How to Employ Trauma-Informed Practice

In Part 1 of this article, I shared about a webinar I attended on trauma-informed practice, hosted by the Northwest Center for Public Health Practice out of the University of Washington titled, “Trauma-Informed Practice – A Rural Perspective”. The presenter was Karolyn Holden, BSN, RN, Director of Grays Harbor County Public Health & Social Services, Washington State. (You can access the webinar slides here).

Karolyn Holden shared Grays Harbor’s experience in learning about trauma-informed practice and coming to grips with the widespread influence of Adverse Childhood Experiences (ACEs) on their community’s health. Grays Harbor not only educated themselves about the affects of ACEs in their community, but they changed their approach to interacting with their community as well.

Part 1 discussed NEAR science and ACEs and gave an overview of how becoming trauma-informed can positively affect your work in public health. Part 2 will cover some specifics on how Grays Harbor changed their approach and offer some tips on how to begin employing a trauma-informed approach in your community.

Be Trauma-Informed, Not Trauma-Organized

Firstly, you will want to ensure your health department is trauma-informed, not trauma-organized. Trauma-organized refers to unhealthy behaviors that develop as a result of, or in reaction to, trauma. Being trauma-informed, on the other hand, encourages healthcare professionals to think differently and be more empathetic to those who may be suffering from adverse childhood experiences. Being trauma-informed can help you change your approach and better address the root cause of adverse health effects in your community, as well as help you affect better outcomes.

There are many examples of how being trauma-informed changes your thinking and approach, but here are a few:

Changing phrasing of questions
  • “What happened to you?” Not “What’s wrong with you?”
Having a positive attitude
  • Being respectful Not passing judgment
Having a positive approach
  • Being assertive Not being aggressive
Having positive thoughts
  • Being curious Not making assumptions
Making use of information
  • Treating information with openness and transparency Not using information as power
Communicating well
  • Communicating directly Not gossiping or triangulating

Change Management: Generate Buy-In

Changing your approach requires buy-in. Karolyn Holden shared that Grays Harbor’s process from concept to implementation spanned about two years. She began educating the board and generating support for trauma-informed practice in 2016. Next steps included organizing educational opportunities for her staff to help them understand the new approach as well as envision them. Throughout the next year, Grays Harbor continued holding regular educational meetings and offering opportunities for staff discussion. During that year, the leadership team began to implement a framework behind the scenes that would support the changes; this included training of staff as well as changing policies and practices. Lastly, Grays Harbor has worked to develop a new culture with new expectations for behavior as well as increased leadership development and peer support.

To recap:

  • Educate– your board and your staff on the why of a trauma-informed approach and what it means. This can include:
    • Trainings
    • Meetings
    • Discussion
    • Envisioning
  • Organize– a framework to support the changes you intend to implement. This can include:
    • Changes in processes
    • Teamwork
    • Communication
    • A willingness to re-evaluate whether something is working
    • A willingness to try something new
  • Implement– the changes you’ve decided to make. This can include:
    • Openness and availability for continued discussion with and questions from staff
    • Reinforcing the new culture from the top, down
    • Changing expectations
    • An excellent support network with clear leadership and strong peer support

Employing the Triple Aim Approach

Part 1 of this article talked about how Grays Harbor tackled the broad idea of employing a trauma-informed approach by breaking it down into three practical areas to address. Karolyn shared that Grays Harbor called this approach the “Triple Aim.” The Triple Aim focused on:

  • Client interactions: the way they interacted with the clients they served
  • Physical Environment: the physical space in which they provided the services
  • Workplace Culture: the culture of the workplace that influences the people who were performing the services

Your health department can also put this Triple Aim into practice. Some simple steps to this approach are…

Client Interactions

Understand the basics of how ACEs affects members of your community and recognize that, due to the nature of your work, it’s very likely many of the people you interact with may have elevated ACE scores.

Grays Harbor felt that, of the three Triple Aim areas, Client Interactions was the most neutral area to begin affecting change. “We focused our initial conversations with the staff on client interactions because it’s sort of the end-game we’re working toward. It’s the quality product we want to produce. For most of us, it’s also the easiest part of this to engage and understand. We all understand that we’re here to do good work with the people that we serve.” — Karolyn Holden

Educate yourself and your staff on:

  • ACEs, developmental trauma, and toxic stress and how it affects people across their lifespan
  • The science of resilience and how it can mitigate the harm caused by trauma and how you can help provide resilience
  • Understanding the “why” (neurobilogy and epigenetics)
  • Learning to avoid trauma re-enactment

Grays Harbor created a resource room for their staff so that they could continue learning about those topics. Some of the resources Karolyn Holden recommended are linked at the bottom of this article. They also held a lot of discussions and trainings for staff to help the staff really understand the topic.

It is especially crucial to avoid re-traumatizing. The first goal of public health should be to do no harm. It’s important to be willing to step back from unproductive encounters and be willing to re-engage in a healthier way. Ensure you…

  • Defer value judgements (they are really unproductive)
  • Step away from the re-enactment triangle

“Disempowerment and disconnection are at the core of trauma-organized behavior. So it’s paramount that we empower and support rather than solve and direct.” — Karolyn Holden

“Disempowerment and disconnection are at the core of trauma-organized behavior. So it’s paramount that we empower and support rather than solve and direct.” — Karolyn Holden

The re-enactment triangle

The Re-enactment Triangle from Karolyn Holden’s slide presentation

We all experience pressure and the expectation of doing more with less. “Being trauma-informed means we don’t allow that pressure drive how we engage with clients. We want to engage in problem solving that allows us to be responsive to special circumstances while maintaining appropriate boundaries. We call this, ‘living in the gray areas.’ We support staff to develop the skills necessary to do this, by debriefing situations… that have occurred, and providing tools to support [staff] decision-making.” — Karolyn Holden

Karolyn refers to this idea of “living in the gray area” as “flexible empowerment.”

