTURAL, HISTORICAL, AND GENDER
ISSUES
These principles align well with the best of person-
centered and person-directed care. Integrating
trauma-informed principles into the care model
of the organization will strengthen all aspects of
person-centered and person-directed care.
When sta members operate within such a culture,
they are able to recognize the ways in which any
person may have been aected by adverse events
and are alert to partnering with each person to
avoid re-traumatization. Person-centered care
and trauma-informed care grow out of the same
fundamental view that honors the self-hood of each
person.
Trauma-informed care
is an important puzzle
piece in providing
person-centered care.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Behavioral Health Resources
Most nursing homes will be creating trauma-
informed organizations rather than providing
trauma-specific treatment. Unless the organization
has a depth of expertise in behavioral health, it will
need to identify resources in the community to
which it can refer for trauma-specific treatment.
To comply with behavioral health-related CMS
Requirements of Participation, organizations will
be assessing a resident’s behavioral health status
and identifying needs for specialized supports and
services. In most cases, the organization will already
have identified practitioners who can assess and
provide treatment for a range of behavioral health
issues as needed. It will be important to check to
see which of these practitioners has experience and
expertise in treating trauma, so that the appropriate
referrals can be made.
That said, in many communities there is a paucity
of behavioral health resources and even fewer
with gerontology or trauma specialties. It may be
helpful to look for practitioners who work with
veterans, abuse survivors, Holocaust survivors or
others who have experienced trauma. Veterans’
organizations, domestic violence organizations,
Jewish organizations and organizations working
with youth in psychiatric or residential treatment
settings may be good resources to identify
practitioners with trauma-related experience.
As trauma-informed care is implemented, it is
also important to assure that there are resources
available to sta members who may also have
experienced adverse events. Be sure to check with
your employee assistance program provider to learn
what resources they have available for trauma-
related concerns.
Create a list of organizations and practitioners who
can provide trauma-specific treatment. This must
be a high priority when implementing trauma-
informed care. Keep in mind that other service
sectors may not be informed about the CMS change.
Creating a dialogue that shares the needs of your
organization and learns about the trauma-informed
experiences of potential resources will help to find
those experts that will best serve your residents
and employees. Consider a protocol for a shared
linkage agreement to assist in communication and
shared expectations between organizations.
Possible Organizations & Practioners
Implications for Short and Long
Stay Residents
Most nursing homes care for individuals who are
with them for short rehabilitation-to-home stays,
and also for individuals who have come to make
this new setting their long-term home. As the
organization plans to implement trauma-informed
care there will be both similarities and dierences
in how they work with these two populations. In
all circumstances, a trauma-informed organization
will treat individuals in ways that promote safety,
empowerment, transparency and respect.
Short Stay
Most people who are admitted for post-acute
rehabilitation stay from three to 30 days. Since these
are brief periods, the most important elements of
trauma-informed care include:
Employing universal trauma precautions in
all interactions
Explaining each medical/ care interaction in
advance
Informing individuals and their families
about the organization’s commitment to
trauma-informed care
Asking individuals, and when appropriate
their families, about their preferences,
including what will make them feel more safe
and comfortable during their stay
Doing a basic psychosocial intake with
normalizing, open-ended questions on prior
adverse experiences; referral to trauma-
specific treatment when appropriate
Considering whether the experience that
led to the short stay may itself have been
traumatic — for example, an accident or fall,
or a frightening medical crisis
Ensuring that discharge planning facilitates
return to a safe home setting
Long-Term Care
For many individuals the nursing home will be
their longer-term home. Many of the elements of
trauma-informed care for short-stays apply:
Employing universal trauma precautions in
all interactions
Explaining each medical/ care interaction in
advance
Informing individuals and their families
about the organization’s commitment to
trauma-informed care
Asking individuals, and when appropriate
their families, about their preferences,
including what will make them feel more safe
and comfortable during their stay
Doing a basic psychosocial intake with
normalizing, open-ended questions on prior
adverse experiences; referral to trauma-
specific treatment when appropriate
And, while these elements apply to short stay
residents as well, for people who will be moving
into a nursing home for the long term the following
will also be especially important:
Learning as much as possible about the
individual's preferences and needs
Communicating with clarity, respect and
transparency
Asking and observing the situations
and interactions that create well-being,
engagement and a sense of safety on the
part of the individual
Recognizing that many individuals who
are long-stay residents have some level
of cognitive impairment that may require
additional sensitivities
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Sta and Trauma-Informed Care
Sta Aected by Adverse Experiences
The inclusion of a focus on trauma-informed care
in the CMS Requirements of Participation for
nursing homes reflects increasing recognition that
the experience of trauma is widespread across the
population. This includes sta members.
