Reframing Trauma Informed Care as a Systems Approach

At the Core of Care

Published: December 20, 2022

SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities. 

I'm Sarah Hexem Hubbard with the Pennsylvania Action Coalition and the Executive Director of the National Nurse-Led Care Consortium. 

As part of our special training coverage, this episode features a conversation about Centering Trauma Literacy in the Health Center Medical Home. We’ll hear how providers and health systems can cultivate trauma-aware practices as part of their delivery of care.

My colleague Jillian Bird, Director of Training and Technical Assistance at the National Nurse-Led Care Consortium, will lead the conversation. Through a wide variety of ongoing programming, Jillian and her team help support providers working at community health centers across the country.


JILLIAN: Thanks Sarah.

Our guests for this conversation are Kathleen Metzker and Sara Reid, and they’re joining us by Zoom.

Kathleen works in Philadelphia as the Director of Integrative Health and Mind Body Services at the Stephen and Sandra Sheller 11th Street Family Health Services of Drexel University. In this multidisciplinary health care setting, more than 6,000 patients access a range of services, including: primary care, behavioral health, dental services, and health and wellness programs.

And Sara is based in Boston where she is a health educator, support group facilitator and consumer board member for the Boston Healthcare For the Homeless. Sara is a public speaker and delivers trainings on transgender priorities, including teaching medical and behavioral health providers how to provide gender-affirming healthcare.

Welcome Kathleen and Sara to At the Core of Care.

KATHLEEN: Thanks for having us here Jillian.

SARAH: Thank you.

JILLIAN: At the beginning of each episode, we always like to ask our guests why they do the work they do. Kathleen, can you start us off?

KATHLEEN: Well that's a very good question, why I do the work that I do? I think it's natural for me to want to do work that is in the service of others. There are so many people that show up for their job to get a job done, to get home, to have the rest of their lives. But remembering that we are in constant relationship with one another is a core principle in my own life. So I’ve really had the opportunity for that to show up in my personal life every day. And it reminds me that I'm alive. And that is why I do the work that I do.

JILLIAN: And Sara, what about you?

SARAH: Actually a couple of reasons. As a mother of two, grandmother of four, you know, thinking about making the world a better place and, be better than I found it is kind of like core to who I am. And also, I've spent the last 30 years in one form of counseling or another, and you know, around the issue of trauma, the medical system itself has been very traumatic, because of kind of the era that I came out in. I'm a trans woman myself, and it was just all barriers, all stigma. We were almost universally discriminated against. And, you know, I would like to be the young 18-year-old starting out with a good prognosis a good outcome for the medical interventions and, and look forward to a whole life of you know, just being myself. But it wasn't possible for me. And I guess, one of the ways I make use or reconcile the lost time of, you know, big chunk of my life is to make sure that it never happens to anyone else again.

I struggled to get to where I am. I went through six years of reparative therapy, or they call it conversion therapy, to try and kill it off. And then having come to the end of that, I went in looking for gender affirming care, and I just couldn't find it anywhere, you know, I ended up getting referred around like a hot potato. And then interacting with the community that I directly work with, I found that, you know, my story is kind of pretty average. And the stories that have been told to me, you know, I kind of wanted to do something about it. But at the time, you know, I was having the conversations I didn't have any direct way to make the medical interaction with my community better, but I've kept it in my heart and opportunities have risen, I've taken an opportunity to kind of speak to those issues and keep the people that were kind enough to share their stories with me in mind as I went forward to do some teaching, and help people understand better.

JILLIAN: Thank you very much for sharing those perspectives with us and before we dive into our discussion, let's first hear about the communities you're currently serving and what key needs you've been concentrating on addressing?

SARAH: So my entry point into working mainly with my nurses, you know, I love working with my nurses, they've been, you know, a godsend to me, and they're just some of the finest people I know. But the sort of my entry position was seeking out help. And the most welcoming, friendly place to trans care was Boston Healthcare for the Homeless, believe it or not. Absolutely no discrimination or stigma, they've been wonderful. And with that, my interaction with patients has gone two ways. One is I'm interacting with our general patient population, as well as I sit on the board of directors. So I'm, I'm like on both levels, I'm with the executives monthly and then interacting with patients and peers. And then my, you know, where my heart lives is where healthcare touches the needs of gender affirming care for trans identified people. And I've had quite a lot of experience with that over the last decade. Things are changing in some ways, but we've still got a long ways to go.

