Trauma-Informed Care Addressing the Mental and Emotional Needs of Patients With Cancer

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Trauma is present in the lives of almost all patients and staff, requiring recognition and management to develop effective and collaborative treatment relationships (Litam & Balkin, 2021; Schein et al., 2021). Implementing trauma-informed care (TIC) at macro and micro levels can have lasting improvements on the health and well-being of patients and care team members (Dowdell & Speck, 2022). Although many systems adopt the definition developed by the Substance Abuse and Mental Health Services Administration (2024), there are no operational manuals guiding the implementation of TIC into clinical oncology practice (Davidson et al., 2023). However, TIC can serve as a framework to provide clinical oncology care. Healthcare providers and systems working together create safe environments for delivering TIC, which maximizes positive regard while enhancing meaning and purpose to address the drivers of burnout (e.g., lack of resources, increased demands, reduced autonomy, poor work–life integration, isolation/lack of support, misaligned organizational–personal values) (Swensen & Shanafelt, 2020). Integrating TIC into standard care can help patients with cancer, oncology clinicians, and organizations. Applying TIC can result in the following: (a) patients’ increased satisfaction, treatment adherence and retention, and safety, as well as decreased use of restraints; (b) increased staff autonomy, satisfaction, and retention; and (c) improved organizational policies and procedures, decreased turnover rates and related costs, and increased organizational transparency.

Background

Trauma Defined

In the past, a discussion about trauma may have been considered taboo; however, trauma as a concept is now widely discussed and disseminated in published literature and social media, and is more broadly accepted (Pandell, 2022). Although concepts of trauma range from highly volatile and life-threatening peak events to more emotionally toxic, insidious, and eroding experiences, there is a growing consensus that individual and collective experiences of trauma have lasting effects (Dye, 2018). The American Psychiatric Association (2013) defines trauma somewhat more strictly as “the emotional response to a terrible event in which one experiences or is exposed to actual threat or threatened death, serious injury, or sexual violence” (p. 271). This includes experiencing these events firsthand, witnessing these events occurring to another person, learning about the traumatic experience of someone close, and having “repeated or extreme exposure to aversive details of the traumatic event” (American Psychiatric Association, 2013, pp. 271–272). Recognition and discussion of the traumatic event is not central to TIC; instead, TIC focuses on the emotional effects or responses to the event. Maté and Maté (2022) noted that “trauma is not what happens to you. Trauma is what happens inside you when something happens to you” (p. 20).

Post-Traumatic Stress Disorder

Despite ongoing discussions that highlight and dilute trauma terminology, trauma as a concept has a strong foundation in research. Although aspects of trauma were initially recognized and studied in veterans of war dating back centuries, it was not until symptoms of post-traumatic stress disorder became more apparent in veteran generations following World War II and the Vietnam War that psychological and medical providers began studying trauma (Briere, 1997). The focus then broadened to include nonmilitary trauma, such as intimate-partner violence, rape or sexual assault, child abuse and neglect, community violence, severe injury, medical crises, and more (Ballenger et al., 2000). Researchers now suggest that as much as 80% of the U.S. population will be exposed to at least one trauma in their lifetime (Barzilay et al., 2019). Although a small proportion will develop and need treatment for post-traumatic stress disorder, for many people, the emotional and physical sequelae of their traumatic experiences will manifest in other mental illnesses, substance misuse, chronic physical illnesses, and social and financial problems (Bürgin et al., 2020).

Trauma in Patients With Cancer

Clinical oncology providers have expertise in the physically, emotionally, and even spiritually challenging aspects of a cancer diagnosis and subsequent treatment (Lee & Ramaswamy, 2020). Despite advances in medical science and increasing survival rates for previously incurable cancers, nearly every person diagnosed with cancer will receive this news as a threat to their lives and/or their hopes (National Cancer Institute, 2023; Rahib et al., 2021). A person diagnosed with cancer acknowledges the threat to their livelihood well before they undergo the multitude of required tests and procedures, receive challenging news, and experience illness-associated isolation. A patient experiences several adverse effects; body changes; and financial, social, and interpersonal changes, creating risk for retraumatization (Abrams et al., 2021). Every aspect of life could be touched by a cancer diagnosis and its related illnesses. If, with treatment, a patient survives relatively unscathed, or at least not permanently disabled, the they may be expected to resume life as if nothing life-altering just happened to them (Cesanek, 2022). Despite being traumatized, the patient may be expected to overcome their diagnosis and provide hope to their loved ones. Oncology providers have to be active in the support of the patient (Hlubocky et al., 2016). A meta-analysis showed that studies have contributed to an understanding of trauma, clarifying common sources of trauma and acknowledging that aspects of oncology and medical care are traumatic (Shand et al., 2015). As a foundation for care, clinicians can apply the TIC framework to aid the patient and respect the humanity of providers (Reeves, 2015).