The ACEs study
13
demonstrates the likelihood
that there are sta members at all levels of the
organization who have experienced challenging life
experiences. It is also likely that each of these sta
members will be in a variety of situations or places
with respect to the trauma they have experienced.
For some, challenging life events resulted in a
traumatic stress response or more significant
response. It is impossible to look at someone and
know whether they have experienced trauma.
Further it is unwise to assume or diagnose.
Some trauma-impacted employees may have
recognized the trauma and received trauma-specific
treatment. These individuals may know what works
best for them in coping with and healing from the
long-term eects of trauma. These individuals, if
willing to self-identify, may be good resources for
the organization in its trauma-informed journey.
Other sta members may acknowledge that they
have had dicult childhoods, lived through natural
disasters or fled from war-torn countries. Yet others
may be currently living in situations of domestic
violence or other ongoing trauma. Some sta
members will not be aware of how trauma has, or
is, aecting them, nor of what might trigger their
own re-traumatization.
Additionally, it is important to respect and
understand that two individuals who have
experienced the same event will not necessarily
both identify the event as traumatic. Therefore, it is
vital for employees and residents to avoid creating a
predetermined list of what is considered traumatic.
It must also be acknowledged that working in
the nursing home setting can, at times, result in
stressful or challenging experiences. Unfortunately,
there are also times of trauma in the nursing facility
that may include violence, assault, disaster, and
so forth. These may initiate a stress response or
spark a traumatic stress response from a prior life
experience.
It is for these reasons that training in trauma-
informed care should be approached with care and
sensitivity. When introducing trauma-informed care
and throughout implementation, it is important to
let sta members know that it is understood that
this may be dicult subject matter and individuals
need to do what is helpful for them to feel grounded
and safe. As noted elsewhere in this Guidebook,
it will be helpful to discuss your organization’s
implementation of trauma-informed care with your
Employee Assistance Program (EAP) and to have
them identify trauma-specific treatment expertise
when needed.
Fortunately, a trauma-informed organization is
a work environment that supports employees. A
trauma-informed organizational culture provides an
understanding, safe, transparent and empowered
community of employees who recognize the signs
and symptoms of potential traumas for themselves,
colleagues, and residents.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Sta and Trauma-Informed Care Continued.
Sta Working with Residents Aected
by Trauma
Organizations that have provided supports and
services to aging veterans and Holocaust Survivors
have come to assume that past trauma is a very
present issue for many people they serve. They have
learned what some of the specific triggers might be
and have taken steps to minimize those. They have
worked closely with families and learned from their
wisdom and experience. They have also honored
the resilience of individuals who have been through
trauma when young and who have persisted
nonetheless. Sta members who have worked
regularly with individuals aected by trauma have
learned a great deal about trauma-informed care,
even if simply through experience.
At times, as noted above, sta members in these
environments recognize that they themselves
have been aected by the traumatic experiences
of the individuals for whom they are caring. This
phenomenon is called secondary or vicarious
trauma. In all settings, it is important to be alert
to the potential for secondary trauma among sta
members for whom the traumatic stories and
experiences of others may cause emotional duress.
Good self-care and peer support will be valuable for
them.
Sta Benefit from Trauma-Informed
Workplace Cultures
By creating trauma-informed cultures, residents
and employees will benefit from a safe, supportive,
trustworthy and responsive environment. Trauma-
informed workplaces that truly embrace the
principles are great places to work. They emphasize
these basic principles:
Safety – physically, socially and psychologically
safe communities
Trustworthiness and transparency – above board,
straightforward communication
Peer Support – being able to count on others in
an open and caring way; that means asking and
oering help
Collaboration and Mutuality – an emphasis on
leveling power dierences and valuing all
Empowerment, Voice, and Choice – recognizes,
encourages and builds on the strengths of
everyone
Cultural, Historical, and Gender Issues – moves
beyond stereotypes and is culturally aware
Sta wellness and self-care are high priorities, as is
accountability to one another. In a trauma-informed
environment sta learn that trust must be earned
and not assumed. Positive working relationships
are respectful and provide support, safety, and
calming in times of stress. Cultural humility is
practiced. Organizations committed to trauma-
informed care believe that this culture contributes
to greater workplace engagement and satisfaction,
and increases retention. Therefore, as trauma-
informed care is implemented employee reviews
and evaluations should incorporate the ways in
which employees demonstrate its principles and
practices.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
The family lives with the legacy of the resident
having survived the Holocaust when many family
members did not.
The resident is a combat veteran and the eects
of his post-traumatic stress has been a challenge
for the family.