  • Empower vs. rescue
  • Don’t allow outside pressures to affect how you engage with your clients
  • Maintain professional boundaries while also engaging in problem solving
  • Recognize that inflexibility is not trauma-informed
  • Be supportive vs. being directive

Physical Environment

As Grays Harbor changed their approach to become more trauma-informed, they noticed that much of their physical environment needed to change in order to reduce potential stressors and make sure clients had clear cues about how to navigate and engage. They wanted to support a sense of privacy and provide comfortable, welcoming, and attractive surroundings. Some of the changes they made included…

At the reception counter:

  • Decreasing barriers to eye contact with staff
  • Providing more space in front of the counter to wait in line
  • Creating a more open, approachable area

In the waiting area:

  • Providing more visual interest by adding art to the walls and better information on the bulletin board
  • Changing the seating layout to create a warmer, more welcome environment (previously two rows of seats had faced each other creating an awkward situation where clients weren’t sure where to rest their eyes)
  • Installing a pink noise machine to help provide privacy

In the child play area:

  • Making it more enclosed
  • Moving visuals and wall toys to child-level
  • Employing specialists in early child development to select toys
  • Rearranging seating to support adult engagement in play and adult supervision
  • Moving the child play area very far from the reception desk

At the entrance:

  • Creating a quiet space for adults without children to wait
  • Providing staff photos on a bulletin board
  • Putting up an informational table (which doubled as a space where someone could stand, with their back to the room, if they were not prepared to engage with others in the waiting area)

A private space to step away:

  • Providing a private room where a person or parent and child could step away if they needed some privacy
  • Using soft lighting
  • Providing furniture to support breastfeeding

Other changes:

  • Hanging artwork from local artists that showcased the community and helped instill local pride

Workplace Culture

“Systems can become trauma-organized just like individuals. The work can begin to feel directionless, value-less, fragmented, mission-less, dis-empowering, overwhelming and stuck. …People working in trauma-organized systems might therefore find it really difficult to engage in the empowering, focused, goal-oriented activities that help clients manage the effects of their own trauma exposure.” –Karolyn Holden

“Systems can become trauma-organized just like individuals. The work can begin to feel directionless, value-less, fragmented, mission-less, dis-empowering, overwhelming and stuck.” — Karolyn Holden

A trauma-organized work environment can become toxic. Karolyn likened the situation to an iceberg, with much of the issues happening under the surface. To become a trauma-informed workplace, rather than a trauma-organized workplace, a few changes need to occur:

Changes in the way staff engage with each other:

  • Ask “What happened to you?” Not “What’s wrong with you?”
  • Have inclusive leadership Not Authoritarian leadership
  • Engage in openness and transparency Not Holding information as power
  • Employ direct communication Not Gossip or triangulation
  • Offer respect Not Judgement
  • Be Assertive Not Aggressive
  • Be Curious Not Assuming

Become an environment based in trust. Model the values of trauma-informed work, being collaborative and deliberate in your approach:

  • First, do no harm
  • Acknowledge risks
  • Accept vulnerability
  • Engage conversations in a neutral way, without being defensive
  • Develop leadership
  • Use parallel process (provide support to the employee that parallels the support the employee is providing to their client)


Grays Harbor are proud of what they’ve managed to achieve since 2016. Some of the things Karolyn wanted to emphasize Grays Harbor had done right were:

  • The initial focus on client-interactions provided a safe way to engage the broader issue, starting in a neutral territory
  • They walked before they talked (They discovered what steps were needed at a leadership level and employed them without announcing beforehand what their intention was, they only called attention to it after the changes had been observed and recognized)
  • They focused on concrete, observable behaviors as the changes they wanted to see, rather than feelings or attitudes (this helped re-direct circular conversations and provide a measurable standard for change)
  • They focused on gratitude
  • They used existing resources as a deliberate investment (i.e. they were able to fund some of the changes to the physical environment with some WIC funds)

Positive changes they’ve seen as a result include:

  • Staff are employing their new skills with clients and they are seeing a higher case retention rate
  • They’ve received positive feedback from clients on the physical environment changes
  • They’ve seen increased positivity in staff and a willingness to be part of the solution
  • They see a greater willingness for direct communication and an increase in trust among staff

What do they wish they’d done better?

  • Thinking about the full scope of the project and evaluating what the team was ready for
  • Ensuring the scope of expectations was reasonable
  • Considering the current level of trust among staff


Grays Harbor took everything they learned about trauma-informed practice and put it into action. They began to ask themselves, “Where does the rubber meet the road?” and were willing to make changes in their client interactions, physical environment, and workplace culture as a result. Karolyn Holden’s webinar presentation was incredibly informative and highly useful. You can view Karolyn Holden’s full presentation recording here (it was excellent!).

To learn more about how Nightingale Notes EHR empowers your health department to evaluate ACEs in your community so that you can begin employing a trauma-informed approach, contact us today!


  • The Body Keeps the Score (a book exploring the profound extent of trauma’s impact in a person’s life)
  • ACES website
  • Paper Tigers (a documentary film about a high school that became trauma-informed)
  • Resilience (a documentary film about how ACEs can be linked to destructive behavior and medical diseases)
  • Trauma Stewardship (a book with wisdom for self-care for those working with victims of trauma)