Enablers and barriers to trauma-informed systems, organisations and workforces: evidence review

Section 8: Discussion

The main findings of this evidence review indicate that the while research about the implementation of trauma-informed approaches in different systems, services and organisation is growing area, it is still at an early stage. The evidence reviewed was also constrained by inconsistencies and methodological weaknesses, which might be due to the need to implement broad strategies that are context- and population-relevant (see Bunting et al., 2019; Jankowski et al., 2019). Nonetheless, this evidence review also highlights the promising effect of certain strategies supporting the implementation of trauma-informed interventions and their positive impact, in the short- and medium-term, on individuals and organisations.

More specifically, these findings support the role of a particular strategy, workforce development, and its positive impact on the successful implementation of trauma-informed interventions and the positive short- and medium-term outcomes that come with it. Within workforce development, staff training seems to be the most used strategy, helping the creation of shared knowledge and understanding of trauma, its impact, ways of avoiding re-traumatisation, supporting those with lived experience of trauma (see Bunting et al., 2019; Galvin et al., 2021; Murphy et al., 2017). Additionally, it can also help increase staff awareness of their own, but also their colleagues' trauma and burnout symptoms and aid them address secondary trauma stress (Baetz et al., 2021; Connell et al., 2019; Lang et al., 2016). According to Jankowski et al (2019), broad Trauma-Informed Care training may be necessary to support changes in practice. However, more specific training may create challenges were the areas of practice are narrower (Department of Health and Human services, 2012).

The implementation of trauma-informed approaches should not be based on a single strategy and workforce development cannot be considered in isolation. Rather, it should encompass cultural and organisational changes. This aligns with Purtle's (2020) conclusions that trauma-informed interventions appear to be most meaningful when they include other components that supplement staff training. According to Galvin et al. (2022), institutions need to "become trauma-informed rather than do trauma-informed care, to sustain and embed" (p. 666) these approaches. In line with this, additional strategies have been identified, although the scarce evidence available means it is not possible to make a clear judgement about their efficacy yet. In this regard, developing organisational readiness or pre-intervention strategies, promoting trauma-informed leadership, delivering training and education parents, carers or people with experience of trauma where appropriate, or using trauma screening or routine enquiry seem promising in promoting improvements linked to the adoption of trauma-informed care.

These preliminary findings provide information about what could be the components of effective trauma-informed interventions in the short- and medium-term. These could include broad initiatives, where workforce development is a core strategy supported by a thorough analysis of the organisations, systems, and population needs that can lead to tailored interventions. This approach, supported by effective trauma-informed leadership and the involvement of other stakeholders who are knowledgeable about the pervasive impact of trauma, seems to be key to driving organisational changes and buy-in. This broad involvement and shared trauma-knowledge are likely to promote what Galvin et al. (2022) understand as becoming trauma-informed. The combination of these strategies could also help develop a foundation that leads to transformational changes across all organisational levels and stakeholders, helping promote systemic change, which as Perry and Daniels (2016) say, "cannot happen overnight" (p. 185).

Additionally, these initiatives might also benefit from including trauma-specialist services, focused on supporting those that might need additional help. According to Bunting et al., (2019), the implementation of trauma-informed screening was a common element of the studies reviewed, which, when assessed, had positive results, was supported by staff and led to higher numbers of children screened during intake.

The impact of other strategies such as adopting a creative and flexible implementation approach or using longer implementation times for these programmes might be playing an important role promoting the successful adoption of trauma informed approaches. However, there is currently limited evidence available about their impact, which means their effectiveness is deemed inconclusive. Nevertheless, creativity and flexibility could be tools that ensure that trauma-informed interventions are adapted to the needs of staff and of service users, who might gain more control about how they want to engage with the programme (see Galvin et al., 2021). Additionally, it is important to consider that not all areas of intervention will react in the same way to these initiatives, and some might need more time than others to demonstrate reliable outcomes, such as emotional difficulties (see Murphy et al., 2017). While it seems that longer implementation times could be an important component in trauma-informed interventions, it would be necessary to determine what are considered effective implementation times, something that may vary across the different systems and services.

Two additional strategies often discussed are the promotion of positive involvement, communication and relationships with stakeholders and the adoption of strengths-based approaches. The promotion of positive communication and relationships with stakeholders is usually linked to positive outcomes, such as the creation of community-support networks (see Perry and Daniels, 2016) or promoting empowerment (see Avery et al., 2021). Additionally, proactive strategies such as using healing, strength-based approaches instead of punitive practices (see Avery et al., 2021), or creating protocols to respond to critical incidents (see Diggins, 2021) might also be promising in creating changes for individuals and organisations. However, the strength of the evidence demonstrating that positive link is very limited and not standardised. Therefore, these examples, of what seem to be strategies of potential, and the ones previously described, support the need for stronger evidence. Particularly evidence that assesses the specific impact of these strategies, to determine their role, helping create a body of literature that supports the enhancement of trauma-informed interventions.