JILLIAN: And Kathleen, what are the needs you feel like are being addressed in the communities that you're serving currently?

KATHLEEN: Thinking about it through the lens of the health home, we're a federally qualified health care center. So we're operating under the assumption and the knowledge that the greater majority of our patients live below the poverty line, low-income, socio economic status. Our demographics of approximately 6000 patients, where about 75% individuals identify as Black and African American, and the rest of the breakdown, pretty much divides between white, Latino and other. But the thing we know about individuals and communities like ours, that are really up against more social determinants of health. And there's an increase in adverse childhood events, which, as we know, then impacts health outcomes of mind and body later on in life. So thinking about this through a trauma-informed care lens, operating under universal precaution. And keeping that in mind as we're interacting with our community and patients. Also the Health Center is set right in the middle of four public housing communities. We've been there over 20 years. So especially as we emerge from the pandemic, I keep reminding my team or reminding each other we almost need to act as if we just got here, right, because we're a university affiliated medical home. So there's the history of mistrust, needing to build trust and relationships. And even in the 12 years that I've been there, generations have changed. So what used to be the children of clients are now the parents of the children, and caretakers of their elders. There's, of course, the impact of the pandemic, and the increase in community violence in Philadelphia. So all of these things are impacting the well-being of the individuals in the communities that we’re intended to serve. So really keeping all of these things in mind and understanding the complexity of those needs, is really where we're landing right now.

JILLIAN: Thank you. And I always think of where you are and the organization that you're working with as being a leader in this space, for so many reasons. And hopefully, we'll be able to touch on some of those in this discussion. But kind of following in that leadership, we've seen of continual shift and healthcare spaces to try to be more trauma informed and trauma literate, and have a more holistic understanding of what being trauma aware is. So I'm curious, Kathleen, as you think about your own organization, and also this general evolution, are there some real examples at your health center where you work that you might be able to share that sort of really highlight or encapsulate these concepts and then how they look in practice?

KATHLEEN: Yes, and I appreciate the use of the word holistic. And at the same time, I think that feels from a healthcare or scientific lens, sometimes it feels a little soft. So if we could even recontextualize it in thinking of trauma informed care as a systems approach rather than addressing technical needs.

We're also talking about humans interacting with humans, which becomes complex, and cultural perspectives. And when we think of the patient provider relationship, even through a trauma informed care lens, the ideal would be recognizing that potentially trauma has impacted this individual, their behavior, their health outcomes.

Then we have the provider patient relationship that has inherent power dynamics. So when we're considering communities that would otherwise be considered marginalized or disenfranchised. These kinds of buzzwords of people being treated like others, those power dynamics play a big part. So understanding that and that felt and lived experience for the patient and the provider, and the provider who's also having a very human experience and potentially carrying their own trauma. And even just their own day to day lives. So I always refer to trauma informed care as this practice of being skillful humans together. So thinking about how we use language is significant.

So really, we're cultivating a type of culture in professions who aren't necessarily trained to understand trauma, or to understand the lived experience of those that are oppressed. So we need to do that in ways that are relatable.

So really a real time example of something that we're navigating in this moment is how we're responding to patients that we would consider or might be called disruptive or having outbursts. So even just that language like this is an outburst? And how do we manage de-escalation can feel oppressive to that person and feel marginalizing or dismissive. So what if we change that language a little bit? But then how do you how do you train the provider to think about that?

So on another hand, if a patient came in with a limb, that might be symptomology of an injury in the leg? So looking at an analogy here, if a patient comes in with behavior that feels outside of cultural norms, so an outburst for example, that's a symptom, perhaps of trauma, or that something has happened to this person, not that something is wrong with this person.

The neurobiology of trauma, so what does that really look like? And how does that show up and, at the same time, needing to equipped ourselves then with those soft skills of compassion, active listening, of self care, and all of this needs awareness.

So for example, a provider, taking that pause to ask themselves, how am I doing in this moment? How am I really feeling in my mind and my body and my heart? And in the midst of the culture of health care, how can we possibly take care of our nervous system? It's fast, there are expectations around time. There's a lot of complexity. You're up against a lot, especially now when one of the things that we're up against his staff turnover and being short staffed as a result of the pandemic.