The resident grew up with a parent with mental
illness and substance misuse, but her children do
not know that.
The family experienced a devastating fire that
consumed their home and resulted in a loss of
life.
One family member has had a serious chronic
illness and has experienced dicult medical
procedures, some of which were painful and
frightening.
And, of course, the list could go on and on. As
could descriptions of the ways in which these
adverse experiences aected these families. Family
responses could include:
Breaking the cycle of trauma through counseling
and intentional resilience building
Keeping secrets and just moving on
Using a variety of coping and defense
mechanisms that worked, but in some ways have
had adverse and unintended consequences
Extreme dysfunction
Fractured relationships
Not recognizing or understanding the long-term
eects of the trauma
Recognizing and acknowledging the trauma and
dealing with it as issues arise
Using the family as a resource in ways that
strengthen bonds and help with coping
Again, the list could be nearly endless. Recognizing
these ripple eects, the importance of including
families in a trauma-informed approach becomes
clear.
Families and Trauma
Each family
*
, as is true with individuals, experiences
trauma dierently depending on the nature
and duration of the trauma and the specific
characteristics and circumstances of the family. In
the nursing home setting, some family members
have very close relationships with the patient/
resident/ client (hereafter resident in this section)
and others may be distant or have only occasional
contact. It is important to extend the trauma-
informed care approach to all family members
and this begins with communication that is open,
transparent, and respectful.
Communication with families emphasizing that
the organization practices trauma-informed
care is beneficial in many ways. It provides the
opportunity for family members to share their own
or the resident’s trauma history. It reassures family
members that there will be an emphasis on safety,
dignity, collaboration and respect. And, it opens
the door for spreading the word about the lasting
eects of trauma, and the opportunity to reduce
shame and stigma.
Families may be aected by trauma in many ways.
And, the trauma(s) may have been experienced
directly by the resident, their child or children, their
spouse, their ancestors, and/or the entire nuclear or
extended family. Consider just a few examples:
The resident has recently experienced physical
and/or emotional abuse by a family member.
The resident was a refugee from war or genocide
in another country as a young adult.
The resident abused his daughter and was,
himself, abused as a child.
The family has lived in a violent, distressed
and disinvested urban neighborhood and has
witnessed and experienced violent death,
poverty and racism for several generations.
* Please note that family here is meant to include biological relatives
and/or others who are in close and caring relationship with the resident.
In other words, a person’s family includes those s/he chooses to include.
It is important to extend
the trauma-informed care
approach to all family
members and this begins
with communication that
is open, transparent, and
respectful.
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Families and Trauma Continued. Even though
the nursing home may not be providing trauma-
specific treatment to residents and their families,
implementing a trauma-informed approach will
mean the entire sta is alert to the ways in which
residents and their families may have been aected
by trauma. And, consequently, they will engage
with family members in new ways. For example:
They will recognize that trauma may be the
genesis of discord among family members
regarding the course of treatment.
When trauma is identified and treatment Is
recommended, they will encourage the family
to become involved, and will encourage families
to view adverse experiences as challenges for
the family to face together. However, trauma
sometimes fractures family relationships
and some family members, to keep healthy
boundaries, may choose not to associate with
others.
They will treat family members with the same
open, respectful, collaborative principles as they
do residents and sta members.
They will create safety and respect for the
resident as a first priority.
They will address the intersections of trauma with
culture, history, race, gender, language, and will
value the unique needs of diverse communities.
Trauma-informed care aects every aspect of
the functioning of the organization – including
relationships with families.
As noted in the sta section of this book, consider:
SAFETY – physically, socially, and psychologically safe
communities
For families this may take the shape of
welcoming facilities, approachable employees,
operating without blame and judgement
directed at the family or resident when dicult
issues arise, and openness to receive feedback,
concerns or questions from family members.
TRUSTWORTHINESS AND TRANSPARENCY – above
board, straightforward communication
For families this may mean extraordinary
customer service when responding to
questions, asking questions, and treating
information that is shared with great care.
PEER SUPPORT – being able to count on others in an
open and caring way; that means asking and oering
help
For families, this could mean creating support
opportunities with other families, or permission
to maximize a trusted relationship with sta
regardless of the position in the organization.
COLLABORATION AND MUTUALITY – an emphasis
on leveling power dierences and valuing all
All employees carry out their work
acknowledging the expertise and importance of
the family and their experiences in the care and
service for the resident.
EMPOWERMENT, VOICE, AND CHOICE –
recognizes, encourages and builds on the strengths of
everyone
As noted above, families feel invited and safe to
join fully in the care or treatment team.
