The case for mandating trauma informed care
Long-term care (LTC) facilities are people’s homes. It’s where many Canadians live out their final days. But not all of the residents in LTC receive the specialized care they need.
These are common stories, though the names have been changed for privacy.
Priya lives in a long-term care facility. She often shouts and swears when care aides try to help her with personal hygiene activities. Staff are told she is difficult, but no one asks why she is upset. Her intake file says nothing about childhood sexual abuse because her diagnosis is dementia, not trauma or post-traumatic stress disorder (PTSD).
Angela wanders the halls at night, entering other resident rooms. She also frequently rings the call bell for help but is unable to explain what she needs as she often slips into her first language, which is not English. Some staff think it’s early signs of dementia. No one asks if her experiences living through her country’s civil war might be a factor.
Then, there is John, a resident whose reaction to loud noises like a crashing meal cart is becoming more extreme, or Daniel, who becomes extremely agitated anytime he smells smoke, such as toast burning.
Tala is a care aide who has spent most of her working life in the LTC sector. She’s met many individuals like Priya, Angela, John and Daniel. She has seen other residents freeze in fear, yet she hasn’t received any formal training on how to deal with situations like this when they arise or what they might mean.
Today more than 770,000 Canadians are living with some form of dementia and by 2030, nearly a million Canadians will be living with dementia. The vast majority of residents in LTC in Canada have dementia (69 per cent) or another form of cognitive impairment (87 per cent).
What is the relationship between dementia, trauma and PTSD?
While trauma increases the risk for dementia, dementia can also increase the risk for delayed-onset PTSD. As my colleagues and I wrote in the Journal of the Medical Directors Association (JAMDA 2022), the overlap between symptoms can also lead to misunderstanding resident needs and providing ineffective treatment options.
Long-term care staff are overwhelmingly caring and skilled providers, but they often lack trauma-informed care training.
The good news is that trauma-informed care is actually included in Canada’s new (2023) national long-term care standards – a positive first step. Unfortunately, the standards are voluntary, which means most provinces haven’t begun to implement them.
Accreditation Canada, which accredits roughly two-thirds of Canada’s long-term care homes, has adopted this standard for its reviews The Commission on Accreditation of Rehabilitation Facilities (CARF), an international accreditor active in Canadian aging services, already lists trauma-informed practice among its own accreditation criteria.
But without a mandatory requirement for trauma-informed care training in LTC, limited resources and stretched-thin staffing means the default approach to problematic resident behaviour may too often be medication.
In a 2022 study, we reported 53 per cent of care aides perceived caring for one or more residents with a history of psychological trauma in the previous two weeks. While this study did not address this specifically, it may well be the case that some of the residents are experiencing PTSD symptoms of combined PTSD and responsive behaviours of dementia.
It’s clear, LTC care providers need more support and training to address the needs of a complex resident population. But training alone will not get us there.
The U.S. Substance Abuse and Mental Health Services Administration’s (SAMHSA) principles of trauma-informed care include safety; trustworthiness and transparency; peer support; collaboration; empowerment, voice and choice; and attention to residents’ cultural and historical context. They describe a shift in how a care home operates, not a course staff complete once and set aside.
SAMHSA’s model spells out what operationalizing those principles actually requires. In a nursing home, that would mean:
- Leadership that commits real funding to trauma-informed care, not just an unfunded policy statement.
- Admission screening that asks about past trauma the way it already asks about medications and allergies.
- Physical spaces and routines designed with trauma in mind, from private options for personal care, to quieter alternatives to alarms during fire drills, to quiet, reflective spaces for staff.
- Ongoing measurement of whether care and staff outcomes are actually improving, not just whether a training module gets completed.
Trauma-informed care should not be optional; it must be mandatory, it must be funded, and it must be reviewed like any other required standard for accreditation.
Care that is not trauma-informed may results in resident suffering both because they are re-traumatized (albeit unintentionally) and because staff who are burned out and themselves struggling with symptoms of traumatic stress, may be unable to deliver optimal care, not to mention these may contribute to high staff turnover. LTC residents deserve better.
Care aides carry much of this burden themselves.
Interviews with two dozen Alberta care aides found the same pattern up close: they could describe trauma-related behaviour in vivid detail, but had no training in how to name it, no framework for responding to it and no formal recognition that this work was even part of their job. As one aide put it, “we feel like we don’t matter.” A third described being hit, choked or chased by a resident reliving what researchers believe was a traumatic memory.
The cost to care aides’ own mental health is measurable.
In a 2024 survey of more than 2,200 care aides across 61 Alberta homes, nearly one in five screened positive for PTSD. A related TREC analysis found that compassion fatigue – the toll of repeated, indirect exposure to resident distress – was strongly associated with a positive PTSD screen, more so than any single feature of the workplace itself.
Trauma-informed care, in other words, is not only a resident-safety issue. It is a workforce-retention issue, in a sector that is already short-staffed and cannot afford to keep losing the people who know this work best.
We need trauma-informed training for all care home staff as well as employee assistance programs to help people manage ongoing workplace stress. LTC facilities in Canada are still seeing the negative impacts of COVID-19 – a trauma in itself.
We also need routine screening for trauma in residents in LTC, and resident programs that offer sensory stimulation and embodiment in safe surroundings and with a proven track record – music, dance, yoga, pet therapy and the like – to help manage reactive responses. These are programs that are based in neurobiology and trauma-informed research, and they support trust, safety, empowerment and include cultural sensitivity when done appropriately.
Resident trauma and staff trauma affect all those in the circle of care, from residents and families to frontline staff and managers. It’s time that we made trauma-informed care routine and that governments mandate and fund training across the country.
The federal government could play a lead role in this and skirt around the “but LTC is a provincial matter” thinking. Mental health funding targeted specifically for staff mental health during and in the aftermath of COVID (firewalled if you will), is an example of strong federal leadership in action in the health sector. It can be done.
Our long-term care residents deserve to feel comprehensively cared for in their homes by well supported staff in their final years.
Photo courtesy of DepositPhotos
