Trauma-Responsive Perinatal Leadership

Introduction Recently, much focus has been on the importance of implementing trauma-informed care in the maternity care setting. However, for this to become reality for patients it must also be integrated organizationally. Perinatal nurses are regularly exposed to trauma in their day-to-day work. Nurses' exposure to trauma affects patient safety, nurse retention, and workforce wellbeing. Perinatal nurse leaders are foundational to improving these outcomes and can begin to cultivate improvements by irritating and supporting trauma-responsive leadership strategies. Strategies that perinatal nurse leaders can use to create a workplace culture aligned with the Substance Abuse and Mental Health Services Six Key Principles of a Trauma-Informed Approach are discussed. Trauma occurs when the nervous system experiences something that is too big, too fast, too soon, too hurtful, or too little for too long (Van der Kolk, 2014). This definition of trauma can be applied across nursing specialties and relates to the experiences of nurses during early months of the pandemic and by many nurses in their day-to-day work. Exposure to trauma in the workplace may cause compassion fatigue, burnout, and secondary traumatic stress, affecting the wellbeing and resilience of nurses as well as workforce retention and patient safety (Quillivan et al., 2016; Wolotira, 2023). Nurses in perinatal settings are regularly exposed to traumatic events (Sheen et al., 2022). Nicholls et al. (2021) surveyed 144 labor and delivery nurses, and 84.7% reported witnessing a traumatic birth, highlighting the pervasive exposure to trauma within the specialty. The unpredictable, sudden, and often emergency nature of maternity care may further potentiate the risk of workplace trauma among perinatal nurses (Sheen et al., 2022). Therefore, it is critical for perinatal nurse leaders to consider ways to support perinatal nurses after traumatic events to promote nurse wellbeing, workforce retention, and patient safety. Many often perceive that a perinatal clinician is only exposed to trauma when caring for or observing a patient that has a devastating outcome such as maternal or infant death. Foli (2022) described multiple types of psychological trauma in nursing; vicarious or secondary trauma, historical trauma, workplace violence, system and medically induced trauma, insufficient resource trauma, second-victim trauma, and trauma from disasters. In many cases, for nurses, these types of traumas intersect and are compounded over time. Debriefing the Front Lines (2024) defines Cumulative Care Taking Trauma® as the overexposure of abnormal and traumatic events with no time for acknowledgment, discussion, processing, and recovering a sense of safety that results in emotional, physical, and spiritual suffering. Cumulative Care Taking Trauma® is a result of overexposure to abnormal and traumatic events and the perpetuating factors contributing to the physical and emotional complexity of the job such as inadequate staffing, limited resources, lateral violence, insufficient mentorship, lack of psychological support, and structural racism. Unfortunately, many nurses report receiving inadequate support from their organizations, administrators, and colleagues after a traumatic event, which may influence their ability to cope and ultimately their decision on whether to stay in the profession after experiencing a traumatic event (Crawford & Williams, 2024; Nieuwenhuijze et al., 2024; Sheen et al., 2022; Shorey & Wong, 2022; Slade et al., 2020). Without appropriate support, traumatic events can significantly affect perinatal nurses' wellbeing, retention, capacity for empathy, teamwork, quality of care provided, and patient safety (Wolotira, 2023). Recently, there has been a significant focus on the importance of implementing trauma-informed care for maternity patients (American College of Obstetricians and Gynecologists [ACOG], 2021). However, it is critical to note that for perinatal nurses to fully implement a trauma-informed approach for patients, principles of trauma-­informed care must also be implemented organizationally (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Clinician trauma is a structural issue that should be addressed by health care organizations using system-level approaches (Runyon et al., 2024). Perinatal nurse leaders are central to an organizational strategy to address perinatal nurse trauma and its impact on workforce retention, nurse wellbeing, and patient safety. Although perinatal nurse leaders cannot eliminate trauma from occurring, they can mitigate workplace trauma by building healthy work environments and organizational cultures that promote personal connections, foster trust, and authenticity, and prioritize rest. In the Alliance for Innovation in Maternal Healthcare Support After a Severe Maternal Event Consensus Bundle, Morton et al. (2021) specifically mention the critical role of perinatal nurse leaders in implementing programs of support for their team members. Perinatal nurse leaders are instrumental in supporting culture change, normalizing the emotional impact that may be associated with workplace exposure to trauma and encouraging clinicians to seek help when needed. To develop and sustain perinatal programs that support the delivery of trauma-informed care to patients, perinatal nurse leaders can serve as role models and mentors in the provision of trauma-informed care practices and reflect these practices in their interactions with staff (Huo et al., 2023). Trauma-Responsive Leadership Although perinatal nurse leaders are in no way expected to be experts in the behavioral health needs of their team members, they play a crucial role in supporting them in their day-to-day work, identifying those who may be struggling, and connecting them with support services when needed (Sherman, 2021). Like the practice of trauma-informed care with patients, trauma-informed leadership is grounded in the same four core assumptions, the 4Rs; realize, recognize, respond, and resist re-traumatization: 1) realize the widespread impact of trauma and understand potential paths to recovery for nurses, 2) be able to recognize signs and symptoms of trauma in nurses, 3) respond to nurses in a trauma-informed way and integrate trauma-informed care into unit and organization-wide policies, procedures, and practices, and 4) seek to actively resist retraumatizing staff (Sherman, 2021; SAMHSA, 2014). Trauma-responsive differs from trauma-informed in that it moves toward the application of the principles of trauma-informed care versus only the awareness of the principles. Trauma-responsive leadership is both a style of leadership and a set of tools nurse leaders can use to create a workplace environment that supports resiliency and post-traumatic growth (Wignall, 2021). By working to understand the lived experiences of their team, perinatal nurse leaders can prevent re-traumatization