Addressing health care workers’ trauma can help fight burnout

Burnout is a growing crisis in health care: More than 50% of health care professionals report symptoms of it. Addressing the trauma they face at work can help.

Halting burnout straddles the tension between addressing the individual factors versus the organizational factors behind it. It was once believed that burnout was related to health workers’ inability to cope with the natural stresses of their job. But research has clarified what clinicians have long known: They are inherently resilient. Instead, systemic factors are the primary drivers of burnout.

One key way to address workplace stress without blaming employees is to explore the contributing role of trauma. Health care professionals are routinely exposed to trauma in the course of their studies and professional duties; they witness pain, suffering, injustice, and dying. They experience microaggressions, workplace violence, and moral injury. In short, trauma is an occupational hazard of the job. In addition to work-related stressors, health workers bring their own set of challenging life events to the job, including adverse childhood experiences (ACEs).

Adverse childhood experiences — including abuse, neglect, and household challenges such as caregiver mental illness or homelessness — can change the brain’s biology, leading to chronic stress, illness in adulthood, and an increased likelihood of perceiving future adversities as traumatic. For example, a top predictor of PTSD among combat-exposed veterans is not the gruesomeness of the combat — it’s a history of ACEs. Recent studies show that nurses and physicians with higher ACE scores have an increased risk of burnout in their professions. Rates of both adverse childhood experiences and PTSD are also higher among women and gender and racial minorities (due to a host of structural factors), groups who often experience higher rates of burnout.

Health care workers are also feeling the burden of society’s global crises — the aftermath of the Covid-19 pandemic, racial injustice, wars, the Great Resignation, and political divides. Their daily work has been challenged by staffing shortages, the growing complexity of patients’ medical and social health, and increasing demands from electronic health records and insurance companies. Prior adversities, mental health issues, and new traumas or re-traumatization in the workplace can exacerbate one’s experience of burnout.

So far, no single framework has been successful in offering a comprehensive strategy to shield health care workers, and the systems they work in, from burnout. Anti-burnout health care advocates, including the American Medical Association, Stanford Medicine, and Mayo Clinic have published guides highlighting organizational strategies as the cornerstone, though they rarely utilize a trauma lens and focus mainly on physicians, rather than health workers at large.

While these and other anti-burnout strategies focus on much-needed systems solutions for employee success, they miss an opportunity to address the full scope of health workers’ plight by accounting for the impact of traumatic stress on the brain and body. Adopting a trauma-informed approach may have a transformative impact on anti-burnout solutions, redirecting the course of the health care crisis.

Trauma-informed care is an evidence-based, strategic framework for supporting trauma survivors, and is particularly relevant in today’s environment. It is an organizational model that encourages acknowledging the widespread impact of trauma, recognizing the signs and symptoms of trauma, responding by integrating knowledge about trauma into practice, and resisting re-traumatization.

In recent years, trauma-informed care has been integrated into medical education curricula and training for primary care clinicians with promising outcomes. It has also reached public education, legal aid, and even popular media — Oprah Winfrey and Dr. Bruce Perry’s book, “What Happened To You?” is firmly rooted in trauma-informed principles. There is also growing interest in trauma-informed workplaces.

How can trauma-informed healing be brought to the country’s wounded health care system? Health care organizations can promote individual, interpersonal, and institutional well-being by building trauma- and resilience-informed operations and culture. The suggestions below are drawn from a recent publication on leading trauma-informed health care organizations.

On an individual level, employees within a health care system can learn to recognize cues that they or their patients are feeling physically or psychologically unsafe. Acknowledging triggers can help one respond thoughtfully rather than react. Creating private, quiet spaces at work can help patients and staff find calm in otherwise stimulating environments. In my own medical training, using grounding strategies (like box breathing) to calm my nervous system was neither taught in medical school nor modeled by mentors in practice. Whether your patient had just died, received a life-changing diagnosis, or shared their stories of abuse, it was all the same: address their issues within 15 minutes and move on to the next case.

On an interpersonal level, it would be beneficial to train all patient-facing staff in trauma-informed clinical skills that boost their abilities to care for patients, themselves, and one another. Particularly in an era when patients access medical records online, culturally sensitive and patient-centered documentation is essential. Words matter: Labeling someone as an “alcoholic” versus describing them as a “person with alcohol use disorder” influences the patient experience, as well as workplace culture and morale. Clinicians can also learn to speak, move, and behave during physical exams and surgical procedures in ways that feel safe and empowering for everyone, rather than re-traumatizing. Peer support programs can be extremely helpful for staff, including on-site, judgment-free, incident debriefing after challenging events.

On an institutional level, employees can feel disengaged when changes related to staffing, patient scheduling, and time off are made without input from the affected parties. Leadership should hold listening sessions and invite diverse groups — including patients — to decision-making tables. Providing advanced notice with transparent communication about changes that will impact staff, along with clear avenues for feedback, is central to a trauma-informed philosophy. Revising written policies to ensure that language is free from bias, and eliminating requirements for providers to disclose their mental health treatment history, are also important.

At its core, a trauma-informed organization is a person-centered one. Cultivating a work environment that is inclusive, flexible, and supportive is more relevant now than ever.

Cultural transformation requires leadership buy-in, resource allocation, cross-sector collaboration, and adjustments over time. As an initial step, an organization can establish a collective vision for trauma-informed systems change that aligns with its mission. Investing in interdisciplinary training on trauma-informed care can yield practical tools to improve the experience for patients and staff, along with identifying leaders within the organization who can facilitate collaborative project development.

In my experience giving master-class trainings on trauma-informed care, health care audiences do not shy away from the subject of “trauma” — they welcome this discussion as an issue they knowingly face without sufficient resources to manage it. Feedback from these trainings suggests that trauma-informed practices can promote healing, rekindle meaning and purpose, expand the capacity to cope, facilitate collaboration, and allow for greater joy at work.

Trauma-informed care offers a framework for upgrading current anti-burnout strategies and infusing a new approach to address the nation’s health care crisis. Patients and their families, health workers, trainees, leaders, and all stakeholders can benefit from safe workplaces that empower everyone, collaborative relationships that promote belonging, and healing environments that foster resilience.

Sadie Elisseou, M.D., is a primary care physician for the Veterans Health Administration and an instructor at Harvard Medical School and Boston University School of Medicine who trains organizations about trauma-informed care.