Adverse Childhood Experiences and Health Outcomes

To explore a broader scope of trauma and understanding of adverse experiences, social scientists have studied how all people, including those in historically marginalized or underrepresented communities, could be affected over time by adverse childhood experiences (ACEs). For example, in the late 1990s, Kaiser Permanente published a longitudinal study about ACEs, which highlighted the consequences of trauma experienced in early childhood (Felitti et al., 1998). ACEs are conceptualized across domains of abuse, neglect, and relational or household dysfunction (see Table 1). 

Higher ACEs scores have been associated with an increased risk of a variety of potential health outcomes (Crandall et al., 2019). Although there is extensive academic and clinical support for ACEs, critics suggest that a lack of focus on community and interpersonal identities may also create risk (Matlin et al., 2019; Rides At The Door & Shaw, 2023). Another research area has focused on the effects of trauma associated with weathering. Geronimus (1991) termed, researched, and advocated around the concept of weathering, defined as when Black adults (later expanded to include other underrepresented racial groups) experience negative health outcomes caused by the cumulative effects of political marginalization or social or economic adversity (Geronimus, 2023; Geronimus et al., 2023; Hampton-Anderson et al., 2021).

Although early work by Geronimus (1991) was highly controversial, more recent data have confirmed what researchers also refer to as allostatic load on members of marginalized communities including Black, Indigenous, and people of color, as well as lesbian, gay, bisexual, transgender, queer/questioning, intersex, or asexual people (Levenson et al., 2023; Meléndez Guevara et al., 2021; Rides At The Door & Shaw, 2023). The theory of allostatic load proposes a slow and steady wear and tear on the body or damage to biologic systems caused by the effects of chronic stress. Allostatic load can negatively affect many health outcomes (Guidi et al., 2021; Parker & Johnson-Lawrence, 2022). Much like ACEs, the effects of weathering and allostatic load have been linked to economic and health outcomes, including cancer (Shen et al., 2022), cardiovascular disease (Borrell et al., 2020), chronic pain (Mickle et al., 2022), diabetes (Macit & Acar-Tek, 2020), maternal and fetal mortality (Riggan et al., 2021), obesity (Cullin, 2023), anxiety (Finlay et al., 2022), depression (Beydoun et al., 2023), post-traumatic stress disorder (Carbone et al., 2022), and increased risk of suicide (Valderrama et al., 2022). In addition, trauma has been associated with social outcomes, including alcohol and drug use (Rogers et al., 2021), tobacco use (Wiggert et al., 2016), educational attainment challenges (Gilmore et al., 2022), legal issues/incarceration (Gibbons et al., 2020), and poverty (Ribeiro et al., 2018).

Purpose and Methods

This article provides a literature-based overview of using TIC when caring for people with cancer based on clinical studies, expertise, and data-based guidelines. Relevant literature in psychological and nursing sciences were reviewed, with the inclusion of published and seminal works. To support and illustrate TIC applied to clinical oncology practice, this article reviews the TIC model created by the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration; the value of TIC to patients, staff, and organizations; a patient case study; nursing approaches to TIC and implications; and TIC resources.

Results

TIC

Based on a more inclusive definition of trauma that incorporates resilience and effective coping, the TIC model aims to better understand the lived experiences of individuals who have experienced a variety of traumas, recognize the effects of these experiences, and limit retraumatization (Dowdell & Speck, 2022; Erickson & Harvey, 2023; Goddard et al., 2022). This model is nonhierarchical. By approaching the patient’s trauma and ensuring respect for their individual experience, TIC can be experienced equally by the patient and the provider or care team member, in contrast to a top-down approach that affects only the patient. Rather than solely focusing on what experiences the patient may bring to the interaction, providers are aware of their own traumatic experiences, too, informing the clinical space and their relationship with the patient (Menschner & Maul, 2016). Trauma is associated with a patient’s perceived absence of safety, and TIC can establish a sense of physical and emotional safety (Parker & Johnson-Lawrence, 2022). Figure 1 illustrates the TIC model. 

Applying TIC in Oncology Care

Studies have demonstrated the value of TIC in a variety of settings and populations, including schools, mental health facilities, and medical settings (Centers for Disease Control and Prevention, 2018). When applied in the oncology setting, this approach can enhance patient–provider collaboration, including more transparent discussion of disease, treatments, side effects, adherence, quality of life, and end-of-life concerns (Mahon, 2022). Oncology providers can apply an assumption of historical trauma or a universal precautions approach to effectively connect with the patient’s needs and provide appropriate care (Goddard et al., 2022). This approach assumes that each patient has a wealth of challenging prior experiences and traumas, as well as strategies and adaptive skills to bolster their resilience (Hales et al., 2019; Mahon, 2022). To build a healthier workplace culture, this approach can also validate the experiences of providers and their colleagues, recognizing their need for support (Menschner & Maul, 2016).

