Trauma-Informed Care for Inpatient Palliative Care Social Work: Applying Existing Models at the Bedside

Abstract

Coexisting serious illness and posttraumatic stress place hospitalized individuals at risk for complex pain, anxiety, and retraumatization. Hospital palliative care social workers increasingly recognize the value of trauma-informed care (TIC) for reducing harm in the inpatient setting. Despite this recognition, there is limited operationalization of TIC principles for inpatient interventions. This paper integrates each TIC principle with inpatient psychosocial interventions to advance trauma-informed competencies among inpatient palliative care social workers and to provide a foundation for future TIC implementation research.

Introduction

Trauma is an event or set of circumstances experienced as physically or emotionally harmful that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual functioning (Substance Abuse and Mental Health Administration [SAMHSA], 2014). Experiences of trauma can lead to chronic, lasting symptoms called posttraumatic stress; these symptoms may include anxiety, agitation, and cognitive difficulties that impact daily functioning and quality of life (Couzner et al., 2022; Cozolino, 2020; Kusmaul, 2018; Van der Kolk, 2014). The onset and timing of posttraumatic stress symptoms may vary, including delayed onset, symptom remission and recurrence, and may or may not include a formal diagnosis of posttraumatic stress disorder (PTSD) (Kaiser et al., 2021; Ricks-Aherne et al., 2020). When an individual with a history of posttraumatic stress needs healthcare services, the invasive nature of our medical system places this individual at unique risk for retraumatization, or re-experiencing of earlier trauma symptoms (Sanders, 2021; Schippert et al., 2023). For example, elements common to the healthcare experience, such as loss of control over the body, use of physical touch, and medical racism, often serve as reminders of past traumatic experiences. These reminders may trigger a patient’s fight or flight response and impair physical, emotional, and interpersonal engagement with the healthcare system (Couzner et al., 2022). For patients with serious chronic illness and comorbid posttraumatic stress, the increased frequency of healthcare encounters can exacerbate the intensity of these symptoms. The prevalence of posttraumatic stress is as high at 64% for patients with critical life-threatening conditions, 74% for patients with HIV, and 68% of patients with breast cancer (Bernard, 2022; Feldman, 2017).

Importantly, experiences of comorbid serious illness and posttraumatic stress are disproportionately distributed across patient populations based on race and ethnicity, with higher rates among individuals and communities experiencing racism, poverty, violence, and intergenerational trauma (Guarino et al., 2009; Makoff, 2020; National Council for Behavioral Health [NCBH], 2019;). Like other instances of societal inequity—histories of oppression and medical harm have contributed to these disparities, making it incumbent on health care clinicians to take responsibility for improving how they deliver care at the bedside (Center to Advance Palliative Care [CAPC], 2021; Goto et al., 2022; Ntizimira et al., 2022, 2; Rosa et al., 2022; Silvers et al., 2022; Weng et al., 2022). The disparate distribution of trauma experiences among populations who have been historically marginalized and oppressed calls for an urgent and equity-focused approach to clinical interventions that can reduce retraumatization during serious illness care.

The Importance of Trauma-Informed Care in the Inpatient Palliative Care Setting

In response to the issue of retraumatization, many healthcare sectors have adopted a model of “trauma-informed care” (TIC) to improve care delivery (Han et al., 2021; SAMHSA, 2014; Wilson et al., 2013). TIC can be applied across system levels of healthcare—at the organizational, community, and individual patient levels. At the individual patient level, the TIC model emphasizes: 1) recognizing trauma symptoms in a patient, and 2) responding with skills and interventions that “resist retraumatizing” the patient (SAMHSA, 2014).

The TIC model is exceptionally important in the acute hospital setting. Hospitalization for serious illness often places individuals at heightened risk of retraumatization in comparison to lower acuity settings, such as outpatient clinic visits (Cations et al., 2021; Couzner et al., 2022; Sullivan et al., 2017; Von der Warth et al., 2020). For example, hospital care has higher levels of physical touch (e.g., toileting, bathing, medication administration), invasion of personal space (e.g., hospital room as the site of daily living and sleep), and loss of personal control to–sometimes multiple–specialty provider teams. Responding with a set of TIC interventions in the inpatient setting involves nuanced steps to ensure that providers seek permission before touch, create physical and psychological safety in moments of acute crisis, and promote best practices for restoring a sense of control and choice over one’s body and treatment decisions, particularly regarding preferences for dying in the hospital setting (NCBH, 2019; SAMHSA, 2014).