Overall, these initial findings support the results of Fondren et al., (2020), who conclude that multi-tiered trauma-informed interventions are feasible. Although these authors focused on schools, the multi-tiered programmes they described use similar strategies as the ones identified in this evidence review. For instance, these kinds of programmes tend to include including staff training, group interventions focused on delivering prevention strategies and personalised services for students who needed them. Another similarity with the current results is that Fondren et al. (2020) maintain that it is difficult to determine the effectiveness of these approaches due to the lack of experimental evidence.

Although not a strategy, another factor that might impact the effectiveness of the implementation of trauma-informed interventions is the characteristics of the service users. According to Zhang et al., (2021), in the case of child welfare systems, the most robust effects were shown in interventions implemented in groups with higher rates of male children from a minority background and of younger age.

This evidence review also identified barriers to the implementation of trauma-informed approaches and challenges linked to them. Although these were not areas addressed by most of the studies, several highlighted the lack of commitment to the programme, lack of practice-based training or access to poor resources as barriers hindering the success of trauma-informed approaches (Bartlett et al., 2016; Galvin et al., 2021). Further challenges described included limited understanding of the relevance of certain strategies, negative impact of these initiatives on staff workload, implementaion delays and difficulties determining the most effective training to deliver (see Akin et al., 2017; Galvin et al., 2021; Hales et al., 2019; Bunting et al., 2019). Other elements to consider when implementing trauma-informed strategies are to bridge the gap between knowledge and practice, deliver relevant training, ensure there is access to appropriate resources, and that the existing workload of staff are considered before and during implementation. Thus, this evidence supports the relevance of tailored interventions that consider the needs of the organisations and those working and collaborating with it.

Trauma-informed interventions that are based on workforce development, but also strive to understand the unique needs and values of the institution/system and staff, promote trauma-informed leadership and involve people who use services, their support networks and the wider community seem to have the highest potential to bring significant improvements to people's experiences of systems, services, and organisations. Broad, tailored, and collaborative approaches like these could help promote the ongoing and comprehensive change that is needed for the successful implementation of trauma-informed approaches, truly embedded across all levels of an organisation. This ties in with Jankowski et al.'s (2019) findings where they mention the need to encourage a critical discussion about the effectiveness of trauma-informed interventions, while considering the resources available, or how to address the needs of service users while seeking to address the needs and challenges confronted by the system(s). They conclude that, more targeted, comprehensive, multi-layered trauma-informed initiatives are valuable due to their potential to initiate changes in practice (Jankowski et al., 2019, p. 95). Tailored approaches are also of value, as considering elements like school readiness, context or collaborative approaches, pre-intervention, are important factors to promote success in the process of change that characterises TIC implementation (Jones et al., 2018, as cited in Avery et al., 2021).

Multi-layered, but also targeted approaches are more likely to cover the key principles of a trauma informed approach. More specifically, building trauma-informed practice from a base of workforce development and focusing on workforce training could support those involved in these services and systems realise how prevalent the experience of trauma and adversity is. It could also give them the tools to recognise the different ways that trauma can affect people and respond by supporting recovery and resilience. Additionally, there is also great value in understanding the needs and values of trauma affected people and developing bespoke interventions where stakeholders and the wider community are involved. These approaches could help resist re-traumatisation and increase the sense of choice, trust, empowerment, collaboration and safety of staff and service users, while recognising the central importance of relationships.

Gaps in the literature

Although there is increasing interest in understanding how to implement trauma-informed approaches in different systems and services that can have positive impacts on staff and service users, there are areas that are still under researched. For instance, there is an emphasis on understanding the impact of trauma-informed school-wide initiatives on different stakeholders. However, key components such as organisational change and staff wellbeing are rarely assessed, despite their key role in the implementation and maintenance of trauma-informed care and practice (see Avery et al., 2021; Bunting et al., 2019). Additionally, in the school-based trauma-informed research, there is limited reporting of their impact on student engagement or academic outcomes. However, Avery et al. (2021) believe that these areas should be examined in future, as the key areas of trauma-informed practice (student wellbeing, strengths and skills development, etc.) are closely linked to academic achievement.

Similarly, there is a lack for research that reports on the impact on outcomes for adult service users, this was a consequence of most of the research reviewed being studies that looked at education or child welfare settings. While several studies explored initiatives implemented in with adult service users, commonly community-based (see Hales et al., 2019; Racine et al., 2021), that assessed intervention impacts on client satisfaction or health outcomes, most focused on staff and the effect that trauma-informed initiatives had on their knowledge, competence, and satisfaction (see Damian et al., 2017; Perry and Daniels, 2016; Singh et al., 2021). The need to understand the impact of these interventions on staff and the predictors that support their work during implementation and sustainment phases is important. However, it is also important to understand the impact that implementation trauma-informed approaches in services and organisations used by adults is having on short-, medium-, and long-term outcomes.