So all that being said, at our health center, staff wellness is emphasized on a regular basis. It can't be just something we say on paper needs to be ongoing. And one of the skills that we use is the practice of mindfulness. And mindfulness supports these qualities of compassion, active listening, self-awareness and self-regulation. You can't regulate yourself, if you haven't checked in to begin with to know that you need it. So becoming more self-aware in our relationships with one another, again, this idea of being skillful together. Some of the ways they we do this more practically, is we at the beginning of our meetings, including our huddles, we have check ins “How are you feeling in this moment? Do you need any support today? And who can you ask for that support?” And these are some of the questions that come out of the sanctuary trauma informed care model. So I want to make sure to give them credit.

We have moments of mindfulness at the beginning of most of our meetings. It could be real practical mindfulness, maybe we're doing some breath awareness, maybe some body sensations and grounding. We have created physical spaces for respite rooms, so that if staff need to step away, because often in healthcare setting, you don't have privacy during the context of your workday.

We have daily practices at lunchtime, whether it's a yoga practice, meditation practice, maybe engaging in some art or music therapy. We are fortunate to have a fitness center on site. And I realize that not everybody has these things. But there are ways that you can create these things. All you need is a room. You could put on a YouTube video, and you could do yoga together for five minutes, or you could do a five-minute meditation. So there are always ways to make these things work.

And another thing we find very helpful is visual cues around the building. We have gold stars all around the building. And they're reminders for you to pause and to check in with yourselves. We asked staff to submit quotes of affirmation or encouragement. And then we have handwritten signs all around the building that staff were asked to hang in places that felt relevant to them are felt visible to them. So as they move through the space, and as the patients move through the space, they see these.

And last example offer is we created something we call the mind body toolkit. So it's both a visual cue that hangs, it looks a little different right now because of pandemic. It's more technologically oriented, but their visual cues and primary care tools that both the patients and the providers can use to help themselves to pause. Maybe it's little signs of affirmation, or breathing practices, or even a stone just to hold for sensation and grounding. Another benefit of that in addition to helping someone just kind of get settled, get present. It improves the relationship between the provider and the patient so that they can they can be humans together while still attending to the to the needs of the visit.

JILLIAN: Thank you so much. Yeah, I'm thinking about how you're giving very concrete examples of how both the care team, the members of the care team, and those that are in the health care delivery setting are also working on themselves, and at the same time able to support the patients that are coming in. I'm imagining that creates an environment where patients feel this sense of comfort that they know that there's work being done on both sides here. It's not just as one direction of I'm being told that these are things I need to work on, but that in fact, the entire environment is committed to being trauma informed, and also supporting the health care team. So I'm curious, Sara, from your perspective, and from your lived experience, as well as the expertise you have with training health care providers, what considerations around trauma are you highlighting for providers and the health system to keep in mind as part of their delivery of care?

SARAH: Where I usually try to meet them, the providers is with what they're experiencing. And I do that with whatever community I'm working with. So when I am doing a training, I'll always say, as you know, is as to my community, you'll find that we're not always the easiest patients to have or to deal with. We sometimes have short fuses. Sometimes we seem angrier than other patients. Sometimes, we’ve got a, what they call a hair trigger for switching a friendly hello into something escalated. And I think understanding a little more about what happened to this person on the way to this visit.

I worked customer service for a lot of years in retail, and I learned that no interaction, even with an angry customer, it's never about me. So, with our patients, they have had, ongoing trauma throughout their, say the last month. They may have had 50 things happen to them. Some of the things may have happened on their way into the meeting. Sometimes people feel empowered by picking on people they feel are fair targets that they can get away with. People get misgendered, rejected by their families. Some have lost jobs.

I’m at the intersectionality between undocumented asylum seekers, Latino community, and then we have a lot of substance use. This is just in our general practice. So I think to some of what Kathleen was saying is, you know, we got to have a team attitude towards this, you know. What I love about my clinic Health Care for the Homeless is that it is always a collaborative effort from CEO all the way up to the patient, you know. And we are a team, and are always checking in with each other. And it's a genuine thing, which is, I think, in some ways, you know, rare and wonderful.

