The impacts of vulnerability and associated trauma endure from childhood into adulthood and affect an individual's health and wellbeing in ways that are not always visible to others (Felitti et al, 1998). Nurses and midwives must understand the research and literature behind these concepts if they are to help affected people enhance their health and wellbeing.
Although the recognition and understanding of trauma has been developing for more than 50 years, appreciation of the enduring impact it has from infancy to adulthood is a relatively recent concept. Originally considered in terms of the mental health problems experienced by soldiers on their return from war, trauma was formally recognised as post-traumatic stress disorder (PTSD) in the 1970s. Since then our understanding of trauma has broadened to include many other types of traumatic experiences (Asmussen et al, 2022).
What is trauma?
Trauma may be an event, a series of events, or a set of circumstances that a person experiences as physically or emotionally harmful or life-threatening. Usually unexpected, it overwhelms an individual's coping resources and causes them to feel frightened, vulnerable, and helpless. While specific to the individual, generally the experience of trauma in the absence of protective factors will cause lasting adverse effects, limiting the ability to function and achieve mental, physical, social, emotional, or spiritual health and wellbeing. Conversely, the presence of strong protective factors can change the outcomes considerably, making any impact temporary and allowing the individual to benefit from education, employment, and friendships (Substance Abuse and Mental Health Services Administration (SAMHSA), 2012).
What does vulnerability mean?
The experience of trauma is known to be unequally distributed throughout society. Individuals are more likely to experience trauma because the circumstances in which they are born, live, their age, or disability increases the likelihood of abuse and neglect (Felitti et al, 1998). This means that they need others to provide special care, support or protection to reduce their risk of trauma and susceptibility to harm. The definition of vulnerability is different for a child and an adult. A child is dependent on the adult to keep them safe from harm. Vulnerability therefore increases when the adult's actions or inactions cause the child harm (Children's Commissioner, 2017).
For an adult, vulnerability is defined when a person over the age of 18 years is at risk from exploitation (including financial and sexual exploitation). Again, when unable to care for themselves, the adult is reliant on others to keep them safe from harm (Office of the Public Guardian, 2022). Usually, this supportive and practical care is provided by family and friends but in their absence, people are reliant on formal carers provided by social care organisations. Irrespective of the source, vulnerable adults require safe and supportive care from others who can prioritise their needs (Office of the Public Guardian, 2022).
Why is it important to consistently define vulnerability?
Consistent messaging about trauma and the factors which lead to vulnerability (including alcohol and drug use, domestic violence, and abuse) increase the potential for early recognition and the implementation of care, services, and practical help, known to reduce the trajectory of vulnerability into adulthood (Asmussen et al, 2020). The earlier this happens in life the better the outcomes. Inconsistency means that early warning signs continue to be missed and children enter adulthood unable to maximise their health and wellbeing.
What is trauma-informed practice?
Originating in the field of mental health, trauma-informed care has moved from being a series of interventions used to engage vulnerable individuals in evidence-based mental health treatments to a broad set of principles used to facilitate neurological, biological, psychological and social development despite the limitations caused by traumatic experiences (Table 1). This set of principles has been adopted by schools, child protection services and the criminal justice system to create measurable benefits for children and adults (Homes and Grandison, 2021).
Table 1. The six principles of trauma-informed practice
| Principle | Practice | |
|---|---|---|
| 1 | Safety | Ensuring consistent and efficient physical, emotional, and environmental safety |
| 2 | Trust | Providing clear and accurate information about aims, objectives and professional boundaries |
| 3 | Choice | Recognising and providing opportunities for choice and shared planning |
| 4 | Collaboration | Prioritising and providing opportunities for shared decision-making and partnership working |
| 5 | Empowerment | Promoting and enabling people to develop skills, knowledge and understanding to voice their opinions and choices |
| 6 | Cultural consideration | Practising and prioritising client and practitioner voice and inclusivity |
Rather than treating trauma-related difficulties, trauma-informed practice seeks to remove the barriers including fear, the lack of choice and loss of control caused by the traumatic experience. The aim is to increase service accessibility by creating culturally sensitive, safe services that people trust and want to use. It also seeks to prepare practitioners to work in collaboration and partnership with people and empower them to make choices about their health and wellbeing (Fallot and Harris, 2009).
For nurses, midwives and the wider health and social care professional workforce working in this way increases the potential to recognise that people's ability to access and use services may be influenced by their experiences of trauma and vulnerability. It also helps them to adapt their practice so that they can engage and develop therapeutic relationships with people using their services.
Being aware
Why should health and care professionals be aware of these terms and understand the impact they have on people? Both vulnerability and trauma are important concepts to understand because the impact of traumatic life experiences are not always visible at the time of the event but may affect people's lives later.
Vulnerability is complex and multifaceted and may be temporal, so specific populations may be at greater risk of poor health outcomes in times of crisis. Those affected may stop achieving in life and feel unable to engage or access services once they experience the impact of the traumatic event.
