Implementing a trauma-informed care training for inpatient psychiatric units : a quality improvement project
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Background and Significance: Trauma, defined by Substance Abuse and Mental Health Services Administration as an experience(s) that is emotionally or physically harmful that is accompanied by long-lasting negative sequelae affecting the spiritual, mental, emotional and/or physical function in mental health patients, is widespread (Jackson & Jewell, 2021; Cilia Vincenti et al., 2020). Trauma is often the root of many mental illnesses, including depression, and post-traumatic stress disorder (Darnell et al., 2019). Trauma informed care (TIC) is the practice of understanding and appreciating the effects of psychological trauma and using that understanding in interactions with the patient (Sweeney et al., 2018). Many patients admitted to inpatient psychiatric facilities have experienced trauma (Muir- Cochrane et al., 2018). Inpatient facilities have a long history of utilizing seclusions and restraints (S/Rs) to keep patients safe from harming themselves and others (Perers et al., 2022). Although there is widespread concern relative to the continuation of S/R practices, those practices continue to be utilized (Muir-Cochrane et al., 2018). When patients are subjected to S/R, the effects identified are mostly negative, including feelings of distress and punishment (Perers et al., 2022). Additional poor outcomes after an S/R intervention included feelings of humiliation, anger, fear, and powerlessness (Perers et al., 2022). Furthermore, S/R practices have led to many negative outcomes, including injury and death (Muir-Cochrane et al., 2018). Both the Joint Commission and Centers for Medicare and Medicaid Services clarify that S/Rs should only be used as a last resort in the protection of a patient or others. However, they are commonly utilized on patients who feel frightened and have a perceived lack of control over their own lives after having been subjected to the control of others (Azeem et al., 2017). Alternatives to S/R, including TIC practices, have only been developed in the last two decades (O’Dwyer et al., 2021). The perceived benefit of using TIC instead of S/Rs is that TIC does not use methods that will physically overpower the patient, does not cause feelings of humiliation and punishment and avoids the disruption in the therapeutic relationship between patient and caregivers (Hawsawi et al., 2020). In addition, the implementation of TIC in place of more restrictive interventions may increase staff morale and foster more collaboration amongst the healthcare team that cares for these patients due to the preservation of the therapeutic relationship, which is based on trust between the patient and the caregiver (O’Dwyer et al., 2021). Trauma in the form of post-traumatic stress disorder costs the United States over $232 billion in 2018 (Davis et al., 2022). Trauma takes a toll on those experiencing trauma through a decline in mental and physical health, including increased suicide attempts, increased medications, and hospitalizations (Sweeney et al., 2018). If trauma is not addressed through appropriate mental health treatment, the cost of psychological trauma may continue to rise, and that trauma could be passed from one generation to the next (intergenerational trauma; Sweeney et al., 2018). Additional financial implications of trauma and S/R interventions on the inpatient mental health units include the possibility of injury to staff and patients, resulting in additional financial burdens for treatment of these injuries, lawsuits filed by the patients, and employee workers' compensation claims (Perers et al., 2022). Implementing an alternative protocol to S/R, such as a TIC protocol, may assist in decreasing those costs.
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