Integration of trauma-informed practice and palliative care social work began with the work of Gwyther et al. (2005) and Wilson et al. (2013) and was later explicitly applied to the inpatient palliative social work setting by Feldman (2017), Ganzal (2018), Glick (2018), and Kusmaul (2018). Most recently, the relationship between COVID-19 and the heightened risk for trauma during acute hospitalizations sparked a resurgence in education and implementation efforts for TIC within inpatient palliative care social work (Brown et al., 2020; National Hospice & Palliative Care Organization [NHPCO], 2020; Ricks-Aherne et al., 2020). To date, palliative care literature regarding TIC principles has largely focused on applying TIC to palliative care case examples. While these case examples provide one crucial type of guidance for palliative care social workers, further operationalization of the breadth of TIC interventions in the inpatient hospital setting can foster increased implementation and standardization of TIC models. Guidelines for specific inpatient interventions can also increase knowledge and confidence for palliative care social workers who recognize complex pictures of posttraumatic stress among their hospitalized patients. With the goals of specificity and clinical applicability, this paper will apply each unique TIC principle to specific inpatient palliative care interventions that can be practiced in the hospital setting.

The alignment of general palliative care principles and TIC principles supports the integration of these two types of care. For example, the National Consensus Project (2018) outlines practice guidelines across eight domains of palliative care, which highlight patient-centered care, promotion of psychological safety, transparency of choices, and collaborative decision making. These palliative care guidelines mirror core TIC principles of safety, trustworthiness and transparency, choice, and collaboration (Brown et al., 2020; National Consensus Project [NCP], 2018; SAMHSA, 2014). Despite the similarities between TIC and palliative care principles, TIC models remain distinct from typical palliative care in their intentional response to reduce trauma symptoms among hospitalized patients. For example, when caring for a hospitalized palliative care patient who is at risk for retraumatization, a typical palliative care response may include meeting with the patient during hospitalization, acknowledging the patient’s anxiety or agitation, normalizing and validating this emotional response, and striving to partner with the patient at all times when creating a care plan in the setting of this emotional suffering (NCP, 2018). In contrast, a palliative care social worker who adopts TIC principles would provide general palliative care support, while also being attuned to the ways in which the hospital environment may serve as a reminder of past traumatic experience (i.e., trauma triggers)—such as providers not seeking permission to use physical touch, or facing a life-threating crisis with little control over the outcome. Understanding of TIC principles equips the inpatient palliative care social worker with knowledge and competency in safely exploring environmental and interpersonal sources of retraumatization with the patient, as well as how to educate various hospital team members (e.g., nurses, physicians, phlebotomists, cleaning staff) on modifying the environmental and interpersonal causes of retraumatization (NHPCO, 2021).

Current TIC Models

Two predominant models of TIC can be integrated into inpatient palliative care social work practice. The integration of these models with inpatient social work practice can improve clinicians’ ability to move beyond recognizing the impact of trauma, to actively reducing retraumatization among hospitalized patients with serious life-limiting illness. In turn, clinicians can begin to rupture cycles of repetitive harm in the healthcare setting that exacerbate experiences of trauma. For example, a patient may have a history of racial or social trauma that is tied to being repetitively labelled as “difficult” or as someone who “refuses care.” A TIC approach would resist labelling the patient’s behavior, and instead encourage building trust and rapport with the patient, and subsequently explore environmental and interpersonal sources of anxiety or distress in the hospital setting that may lead to continued mistrust and fear. The application of TIC models of care can foster exploration of the patient’s experiences of threats to safety and trust, modify and repair care delivery in the hospital setting, and create space for rebuilding relationships with providers and improving healing in the inpatient space.

Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma-Informed Care Model

The Substance Abuse and Mental Health Services Administration (SAMHSA) established the first general TIC model, consisting of six key principles for incorporating a trauma-informed approach into clinical practice: 1) creating safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) attention to cultural, racial, historical, and gender issues (SAMHSA, 2014). Given the flexibility of these principles, the original TIC model has been conceptually applied across different healthcare settings—behavioral health, psychiatry, family medicine, and palliative care (Cations et al., 2021; Couzner, 2022; Ganzel, 2018; McGinley & Waldrop, 2019; Ricks-Aherne et al., 2020). Although the SAMHSA Model principles are applicable across clinical settings, there is a need for tailoring TIC to unique patient populations, such as inpatient palliative care patients. Specifically, general SAMHSA principles such as “creating safety” require increased nuance when considering the needs of a hospitalized patient who has a serious illness or is nearing the end of life. Given the extent of symptom burden for this patient population, as well as the unique nature of the hospital setting, fostering safety can prove more challenging in comparison to populations that are physically stable and in the comfort of their own home environments.

Stepwise Psychosocial Palliative Care Model

The Stepwise Psychosocial Palliative Care Model (SPPC) focuses on the unique impact of posttraumatic stress on the illness and dying experience–such as increased pain related to life-limiting illness, death anxiety, and difficulty engaging in treatment planning (Alici et al., 2010; Feldman 2017; Feldman & Periyakoil, 2006; Ricks-Ahernes et al., 2020; Roth et al., 2013; Von der Warth et al., 2020). The SPPC Model incorporates TIC principles with brief cognitive and behavioral anxiety-reduction skills. Specifically, the model consists of three stages that the palliative care social worker can advance through with the patient, depending on the patient’s physical and emotional stability and life expectancy (Feldman, 2017). These stages include: 1) palliate immediate discomfort and provide support; 2) provide psychoeducation to enhance coping skills; and 3) treat specific trauma issues. Within each stage, palliative care interventions are proposed. For example, palliative care interventions in the first stage involve educating healthcare teams on how to reduce sources of retraumatization (i.e., triggers) in the medical space (Feldman, 2014). Through exploration with the patient, the palliative care social worker identifies which aspects of hospital care lead to distress, anxiety, or activation of the “fight or flight system,” and these triggers can then be discussed with the medical team for modification, or removal from the environment whenever possible. An example of applying this type of TIC intervention in the hospital setting will be explored in the Case Example below.

The flexibility of integrating TIC principles alongside staged TIC interventions has fostered the use of the SAMHSA TIC Model and the SPPC Model among palliative care social workers ( Brown et al., 2020; Ganzel, 2018; Glick et al., 2018; Ricks-Aherne et al., 2020). Given the acute nature of the hospital setting and the role of many palliative care social workers in facilitating difficult and timely decision making, the value of responding skillfully and therapeutically to trauma symptoms among hospitalized palliative care patients cannot be understated. When the palliative care social worker uses the TIC interventions discussed, the patient will hopefully experience an increased sense of safety, connection, and engagement with crucial care planning tasks during hospitalization (Feldman, 2017; Ricks-Aherne et al., 2020).

TIC Interventions for Inpatient Palliative Care Social Work

The following Inpatient TIC Intervention Table (See Table 1) integrates the SAMHSA and SPPC TIC Models and provides an overview of key inpatient interventions for each TIC principle (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and consideration of cultural, historical, racial, and gender issues). For example, when considering safety, the first principle of TIC, the inpatient palliative care social worker should “explore with the patient how to prepare for moments when they may become activated by reminders of trauma or experience a heightened fear response” in the hospital setting (DiBiase & Nathanson, in press). The palliative care social worker should also identify which aspects of care meetings in which the patient may be able to gain a sense of control. Increased sense of control may be possible in a number of ways such as, timing of a meeting, number of providers in the room, and topics to be discussed. The following case example provides an illustration of how principles outlined in the Inpatient TIC Intervention Table can be applied at the bedside. For additional examples of specific communication phrases, as well as clinician self-inquiries, the Inpatient TIC Intervention Crosswalk provides deeper guidance for inpatient palliative care social workers (See Table 2). The Inpatient TIC Intervention Table and Inpatient TIC Intervention Crosswalk both identify opportunities during inpatient clinical encounters for the social worker to partner with a patient to co-create a plan for preserving their identity and agency when receiving hospital care. Both patient and clinician work together to understand how to support psychological and physical safety in a way that dynamically responds to a patient’s embodied experience of trauma and illness. Together, the patient and social worker can intentionally slow down the fast pace of the acute hospital setting, which allows for co-regulation in times of distress.

Table 1.