CULTURAL, HISTORICAL, AND GENDER ISSUES –
moves beyond stereotypes and is culturally aware
Relationships with the family must respect
culture, history, gender, ethnic or other issues
that may be similar to, or perhaps somewhat
dierent from, the resident. All relationships
respect the individual’s uniqueness and value.
Policies and Procedures
An important part of building a trauma-informed organizational culture is including trauma-informed care in the
organization’s policies and procedures. This includes both how policies and procedures are developed, and how
they are operationalized. In the journey of becoming trauma-informed, tending how trauma-informed principles
and practices are threaded through policies and procedures will advance success. Leaders need to ensure
that all relevant policies and procedures reflect the organization’s trauma-informed principles and practices.
Pay particular attention to the following:
Governance-Related Policies
Once again, it is critical that in drafting and revising
policies and procedures these basic principles are
addressed:
SAFETY — physically, socially and
psychologically safe communities
TRUSTWORTHINESS AND
TRANSPARENCY — above board,
straightforward communication
PEER SUPPORT — being able to count on
others in an open and caring way; that means
asking and oering help
COLLABORATION AND MUTUALITY — an
emphasis on leveling power dierences and
valuing all
EMPOWERMENT, VOICE, AND CHOICE
— recognizes, encourages and builds on the
strengths of everyone
CULTURAL, HISTORICAL, AND GENDER
ISSUES — moves beyond stereotypes and is
culturally aware
IMPLEMENTING TRAUMAINFORMED CARE: SPECIAL CONSIDERATIONS FOR NURSING HOMES
Human Resources
Background screening
New sta orientation
Training – sta and supervisors
Support for supervisors to coach employee
performance using a trauma-informed lens
Performance review documentation and process
Employee development plans including
progressive discipline
Grievance and other conflict resolutions models
and practices
Employee Assistance Program
Temporary or agency sta
Contracted health professionals
Environmental Services
Safety
Privacy
Security
Care Planning
Assessments
Person-Centered care planning
Mood and behavior policies
Specialist referrals
Discharge planning
Abuse and Reporting
Quality Assurance and Performance
Improvement
Financial and Budget Policies
Communications
With employees
With residents
With families
With others – volunteers, stakeholders, vendors,
and contractors
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
RESOURCES
Our sta members will need skills and guidance on
identifying symptoms of trauma, talking with residents
about trauma, and acting in a trauma-responsive manner;
Our sta members deserve an environment and supports
that acknowledge their own experiences of trauma and
that working with residents with trauma histories can
result in secondary or vicarious trauma for sta;
We intend to involve our residents and their families as
well as sta members and community partners in this
journey through education and opportunities to provide
input;
As leaders, we must demonstrate our commitment to this
approach and to sponsoring the systems change process
involved in creating a trauma-informed culture;
The work of implanting trauma-informed care and creating
a trauma-informed culture takes time, the investment of
resources, and accountability mechanisms;
We are committed to full implementation of the trauma-
informed care requirements as codified in the CMS Final
Rule — these requirements pertain to comprehensive
person-centered care planning (42 CFR 483.21(b)3(iii),
quality of care (42 CFR 483.25) and behavioral health
services (42 CFR 483.40).
Trauma-informed care is an important component of
enacting our commitment to person-centered care
through which we oer individualized support and
services that are responsive to our residents’ wishes and
goals;
Our work will be informed by the guidance oered to
us by the Substance Abuse and Mental Health Services
Administration in its publication, SAMHSA’s Concept
of Trauma and Guidance for a Trauma-Informed Approach;
Trauma impacts a significant portion of the population
across the lifespan and produces physical, mental, and
social health outcomes that complicate aging and can,
if unrecognized, be misunderstood as manifestations
of other conditions and disorders and thus subject to
inappropriate treatment;
Residents who have a trauma history deserve access
to care that is trauma-sensitive and behavioral health
treatment, as appropriate, that is trauma-specific;
Our organization can and should have an organizational
culture that is trauma-responsive and so avoids re-
traumatizing residents and creates an environment of
safety;
Statement Of Intent
As you undertake the journey of adopting trauma-informed approaches to care in your organization, we
encourage you to review and adopt the following Statement of Intent, or something similar, as a formal
indication of your understanding of what is involved and your commitment to enhancing your ability to provide
person-centered care to residents who have experienced trauma.
As an organization, we are committed to learning about trauma and its eects and to engage with and implement
trauma-informed approaches to the care we provide and the organizational culture we create.
We understand that:
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Preliminary Organizational Assessment
The following questions are designed to help you assess the current state of your organization as you begin to
implement trauma-informed care, and to identify areas that may require greater focus prior to launching a formal
initiative.
