A Practical Training Manual for Nurses, Nurse Practitioners, Physicians, Providers, and Administrative Staff

Table of Contents

1. Introduction: Why Trauma-Informed Care Matters in Primary Care

2. What Is Trauma?

3. The Impact of Trauma on Health

4. Core Principles of Trauma-Informed Care

5. Trauma-Informed Communication

6. Trauma-Informed Clinical Encounters

7. Trauma-Informed Administrative Practices

8. Preventing Re-Traumatization

9. Boundaries, Documentation, and Scope

10. Staff Wellness & Preventing Secondary Trauma

1. Introduction: Why Trauma-Informed Care Matters in Primary Care

Primary care is often the first — and sometimes only — place people seek help for physical and mental health concerns. Many patients entering primary care settings have experienced trauma, whether or not they disclose it.

Trauma-informed care (TIC) is not a specialty service. It is a framework for how we interact with every patient, every day.

Trauma-informed care means:

• We assume trauma is common.

• We recognize signs of trauma.

• We respond in ways that promote safety and autonomy.

• We actively avoid re-traumatization.

Trauma-informed care benefits:

• Survivors of abuse and violence

• People with chronic illness

• Neurodivergent individuals

• Survivors of parental abuse/neglect

• LGBTQIA+ communities

• Refugees and immigrants

• People with medical trauma

• Anyone who has felt dismissed, unheard, or harmed in healthcare

Importantly, trauma-informed care improves outcomes for all patients, not just those with known trauma histories.

2. What Is Trauma?

Trauma is not defined by the event.

It is defined by the nervous system’s response to overwhelming stress.

Trauma may include:

• Physical, emotional, or sexual abuse

• Medical trauma

• Racism and discrimination

• Gender-based violence

• Chronic invalidation

• Parental neglect

• Witnessing violence

• Sudden loss

• Poverty and systemic oppression

• Healthcare discrimination

Types of Trauma

• Acute trauma – single event

• Chronic trauma – repeated exposure

• Complex trauma – prolonged interpersonal trauma

• Developmental trauma – occurring in childhood

• Systemic trauma – discrimination, racism, anti-trans legislation

• Medical trauma – painful procedures, dismissal, forced exams

3. The Impact of Trauma on Health

Trauma affects:

1. The Nervous System

• Hypervigilance

• Panic

• Dissociation

• Shutdown

• Startle response

2. Physical Health

• Chronic pain

• IBS

• Headaches

• Fatigue

• Autoimmune conditions

• Cardiovascular disease

• Sleep disturbances

3. Healthcare Interactions

• Fear of exams

• Avoidance of care

• Distrust of providers

• Difficulty advocating for self

• Appearing “difficult” or “noncompliant”

What may appear as:

• “Resistance”

• “Noncompliance”

• “Overreacting”

• “Angry patient”

May actually be:

• A protective nervous system response.

4. Core Principles of Trauma-Informed Care

Based on widely accepted trauma-informed frameworks, core principles include:

1. Safety

Patients must feel physically and emotionally safe.

2. Trustworthiness & Transparency

Explain what you are doing and why.

3. Autonomy

Offer options whenever possible.

4. Collaboration

Healthcare is done with patients, not to patients.

5. Empowerment

Focus on strengths and resilience.

6. Cultural Humility

Recognize systemic inequities and bias.

7. Informed Consent

The patient should be explained the risks and benefits of all treatments offered including declining treatment, and the patient should consent before being touched in any way

5. Trauma-Informed Communication

Applies to:

• Front desk staff

• Medical assistants

• Nurses

• NPs

• Billing staff

Tone

• Calm

• Non-judgmental

• Curious rather than assumptive

Language Shifts

Instead of:

• “Why didn’t you…?”.

• “Why did you need that?”

• “You need to…”

• “You should…”

• "Why did you stop taking your medications/ not start them?"

Try:

• “Can you tell me more about what made that difficult?”

• “Would you be open to discussing options?”

• “Could I tell you more about [condition/ treatment]”

• “Would you like to talk about medications only, lifestyle only, or a combination of both for treatment?

• “What feels realistic for you right now?”

• "Would you like to send me the information you want to share in the visit as a message prior to the message?"

• "Would you like to bring written notes?"

• "What led you to decide to stop your medication/ not start what was prescribed?"

Ask Permission

• “Would it be okay if we talk about your eating patterns?”

• “Is it alright if I ask a few questions about trauma history?”

• “Would you like to continue this conversation today or schedule a follow-up?”

Validate

• “That sounds really overwhelming.”

• “It makes sense that you’d feel anxious about that.”

• “Thank you for telling me.”

Validation = acknowledging emotional reality

6. Trauma-Informed Clinical Encounters

Before the Exam

• Review chart to avoid asking patient to repeat trauma history unnecessarily.

• Prepare room for privacy.

• Ensure correct name and pronouns are visible.

• Avoid assumptions about gender, relationships, sexual behaviors, lifestyle habits, substance use patterns, etc. Assume nothing

During the Visit

1. Set Agenda Collaboratively

“I had these two issues as our two items to focus on, can you confirm that is what we are talking about or did you want to change our agenda?”

2. Explain Steps in Advance

“I like to do a pap smear like this. First I’ll do an external exam. Then I’ll ask if you’re ready for a single gloved lubricated finger to locate your cervix and determine what the smallest speculum size we can use is for your exam. Then I’ll get the speculum ready and ask if you’re ready. Once I hear you’re ready I’ll insert it slowly and check in with you. If you need to stop or are done you can let me know at any time”

3. Consent. Ask permission prior to touching someone else ever including vital signs, exam, etc. and ask permission before sharing information around sensitive topics in particular (lifestyle changes, sexual health, etc)

4. Offer Control

• “You can ask me to stop at any time.”