Nurses and other health professionals who do not know the terms or understand the concepts may incorrectly respond to the signs and symptoms that people show because of trauma. For example, children's behaviour may be poor and disruptive, and adults may constantly refuse services and display non-concordance with treatments, which can falsely suggest that adults should be excluded from services, for example, or a child disciplined, rather than offered greater support and practical help.
Why is trauma-informed practice important?
Vulnerability, traumatic experiences and wider inequalities can impact on people's health and wellbeing from childhood, and across the life course. Knowing that the impact is not always visible and understanding how best to support vulnerable people to access services will enable nurses, midwives and other health and care professionals to provide accessible, appropriate, and effective care.
The ability to see beyond the presenting behaviours, which can be a defensive response and to ask ‘What does this person need?’ rather than ‘What is wrong with this person?’ can help reframe the practitioner's approach, improve service outcomes, efficiencies and effectiveness (Table 2).
Table 2. The importance of trauma-informed practice to the NHS
| Implications of trauma and vulnerability | Advantages of trauma-informed practice | |
|---|---|---|
| 1 | The financial cost of late intervention is estimated to be more than £16 billion a year | Trauma-informed practice would save the NHS more than £16 billion a year—money that could be invested in effective early intervention |
| 2 | The cost to society | Trauma and vulnerability create more health and social inequalities.This creates a cycle of deprivation, because some social determinants of health, including unemployment and poor educational attainment, make people more vulnerable. Addressing these factors should also reduce health inequalities more generally |
| 3 | Social exclusion | A lack of awareness about the impact of vulnerability can lead to social exclusion, a lack of support or onward referral, and the potential for re-traumatisation. There can be a link between the experience of trauma, sometimes from childhood, and the risk of a range of poor outcomes. For example, children who are vulnerable are more likely to achieve lower grades at school, be involved in crime and enter the justice system. Adults who were vulnerable as children are likely to be in the care system, have lower paid jobs, be homeless and experiencing physical and mental ill health |
Enhancing knowledge and action on trauma-informed practice
To support all nurses, midwives and the wider health and care workforce to enhance their knowledge and, more importantly, to take greater action on key public health issues such as trauma, free online e-learning resources have been published as part of a programme entitled ‘All Our Health’ (Health Education England e-Learning for Healthcare, 2022). The ‘Vulnerabilities and Trauma-Informed Practice’ e-learning resource aims to support professionals to:
- Provide better access to health and care services and promote wellbeing as part of their everyday practice
- Address the impact of vulnerabilities when they work with individuals, families and communities.
Building back better and fairer
Throughout the recovery phase of the COVID-19 pandemic it will be essential for the nursing, midwifery and wider health and care workforce to appraise the lessons learnt and consider the changes needed to ensure better and fairer access to health and care services. This will require the professions to use the 2020s as a decade of transformation, where the management and treatment of disease is given equal importance to the protection and promotion of the public's health and the prevention of disease. Throughout their practice, health and care professionals should acknowledge that vulnerability can cause preventable ill health and inequalities. The All Our Health resources and tools provide a useful framework, which supports these professions to consider the evidence-based interventions that will make a difference to individuals, communities and populations.
CASE STUDY
Kate Stevenson and 8-week-old Samuel* attend their GP surgery for his first set of primary immunisations. This is the first time Kate has had regular contact with primary healthcare services since her own childhood.
The waiting room is crowded, Samuel is unsettled and crying. Kate is cross because she has been waiting for over an hour. She is also anxious because it is bringing back childhood memories of when she attended with her mother, who had enduring mental health issues. Even then, they always had to wait and then fight to get their voices heard. Despite having a difficult start to life, and the death of her mother, Kate lived with her auntie, managed to pass her exams, and has recently become a senior manager. She thought these fears were behind her.
As the practice nurse in a busy surgery, you are always apologising because the clinic is running late. Most of the time people are very understanding but Kate is different, unlike the others she doesn't say it's alright. You have recently completed the All Our Health course about vulnerabilities and trauma-informed practice and learnt not to make assumptions when faced with challenging reactions from people.
Even though you are running late, you take your time to introduce yourself and explain the process for the immunisation. Samuel has stopped crying, and has started to smile, so you make a point of commenting on how calm Kate is. You ask Kate about his temperament and how she thinks he might respond to the injections. This enables Kate to tell you she thinks he is scared and that she is worried she won't be able to comfort him. You ask Kate what she finds usually works when Samuel is upset and suggest she might want to try this after the immunisations. Taking the process one step at a time allows Kate to prepare herself and Samuel. You also give her time at the end to comfort him. As Kate is leaving, she looks calm, thanks you for your time and asks whether she could book an appointment with you to discuss contraception.
Allowing time and not making assumptions has meant that you have been able to help Kate manage the situation and further engage with the service to address her own health needs. Although you do not know why Kate reacted the way she did, you know you have gone some way to building her trust in accessing services for herself and her baby.