Trauma Informed Care in a Paediatric Setting
Summary
My goal for this fellowship was to embody a Trauma Informed Care (TIC) praxis through immersive and theoretical knowledge acquisition, and to be able to apply this knowledge in my everyday practice, but especially during difficult situations. The primary goal of praxis is to combine theory and practice. As I immersed myself in the theoretical world of TIC, the depth and breadth of knowledge and resources was overwhelming. It was easy to take too deep of a dive into TIC before realizing I needed to pull back and refocus on the fundamentals. With some practice, I was eventually able to identify and cease this temptation. Though I have developed significant foundational knowledge in TIC, I believe to embody a TIC praxis will require extensive additional knowledge and experience.
I had also planned to learn about TIC clinically primarily through immersion within the SickKids Complex Care Team. This objective proved challenging because of significant limitations due to the emergence of COVID-19. Rounds involving multiple healthcare providers were discouraged and many teams switched to virtual clinical activities. These barriers forced me to pivot and re-route my fellowship plan, in a way, that ultimately served as advantageous. This enabled me to complete a Certificate in Trauma Counselling for Mental Health Professionals and focus clinical fellowship hours primarily in the emergency department; with the patient and family representative; and with COVID-19 screeners. By shadowing the emergency department social worker, on multiple occasions I was able to witness how he was able to mitigate a crisis situation using TIC. This experience supported my evolving development of TIC and the application of trauma principles.
Though there were limited staff aware of the concept of TIC, I began to find individuals throughout SickKids—some in nursing, but largely social workers—who were integrating trauma-informed approaches into all aspects of their work. As I built working relationships with these individuals, a network of supportive TIC resources across the hospital emerged. With the guidance of these practitioners, I grew more comfortable integrating the theories of TIC into my practice. On several occasions I reached out for consultation and in-the-moment support to review situations I was involved in. Now, with the occasional glance at a cue card and with the commitment to a mindfulness moment for myself, I have been able to integrate a flexible trauma-informed framework for engaging in difficult conversations where either patients, families or staff are potentially activated by past traumas.
The objective to interview leaders changed from a focus on crisis interventions to difficult conversations. I began to realize that having meaningful difficult conversations is interconnected with a TIC approach, and if we have these difficult conversations it may actually avoid a crisis situation. Healthcare providers, and in the past I myself, have dreaded, and even avoided difficult conversations. Understandably, leaders are often asked for a script. Though providing a script is difficult, surveys reflected that leaders often did have inquisitive approaches they found helpful. Themes, beliefs, tips and resources emerged. The importance of risk, vulnerability, honesty, curiosity, listening, were the most common themes, as well as the importance of practice. Engaging in difficult conversations takes practice. Prepare to fail, reflect, learn and repeat. Eventually we all will get better and we must, because as one executive leader said, “that's where the magic happens”. I have used the wisdom of these experiential learnings to produce a game to share with staff in educational sessions.
With this knowledge and additional experience, at this point, I feel much more confident and comfortable modelling, coaching and doing direct teaching on the fundamentals of trauma-informed practice. Staff have begun reaching out for guidance and advice within the scope of trauma-informed care. Among the hospital administrator team, my colleagues are opening themselves to new ways of understanding difficult and often frustrating situations. TIC is not an algorithm or formula; it is a way of Being: it is the understanding that our past experiences influence how we react and respond to our present-day experiences. Through this understanding, many possibilities for new ways of being with especially ‘difficult’ patients and families emerge. Compassion within staff is cultivated not only intellectually, but at the heart level. Drawing on a trauma-informed lens has contributed to an energy of hope and inspiration among my colleagues. In the same way that trauma is learned through our experiences, trauma can also be unlearned—that is, it can be changed and shaped by TIC that centres patients and families as informed collaborators rather than recipients of healthcare.
Outcomes
Just prior to the fellowship, I had an experience with a teen that did not go well. For the first time in my thirty-five years, I initiated a 911 call to Toronto Police Services. That was the first of many “code whites”—meaning, behavioural/agitation and aggressive situation—initiated on this patient. Near the end of this patient's discharge we learned of significant trauma and that he felt unsafe, vulnerable and scared.
