Trauma-Informed Nursing Practice

Joan Fleishman, PsyD; Hannah Kamsky, BSN, RN, CCCTM; Stephanie Sundborg, PhD


Online J Issues Nurs. 2019;24(2) 

In This Article

Abstract and Introduction


Trauma-informed care (TIC) is a patient-centered approach to healthcare that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff. TIC is applied universally regardless of trauma disclosure. Grounded in an understanding of the impact of trauma on patients and the workforce, TIC is conceptualized as a lens through which policy and practice are reviewed and revised to ensure settings and services are safe and welcoming for both patients and staff. The TIC framework is being implemented in healthcare and should be incorporated in daily practice, especially in nursing. Nurses have ample opportunities to influence the experience of patients and colleagues, and nursing is a critical field in which to introduce a trauma-informed approach. However, TIC implementation can be challenging if it's unclear what to do. This article discusses trauma-informed care, and TIC in healthcare and provides strategies for trauma-informed nursing practice, followed by organizational considerations for the nursing workforce.


Two-thirds of adults responding to the 2018 Stress in America Survey (n=3,458) indicated significant levels of stress in a number of areas, including healthcare (American Psychological Association [APA], 2018). This reinforces a pattern that has been steady or increasing for years, across all demographic groups. Stress occurs when individuals are uncertain about how to ensure their own social, physical, or mental wellbeing (Peters, McEwen, & Friston, 2017). In fact, uncertainty is associated with both subjective and physiological measures of stress (De Berker et al., 2016). When a stressor is temporary or manageable, the stress response system is efficient and effective (McEwen, 2007). However, when stressors persist and uncertainty continues, the stress response can become maladaptive and lead to illness and disease (Hackney, 2006; Peters et al., 2017).

More than two decades of research have contributed to the knowledge that stress and adversity is associated with poor social, emotional, and physical outcomes later in life (see the seminal manuscript by Felitti et al., 1998). Specifically, childhood adversity or trauma is associated with increased risk of heart disease, diabetes, autoimmune disorders, and even premature mortality (Brown et al., 2009).

Stress and trauma also affect behavior and engagement with services. The healthcare system can be re-traumatizing for patients with trauma history (Dubay, Burton, & Epstein, 2018).

When individuals feel threatened they rely on the parts of their brain aimed at survival, or the flight, fight, or freeze system (McEwen, 2007). As a result, the rational parts of the brain involved in memory, planning, decision making, and regulation become less important. In healthcare settings, this can impact the patient's engagement with services and ability to adhere to treatment plans (Sansone, Bohinc, & Wiederman, 2014). Healthcare organizations are striving to incorporate this understanding into their own settings and practices, recognizing the potential for re-traumatization and its impact on care (Schulman & Menschner, 2018). They are turning to approaches like trauma-informed care (TIC) for guidance.

This article begins with an overview of TIC, and then discusses implications of a TIC framework in healthcare, generally, and then specifically as it relates to nursing practice. Nurses have ample opportunities to influence the experience of patients and colleagues and nursing is a critical field in which to introduce a trauma-informed approach. To assist in TIC implementation we will provide strategies for nurses to use in practice, followed by considerations for organizations and the workforce.