Statement
Strongly
Agree
Agree Disagree
Strongly
Disagree
Unsure/
Don't
Know
Intake and Admissions
Our admissions sta are trained to use a strengths-based, person-
centered approach to interviews with prospective and new
residents and family members.
Our admissions sta ask questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Our admissions sta use a sensitive and respectful approach to
interviews and respond to any emotional disclosures or reactions
in a gentle, non-confrontational manner.
The form completed by the potential resident’s physician asks one
or more questions concerning adverse life experiences that may
impact him or her.
Please rate the extent to which you agree that sta in each department is currently implementing the practice described.
Statement
Strongly
Agree
Agree Disagree
Strongly
Disagree
Unsure/
Don't
Know
Medicine
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
Nursing
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Statement
Strongly
Agree
Agree Disagree
Strongly
Disagree
Unsure/
Don't
Know
Physical, Occupational and Speech Therapy
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
Social Services / Social Work
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
Activities / Enrichment
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
Discharge Planning
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
ensuring a smooth transition post-discharge and the continuing
provision of quality care.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Statement
Strongly
Agree
Agree Disagree
Strongly
Disagree
Unsure/
Don't
Know
Environmental Services
Using a strengths-based, person-centered approach in interacting
with and providing care for residents and in interacting with
family members.
When appropriate, asking questions concerning prior life
experiences that might impact the individual and be important to
providing quality care.
Using a sensitive and respectful approach to interactions, and
responding to any emotional disclosures or reactions in a gentle,
non-confrontational manner.
Additional Dimensions
Below are statements about the capacity of your current sta to implement specific aspects of a trauma-informed approach. Please
indicate the extent to which you are confident that sta in each specified area is ready and able to do so at this time. Please factor in both
skills and attitudes in your rating.
Statement
Strongly
Agree
Agree Disagree
Strongly
Disagree
Unsure/
Don't
Know
The lead sta person in Environmental Services can design and
implement a systematic review of our physical environment in a
trauma-sensitive manner, looking for ways in which our facility
may feel unsafe or may contribute to agitation.
The lead sta person responsible for Training and Workforce
Development can design and implement introductory education
and training on trauma, traumatic stress and trauma-informed
care for all sta.
The Trauma-Informed Care team is prepared to design a way
to track and assess progress toward trauma-informed care and
achievement of related goals.
The lead sta person for Human Resources can coach supervisors
on managing sta to ensure trauma-informed care is provided.
The lead sta person for human resources can coach supervisors
on ways to support sta experiencing vicarious trauma or the
impact of their own prior adverse experiences.
The organization is prepared to help sta and residents access
behavioral health resources.
Additional Comments:
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Trauma-Informed Care Implementation Team Formation Worksheet
As you identify individuals who might add to the work of this team, keep in mind that it is important to select sta
members from dierent levels – from senior leaders to direct care workers. It is also important that those selected be
individuals whom others trust, and who are willing and able to be champions of trauma-informed care.
Departments Potential Candidates
Individual(s) Selected &
Agreeing to Serve
Notes
Nursing/Clinical
Direct Care
Social Work
Spiritual Life/
Chaplaincy
Human Resources
Environmental
Services
Other
Person who will manage coordination and communication:
Meeting schedule:
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Implementation Plan Checklist
Task Who What When Notes
Read Foundations of Trauma-
Informed Care: A Primer
Adopt a Statement of Intent
Read relevant sections of CMS
Requirements of Participation
and CMS Guidance
Read Implementing Trauma-
Informed Care: A Guidebook
Identify abuse reporting
requirements
Form a Trauma-Informed Care
Implementation Team
Orient team to team roles and to
trauma-informed basics
Hold a launch event to announce
the trauma-informed care
journey
Educate all sta on trauma-
informed care basics
Establish a budget for trauma-
informed care implementation
Create a communication plan
Perform a preliminary
organizational assessment
Develop a plan to address
assessment results
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Task Who What When Notes
Address human resource
practice intersections
Address trauma-informed
care with physicians and other
contracted health professionals
Identify and implement
practices across the
organization that create a
culture of safety, respect,
openness, empowerment, and
collaboration
Use external training and
consultation as needed
Identify potential barriers to
implementation
Review, revise and add to
policies and procedures
Identify behavioral health
resources for residents and sta
Establish and monitor measures
of success in implementation
Make plans to move to Level
Two implementation
Implementation Plan Checklist Continued.
Leading Change
Creating a trauma-informed organization means
creating a culture that is respectful, open, and
emotionally safe for everyone. The process
of becoming a trauma-informed organization
will require new ways of thinking and acting.
