QI Project: Trauma-

Informed Care Training in

the Workplace
Leticia Anderson, Taylor Sunseri, Sara Vo, Alex Wheeler, Leslie Yip
Topic

Building a trauma-informed culture with ED staff to reduce violence in the

workplace, specifically violence in the ED due to behavioral health
emergencies
Background

● The emergency department environment is very stressful, especially for those

experiencing behavioral health emergencies
○ Inequities in healthcare services for mental health conditions and
substance use disorders
○ ED staff may not view mental health as a part of their scope of practice
● Trauma-informed care reshapes the environment to avoid retraumatizing
patients
● Trauma-informed care can reduce agitation and aggressive behavior toward
staff
 Manpower Methods
Lacking protocol for behavioral
Inadequate training in working
health trauma
with those facing mental
health issues The communication between staff
Staff burnout
(stressful tones)
Lack of understanding for patients
Behavioral health
crises in patients and
retraumatizing leads
Using force to restrain a combative
patient, risking injury to self and patient Patient volume to violence toward
Surrendering of clothes and personal
staff
Beeping machines
belongings→ scrubs
Long wait times in the hallway or ligature-
resistant room
Addition of a sitter

Equipment Environment
Root Cause Analysis

● Not understanding that behavioral health crisis IS JUST AS SERIOUS as medical crisis
● inadequate training for staff // lack of protocol for behavioral health emergencies
○ “Lack of organizational policies and training for security and staff to recognize and deescalate
hostile and assaultive behaviors from patients, clients, visitors, or staff” (The Joint Commission,
2018)
● Summary statement: Protocols on how to care for patients coming into the ED in a
mental health crisis were minimal to none, so ED staff did not understand the needs of
these patients, and the quality of care these patients received suffered
Action to Prevent Further Occurrence
● Root cause categories:
○ Lack of training
● What is missing?
○ Trauma Informed Care (TIC) education package for ED nursing staff that explains the neurological,
biological, psychological, and social effects of trauma on an individual’s mental health, and puts it into
practice
● What is influencing staff to rely on personal judgement instead of policy?
○ Although nurses are provided with a framework to reduce restrictive interventions including seclusion or
physical restraint
○ BUT nurses are still not being properly educated on the use of TIC and how to utilize the skills into practice
○ → exacerbate symptoms of past trauma leading to aggressive or violent behavior and risk of harm to self
and others
● What tools/resources are needed?
○ Specific education about the effects of trauma on an individual’s mental health + Opportunities to practice
acquired knowledge in supportive peer environments = TIC education package with practice of skills into
practice
○ ED mentors and leaders to continue with supportive care and ongoing education
(Hall et al., 2016)
 Action Statements

● TIC training manual with visual presentation materials

○ Rationale:
■ To avoid re-traumatising a patient during care which could lead to triggering memories of violence
or victimization.
■ To reduce the likelihood of aggressive and violent behavior and harm to self/others
● On the day of TIC education, a pre- and post-education 18-item questionnaire will be filled out
○ Rationale:
■ Pre-questionnaire will ask about current practice and display nurse’s own biases and
incompetencies within trauma education.
■ Post-questionnaire will allow nurse to respond about what they learned and promote change in
their response to mental health crisis in the ED

(Hall et al., 2016)

 Action Statements

● Three-month post TIC education package qualitative focused interview

○ Rationale:
■ Allows the nurse to ensure they are actively working on their TIC over those three months after the
TIC education.
■ The interview will ask what changes they have made and how they have applied their training into
practice. Encourages the nurse to think of actionable change for the future
● Provide a resource in the ED specifically for mentoring, regular debriefing, and ongoing TIC education
○ Rationale:
■ Ongoing support and active leadership may assist in the translation of knowledge into
practice

(Hall et al., 2016)

Trauma Informed Care Modules

What would the TIC education plan look like?

● Introduce and define Trauma Informed Care

● Introduce the neurobiology behind trauma and its effects on the brain/amygdala
● Discuss social consequences of prolonged trauma (adverse childhood events, etc)
● Describe the Cognitive Model of Trauma - how short-term solutions become long-term problems
● Discuss ways to avoid reinforcing negative beliefs
● Responding to stories with compassion and concern
● Discuss the effects of stress on mental health professionals and strategies for self-care
● Discuss how the training has influenced knowledge of trauma and how to implement new knowledge into the workplace for immedia
effect

(Hall et al., 2016)

Outcome Measures

Numerator: Total number of minutes restraints used in ED for all patients

Denominator: Total number of all patients in ED where restraints used

Threshold: 98% of the minutes in ED will be restraint-free

Date/Time Frame: Data from 8 hospitals in the United States will be collected for 18 months
Outcome Measures Type

● Type: Adverse Event Outcome

● Rationale:
○ To demonstrate that staff training in trauma-informed care reduced the
occurrence of patient violence and staff assaults in the ED
○ This outcome measure is effective because improvement of the action
reduces the incidence of adverse events
● Outcome statement: Three months following staff training, average daily
duration (in minutes) of restraints used in the ED will be reduced by 50%.
Stakeholder Analysis

Internal (unit) stakeholders External stakeholders

● ED staff ● EMS
○ Nurses, doctors, techs, aids, and admin. ● Mental health services
● Hospital organization ● Patients
○ Reimbursement ● Visitors
○ Family members and loved ones
Force Field Analysis
Forces FOR change
(Driving forces)
● Lack of policy, training, and education
● Environment in the ED is not
conducive for patients experiencing a
mental health crisis
● Lack of continuity of care
Strategies to Mitigate Restraining Forces:
● Evidence-based practice education on trauma-informed care
● Upstream approach
Forces AGAINST change
(Restraining forces)
● ED staff not viewing mental health
services as part of their scope of
practice
● Stigma of mental health conditions
and substance use disorders
● ED staff secondary traumatization
and burnout
References
Coutré, L. (2019). Healthcare workers face violence 'epidemic'. Retrieved from

https://www.modernhealthcare.com/providers/healthcare-workers-face-violence-epidemic

Hall, A., McKenna, B., Dearie, V., Maguire, T., Charleston, R., & Furness, T. (2016). Educating emergency department

nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC nursing, 15,

21. https://doi.org/10.1186/s12912-016-0141-y

IAHSS Foundation. (2019). 2019 Healthcare Crime Survey. Retrieved from https://iahssf.org/assets/2019-Healthcare-

Crime-Survey-IAHSS-Foundation.pdf
References

Schall, M., Laderman, M., Bamel, D., Bolender, T. (2020). Improving Behavioral Health Care in the Emergency Department

and Upstream. IHI White Paper. Boston, Massachusetts: Institute for Healthcare Improvement

The Joint Commission. (2018). Sentinel Event Alert. Retrieved from

https://www.jointcommission.org/-/media/documents/office-quality-and-patient-

safety/sea_59_workplace_violence_4_13_18_final.pdf?db=web&hash=9E659237DBAF28F07982817322B99FFB

VA National Center for Patient Safety RCA Tools (2015). Root Cause Analysis Tools: VA national center for patient safety.

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