But back to the patients, you know, they'll come in and they'll be upset, maybe you use the wrong pronoun or something. And the easiest way to deal with this to say I'm sorry and move on. But in understanding or having some sort of a picture of what they may have going on in their lives.

If you take a step back, take a breath, and realize, you know, it's not about you. And then don't patronize because that's another one of our triggers. We know when we're being patronized, and somebody's being insincere. But I think just, by seeing another human being somebody's kid, somebody, sibling, maybe somebody's spouse, or parent.

You know, that this is a person just like me, that goes a long ways. Kathleen mentioned about patients, feeling like they're listened to. One of the greatest things, twice, I've had it happen in both points in my life, were turning points where I met a new group. Well, the second time I met a group of trans women from Cambridge. They were all Latinas. And I remember going down the list of the mess that I was in at the time. I was going through a divorce, I wasn't going to see a paycheck for the next 15 years because of my own sense of shame. I had taken on all the marital debt. I was still trying to be as involved with my children as I could, working couple jobs, with no money to no place to live. And on and on and on. I remember talking to this just wonderful, beautiful, trans woman from the community. And she listened to me and she says, ‘Oh, that sounds about that sounds about right. That sounds about like most of us what we're going through. I believe you.’ And just those three words, I believe you. It just means so much.

And I found it, you know, going across to other groups that we work with that that really helps a lot. If you have a patient, maybe who's coming from a vastly different culture and or somebody that's dealing with a mental illness, and they're having things that we would consider not necessarily real, but we can still believe that it's real to them, and kind of get in get in to tell me more about that. That sounds really scary. And you can be real about it to do other people see this person talking to you or is you know, just like is it just between you and them. You can contextualize it and kind of get into it and just be supportive of them. And that's a good place to start. Once they feel listened to you can start building up from them.

So back to us being rough patients. I always say you know, you may be the first person in a month to give us a break. So maybe you don't understand this patient in front of you, you don't understand why this is, this is such a challenge or obstacle for them why this is such a struggle. But just that human contact, that genuine sense of I believe you. Let's start here, let's start working on these things right now and see where you are in a few years.

JILLIAN: I hear a lot and what you're both saying the power of listening, and seeing people, being with people. And in so many ways, it's speaking to really supporting that psychological safety that I don't think is often considered and sort of the flow chart, you know, how the patient flows in and out of the clinic, and, you know, all of the logistics and operationalizing that we do to ensure that our medical system is functioning. We want to put the human back into the center. And really considering that psychological safety is as important, I think, in many ways as to, you know, finding the right diagnosis and continuing to build on the right care plan and making sure the medication is correct. And are you seeing psychological safety? Or something along those lines being part of how you consider care that's being received? Or if this is quality care? Is that part of the conversation for either of you?

SARAH: Yes, actually, it's been astonishing. My nurse and I, that I partner with, in a lot of the trainings, we were invited to be part of the transgender Task Force at Boston Medical Center, when they outwardly declared themselves as having a comprehensive trans care component of their practice. Now, that's not something anybody would have advertised 15 years ago. But strangely, Healthcare for the Homeless did 13 years ago, and I keep telling my nurses how unusual and wonderful that is that they actually said, Oh, no, this is what we want. It's it wasn't like the last thing on the list. It says, No, we're a transgender clinic. And everyone's like, wow, that's different. Because there's so much stigma back then.

So a big part of Boston Medical Center, and we see it all around town is just posting like, little diversity stickers, or flags, or a transgender flag. A GLBT flag is one that includes people of color now, it's sort of like a universal flag. And I always thought that, you know, considering the trauma that we go through, like, you know, what good is that gonna do? But amazingly, seeing those around, like, I see them around in town where I live. And it's an amazing psychological relief to realize that not every transaction I might have is a person who's a little different, could escalate into you know, somebody calling the police or something, some awful, you know, new trauma. But seeing that little flag, it's like, okay, this is a friendly place, these people have had some training. My mind hasn't really prepared me from how much of a psychological relief that is. So, I think, you know, like, as far as communicating safety is to meet people where they're at, call them what they'd like to be called.

