no secret that our health care workforce is in a precarious state. Hiring and retention is more difficult, especially in our medical assistant, nursing, and provider workforce. There is an understandable urge to ignore or take it easy on a team member who exhibits concerning behavior, like showing up late or having an explosive interaction with a patient or a colleague. A lack of accountability, however, affects our bottom line and our retention.

By having a trauma-informed communication and management plan, we keep our providers and staff engaged in the workforce and doing their job well because they feel supported and experience a sense of psychological safety at work.

At Madsen Health Center, in our family medicine clinic, we experienced two traumas, almost exactly one year apart. Our first collective trauma occurred in January 2019, when we lost one of our residents unexpectedly to domestic violence. We grieved her death together and imagined what it would feel like when we would mark the anniversary of her death. Just as we were marking one year, the second collective trauma of COVID-19 occurred in March 2020. Public traumas are something we all recognized and openly discussed, and yet there are also undisclosed traumas happening behind the scenes all the time. Racism, divorce, and other familial losses are silently affecting our workforce even if we don’t discuss them openly.

What is trauma? 

Trauma can affect anyone of any age who has experienced violence, victimization, loss, or disaster. These incredibly stressful events can overwhelm a person, leaving them unable to cope with what they have gone through, while also impacting day-to-day functioning.

Many of us will experience traumatic events in our lives and recover; how long it takes to recover and what support we need to be able to do so can vary greatly. The magnitude of the effect of trauma on our lives can also differ greatly depending on many factors including:

• If the trauma was a one-time event or recurring.  

• If we have the support of safe attachments to family or friends to help us process the experience. 

• If it occurred during childhood, such as repeated abuse or neglect; particularly when perpetrated by a caregiver

Some people, such as individuals who identify as neurodivergent, BIPOC, or LGBTQ+, are more likely to experience trauma. But no matter where we live and work, trauma is all around us.

Leaders at all levels need to be aware of how it can affect work and behavior and educate themselves on how to handle these effects in a trauma-informed manner.

What does trauma look like in the workforce? 

Trauma has complex effects on the brain. People who have experienced recurring, complex trauma, may be more easily triggered to have a flight-or-fight response. This may manifest as poor executive functioning, evidenced by trouble thinking through processes, making plans, or communicating needs, experiences, and feelings.

These complex effects and the additional cognitive load of trauma can lead to performance issues in the workplace. In health care, we may see issues such as:

• Arriving late to work.
• Difficulty completing expected tasks such as charting or managing an inbox.
• Engaging in explosive or negative interactions with other team members.

Practicing trauma-informed leadership  

Part of trauma-informed communication is approaching these issues with the idea of supporting, instead of punishing. Typical responses to behavioral concerns might include warning someone that their behavior will lead to being fired. For an individual with underlying trauma, this type of communication can be perceived as threatening and could actually result in re-traumatization. Instead, in our clinic, we ask genuine, open questions about what is going on in an employee’s life in order to gain a better understanding of what might be contributing to these performance issues. We then try to empower employees to create solutions for their own performance deficits.

For example, when we started to bring COVID-19 testing into the clinic, we initially experienced a high amount of team dysfunction. As leaders, we had to be patient and listen to concerns. We asked everyone what exactly was causing these emotions and issues at work.

The time we invested in listening ultimately paid dividends because we discovered the true source of the emotion dysregulation and dysfunction. Our workforce was concerned about safety because they felt that transitioning to testing people indoors would put them and their families at risk. We spent time with our staff reviewing the data to demonstrate its safety, to show that few people were getting sick at work, and to illustrate that PPE works. We reiterated the information in group meetings and engaged in one-on-one conversations.  With clear, consistent communication that took into account these concerns, we were able to help improve team performance, morale, and cohesiveness.

But the pandemic is obviously not the only form of trauma people are experiencing. People experience trauma related to their race, sexuality, and/or gender; they experience interpersonal violence; they experience the loss of loved ones. These forms of trauma are happening all the time.