Inpatient TIC Intervention Table

TIC Principle	Inpatient Intervention
Safety: Promote physical safety in the environment and psychological safety with interpersonal relationships	• “Explore with the patient how to prepare for moments when they may become activated by reminders of trauma or experience a heightened fear response” (DiBiase & Nathanson, in press). • Delineate which aspects of care meetings the patient may have control over, such as timing, provider attendance, and topics discussed, and reflect with the patient the value of making these choices. Facilitate modifications to care meetings accordingly.
Trustworthiness & Transparency: Provide consistent information and build rapport	• In preparation for a care meeting, make sure the patient knows: who will be present, how long the conversation is expected to last, which topics are going to be addressed, what the follow up plans are. • Validate the uncertainty that patients must tolerate during hospitalization- the number of assigned staff involved in care, lack of clarity regarding staff/provider role in the care plan, timing/scheduling of tests and procedures. Seek opportunities to foster restoring choice.
Peer Support: Increase recovery and healing by sharing of stories and lived experiences	• Avoid the assumption that family, friends, community members are safe and supportive. Instead, assume a neutral, curious stance and explore which relationships feel supportive to the patient, and how they can increase access to them during stressful moments of hospitalization. • Facilitate buy-in to peer support, making referrals to support groups, literature, and social media, while recognizing the potential difficulty in sharing and taking in others’ experiences that may be different.
Collaboration & Mutuality: Promote a sense of control by partnering and leveling power differences	• Look for opportunities to adapt the hospital environment to the patient’s preferred daily rhythms; Incorporate information about the patient’s daily routine into the care plan whenever possible. • Manage the balance between collaboration, paternalism, and non-abandonment. Explore the patient’s experience within the conversation and look for themes around the patient’s relationship to control.
Empowerment, Voice, & Choice: Foster resilience by encouraging autonomy and use of internal strengths and resources	• Ensure that patient choices are reasonably informed and respected by the team. • Reflect on ways the patient is coping that are congruent with their own sense of self, solidifying an ongoing sense of an internal presence of self and creating an opportunity for regaining a sense of control.
Consideration of Cultural, Historical, Racial, and Gender Issues: Reduce retraumatization and increase healing by identifying and considering the impact of intersectional identities	• Be mindful of ways that you are relying on the language and cultural norms of the hospital and dominant local culture when engaging in dialogue with patients, recognizing that certain terms may be unfamiliar and even harmful. • When a patient speaks of racism or oppression, allow space, acknowledge the entirety of their response, affirm the harm that was done, and explore how this might impact their health care experience.

Table 2:

Inpatient TIC Intervention Crosswalk

TIC Principle	Social Work Intervention	Sample Communication	Questions for Deeper Clinical Self-Inquiry
Safety: Promote physical safety in the environment and psychological safety with interpersonal relationships	“Explore with the patient how to prepare for moments when they may become activated by reminders of trauma or experience a heightened fear response” (DiBiase & Nathanson, in press) Note signs of dissociation and hyperarousal in order to regulate the level of intensity of the conversation, evaluate the need for grounding, and renegotiate consent to continue conversation as tolerated Communicate to team about patient’s ability to cope with difficult conversation and suggest modifications to team for bedside interventions and communication Delineate which aspects of care meetings patient may have control over, such as location, timing, attendance, and topics discussed, and reflect with patient the value of making these choices Provide structure and containment to the hospital environment by acknowledging the parts of the process that the health care team has responsibility for, including information about treatment options, management of medication, and treatment side effects Actively relate to all parts of the patient, not just the sick parts, to assist the patient in connecting to internal resources for coping and encourage integration of the patient experience into the self	“Having difficult conversations about your health and your body can often feel overwhelming. Please know that we can take a break from talking at any time.”(DiBiase & Nathanson, in press) “What are some ways that we will be able to tell if you’re feeling overwhelmed? If you’d like, we can even think of a phrase together that you can use if you wish to take a break or stop the discussion.” (Brown, et al. in press) “I will be sure to look out for these signs and take a break if we have been talking for too long.” “What does a conversation going well look like to you? For some people, it’s feeling supported or heard, and for others it means leaving with an action plan.” “What is it like for you to be [a person] going through this?”	Do I know my own normal, daily signs of dissociation and hyperarousal? Do I know what cues are likely to trigger me out of my window of tolerance? Do I know how to navigate my own internal world through the subtle shifts of hyperarousal and dissociation, and to be able to bring myself back? When I am the patient, who do I think I need to be in order to get good care?
Trustworthiness & Transparency: Provide consistent information and build rapport	In preparation for care meetings, make sure patients know: who will be present, how long the conversation is expected to last, what topics are going to be addressed, and what the follow up plans are Validate the uncertainty that patients must tolerate during hospitalization- the number of assigned staff involved in care, lack of clarity regarding staff/provider role in the care plan, timing/scheduling of tests and procedures; Orient and reorient the patient to processes within the hospital for greater transparency If the timing of interventions are unknown, acknowledge this, offer regular updates or explain why regular updates are not available, and provide opportunities for patients to express their emotional reactions and needs Explicitly communicate your availability, responsibilities, and follow up plans - does the patient know with whom/how to communicate concerns? When choices are limited, acknowledge this limitation and provide anticipatory guidance about what to expect moving forward (Brown, et al. in press) If the social worker misspeaks or misinterprets an aspect of the patient’s care, acknowledge this and offer a plan to rectify any errors or harm caused Know the difference between acute stress disorder, PTSD and prolonged grief disorder; be able to make specialized referrals and facilitate buy-in to these referrals	“Like we mentioned yesterday, this afternoon we are hoping to meet with you for about an hour to discuss next steps in your treatment plan. About five members from different teams will be joining including [names], all of whom have been involved in your care. Is there anyone else you would like to include in this discussion? Does this plan work for you? Is there anything else we should consider?” “I understand that you’re receiving care that you really need and it’s hard to get to know so many of the hospital’s providers at one time in order to make important choices about this care. What do you want to make sure the hospital’s providers know about you to give you the best possible care?” (Chochinov, 2007) “I apologize for the way I described your experience; I can see now that it was not accurate and may have been upsetting. I am grateful that you let me know.” “As we have gotten to know one another, we have identified when it might be especially hard for you to stay connected in the present moment, to make decisions, or keep track of what the doctors are telling you, etc. This is something we often see with people who have experienced trauma/ a lot of stressful times in their lives. There is treatment available that many people find can help reduce the impact of these symptoms on your daily life. If you would like to hear more, I can describe what this treatment looks like.”	Do I have a sense that others are likely to be trusted with my vulnerabilities and needs? How have I historically compensated for violations in this trust? What experiences in my life have contributed to my felt sense of either needing to overly rely on myself, overly rely on others, or have a healthy sense of trust?
Peer Support: Increase recovery and healing by sharing of stories and lived experiences	Facilitate buy-in to peer support, making referrals to support groups, literature, and social media, while recognizing the potential difficulty in sharing and taking in the experiences of others, and navigating when others’ experiences are different Avoid the assumption that family, friends, and/or community members are safe and supportive. Instead, assume a neutral, curious stance and explore which relationships feel supportive to the patient, and how they can increase access to them during times of hospitalization Include community and spiritual support systems, both by increasing patient access and offering inclusion in important conversations	“What do you think it would be like to join a support group? How do you imagine it would be to have others hear about your experiences, and for you to hear about theirs?” “I am hopeful that a support group would be helpful for you. I have seen many patients struggling like this and often, groups can help people feel less alone.” “Who has supported you since your diagnosis? How has that support felt for you?”	In what ways do I welcome a shared narrative, and in what ways do I find it intrusive or abandoning? Do I respond with “that isn’t exactly right so it’s not resonant for my experience,” or do I look for similarities in themes and feel comforted? Do I believe that others are capable of understanding my experience, and that others want to hear what I have to say?
Collaboration & Mutuality: Promote a sense of control by partnering and leveling power differences	Manage the balance between collaboration, paternalism, and non-abandonment. Explore the patient’s experience of the conversation, and look for themes around the patient’s relationship to control Look for opportunities to adapt the hospital environment to patient’s typical daily rhythms; Incorporate information about patient’s daily routine into the care plan whenever possible Recognize that patients are not assenting, nor consenting, to certain aspects of their care (e.g., they are often not able to choose precisely who will care for them) and that many decisions are often made under duress and possible mortal fear	“How was this conversation for you? Were there any surprises? Did you feel you could speak freely? What worked well about it, and what would you want to see done differently in future conversations?”	How do I feel about being in authority, based on both my perception of my professional role and my family and interpersonal histories? Do I feel more comfortable with more perceived authority, or less? And can I have expertise without authority? How does our team feel about assumptions of authority? How does the patient feel? What does it take for me to feel comfortable to speak freely, and what does it take for me to consciously or unconsciously begin to filter my experiences?
Empowerment, Voice, & Choice: Foster resilience by encouraging autonomy and use of internal strengths and resources	Ensure that patient choices are reasonably informed and respected by the team Reflect on ways the patient is coping that is congruent with their own sense of self, solidifying an ongoing sense of an internal presence of self and creating an opportunity for regaining a sense of control	“What have you found to be most helpful for [blank] when you are in the hospital?” “It sounds like it’s helpful to have your partner on the phone for all conversations with the doctors and staff. Let’s think about how I can support you in communicating this request to the team.”	Do I feel empowered on my team? Do I feel like my voice is heard, respected, and acted upon? Do I feel empowered in my life? Is it okay for me to take up space with my own needs?
Consideration of Cultural, Racial, Historical, and Gender Issues: Reduce retraumatization by identifying and considering the impact of intersectional identities	Be mindful of ways that you are relying on the language and cultural norms of the hospital and dominant local culture when engaging in dialogue with patients, recognizing that certain terms may be unfamiliar and even harmful When a patient speaks of racism or oppression, allow space, acknowledge the entirety of their response, affirm the harm that was done, and explore how this might impact their health care experience Recognize that some community traumas are implicitly embedded into a collective experience and are not always explicitly named- this may manifest as hypervigilance, mistrust, agitation, etc. Recognize that not every individual and/or community identifies as having been traumatized or welcomes the label as such, and consider more explicit efforts towards transparency and mutuality Consider identification of and connection to community as a resource; explore strengths within the collective narrative	“Can you tell me more about what that experience was like for you?” “Are you comfortable sharing more about what it was like for you and your family when your brother was being treated for cancer?” “It sounds like you’ve known a lot of people who have not received good care in the hospital. I really wish this wasn’t what they went through. It must be really hard for you to be here. Is there something we could do/ can we brainstorm ways to make the care better?”	Do I fear moving towards these themes, for my own discomfort, anger, or fear of misstep? Do I understand the ways in which my ancestors’ experiences in the world have shaped the psychologies of my family of origin, and my experiences in the world? Do I have a sense of my own biases and how they shows up in practice (what do I feel in my body and how is this expressed/not expressed)?

