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

Section 2: Evidence on trauma-informed approaches to systems change

What evidence is there on the effectiveness of trauma-informed approaches improving people's experiences of services / organisations / systems?

Overview

The papers identified in the literature search process were reviewed to identify the predictors that could be support the implementation of trauma-informed interventions across different systems, organisations and workforces, and that could also deliver the greatest benefits to staff or people who use services. This evidence review was international in scope. Most of the studies were from the USA, with others from Europe, Australia and South America.

Most of the literature reviewed focused on education and child welfare, mainly within schools (see Avery et al., 2021; Fondren et al., 2020; Diggins, 2021; Tabone et al., 2020) or child welfare systems (see Bartlett et al., 2016; Bunting et al., 2019; Murphy et al., 2017). The second most common area was that of community-based organisations where, for example, researchers implemented trauma-informed interventions to support people experiencing substance abuse, mental health difficulties and homelessness (Hales et al., 2019), or mothers and children experiencing interpersonal violence (Singh et al., 2020). The remainder includes mental health services (Azeem et al., 2017) and the justice system (Lathan et al., 2019).

One of the main characteristics of the papers reviewed here is the significant variation amongst them. This variability mainly refers to the characteristics of the interventions implemented, and the methodologies adopted to assess their effectiveness. More specifically, some interventions were developed in one or two organisations, such is the case of Barnett et al. (2018) who implemented a multi-layered trauma-informed programme within a residential treatment centre and accompanying specialist school or Baetz et al. (2021) who did the same in two juvenile detention facilities. Alternatively, others like Bartlett et al. (2016) and Barto et al. (2018) were involved in the adoption of a trauma-informed programme at a regional level – e.g. the Massachusetts Child Trauma Project (MCTP).

Moreover, authors took different approaches to evaluate the impact of interventions. For instance, many used surveys filled out by staff, services users or both; sometimes supported by relevant administrative data that could, for example, focus on the number of critical or violent incidents in said residential treatment centre or juvenile detention facilities (see Baetz et al., 2021; Barnett et al., 2018). Others relied on family judgements (see Diggins, 2020) to assess the impact of a school-wide trauma specific intervention implemented at a specialist school or used semi-structured interviews to explore participants (staff) experience of the intervention (see Singh et al., 2020). Very few studies used experimental, or, quasi-experimental designs (see Murphy et al., 2017), while others took a descriptive approach to discuss trauma-informed interventions (see Akin et al., 2017).

Kirkpatrick's model of training evaluation criteria has been used to analyse the evaluation approaches used on different TIC training curricula by authors like Gundacker et al. (2021). According to Praslova (2010) there are four levels in Kirkpatrick's model, which Gundacker et al. (2021) define as follows. The first of these four levels is reaction or how well training is accepted and appreciated, examples including training satisfaction or engagement. The second level is learning or the new knowledge or skills acquired, such as improved knowledge about ACEs or increased resource awareness. Level 3, behaviour, refers to the application of knowledge into practice, which could be measured by self-reported changes of behaviour or patient-rated visits. The fourth level, results, focuses on the effect of training on practice reflected patient satisfaction and effects on health (Praslova, 2010). The first two levels (reaction and learning) are deemed as internal criteria because their focus is on what happens within the boundaries of the training course. Alternatively, the last two criteria (behaviour and results) are deemed as external due to their focus being on changes that occur beyond and after the training itself (Praslova, 2010).

One limitation identified concerning data analysis was that not all studies measured the impact of the trauma-informed strategies. Therefore, it was challenging to attribute the specific effects of the various strategies on outcomes for staff and service users. A further challenge concerning outcomes was that the implementation time for all the interventions reviewed ranged from one to five years, which meant their focus was on the impact of trauma-informed intervention in the short- and medium-term and not over a longer period.