Obviously, we have to record them certain ways, you know, to have to do with documenting interactions, records, taping and then the important part of billing. But still, most every one in the world has a nickname and some really love their nickname better than their name. So, you know, even with, if you apply that context onto like transgender care, it isn't that hard if you realize that while people have nicknames and you know I'm going to get to know Susan and she wants she/her pronouns. Then there's no obstacle for us to go forward and deal with that, that fever, that rash, that internal pain. And, again, it's the personal connection, I think that does have the healing.

JILLIAN: It really sounds like you're embodying the practice of mindfulness that Kathleen was sharing with us earlier that you know, being with and that presence and that skill of listening and keeping that loving kindness, that openness. It's a beautiful thing. And as you mentioned, it can be very enriching, it fills you as you're working with others. Thank you for giving us that insight. And, Kathleen, I'm not sure if you'd like to share anything on this as well. But this idea of the psychological safety, and that there is an opportunity to build skill. I'm curious if that's something that you all are working on at your health center?

KATHLEEN: First, I want to say appreciate so much of what you're sharing, Sara, and how we can be kind of saying the same things, two sides of the same coin. Right. And, and that skill does take practice. I think we could all relate to that. I also really appreciate the use of the language around psychological safety. Because I'm pretty confident we don't say that explicitly. But that is what we're talking about. We might say creating safe spaces or understanding where someone's coming from. And I once heard someone talking about medical providers, not so much a specialist, but partialists. So not thinking about someone's psychological experience when they're there for a liver condition. But that liver lives within a body that lives with the nervous system that has thoughts and feelings and memories and experiences and whether we want to or not, we always bring all of that to the table.

So this is a piece I'm going to take with me is this use of how do we talk about psychological safety and its relevancy within the context of health care? But yes, just to reiterate, first of all, know what we are bringing to the table, right? This skill that you're talking about Sara, and the ways that we can do that. And maybe that's maybe that's a pause before you walk into the room. Or when a conversation does feel a little challenging, giving yourself that moment just to feel your breath. And maybe prayer is significant to you, make that part of your day, or music or whatever it is. Do the things that remind you that you are present with yourself and each other. So that could look like a lot of different things. You mentioned the flag, Sara, that gave a sense of like safety and welcoming and having the visual cues that let the patient community know like we see you. This is why we're here. We understand. Or we're trying to understand where your lived experience and be in relationship with one another. So I shared about some of those visual cues earlier. But we get feedback all the time, like you're saying that that that does create a sense of comfort. And it also reminds us as providers every day when I go into the building, I see the sign that Black lives matter and it's like yes, I'm going to reaffirm that again because I'm a white woman from the suburbs. Seeing that sign is important to me to remember whose community I'm walking into.

Also, we're very lucky that we're an integrated model of care. So we have behavioral health providers within our primary care setting that can be available for visits. So maybe someone is coming with some additional psychosocial stressors, and they have the option to meet with a behavioral health professional, or an option to be connected to someone like myself that might connect them to wellness services. And again, remembering that could be many things. So maybe it's yoga, maybe it's meditation, maybe it's fitness and exercise. But because these auxiliary services are there, at the very least making that part of the conversation with the patient, like what are the other ways you're taking care of yourself. And also remember, it can exist within a silo, right, that this conversation needs to live outside of the visit.

So Sara mentioned, and reiterated the idea of team support and reflecting with one another and getting feedback from one another and how important that is. And one thing I have observed, especially in the beginning or with new staff, kind of asking the question, Can I really talk about these things? Can I as a white provider, say, or as a heteronormative provider say, this is how I showed up? And I'm not sure I did it so skillfully, right, because there's that fear of losing your job or punitive response. But if we're thinking about the culture, systemically, like in the bigger picture, then we need to be creating resources to support those providers to educate them. So we can lean towards learning and change and growth as opposed to behaving out of fear that maybe we're gonna mess it up. So that we're creating supportive environments, just for the psychological safety of both the staff and the community members.

