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May/June 2024

May/June 2024 Issue

Trauma-Informed Care in Long Term Care
By Sue Coyle, MSW
Today’s Geriatric Medicine
Vol. 17 No. 3 P. 14

Implementing trauma-informed care in long term care facilities benefits not only the residents but the staff and leadership, as well.

In recent years, society’s understanding of trauma and its impact on individuals has evolved. Though trauma is still most commonly linked to veterans and active-duty service members struggling with PTSD, many recognize that trauma is not limited to military service and can be experienced by and influence a wide range of individuals with varying lived experiences.

Among those who can and have endured trauma are individuals older than the age of 65—the population most likely to live in long term care facilities. Depending on their age, today’s residents of long term care have fought in and witnessed wars, survived a pandemic that was particularly dangerous and isolating for them, and lived through times of instability nationally, regionally, and individually. In addition to known, shared traumatic events, it’s likely many have experienced personal trauma, which can include but is not limited to neglect, assault, abuse, sudden loss, and exposure to violence.

Kelseanne Breder, PhD, PMHNPBC, a clinical assistant professor at the NYU (New York University) Rory Meyers College of Nursing, notes that the baby boomer generation, particularly the younger members, have an increased risk of experiencing homelessness. “Twenty to 30 years ago, 10% of individuals experiencing homelessness were over the age of 50. Today, 50% are over the age of 50,” she says.

“It doesn’t preclude them from attaining care in long term care facilities. Many may experience homelessness and then later become admitted to long term care,” she continues. “As those types of patients enter long term care, staff need to understand that those experiences are significant and an indication that trauma has occurred.”

Nancy Kusmaul, PhD, MSW, an associate professor in the Department of Social Work at the University of Maryland, Baltimore County, adds that, in fact, the events immediately leading up to an individual moving into long term care can often be traumatic, as the individual may have experienced “a serious illness, an ICU [intensive care unit] stay, or a fall,” she says. “Sometimes we see people who fall and lay on the floor for three days before somebody finds them [prior to entering long term care].”

The impact of and response to trauma, both long and short term, is unique to the individual. Some will feel the effects more than others. Regardless, it’s important that anyone who has experienced trauma receives treatment in their long term care facility that takes into account what has happened to them. They must receive trauma-informed care.

Trauma-Informed Care
According to Brian Sims, MD, senior medical advisor at the National Association of State Mental Health Program Directors, trauma-informed care is an approach that, at its simplest, is about “treat others as you would like to be treated. Many of us go into [direct service] with a professionalism that kind of pushes us toward dictatorial as opposed to compassionate care,” he says. When a provider, instead, approaches a patient thinking about how they can partner with and truly listen to the individual, they open the door for a higher quality of care.

Two of the key processes that Sims highlights are collaboration and connection. “If you believe in the individual, you have no problem collaborating,” he says. “Connection is speaking at their level and listening for responses. People will ask a person a question, but then they don’t give them enough time to answer. They don’t think that you’re even hearing them. It becomes a very sterile environment for them. If you connect and collaborate, you can empower that individual, and you’re going to do it all with empathy. Empathy is the key to trauma-informed care. You do not have to have the answers. You simply have to be there,” he adds.

When a provider is truly present for a patient or resident, the individual may feel more able to share that they have experienced a trauma. They may not provide the details and should not if they are uncomfortable, but knowing that a trauma has occurred can help shift a provider’s perspective on how further care will be provided.

“Trauma-informed care is about understanding how the presence of or history of trauma can impact a person on a daily basis and actively working to prevent triggering or retraumatizing the individual through the course of care,” explains Jodi Eyigor, director of nursing home quality public policy at LeadingAge, an association of nonprofit providers of aging services, including nursing homes. “Particularly after the COVID-19 pandemic, which disproportionately impacted older adults, we know that trauma is prevalent and pervasive. It impacts the way we live, how we see ourselves, and how we relate to the world.”

According to the Substance Abuse and Mental Health Services Administration, there are six key principles to trauma-informed care, as follows:

1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment and choice
6. Cultural, historical, and gender issues

These principles help guide service providers as they work with individuals but are not step-by-step instructions for how to implement trauma-informed care. According to the CDC, “Adopting a trauma-informed approach is not accomplished through any single particular technique or checklist. It requires constant attention, caring awareness, sensitivity, and possibly cultural change at an organizational level.”1

Implementation and Impact
In long term care, trauma-informed care can begin at the door, with a screening that gives residents the opportunity to disclose trauma if they feel able. “At the most basic, [trauma-informed care] could just include a trauma assessment at the intake and a routine trauma assessment ongoing. Not all trauma is going to come out at the initial meeting,” Breder says. Ideally, she explains, a psychiatrist or team of psychiatrists would be available regularly to meet with residents, again giving individuals an opportunity to share their experiences when they feel most comfortable.

Even when an individual does share a past or present trauma, they may not provide details, and that, Kusmaul says, is fine. “It’s more about how trauma affects care, as opposed to knowing what that specific trauma is. A lot of facilities have erred on the side of ‘as long as we ask about trauma, we’re done,’” she says, adding that that’s simply not the case. “It’s about taking that information and determining how to make the person more comfortable.”

Once staff know that a resident in a long term care facility has experienced trauma, they can use this information to better understand how that resident may be responding and reacting to certain people and/or situations and to shape how they will interact with the resident moving forward both situationally and in general.