Case Example

Mia is a 35 year old woman admitted to the hospital for cancer treatment. She presents with a large sacral tumor that makes dressing, bathing, and toileting difficult and extremely painful. Upon admission, the hospital nursing staff document that Mia presents with “anger towards staff,” including throwing objects across the room and declining to engage with various aspects of daily physical care. Several providers also document that Mia does not make eye contact with male providers, and frequently pulls the covers over her head whenever a conversation about cancer treatment is initiated.

Palliative care is consulted to assist with goals of care discussions and to provide support to Mia. Before meeting with Mia, the palliative care team consults with several providers and nurses who all express concern that Mia is struggling with anxiety and mistrust of the hospital teams. Given Mia’s presentation of agitation, emotional distress, avoidance of physical care, and discomfort with male providers, the palliative care social worker considers the possibility of a history of trauma, or at the very least, that Mia has consistently declined to engage with providers. The palliative care social worker offers to meet with Mia alone prior to the full palliative team consultation. The social worker provides education to her team that the goal of this initial intervention is to lead with a decreased provider-patient ratio, balancing the power dynamic in the room and allowing time to build rapport (SAMHSA, 2014).

Upon arriving at Mia’s hospital room, the palliative care social worker knocks and seeks permission to enter, and then again requests permission to introduce her role in the hospital, and once more seeks permission before sitting in the chair at the side of Mia’s hospital bed. Mia is initially skeptical of the palliative care social worker’s intentions and emphasizes that she “does not need another person to tell her what’s best for her.” The palliative care social worker validates and aligns with this response, and then provides transparent information regarding the reason for the palliative care consult–specifically, that her primary team has been concerned for her how she has been doing emotionally and felt that she may benefit from additional support with thinking about next steps for her cancer care. Mia becomes frustrated with this information, explaining that anyone would be emotional and angry if they were in her situation, and that she “constantly feels like she is being judged by everyone who enters the room.” She adds that she is “particularly frustrated with needing help for things… I don’t want people grabbing me all the time,” and adds that she has been considering leaving the hospital. The social worker maintains calm demeanor and body language as Mia continues ventilating specific frustrations.