SARAH: I've had to work across the lines with, you know, in a way with people that it's, it's not typical protocol, to do certain things, say certain things. And we really have to be adaptable. You know, I think of my own case, I was prescribed my first prescription of hormones about 20 years ago, that for a medical provider to prescribe that as an which is actually an off label, application of this medication, I had to sign forms that, you know, I was taking responsibility for the consequences of that. Now, we no longer do that in medical practice. But even then, I respected the fact that they were taking considerable professional risk to, to get me what I needed. So, I know like, for another example of working with patients, like I said, I work have worked good deal with the Latino community. The people that needed our services, the most, were people who were also asylum seekers. And sometimes when they go to the medical provider, they're very afraid to tell much of their situation. They're afraid to tell of maybe some illegal free silicone that's been pumped into their body because they don't want the medical person to look down on them. There are times they generally don't want to give or they’re very afraid to give the personal information even for records keeping. So we have to hold that precious.

And sometimes we may have to lose a recordable just for being able to help a person that's got a very serious condition, and we have to meet them where they're at, and accept that they haven't really given us the correct information. But I think you know, as healers, and if we remember that we are healers, I think, you partnering up with a supervisor actually helps to try and you know, work out something that you might not have felt, whether or not is was this okay to do this. But at the same time, if we remember, that we're healers first and foremost, we're community members, and that this person coming to me, the thing I always put my mind, is just me on a bad day. Or this is me in a parallel universe, that is another life. Personally, I've had the chance to live in two separate universes that are right alongside each other and I can tell anyone who's ever lived as a male or a female that these are not the same universes. There they are exactly alike in the same space but the life is and experiences and pushback we get through life from our surroundings and expectations about us are quite different.

Sometimes I just feel almost like inadequate, because I haven't been through some of the things that these folks have been through. But again, I believe them. And anything I can do to help them remain stable. In this community that I work with, you can go from years of stability into absolute chaos in an afternoon. Just it could be over, you know, any component of the, the balance of what they have put together for life, it could be you know, housing, something goes wrong in housing, maybe a troublemaker neighbor, or a Saturday night transact interaction with a What started as a friendly face turns into a police encounter. And that just is the first domino in what could devolve into extreme chaos.

So when we're working with patients, we'd like to start out long-term relationships and get to the place where we find other ways of coping, other ways of solving problems of helping patients understand that by doing that they there, yes, they have a pile of 50 problems on it. But even in the condition they are with the choices they're making, we can say, okay, you know, I see this mountain of problems, why don't we work on one. Or part of one. If one is too overwhelming, let's work on a part of one today and see how that goes, see if you're in a better place after we do this a few times.

JILLIAN: When I hear this story, I hear so many aspects of empathy, you know, being greatly empathic and being unconditional with your positive regard of a person, regardless where they are. And it feels rooted in building trust, like you just refer to this long-term view of this person's healing, that it's not transactional, it's not happening right now. I really appreciate that perspective, and that you're seeing people. There's so much to take in here. And basically, what we're talking about is how do we all become more skilled humans with each other? In theory, yes, we get that. But in practice, in what ways can we continuously improve our ability to interact with patients through trauma awareness approaches? And, Kathleen, I'm wondering if as we're kind of wrapping up, what has been your experience with that kind of continual improvement of the interactions with patients through trauma aware approaches, and in that, as you put it previously becoming more skilled humans?

KATHLEEN: I think continuous is the key word here. This becomes the norm in our practice. And that's going to take a lot of work. So I think one approach to that is perhaps creating spaces for practice and reflection. And what I hear time and time again, and I'm sure many nurses can relate is, the time for that is challenging, right. But once it becomes part of the culture, it's not something that we make space for. It's just something that we do, right so that we do need champions. So identifying champions within the workplace, to hold ourselves and each other accountable to that has been really helpful. And also questioning our own workplace cultures, let alone our culture broadly.

But just even in the last couple of weeks, I've had several interactions with individuals that we might be collaborating with that said, I'm so sorry about the delay, I've actually been sick. And it's like, oh, my gosh, of course, please do need more time to take care of yourself? And what they say is, Wow, thank you so much for saying that. I wish everybody would say that. It's like, wow, we're really not giving each other grace. And then we could definitely assume that we're not really giving ourselves grace either.

And remembering that our health is just as much about our minds and our emotions as it is our bodies. So practicing that right for ourselves and it is a muscle that needs to be exercised because culturally we have been exercised the other way around. Like do more, produce more, do more, produce more. And that's really not going to be sustainable for us. And I think we're definitely seeing that, especially with the kind of increase in mental health needs, collectively, is just a sign of something that's always been here, we're just feeling at a different level right now.

