With trauma-related F-tags beginning in less than two weeks, many providers have spent months training their staff and feel quite prepared to manage this sensitive aspect of resident mental health care.
For those who might not be completely ready for the Nov. 28 start date, I offer below some basics on trauma-informed care practices. While none of us know exactly how the survey process will play out, these fundamentals can make it less likely to run afoul of regulations.
The Concept
The general idea of trauma-informed care is that residents who have had exposure to trauma can experience increased sensitivity to interactions in the long-term care setting that “trigger” old feelings and reactions. For instance, Bob, a resident who was physically assaulted several years ago, feels very unsafe and distressed when other residents become agitated.
The Symptoms
An individual who has experienced trauma may have symptoms of Post-Traumatic Stress Disorder (PTSD), such as an exaggerated startle response or repeated intrusive thoughts of the event. Using our example above, Bob shouts loudly in alarm when other residents are noisy or frightening, showing an exaggerated startle response.
The Goal
The new F-tags are an effort to increase awareness that the nursing home environment can trigger past experiences of trauma or exacerbate current traumas and to encourage facilities to make every effort to avoid re-traumatization.
The Interview
The first step in complying with the regulations is to determine whether or not a resident has a current or past experience with trauma. The challenge of the interview is to avoid the possibility that the manner in which the questions are asked becomes traumatizing in and of itself.
To minimize this possibility, hold the interview in as private and discreet a manner possible and “normalize” the process, explaining to interviewees that all residents are being asked about their past experiences.
Increase the interviewee’s sense of control by offering them the option not to answer any items if they feel uncomfortable.
Empower them by asking if there are ways in which the staff can help them reduce discomfort or triggers, but be honest about whether or not the facility will actually be able to accommodate their requests. If Bob asks the interviewer for a private room and he won’t be getting one, it’s better for him to know this and for the team to look for some realistic accommodation, such as making sure his roommate is not someone who becomes loud or agitated.
The Boundary Setting
One difficulty that interviewers may have when asking questions about trauma will be in limiting the amount of information divulged.
The purpose of the exchange is to determine whether there has been trauma and how to reduce triggers while in the facility, not to hear particulars of the event or to begin treatment. Most questioners will not have the time, expertise or private space to do so.
Train your interviewers to be comfortable gently containing a resident who is giving many personal details by saying something along the lines of, “That sounds very upsetting. I’m going to stop you here because I have someone I want you to meet who can help you (the psychologist).”
The Questionnaire
It seems reasonable to add questions about trauma while conducting the PHQ-9, such as, “We ask all our residents if they’ve had any traumatic experiences. You don’t need to tell me any specific details, but has there been any trauma in your life?”
If the answer to the question is yes, if the resident has a known history of trauma or if they’re showing signs of PTSD, the question can be followed up with the PTSD CheckList – Screener (PCL-6), as recommended by trauma-informed care expert Dr. Lisa Lind (via an email exchange).
The PCL-6 is free and it’s very brief. The question about difficulty concentrating is already part of the PHQ-9, so it’s only five additional items that can guide subsequent interventions without being overly intrusive.
The Documentation
In more than 20 years of charting as a psychologist, I’ve found that documentation can reference the occurrence of traumatic experiences without noting specifics. My guess is that it would be better to err on the side of fewer details than to run the risk that personal information could be discussed by team members in a less-than-discreet manner (e.g., loudly at the nursing station) or be open to a data breach.
If my experience holds true, it would be enough to note that Bob has a history of trauma. There would be no need to document that he was assaulted by his brother who is now in prison, even though key staff members may design interventions based on their knowledge of this information.
The Interventions
Aside from intervention basics such as referring a resident with PTSD symptoms to the consulting psychologist and/or psychiatrist, there are many other ways to demonstrate that the facility is attending to trauma. These could include, for instance, providing same-sex aides for sexual assault survivors or offering rooms on the quiet end of the hall to reduce overstimulation.
Bear in mind that many residents will have had some level of trauma exposure related to the circumstances of their admission, such as a fall, health crisis and medical procedures while in the hospital. In addition, it’s highly likely that older adults have been exposed to cumulative trauma over their lifetimes.
An environment where residents feel safe, respected, in control and have choices will go a long way towards reducing re-traumatization.
All staff should therefore be trained in trauma-informed care, with best practices implemented. See Dr. Lind’s Preparing for trauma-informed care in LTC for more information and resources.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.