by anticipating and responding to events that may trigger a trauma response. By entering into all interactions with nurses and other members of the team with empathy and compassion, creating physical and emotionally safe workspaces and implementing organizational policies that are trauma informed, perinatal leaders strive to resist re-traumatization (Trauma Informed Oregon, 2020). Impact of Workplace Trauma on Patient Safety In addition to the 4 R's, there are Six Key Principles of a Trauma-Informed Approach: 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) cultural, historical, and gender issues (SAMHSA, 2014). These principles overlap with the key attributes of a safety culture. Safety culture reflects an organization's commitment to quality and safety and improvements in safety culture are associated with improved operational and clinical outcomes (Ravi et al., 2021). Creating a safety culture and trauma-responsive leadership are inextricably linked. Psychological safety. When adverse events occur, they often have a significant impact on patients as well as the health care workers involved in the event. A workplace culture built on a nonpunitive response to errors where nurses feel supported by leaders and their peers and feel psychologically safe to report errors or near misses without fear of punishment may mitigate the traumatic impact of adverse events on perinatal nurses (Quillivan et al., 2016). Cultivating perinatal units that are built on the concept of psychological safety is a critical component of a culture of safety as well as trauma-informed care. In addition to supporting teamwork, trust, collaboration, and adverse event reporting, psychological safety is needed for nurses and clinicians to feel comfortable expressing themselves emotionally and seeking support after a traumatic event (Edmondson & Bransby, 2023). Trauma-Responsive Strategies for Perinatal Leaders Organizational and unit level leadership support and role modeling of the principles and key tenets of trauma-informed care are foundational to its successful implementation with patients and in creating and sustaining a safety culture. Reflecting on how to effectively cultivate these six principles perinatal nurse leaders can move toward actively modeling them in their interactions with staff (Table 1). Perinatal leaders should consider strategies to embed education about the emotional impact exposure to traumatic events can have on their team's wellbeing and share information about and support nurses in identifying self-care strategies they can implement to ameliorate the impact (Aydın & Aktaş, 2021; Koloroutis & Pole, 2021; Nieuwenhuijze et al., 2024; Schulman & Menschner, 2018). Other strategies cited in the literature as helpful in mitigating the impact of trauma on perinatal workforce include providing ­guidance on how to communicate bad news, structured case conferences for clinicians to emotionally debrief after serious events, and assigning a designating a “listening partner,” to check in with as needed to share and discuss challenging cases (Nieuwenhuijze et al., 2024; Schulman & Menschner, 2018). Promoting safe nurse staffing ratios (Association of Women's Health, Obstetric and Neonatal Nurses, 2022) and evidence-based and respectful maternity care were also listed as strategies to mitigate workplace trauma (Nieuwenhuijze et al., 2024). Table 1. - Substance Abuse and Mental Health Services Six Key Principles of a Trauma-Informed Approach: Key Considerations for Perinatal Nurse Leaders Safety Do nurses on your team feel safe? Are nurses clear in what is expected of them? Do nurses on your team feel they can provide safe care for their patients? (e.g., safe nurse staffing ratios, evidence-based care…) Do patients feel safe? Trustworthiness and Transparency Do you model trustworthiness and transparency? Are you inclusive? Do you follow through on what you commit to? Are you honest with your team? Peer Support Does the organization provide systems to easily access peer support? If these services are available, does your team know these services exist and how to access them? How do you normalize the use of these services? Do you encourage peer support and mutual self-help on your unit? Collaboration and Mutuality How do you model and support the leveling of power differences and promote collaboration? Empowerment, Voice, and Choice Are there systems, policies, and procedures that empower nurses to do their work? Are nurses included in decision-making? Cultural, Historical, and Gender Issues Do organizational policies and protocols incorporate racial, ethnic, cultural, and individual needs? Do you implement strategies to move past cultural and gender stereotypes and biases? Is respectful maternity care supported at the individual, unit, and organizational level? Complied in part from content in Papa and Robinson (2023) and SAMHSA (2014). Many perinatal nurses report not receiving emotional support after a traumatic event (Crawford & Williams, 2024; Nieuwenhuijze et al., 2024; Sheen et al., 2022; Shorey & Wong, 2022; Slade et al., 2020). If an event is perceived as traumatic may vary by individual based on their lived experiences. Nurses may need to access supportive resources at different points in time after a traumatic event. Regularly providing information on how to access resources can be embedded into event debriefs as well as into regular communications with nurses such as a weekly newsletter or staff meeting. To help facilitate the use of available resources, perinatal nurse leaders must be familiar with the process for accessing resources for emotional support at their organization. Perinatal nurse leaders can consider creating a list of supportive resources available through their organization, and instructions on how to access the resources. They should attempt to access the resources themselves so they can feel comfortable with their use and confident in the efficacy of the resources they are providing for support. Talking with their team to determine if they are currently using the resources, the barriers to their use sources, and if they feel the available resources are meeting their needs. Perinatal nurses are regularly exposed to trauma in the workplace potentially affecting their mental health, confidence, ability to provide safe patient care, and desire to stay in the profession (Aydın & Aktaş, 2021). Although perinatal nurse leaders cannot eliminate nurses' exposure to workplace trauma, how they respond, policies they enact, and the resources and support provided has the potential to ameliorate the impact of workplace trauma on nurse wellbeing and therefore nurse retention and patient safety. Recognizing that perinatal nurse leaders are foundational to supporting and strengthening the perinatal nursing workforce, health care organizations' support of education and mentorship to develop trauma-responsive perinatal nurse leaders in essential (Aydın & Aktaş, 2021).