The cost of implementing trauma-informed initiatives is not commonly discussed in the research reviewed. Given the potential scale of some of these initiatives – i.e. that are broad and take place over several years – then the cost implications may impact on the prospects of them being delivered or how sustainable their delivery over time might be. More evidence regarding the cost and potential cost-effectiveness of these strategies would be beneficial, particularly for smaller organisations.

Most of the literature reviewed here has been developed in the USA, with few examples from other countries. Research conducted in the UK, and particularly in Scotland, would be beneficial to develop the evidence base to support the effective implementation trauma-informed approaches

Limitations

The body of literature reviewed in this report covers multiple settings, services and systems, meaning that there are differences between the trauma-informed interventions adopted. How the impact of these interventions was examined also varied. Having different approaches to measuring impact hinders the generalised conclusions that can be drawn from this review. Additionally, the lack of experimental designs, small sample sizes, or the fact that many of the studies reviewed directly or via existing literature reviews did not evaluate the effects of some components of the trauma-informed interventions they implemented, limit the strength of the findings shared here.

Regarding the lack of experimental designs, there is growing debate concerning whether Randomised Control Trials (RCTs) are the most effective strategy to investigate the implementation and impact of trauma-informed interventions (Bailey et al., 2018).In some cases, RCTs are neither feasible nor appropriate due to their complexity and the logistical and ethical considerations that have to be accounted for (Bailey et al., 2018)

For example there are ethical concerns linked to withholding trauma-informed care to individuals who might benefit from it (Connell et al., 2019). Therefore, some authors support the use of different methodologies such as utilising administrative data to assess impact of (see Bailey et al. 2018; Murphy et al., 2017). Berger (2019) highlights that trauma-informed initiatives at school level are sometimes developed as a response to negative events, something that together with ethical and practical reasons, supports the argument that RCTs might not be the most effective approach in these cases (Berger, 2019). Instead, "longitudinal, quasi-experimental" and multi-tiered interventions could be a more suitable alternative (Berger, 2019, p. 661).

A further limitation of the evidence reviewed was the difficulty in determining the specific effects of the components of the different interventions .This was a challenge also experienced by Bunting et al. (2019) or Avery et al. (2018) who observed a disengagement between the many intervention components described, and the limited occasions where empirical data about their impact was available. Therefore, it is was impossible to determine the specific effect of each of these strategies and their role in promoting change and positive outcomes.

The wider use of robust, rigorous and standardised evaluations would increase the quality of evidence about trauma-informed interventions, as is acknowledge in the existing literature (Avery et al., 2021; Bailey et al., 2018; Bunting et al., 2019; Berger, 2019; Fondren et al., 2020; Hales et al., 2019; Purtle, 2020). However, given the many settings in which trauma informed approaches are being applied (e.g. schools, prisons, psychiatric hospitals), and the complexities therein, means that tailored and flexible initiatives are likely to be necessary for the successful implementation and maintenance of trauma-informed approaches. The implications for research are, therefore, in finding a balance between robust methodologies and assessment and flexible and targeted approaches to implementation. One approach to addressing this challenge suggested in the literature is to take an implementation science approach. Bauer et al. (2015, p. 1) define implementation science as "the scientific study of methods to promote the uptake of research findings and other evidence based practices into routine practice". The purpose of implementation science is closing the gap between research and practice, focusing on improving the quality and effectiveness of service provision, being an approach that shares principles with quality improvement and dissemination techniques (Bailey et al., 2018; Bauer et al., 2015). This approach can help fuel substantial organisational and institutional changes, while avoiding the challenges related to multi-layered interventions (Wilson et al., 2012 as cited in Bailey et al., 2018), commonly used in trauma-informed approaches. Proctor (2012, as cited in Avery et al., 2021) maintains that implementation science could also help improve translating knowledge into practice, offering relevant understandings, guidance and methodologies for the application of trauma-informed approaches, particularly within the education system (see Albers and Pattuwage, 2017; Mitchell, 2011). Due to all these reasons, Bailey et al. (2018) and Avery et al. (2021) recommend using implementation science in future research on the trauma-informed interventions field.

A final limitation of this evidence review was the lack of evidence addressing long-term trauma-informed initiatives and their impact. Despite it being one of the initial aims of this report, there was no evidence that described facilitators that sustained long-term implementation of these initiatives beyond five years, or their impact on life chances across all domains of life, or the inequalities faced by people with lived experience of trauma. Trauma-informed research that considered longer implementation times to assess the feasibility and effectiveness of trauma-informed approaches over longer periods of time and the sustainability of the changes they bring to individuals and organisations would greatly bolster the existing evidence base (Singh et al., 2020). One approach to this, in line with Avery et al.'s (2021) conclusions, would be the use of longitudinal studies that evaluate the impact of trauma-informed approaches for more than two or three years.