This fellowship has made me consider ways that I, and other team members, could have potentially managed this situation and prevented further code whites from occurring. This teen was chemically and physically restrained multiple times. I wonder if in a moment of calmness and lucidity if we asked this patient what happened to him, tried understanding his triggers, and collaboratively developed a safety plan, maybe we would have created a safe space for him. A place to feel heard in his story, but at the very least, prevented re-traumatization. I feel we missed an opportunity to transform what became a very disturbing situation for this patient and for all involved.
I share this experience because it encapsulates so much more for me than any one description of ‘outcomes’. The principles of TIC—safety, trustworthiness, transparency, choice, collaboration and empowerment—has the power to shift an explosive situation where someone, or many people, are dysregulated and outside their window of tolerance, into safety and regulation. Trauma-informed practice has changed the way that I approach situations; it has helped embed the principals into both my thought process and practice. And I believe, in the aforementioned situation of the father who wanted to leave against medical advice, using a TIC approach averted a crisis and may have prevented re-traumatization, unlike the patient who had multiple code whites.
I think for my colleagues, becoming aware of the TIC paradigm has been inspiring. One of my colleagues recently asked me for advice on how to manage a conversation with a mother who was well known to be “challenging”. Another asked me how I would approach a discussion with a staff member she was dreading. I turned this latter situation into a TIC case study. On a Friday evening in January, eight hospital administrators participated—on their own time—in a virtual case study applying a TIC lens. At the end of the case study a Senior Manager said “I have done a lot of these with our team. This was better than any of the cases we’ve reviewed with ethics in my time”. My mentors and I have planned to meet every two weeks beyond the fellowship. This will provide an opportunity for learning and sharing multiple aspects of TIC and additional case studies.
I have planned an educational retreat on TIC for our team. They all have expressed great interest and support in learning about TIC. Like myself, I believe with continued education and support, they too will become interested in becoming champions of TIC.
At the level of SickKids as an organization, this opportunity has highlighted my interest in TIC at multiple levels. I have had the opportunity to use a TIC lens when contributing to formalizing several policies and procedures. I have recently been asked by the Associate Chief of Nursing to join the newly established Code White Oversight Committee.
Lastly, a Child Life Specialist and I have collaborated on a pilot project called What Matters To Me?. Selected patients receive a laminated poster and markers. With words and pictures patients share their likes, dislikes and what is important to them. The poster is placed on their door where all staff are asked to view it before entering. Staff in this area have already reported changes in practice as a result. Two of the senior executives were “thrilled” when they learned of this project on a tour of the area and took pictures to share with others. In the end however, our hope is that this project will heighten awareness of the uniqueness of each patient and the importance of them having a voice, agency and feeling seen and heard. All critical to TIC.
Overall experience
This fellowship has given me the enormous opportunity to engage in learning that I would not have had otherwise. When I reflect on my favourite moments, numerous surface: the aha moment when I learned about The Window of Tolerance and a concept called name it to tame it; observing and identifying TIC principles being applied in practice in a compassionate and organic way; the phenomenal trauma counseling course I completed; and successfully piloting two TIC based projects.
A very special and affirming moment occurred however, towards the end of my fellowship which was a gift that left me with a feeling of confidence and validation in the efficacy of TIC. It was elements of all these favourite learning moments, and others, that informed me as I approached a difficult and escalating situation with a father that wanted to leave against medical advice. There were multiple surgical services involved with this patient. Before I went to speak with the father, I joined the healthcare team to hear their story. What I heard from the team was: this child needs to stay here, other hospitals are not taking children due to COVID and this dad is refusing care. When I spoke with the father I heard: I’m being told different information from different practitioners; I was promised a single room but did not receive it; I was told it would be twenty minutes and it’s been over an hour.
Approaching this situation with a TIC approach and working with the medical team in this regard shifted this situation profoundly. One of the tenets of TIC is to change the question “what’s wrong with you” to “what’s happened to you?” This seemingly simple TIC teaching validated the importance of this parent’s experience, eventually restored his confidence in our team, communicated that we were here to truly help, and it gave me hope. That was the moment I knew TIC matters, is possible, and that though I am still learning, I have the capacity to integrate these learnings into my practice and to truly make a difference.