And again, just to reiterate that this is a journey, it's not something that we do. And it's done that we need to stay in the conversation, we need to reflect on ourselves, we need to reflect on each other. And just to highlight something Sara, has been saying in so many different ways, and I really want to reinforce it because I completely agree with you, Sara, is learning worldviews. Learning about other people in the way that they see the world and that there isn't one way to be or one way to behave. And knowing that sometimes an expression of anger might be very culturally normal and healthy for that person. Your reactivity to it is your reactivity. So kind of learning about how we can live in contrast and one another and how we can change for perhaps our own perspective, so that we can work in concert with one another. And I think we'd see a lot of growth if we took some time to do that.

SARAH: Kathleen, I think I hear you on the time constraint as being like the number one challenge that we face, because our interactions with the patient can be very short. But you know, I was speaking earlier about being in parallel universes. One thing I've noticed. Now, I would say a large percentage of nurses are female. And there is a superpower that I've never heard somebody a woman speak about. But I've observed that happening all over the place. And that is the ability to be interrupted in the middle of a conversation with someone and then go through any number of transactions, any number of phone calls, additional like parade of customers, paperwork, responsibilities, and then the next second there with the person. In that quiet moment, she's able to pick up the conversation right where she left off. Like, and that is a remarkable tool that I see even nurse providers provide for their patients. Because maybe the next appointment won't be for two weeks or a month, but it's very, you definitely have the skill to pick it up right where you left off and say, Well, last time, you know, we were talking about this. I wish we had more time. But let's pick up right there where we left off. And this is a marvelous skill to give a person as a patient, a sense that they have a connection and ongoing connection. They have somebody that is a champion for them somewhere in their universe. And having just that one other person in life that you believe cares for you can be all the difference in the world about not just surviving, but eventually getting to thriving and being grateful and more content with one's life.

JILLIAN: As we wrap up our conversation, would either of you like to share any final thoughts with our listeners?

SARAH: Just my gratitude towards the nurses that I've had in my life. And I think the people who have honestly helped me the most gave me you know, the time of day, who gave me a perspective that I hadn't even considered. And back to the main point who believed me when I came with this huge bundle of or I should say, like a ball of string that was very tangled. I just would like to just express some gratitude towards any listeners who are in nursing or the surrounding support people, just how important your work is, and how you really do make a difference every day. You have to often do things that are not necessarily in your job description. And certainly, you could get by quite nicely or maybe with less stress by not taking on that little bit extra. But time and time again, I've seen nursing staff do that. And for me in the last 13 years that I've had my primary medical care at Boston Healthcare for the Homeless, I have just felt like you know, it's like an ongoing relationship. It's like family. And for those of us who have perhaps lost that, it is a very important part of my mental health and sense of belonging in the world. And nobody seems to be more willing or able to provide that for fellow human beings than nurses. So my great thanks and deep gratitude to all of our listeners, and to you.

KATHLEEN: You said it so well, Sara. I'm glad that you did. And it brought me back to something you shared earlier is that it is difficult work. And sometimes it feels personal, but it's not about me. And you've mentioned, the mindset of I get to do this work, right. So kind of the same flip side of that same coin is reminding healthcare providers and nurses of the privilege of doing that work and sitting with that in a deep and meaningful way.

Again, give yourself a little grace, definitely taking care of yourself. So we can keep taking care of each other and remembering that seed of what motivated you to do this work to begin with, because I think sometimes we do get a little lost in the woods. And coming back to that gratitude of that we get to do this work, why we get to do this work, and giving ourselves some breathing room so that we can get up and do it again, the next day with that same motivation.

JILLIAN: Thank you, Kathleen and Sara, for joining us on At the Core of Xare and being a part of this conversation.

SARAH: Thank you.

KATHLEEN: Thank you.


Support for this episode comes from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). It is part of an award totaling $550,000 with zero percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.

You can find our most current and past episodes of At the Core of Care, wherever you get your podcasts or at

And to learn more about the issues we talked about today, check out a related training webinar we have available online. For the link, head to our show notes wherever you listen to your podcasts. You can also access it through the resources at

You can stay up to date with us on social media at @PAAction and @NurseLedCare.

At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder. 

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. 

Thanks for joining us.