When we use the term “trauma,” we’re often referring to experiences like war, being attacked or assaulted, or witnessing a terrible tragedy. However, other traumas can be just as harmful. Patients with cancer may have experienced multiple kinds of trauma throughout their lives, which can contribute to myriad challenges such as chronic health problems, mental illness, and difficulty seeking care.
During a session at the 48th Annual ONS Congress® in April 2023, Meagan Dwyer, PhD, said that nurses must recognize how all patients had lives before their cancer diagnosis. Even a thorough medical history doesn’t elicit every detail of a patient’s life. With the added trauma of a cancer diagnosis, treatment, and facing their mortality, many patients struggle to cope.
Dwyer is the director of professional education at the American Psychosocial Oncology Society (APOS), a licensed psychologist, and owner of Starboard Therapy and Coaching in Kansas City, MO. Elizabeth Archer-Nanda, DNP, a board-certified psychiatric clinical nurse specialist with Norton Cancer Institute's Behavioral Oncology Program in Louisville, KY, and immediate past president of APOS, copresented the ONS Congress session, “Compassionate Cancer Care: A Trauma-Informed Approach to Mental and Emotional Patient Health Needs,” with Dwyer.
Reframe Your Perceptions and Approaches
Patients respond to traumatic experiences in different ways, including sometimes seeming uncooperative or even combative, Archer-Nanda said. It can be easy for nurses to perceive them as difficult patients and may even want to avoid them, but using trauma-informed care can help nurses better understand and support their patients’ psychosocial as well as physical needs.
“When we’re feeling threatened or vulnerable, anger may act as our protector,” Archer-Nanda explained. The first principle of trauma-informed care is for patients to feel safe, physically and emotionally. Nurses must build trust and transparency; they need to be collaborative.
“Trauma-informed care necessitates a person-centered approach, honoring that past experiences can contribute to psychological and emotional sequelae,” Archer-Nanda said. “Trauma can appear as patients being guarded with staff, mistrusting, distant, or even distanced from their physical body.”
A cancer diagnosis can trigger post-traumatic symptoms from an event that occurred months or years earlier. In both trauma and a serious medical diagnosis, a sense of helplessness can arise.
She shared the story of Cher, who was being cared for as an inpatient. Cher had a history of domestic abuse, sexual assault, depression, anxiety, and suicide attempt. She rarely discussed her past and significantly mistrusted most people. One night, Cher was in a delirious state with symptoms of hyperarousal and hypervigilance. After she expressed suicidal intent, pulled out her port needle, and threatened to leave, she was put into four-point restraints.
“I think in medical care, our gut instinct is to rush in, but sometimes we need to give space,” Archer-Nanda said. “The more we rushed in to support her, the more she fought against us because she perceived that we were attacking her.”
Archer-Nanda spent time at Cher’s bedside, ensured she could safely be removed from the restraints, and worked with staff to identify ways to build trust and deescalate the challenging care situation. Staff who Cher found triggering were shifted to other assignments. “We worked to restore trust between Cher and the staff. She deserved to be cared for and helped through this hard thing,” Archer-Nanda said.
Patients should be screened for trauma, engaged in their care, and given as much autonomy and choice as possible, Archer-Nanda said. The Center for Health Care Strategies, Inc.’s Key Ingredients for Successful Trauma-Informed Care Implementation offers strategies for care teams.
Consider Your Own Traumas
Any member of the cancer care team also may have experienced traumas. In some situations, it may make them better suited to help, but it may also trigger past experiences and require the clinician to step away or take space. Healthcare leaders must implement trauma-informed practices to help employees manage their stress.
Archer-Nanda said. “We want to meet the patient where they are, but if we’re not careful, we may meet the patient where we are,” she said. “We need to normalize sharing our challenges with our peers and asking for help when needed. When we grow in understanding of ourselves, we can fully show up, be empathetic to the patient experience, and deliver high-quality care.”