Discussion

Individuals with a history of trauma may experience feelings of powerlessness, helplessness, and fear. Authoritarian communication may further exacerbate these feelings, highlighting the importance of collaborative communication, and fostering partnership and cooperation (Roberts et al., 2019). When nurses allow patients to set the agenda and fully engage in their health care through patient-centered communication, they empower and support the patient’s resilience (Roberts et al., 2019). 

For providers to avoid retraumatizing patients, they can create a safe environment, thoroughly educating patients about what to expect with procedures, appointments, and examinations (Roberts et al., 2019). Nurse–patient communication based on cultural and historical sensitivity honors a person’s identity, including their race, ethnicity, gender identity, sexual orientation, age, religion, experiences, and relationships (Dowdell & Speck, 2022). TIC strives to empower patients by giving them a more central voice, respecting their choices, and building a sense of safety, health literacy, and understanding of the healthcare environment (Dowdell & Speck, 2022). Understanding that uncertainty is associated with subjective and physiologic measures of stress, nurses applying a TIC approach to oncology care can foster understanding and trust. Figure 2 includes resources that support TIC in clinical care. 

Thorough implementation of TIC requires a trauma-informed culture at the macro level (Fleishman et al., 2019). Efforts to ensure that an organization’s culture, policies, and procedures are trauma informed can take tremendous time; however, nurses can apply a trauma-informed lens to their care at the micro level by showing awareness, sensitivity, and responsiveness, one patient at a time (Fleishman et al., 2019). Aligning with the guiding principles of TIC does not require expertise in the treatment of trauma; rather, a TIC approach underscores that provider interactions with patients are within a context of previous trauma (Andrejko & Katrichis, 2022) (see Figure 3). Shifting care from a paternalistic, medical approach to a more collaborative process can establish a foundation for shared decision-making (Dhawan & LeBlanc, 2022). To shift as a profession, healthcare providers must operationalize policies and procedures and build resources for nurses to deliver this care (Foli, 2022). TIC provides care that can be mutually respectful and collaborative. Fleishman et al. (2019) reported that nurses are using trauma-informed principles, with correlations to this practice in action (see Table 2). 

Implications for Nursing

Nurses are recognized as the most trusted professionals in health care (American Nurses Association, 2024) and are uniquely positioned to influence patient experiences and act as advocates within the healthcare system. Rooted in Watson’s (2011) theory of human caring, nurses are able to practice loving kindness, build trusting relationships, and allow space for each individual to share their story and experience. The healthcare system is populated by trauma survivors (Fleishman et al., 2019). A survey by Fleishman et al. (2019) estimated that 73% of respondents had at least one ACE, and an additional 14% experienced trauma caused by various factors, such as community violence or racism. Nurses can recognize the effect that trauma has on patients, as well as the potential effects it can have on healthcare professionals. Patients and healthcare workers can contribute to a foundation of trust and respect toward effective patient–provider relationships. Caring for patients requires nurses to be honest about their own emotional experiences when working with patients and to rely on their team when feeling personally triggered or needing to step away. In addition, acknowledging trauma can contribute to an understanding about patterns of healthcare utilization and adherence, as well as employee turnover and absenteeism (Fleishman et al., 2019).

TIC and mitigating factors associated with burnout prompt the following strategies to be applied in clinical oncology care: Create safe environments with adequate resources; encourage trust and psychological safety; provide space for peer support to limit isolation around challenging cases; foster collaboration, flexibility, and control; empower team members to voice concerns; and align individual and system values, honoring cultural concerns (Dowdell & Speck, 2022). When care is based on poorly functioning systems without a context for trauma or a lens toward well-being, patients and employees can feel detached, cynical, and opposed to adhering to policies (Elisseou, 2023). When applying TIC or using mitigation strategies to reduce burnout, patients and providers can become more engaged and dedicated. When applying TIC to clinical oncology practice, nurses can ask whether this approach to care does the following:

• Make the patient and others feel safe.
• Promote respect.
• Foster trust.
• Offer paths to support.
• Provide the patient with choices.
• Allow the patient’s perspective.
• Honor the individual in the context of how they live. 

Conclusion

Trauma affects all patients. Providers can approach clinical care of patients with cancer using TIC. By applying TIC to clinical oncology care, patients and healthcare providers build a clinical care environment that values emotional space for safety, transparency, collaboration, and hope. This environment allows patients to feel supported and respected. In addition, healthcare providers who apply TIC to clinical oncology care can work collaboratively, which can reduce burnout and support professional fulfillment. 

About the Authors

Elizabeth Archer-Nanda, DNP, APRN, PMHCNS-BC, is an advanced practice clinical director with the Norton Healthcare Office of Advanced Practice and the founding provider and manager of the Behavioral Oncology Program at Norton Cancer Institute, both in Louisville, KY; and Meagan L. Dwyer, PhD, is a licensed psychologist at Starboard Therapy and Coaching in Kansas City, MO. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Archer-Nanda can be reached at elizabeth.archer-nanda@nortonhealthcare.org, with copy to CJONEditor@ons.org. (Submitted November 2023. Accepted February 17, 2024.)