• “Would you prefer a support person present?”

• “Would you like to insert the speculum yourself?”

• “Do you prefer X or Y treatment option?” Offer choices in treatment options when safe and feasible instead of offering a single recommendation

• Can I tell you more about [condition] or [treatment]?

5. Watch for Nervous System Cues

Signs of distress:

• Freezing

• Tearfulness

• Shallow breathing

• Sudden irritability

• Dissociation

If observed:
“I’m noticing this might be uncomfortable. Would you like a pause, to change topics, or be done for today?”

Sensitive Topics

When discussing:

• Weight

• Substance use

• Trauma

• Eating disorders

• Sexual health

• Relationships

• Mental health

• Gender identity or expression

Use:

• Neutral tone

• Non-assumptive questions

• Clear rationale for why you need a specific piece of information

Avoid:

• Asking overly personal questions if they do not inform diagnosis or treatment

• When asking invasive questions, they should only be related to ordering tests, diagnosing conditions, or prescribing medications. Curiosity is not a legitimate reason to ask invasive questions particularly around sexual behaviors, surgery, sterilization, etc

Examples:

1. STI Testing:

• “Can I ask some personal questions about what parts of your body you use for sex so I can order the right tests for you?” If you perform oral sex there is a throat swab. If you use your genitals for sex there is a urine or genital swab. If you have anal receptive sex there is a rectal swab. Which of those swabs do you need?”

• "Since you were last tested for STIs, have you had any new partners or have you had any partners who have had new partners?"

2. Contraception:

• "Is your partner someone who makes sperm and do you have vaginal receptive sex? (when assessing need for contraception)"

3. Hygiene:

• "Can I ask some personal questions about hygiene to see if there are any things that may be contributing to your issue with recurrent infections?"

4. Relationships:

• "Who is the guest you have with us today?" Instead of “Is this your wife/mother?”

• "Are you feeling safe, secure, and free from violence in your relationship?"

• "I do not make assumptions about relationships. Is your relationship monogamous, meaning you and your partner are only sexually active with each other, or are you non-monogamous?"

5. Metabolic Health/ Prediabetes/ Diabetes/ Hyperlipidemia/ Diabetes/ MASLD:

• "Would you like to discuss medication options, lifestyle options, both, or neither today?"

• "Would you like me to offer dietary general principles or would you prefer me to upload our list of registered dieticians who practice from a HAES lens to the portal, or neither?"

6. Reproduction/ Fertility

• "Is having biological children important to you?"

7. Trauma-Informed Administrative Practices

Administrative staff are often the first point of contact. Their role is critical.

Front Desk

• Greet patients warmly.

• Avoid public disclosure of sensitive info.

• Avoid discussing billing issues publicly and/or loudly

• Use language that decreases the risk of patient escalation when possible

Billing Conversations

Instead of:
“You owe this.”

Try:
“There is an estimated balance today of ___. Would you like to review how that was calculated?”

Financial stress can trigger trauma responses.

Scheduling

Avoid shaming language:
“You missed your appointment again.”

Instead:
“We noticed you weren’t able to make your appointment. Would you like help rescheduling?”

Discharge

Avoid shaming language: “You behaved in an unacceptable manner.”

Instead: “Your behavior didn’t align with our patient code of conduct.”

Avoid shaming language: “You are done/ out of here.”

Instead: “You have three late cancellations/ no shows and will be discharged”

Intake Forms

• Avoid overly invasive questions without context.

• Allow “prefer not to answer.”

• Avoid forcing gender binaries.

8. Preventing Re-Traumatization

Re-traumatization happens when healthcare replicates aspects of past trauma, including:

• Lack of control

• Forced procedures

• Dismissal of symptoms or concerns without appropriate investigation

• Being talked over

• Being disbelieved

• Being misgendered

• Being deadnamed

• Being touched without consent

• Paternalism (not giving choices)

Prevention Strategies

• Narrate care.

• Offer choices.

• Avoid surprise touch.

• Use correct name and pronouns.

• Do not argue about lived experience.

• Avoid minimizing symptoms.

Even small moments matter.

9. Boundaries, Documentation & Scope

Trauma-informed care does not mean:

• Providing therapy in primary care

• Over-disclosing about yourself

• Extending visits indefinitely

• Avoiding necessary clinical boundaries

Maintain Professional Boundaries

• Be warm but structured.

• Avoid rescuing behaviors.

• Set clear policies compassionately.

Example:
“I want to support you, and our clinic policy is visits every 6 months for medication management.”

Documentation

• Avoid judgmental language.

• Avoid “noncompliant.”

• Use:

  • “Patient declined”

  • “Patient expressed concern”

  • “Patient reports difficulty due to…”

10. Staff Wellness & Secondary Trauma

Working in primary care exposes staff to:

• Stories of abuse

• Suicide risk

• Chronic suffering

• Systemic injustice

This can lead to:

• Compassion fatigue

• Burnout

• Secondary traumatic stress

Protective Strategies

• Regular debriefs

• Supervision

• Clear role boundaries

• Adequate time off

• Peer support

• Mental health access

Leadership should:

• Normalize emotional impact

• Avoid productivity-only culture

• Encourage staff to step away after intense visits

Trauma-informed care applies to staff as well.

Conclusion

Trauma-informed care is not a checklist. It is a cultural shift.

It requires:

• Slowing down

• Curiosity over judgment

• Transparency

• Consistency

• Compassion for patients and staff

Primary care can be a place of harm — or a place of healing.

When we prioritize safety, autonomy, and respect, we help regulate nervous systems, rebuild trust in healthcare, and improve outcomes across physical and mental health.