The social worker validates and reflects back Mia’s experiences in the hospital setting, and eventually notices that Mia has transitioned from anxious and agitated body language to tearfulness. It is at this point that the social worker seeks permission to share her understanding of Mia’s concerns and hospital experience. When Mia approves, the social worker summarizes and normalizes Mia’s experience, and then adds: “oftentimes folks tell me that when they are in the hospital they are reminded of a difficult time in their life, or situations where they have felt unsafe. This can make being here in the hospital especially challenging or overwhelming. I am wondering if this feels like something you can relate to?” Mia immediately nods, and states “I’ve been through a lot.” The social worker acknowledges this and responds by assuring Mia that they do not need to discuss past experiences at this time if she does not want to, but rather, that the social worker can be a resource to help identify situations in the hospital setting that are particularly overwhelming or triggering for Mia, and to try to make changes to the environment when possible. This affirming, yet containing, statement is made with the goal of fostering psychological safety and opportunity for Mia to regain control in the inpatient space. Mia expresses gratitude and begins to share several pieces of her daily care that feel the most anxiety-provoking for her, in particular, nurses hurriedly starting physical care without permission, and male physicians standing over her bed to talk to her. The social worker seeks permission to share this information with the nursing staff and physicians so that their approach to care can be modified. Mia expresses appreciation for this. After building initial rapport with Mia, the social worker also briefly describes the rest of the palliative care team that is available to support Mia. She is in agreement with a full palliative team consultation, so long as everyone sits down to talk, and so long as the palliative care social worker is present. The social worker follows up with her palliative team, providing guidance on Mia’s history, as well as education regarding interpersonal and environmental triggers that the hospital teams can modify to increase control, safety, and connection for Mia. The palliative care social worker offers to have regular one-to-one sessions with Mia during her hospitalization for ongoing assessment of Mia’s symptoms and coping, and to offer continued advocacy for trauma-informed modifications to hospital care as needed.

Conclusion

In the case of Mia, the inpatient palliative care social worker implemented TIC interventions that fostered physical and psychological safety through identification of environmental and interpersonal triggers in the hospital. Through doing so, the social worker was able to build trust and a collaborative partnership with Mia regarding her care plan. It is not until Mia has been provided with an increased sense of safety and connection that hospital teams can begin to engage Mia around complex decision making and goals of care for her cancer treatments. The palliative care social worker will continue to provide regular meetings with Mia to provide emotional support and teach anxiety reduction techniques that can be practiced during situations that hold risk for increased activation of Mia’s fight or flight response (e.g., showering, toileting, care planning meetings). With Mia’s permission, it would also be incumbent upon the palliative care social worker to include recommendations in her medical chart for other providers to consider, such as “please knock and seek permission before entering Mia’s room,” or “when planning for daily bathing, please consider scheduling time of day and nursing aide assignment with Mia ahead of time.” These modifications and recommendations for Mia’s care plan will provide an opportunity for regaining control and agency in the inpatient hospital setting.

Given increasing evidence of the prevalence of posttraumatic stress and retraumatization in the hospital setting, TIC interventions such as those used in Mia’s case are critical to begin repairing repetitive cycles of harm in the hospital setting (Bernard, 2022; Feldman, 2017; Makoff, 2020). While the Inpatient TIC Intervention Table and Inpatient TIC Intervention Crosswalk provide practical guidance for inpatient palliative care social work, these tables also provide a foundation for future intervention testing and research efforts to truly evaluate effectiveness of TIC for the field of inpatient palliative care social work. Continued efforts to conceptualize and standardize TIC interventions are one way for palliative care social workers to engage in efforts to dismantle the racism, oppression, and violence often embedded in trauma histories, and to break the cycle of repeating this harm in the inpatient hospital setting (Makoff, 2020). While many aspects of care that are retraumatizing require systemic change, in the meantime, it remains crucial to recognize and address interpersonal harm that regularly occurs in the hospital setting. Through continued innovation, critical dialogue, and iterative practice, we can respond to experiences of trauma with humility, skill, and the urgent call to reduce retraumatization for patients who have already lived through, and survived, vast hardship and suffering.