The following steps offer a more supportive and trauma-informed approach to leadership:

1. Normalize trauma experience  

We can normalize and validate trauma experiences with compassion and empathy. We can say, “I realize your experience is different than my experience, and I'm not going to pretend that I understand it. You're going through some things that I haven't gone through, but I am here for you.” When someone feels seen and heard, they are more likely to accept support and participate in conversation about how they can stay engaged in the workforce.

2. Describe and commit to physical safety  

As in the prior example of COVID testing indoors, it is vital for leadership to be dedicated to physical safety—and to communicate that dedication. This might mean communicating data about the use of PPE as COVID protection or having policies in place about violent or combative patients in the emergency department. Employees need to know you have their backs—that their physical safety is a priority.

3. Describe and commit to psychological safety  

Psychological safety means that employees feel comfortable bringing up conflict, needs, and personal trauma in conversation, without fear of retaliation. It’s more effective to work through workplace conflict than to ignore it—or worse, to not have any conflict at all. People who have experienced trauma need to see conflicts resolved well in order to feel supported at work. That means approaching problems with curiosity and openness, instead of shaming and blaming.

Part of psychological safety is encouraging and normalizing self-care among employees. Identifying your own tipping point, and modeling taking breaks as needed, encourages employees to become aware of their own tipping points and to avoid reaching that point themselves. This might mean taking family medical leave, utilizing vacation days, or seeking out therapeutic support. It also means making sure that all team members get proper breaks, both at work and at home, without interruption.

Respecting the boundaries between personal time and work time is vital self-care for teams.

4. Provide regularly scheduled communication with unified voice from team leaders 

Leaders need to appear unified, as a team, to support employees. It’s not enough to voice this support once, either. Regularly scheduled communication helps employees know what to expect. This removes any uncertainty and facilitates confidence in leadership.

For example, we send an email once a week from the leadership team. It comes from all three members of our leadership team so that employees know they will receive the same answer and same information from each of us. The content of this weekly email is clear, concise, and direct. Vagueness or ambiguity can lead to misunderstanding, rumors, or uncertainty in the office.

It’s important to send this email at the expected time every week. Consistency builds trust. It allows employees to rely on the communication to generate expectations for the week and help mentally prepare for what’s ahead.

5. Offer and require accountability  

Accountability is one of the hardest aspects of trauma-informed leadership. It can be difficult to hold someone accountable with the knowledge that their behavior is the result of trauma. However, accountability doesn’t always mean punishment or censure. It can come from a place of empathy.

It is possible to address how behavior is affecting the team without using shame. Validate their emotions, while still extinguishing the behavior. Sticking to feedback on behavior, and avoiding shaming someone for their emotions avoids adding guilt to their already heavy mental load.

For instance, you can say, “I know you are struggling a lot right now, and getting to work on time has been a challenge because of everything you have on your plate. But tardiness impacts the flow of clinic for the whole day. Can we work together to problem solve how to help you get to work on time?” In this way, you have demonstrated a desire to align with the employee, rather than invalidate them. This engenders collaboration to discover barriers and identify solutions to prevent these behaviors, such as setting an earlier alarm or working with a therapist for additional emotional support.

Though you are offering support, it is also important to clearly explain the consequences of poor performance, such as using vacation days to work on charting skills if charts aren’t properly closed. It’s helpful to have these as pre-written policies so it’s clear that you aren’t just targeting one person; you are enforcing policies that apply to everyone’s behavior, rather than being punitive. Be transparent about these policies so your employee knows what to expect, and do not feel personally targeted as a result of their trauma.

Steps to prevent re-traumatizing employees 

As a leader, it is important to support your employees without compromising the company’s mission. You can’t do that without taking into account the impact trauma has on performance and behavior. Trauma-informed leadership begins with a unified communication plan involving all leaders, requires approaching performance issues with curiosity and a growth mindset, and making consequences clear from the outset.

These approaches to communication can help you respectfully support your employees and help them grow, while maintaining the workforce and avoiding re-traumatization.