Recognizing that most organizations are also in
the midst of enacting many other types of changes
and transformations, this chapter will suggest a few
perspectives on leading change, and will identify
additional helpful resources.
John Kotter, in his classic book Leading Change,
identified an eight step model for change that may
be helpful in implementing trauma-informed care.
One could translate Kotter's steps into a trauma-
informed frame:
STEP . CREATE SAFETY — establish the
importance of safety
STEP . IDENTIFY TEAM — collaborate with
all stakeholders and identify an implementation
team that is empowered
STEP . DEVELOP VISION — together,
including leadership and the implementation
team, develop a vision for change
STEP . SHARE THE VISION — share that
vision to build safety, transparency, and
collaboration broadly
STEP . EMPOWER OTHERS — empowering
others increases transparency and
collaboration, and builds safety
STEP . CREATE QUICK WINS — plan for
and create short term wins to build trust, and
celebrate these
STEP . BUILD ON THE CHANGE — continue
to emphasize collaboration, empowerment, and
communication to sustain momentum
STEP . GROW AND SUSTAIN — incorporate
ongoing change to develop, grow and sustain a
trauma-informed culture
Implementing &
sustaining for
change
Engaging &
enabling the
organization
Creating the
climate for
change
2. Identify Team
3. Develop Vision
1. Create Safety
4. Share the Vision
5. Empower Others
6. Create Quick Wins
7. Build on the
Change
8. Grow & Sustain
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Leading Change Continued. Another long-time voice regarding change, William Bridges, talks about
the people side of change in Managing Transitions: Making the Most of Change.
He suggests that change
is situational and is often an external event (such as the implementation of trauma-informed care), while
transition is the inner psychological process that individuals go through as they deal with the change. People
change when they identify and grieve the losses that change involves and are able to let go of the old way. They
then enter a neutral zone where the new is not yet fully embraced nor comfortable. If the transition is managed
well, people move into the new reality with fresh energy and a clear understanding of how they can contribute
to the vision. Bridges says that a change can work only if the people aected by it can successfully get through
the transition it causes. So, it is important to recognize that dierent people will react dierently to change and
will move through transitions at dierent rates.
Since implementing trauma-informed care means some fundamental changes to organizational culture, here
are some questions that it may be helpful to think through:
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Be aware of some of the reasons that individuals
resist change. These may include:
Weariness with constant change
Not understanding the “why” or “what” of the
change
Uneasiness with the unknown
Wondering if this is “the latest fad”
Not feeling part of the change
Lack of trust in those leading the change
Seeing no positive benefit to the change
Again, from a trauma-informed perspective,
resistance to change can result from a feeling of
a lack of safety, or could result from insucient
information, or a lack of transparency or trust.
Collaboration is critical in gaining buy-in for change.
What is changing?
What will actually be dierent
because of the change?
Who is going to lose what?
What is the reason for the
change?
What are the anticipated
benefits?
And then what?
For change to be successful, good leadership is
needed. The team responsible for implementing
trauma-informed care must communicate that
this is a high priority, not only to comply with
requirements, but also to create an organizational
environment that will benefit sta members
as well as patients/ clients/ residents. Leaders
would be served well to tend direct and indirect
communication. This may include how projects are
prioritized and/or what resources are committed
to the change eort. Facilitative leadership that
models the change, listens and engages sta at all
levels of the organization in coming up with ideas,
and continually reinforces the change can help
people embrace a trauma-informed culture.
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Getting the Board 'on Board'
When an organization commits to trauma-informed
care it must do so at every level. Sta leadership
should work with the Board of Directors/ investors/
owners or others in governance roles to educate
them about trauma-informed care and gain their
commitment. It is important to emphasize that
while implementing trauma-informed care is a
Requirement of Participation for nursing homes
in the Medicare and Medicaid programs, the
organization is embracing this approach for the
good of residents and sta alike.
Having those with the ultimate spending and
prioritizing authority committed will ensure that
the appropriate resources will be devoted to
implementing and improving trauma-informed
care.
There are many approaches to getting the Board
'on board', and this list of possibilities should spark
additional ideas:
. Share Foundations of Trauma-Informed Care:
A Primer and invite them to read and discuss
it.
. Share the Statement of Intent found in this
guidebook and invite adoption.
. Ask members of the Trauma-Informed Care
Implementation Team to do a presentation
on the basics of trauma-informed care
and the ways the organization plans to
implement it.
. Facilitate a discussion about how
trauma-informed care fits into existing
organizational priorities, like providing
person-centered and person-directed care.