“Working from a trauma-informed perspective helps a caregiver to better recognize signs of trauma and understand that sometimes an individual’s behaviors are actually coping strategies used with the intention of surviving adversity and overwhelming circumstances,” Eyigor says. “For example, apathy and avoidance are signs of trauma. Knowing that may help a caregiver recognize that behaviors that could be interpreted as resistance to care are actually avoidance, apathy, or agitation related to trauma. As a result, that caregiver might reevaluate his or her approach for more successful care delivery.”

For instance, if a resident needs help getting changed or needs to be checked on in the middle of the night and the staff are aware that this can trigger a response, they may take extra care with the communication they provide both before and during the situation and may alter the way in which they complete the task specifically to make the resident more comfortable.

Such changes in perspective not only benefit the residents but the staff as well. With trauma-informed care, “I think there would be less frustration and more compassion, Breder says. “When I’ve talked to some staff and administrators in long term care, they want to know why is the patient behaving this way and how can we make it stop?” They don’t have a complete grasp on who the person is and what they have experienced before entering long term care. As a result, the staff may see certain behaviors and reactions as an individual being difficult or challenging rather than trying to cope with the impacts of resurfaced trauma. “Not everything that happens in long term care is a result of long term care,” Breder notes.

Support and Self-Care
However, while a trauma-informed perspective can help staff better understand and mitigate frustrating behaviors and situations, it can also be difficult emotionally for them. Hearing about or witnessing others’ traumatic events can be traumatizing or triggering.

Vicarious trauma is often experienced by professionals who work closely with individuals who have experienced trauma and is defined by the American Counseling Association as “the emotional residue of exposure that counselors have from working with people as they are hearing their trauma stories and become witnesses to the pain, fear, and terror that trauma survivors have endured.”2 While most staff in long term care facilities are not counselors, they can still experience vicarious trauma to varying degrees.

Kusmaul says this is why peer support and support for staff is a vital part of trauma-informed care. “We get busy and people put their heads down and go into ‘get-it-done’ mode. That’s the time when we most need to support each other,” she says. Kusmaul recommends that facilities have policies in place that allow staff members to tag out if they are triggered and have opportunities for staff members to debrief after challenging interactions.

“Starting those discussions and then creating a space in the clinical setting where vicarious and secondary trauma can be addressed is a major barrier,” Breder says. “Once they have heard about [the trauma] they don’t know what to do.” She cites the supervisions held in mental health settings as an example of what could help long term care staff as they work through difficulties. “The long term care setting would be revolutionized if there could be community processing.”

For any of this to happen, however, leadership in long term care must be on board. And to a certain extent, they have to be. CMS requires facilities to provide culturally competent trauma-informed care to residents who are trauma survivors. Nonetheless, the degree to which trauma-informed care is implemented and supported relies heavily on how invested leadership is and how seriously they take it.

“Trauma-informed care is an approach to care; it’s everyone’s responsibility. It’s not just about sitting through training once a year and checking the box on a training form. Delivery requires a deliberate structuring of organizations and operations and consistent modeling to ensure that an organization or care setting is one in which everyone feels safe to live, visit, work, and receive care,” Eyigor explains.

There are two types of leaders actively working on trauma-informed care in long term care at present, Sims says—those who really get it and are a part of the implementation and those who delegate the responsibility to their staff. “There’s a huge difference. It isn’t just about teaching. It’s about trauma-informed system transformation. We would go in [to facilities] and the staff would get so excited, but the leadership was ill-informed about the procedurals,” he describes. As a result, policies and practices in place would not align with the trauma-informed care approach. Staff would get frustrated, and the work would not get done. Now, Sims starts with the leaders, bringing them into the training sessions with their staff.

Again, this commitment to trauma-informed care doesn’t just positively influence the residents but the staff and the facility, as well. When leadership creates a system of trauma-informed care they create an environment where staff may be more likely to stay if the position is a good fit, as well as one that’s prepared to welcome new staff. “There’s always going to be some kind of turnover, and so you do have to figure out how you’re teaching new people about this when they’re coming in. But if you can create a system that is more supportive, perhaps you’ll have less turnover,” Kusmaul says.

Leadership and staff in long term care have a variety of resources available to them to become well-versed in (or at least build a foundation for) trauma-informed care. Sims recommends TAMAR (Trauma, Addictions, Mental Health, and Recovery), a 15-module group training created jointly by Joan Gillece, PhD, working then as the project director of the National Center for Trauma-Informed Care and the Substance Abuse and Mental Health Services Administration, as well as the E4 Center which focuses on behavioral health disparities in aging.

Kusmaul has been working with her research team on a series of short trainings on trauma-informed care. “[Each individual training] is a 10-minute video that they can look at on an ongoing basis to give them more understanding or support them once they’ve gotten [an initial] training. We’ve made them so they stand alone, but they also build together as a part of a series.”

Ideally, trauma-informed care training will become more readily available to employees in long term care over time and will become a part of the curricula for students hoping to work in long term care. After all, every resident in a long term care facility struggling with trauma deserves to have a team of professionals working with them who will, as Sims describes it, ask “What happened to you?” instead of “What’s wrong with you?”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.


1. Infographic: 6 guiding principles to a trauma-informed approach. Centers for Disease Control and Prevention website. Updated September 17, 2020.

2. American Counseling Association. Vicarious trauma.