In healthcare, the importance of trauma-informed care (TIC) cannot be overstated. GW Nursing DNP student Lori Hardie, MSN, RNC, NPD-BC, CHSE, a dedicated advocate and co-author of Indiana Senate Bill 45 (2024) "Trauma Informed Care," sheds light on the motivations, challenges, and expected positive impacts of mandating regular TIC training for licensed nurses. Here, we explore Hardie's journey in co-authoring the bill, the key components of the proposed training program, strategies to overcome challenges, and the potential transformation of the healthcare system.
Hardie's journey into advocating for TIC legislation began with a profound realization that trauma has a huge impact on individuals and a widespread ripple effect on society. Exposure to trauma affects almost 70 percent of adults nationally, leading to various social issues such as poverty, violence, incarceration, and addiction. Research in genetics, neuroscience, and epidemiology underscores the pervasive impact of trauma on both the brain and body.
“The shift in approach from "What's wrong with you?" to "What happened to you?" reflects the essence of trauma-informed care. The four "R's" of TIC—Realize, Recognize, Respond, and Resist—form the foundation for creating a patient-centered, sensitive, and culturally aware healthcare environment,” said Hardie. “Implementing TIC education is expected to improve provider-patient communication, patient satisfaction, medication information recall, compliance, and service referrals.”
Recognizing the role of nurses as the first point of contact in the healthcare system, Hardie was moved to address the lack of systematic TIC education for nurses in Indiana. Her Doctor of Nursing Practice (DNP) degree provided the platform to lead an advocacy campaign, resulting in the proposal of a statewide legislative bill mandating TIC education for Indiana nurses.
Indiana Senate Bill 45 outlines comprehensive requirements for the trauma-informed care training program. Foundational TIC education includes defining TIC, creating awareness of trauma prevalence and impact, and incorporating key principles outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA). These principles encompass safety, trustworthiness, peer support, collaboration, empowerment, and cultural considerations.
The program also addresses strategies for implementation and integration, aiming to promote resilience and prevent harm from repeat traumatization. Research supports the effectiveness of TIC training, showcasing significant gains in knowledge, skills, attitudes, confidence, and competency among healthcare professionals. Continuous TIC training is seen as crucial for improving patient outcomes and retaining skilled nursing staff.
Hardie and her co-authors faced challenges in proposing their legislation, particularly in a state where nurses had no continuing education requirements. The Indiana Professional Licensing Agency (PLA) experienced gaps in service, with increased workload and high staff turnover hindering the implementation of previous mandates.
“During the legislative process, the Indiana State Nurses Association (ISNA) initially opposed the bill, citing concerns about the PLA's ability to enforce continuing education mandates,” explained Hardie. “But strategic collaboration and amendments to the bill, discussed with ISNA leadership, paved the way for potential support. We were even able to get State Senator Mike Crider and State Circuit Court Judge Kimberly Dowling to support and advance the bill despite initial opposition.”
On January 24, 2024, Indiana Senate Bill 45 had its second hearing in the Indiana Senate Health and Provider Committee and passed 10-0, paving the way for improved patient care, and opportunities for healthcare professionals, and the healthcare system as a whole, to make meaningful strides.
To ensure the practicality of the training requirements, Hardie conducted a systematic literature review on the impact of TIC education. The bill mandates foundational TIC content, and multiple accessible, free, or low-cost training programs, both online and in-person, are recommended to facilitate nurses' access to education within their work schedules.
Flexibility in training schedules, recognition of prior learning experiences, and tailoring TIC education to nurses' needs and specialties enhance engagement and implementation. Collaboration between healthcare institutions, educational bodies, and professional associations is emphasized to develop and disseminate effective TIC education programs. And although Hardie and her co-authors were careful to make sure the bill outlined a feasible implement plan that would provide equitable care, it still required a fair amount of hand-holding to get it through the state senate.
“Navigating the legislative process requires collaboration and coordination efforts,” said Hardie. “Our approach was informed by the Health Promotion and Chronic Disease Prevention (HPCDP) Policy Change Model.” Stakeholders included healthcare professionals, organizations, trauma-informed care advocacy groups, and Indiana legislators.
“We targeted legislators with a history of supporting TIC bills, serving on relevant committees. Collaborative efforts with the Indiana Committee on Commercially Sexually Exploited Children (CSEC) and the support of State Senator Mike Crider and State Circuit Court Judge Kimberly Dowling played pivotal roles in advancing the bill.”
Hardie’s long journey to co-author and advocate for Indiana Senate Bill 45 reflects her passion and commitment to improving patient care and outcomes through trauma-informed care. With its passage, this bill has the potential to transform the healthcare landscape in the state, making TIC education a mandatory and integral part of nurses' training. Hardie’s efforts are a reminder that nurses serve a powerful advocacy role throughout the healthcare system, from the bedside to the state house and beyond.