. Invite your lead human resources sta
person to talk about organizational culture,
employee engagement and the role of a
trauma-informed approach in creating
a positive workplace environment and
improving retention.
. Invite those in governance roles to attend
webinars or conference presentations.
. If the Board engages in strategic or
generative discussions at its meetings, make
trauma-informed care a topic. Explore how
trauma-informed care will strengthen the
organization.
. Invite the leadership of a trauma-informed
organization from another field, such as
children’s services or behavioral health, to
share how their organization has changed as
a result of implementing trauma-informed
care principles and practices.
. Invite people with lived experience of the
issue to share their stories.
. Invite behavioral health experts (perhaps
from your Employee Assistance Program)
to discuss the importance and impact of
trauma-informed work.
However your organization chooses to engage
those in governance roles, this will be a critical
step in becoming a trauma-informed organization.
By engaging the thoughts and feelings of all
stakeholders about this change and by tending
implementation with sensitivity, the organization
will have a good beginning for creating a trauma-
informed organization.
e organization is
embracing this approach
for the good of residents
and sta alike.
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
Sta Knowledge: Pre- and Post-
Test
When training sta members about trauma-informed
care, organizations may find it useful to administer this
pre- and post-test to document each sta member’s
understanding of trauma-informed care. This is the
answer key and the next sheet can be duplicated for
use with sta members.
. Experiencing trauma causes changes in the
brain and body that occur without us even
knowing it.
a. True
b. False
. If an older person has experienced trauma,
which of the following is NOT true:
a. Providing support and a safe environment
can help an older person heal.
b. Our brains can really only heal and change
when we are young.
c. Older persons may feel uncomfortable
talking about a past trauma because of the
fear of stigma.
d. Older persons may have experienced
childhood trauma, adverse events
throughout life, and specific losses
associated with aging itself.
. One key sign that an organization is “trauma-
informed” is when the organization’s
environment feels and is safe and supportive
for all people who have experienced trauma.
a. True
b. False
. Only a small portion of the population
has actually lived through a traumatic
experience.
a. True
b. False
. Trauma can be caused by:
a. Natural disasters like fires, tornados, or
floods
b. Car, train, or airplane crashes
c. Being the victim of or witnessing violence
d. Emotional abuse or neglect
e. All of the above
6. Trauma aects a survivors’ health and
well-being only in the days and months
immediately following the traumatic
experience.
a. True
b. False
. If someone has lived through a traumatic
experience, which of the following is true?
a. The person might show physical signs like
headaches and fatigue.
b. The person might show emotional responses
like irritability, depression, or anxiety.
c. Every person who experiences trauma will
experience the same symptoms.
d. Both A and B
. Learning about the signs and symptoms of
trauma is important because:
a. We can help ensure that the older persons in
our care feel safe.
b. It can help prevent misdiagnosis and
unnecessary use of antipsychotic
medications.
c. It can prevent us from unknowingly re-
traumatizing someone.
d. It can help us make sense of puzzling
behavior.
e. All of the above
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
. Triggers are things that might remind
someone of dangerous or frightening things
that have happened in their past.
a. True
b. False
. Which of these statements are true?
a. Stress and trauma aren’t exactly the same
thing.
b. Traumatic stress occurs when a person’s
ability to cope with an adverse experience is
overwhelmed.
c. A person’s reaction to an adverse event is
not a choice.
d. A and B
e. All of the above
. Sta members throughout the organization
may have experienced trauma.
a. True
b. False
. Which of these statements is true?
a. We need to know the specifics of a person’s
trauma in order to create a safe environment.
b. Only social workers need to know about
trauma.
c. Creating a trauma-informed organization
improves things for both sta members and
older adults.
d. People with dementia will forget their
traumatic experiences.
A printable version of the Pre- and Post-Test can be
found on the following pages.
TRAUMAINFORMED CARE PRE AND POSTTEST
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
. Experiencing trauma causes changes in the
brain and body that occur without us even
knowing it.
a. True
b. False
. If an older person has experienced trauma,
which of the following is NOT true:
a. Providing support and a safe environment
can help an older person heal.
b. Our brains can really only heal and change
when we are young.
c. Older persons may feel uncomfortable
talking about a past trauma because of the
fear of stigma.
d. Older persons may have experienced
childhood trauma, adverse events
throughout life, and specific losses
associated with aging itself.
. One key sign that an organization is “trauma-
informed” is when the organization’s
environment feels and is safe and supportive
for all people who have experienced trauma.
a. True
b. False
. Only a small portion of the population
has actually lived through a traumatic
experience.
a. True
b. False
. Trauma can be caused by:
a. Natural disasters like fires, tornados, or
floods
b. Car, train, or airplane crashes
c. Being the victim of or witnessing violence
d. Emotional abuse or neglect
e. All of the above
6. Trauma aects a survivors’ health and
well-being only in the days and months
immediately following the traumatic
experience.
a. True
b. False
. If someone has lived through a traumatic
experience, which of the following is true?
a. The person might show physical signs like
headaches and fatigue.
b. The person might show emotional responses
like irritability, depression, or anxiety.
c. Every person who experiences trauma will
experience the same symptoms.
d. Both A and B
IMPLEMENTING TRAUMAINFORMED CARE: RESOURCES
. Learning about the signs and symptoms of
trauma is important because:
a. We can help ensure that the older persons in
our care feel safe.
b. It can help prevent misdiagnosis and
unnecessary use of antipsychotic
medications.
c. It can prevent us from unknowingly re-
traumatizing someone.
d. It can help us make sense of puzzling
behavior.
e. All of the above
. Triggers are things that might remind
someone of dangerous or frightening things
that have happened in their past.
a. True
b. False
. Which of these statements are true?
a. Stress and trauma aren’t exactly the same
thing.
b. Traumatic stress occurs when a person’s
ability to cope with an adverse experience is
overwhelmed.
c. A person’s reaction to an adverse event is
not a choice.
d. A and B
e. All of the above
. Sta members throughout the organization
may have experienced trauma.
a. True
b. False
. Which of these statements is true?
a. We need to know the specifics of a person’s
trauma in order to create a safe environment.
b. Only social workers need to know about
trauma.
c. Creating a trauma-informed organization
improves things for both sta members and
older adults.
d. People with dementia will forget their
traumatic experiences.
ENDNOTES
Karen Heller Key, Foundations of Trauma-Informed Care: An Introductory Primer (Baltimore, MD: LeadingAge
Maryland/ Resilience for All Ages, 2018).
2 "CMS Finalizes Improvements in Care, Safety, and Consumer Protections for Long-term Care Facility
Residents”, Center for Medicare and Medicaid Services, September 28, 2016, https://www.cms.
gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-09-28.
html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir+descending.
Please note that for purposes of this paper and for ease of communication we are using the term “resident” to refer
to individuals receiving care in a nursing home community. We do so cognizant of the fact that many communities
provide rehabilitative care of shorter duration, and in those cases individuals are typically referred to as patients or
using other terms.
Vincent J. Felitti, Robert F. Anda, Dale Nordenberg, David F. Williamson, Allison M. Spitz, Valerie Edwards, Mary P.
Koss, James S. Marks, “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes
of Death in Adults: The Adverse Childhood Experiences (ACE) Study, “American Journal of Preventative Medicine,
(May 1998).
Roger D. Fallot and Maxine Harris, Community Connections: Creating Cultures of Trauma-Informed Care: a Self-
Assessment and Planning. PDF Protocol © .
Mark D. Lerner and Raymond D. Shelton, Acute Traumatic Stress Management ™, PDF © by The American Academy of
Experts in Traumatic Stress, Inc. .
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a
Trauma-Informed Approach. HHS Publication No. (SMA) -88. Rockville, MD: Substance Abuse and Mental
Health Services Administration, .
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a
Trauma-Informed Approach. HHS Publication No. (SMA) -88. Rockville, MD: Substance Abuse and Mental
Health Services Administration,
Diane K. Yatchmeno, Stephanie A. Sundborg, Mildred A. Davis, “Implementing Trauma-Informed Care:
Recommendations on the Process”, Advances in Social Work (Spring 2017).
Dr. Mark Lachman, http://www.sinaihealthsystem.ca/news/post-traumatic-stress-disorder-dementia/, accessed
February 2019.
J. Scott Janssen, MSW, LCSW, Trauma-Informed Dementia Care, Social Work Today, https://www.socialworktoday.
com/archive/exc_0218.shtml, accessed February 2019.
Sheela Raja, PhD; Memoona Hasnain, MD, MHPE, PhD; Michelle Hoersch, MS; Stephanie Grove-Yin, MD; Chelsea
Rajagopalan, BS, Trauma Informed Care in Medicine- Current Knowledge and Future Research Directions, Family
Community Health, Vol.38, No.3, pp.216-226. Copyright 2015 Wolters Kluwer Health, Inc.
Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in
Adults: The Adverse Childhood Experiences (ACE) Study.”
John P. Kotter, Leading Change. (Boston, MA: Harvard Business School Press, 1996).
William Bridges with Susan Bridges, Managing Transitions: Making the Most of Change 25th Anniversary Edition
(Boston, MA. Da Capo Press, 2016).
