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

Section 6: Key findings – challenges

This section provides a summary of the evidence in relation to the challenges or obstacles linked to the implementation of trauma informed approaches. These include:

• Lack of clarity for staff on what a trauma-informed approach involves
• Lack of clarity for staff around what constitutes 'effective training'
• Difficulties related to implementing trauma screening or routine enquiry (where appropriate)
• The length of time required for implementation including unforeseen delays.

Lack of clarity for staff on what a trauma-informed approach involves:

Lack of understanding of certain models, their relevance and scope were a barrier to effective implementation. Galvin et al. (2021) reported that while the programme (The Sanctuary Model) was well supported, some members of the organisation seemed to believe it was only for certain members of staff (clinical and front-line) and not suitable for other teams. The model was also sometimes viewed as a management tool, rather than a trauma-informed approach to working with the young people in the institution.

The implementation of new strategies and policies related to adopting trauma-informed approaches can also lead to difficulties in staff satisfaction when not fully explained, particularly in the areas of "being well-informed of agency changes, experiences of safety in the work environment, and transparency in how staff are evaluated" (Hales et al., 2019, p. 535).

Lack of clarity for staff around what constitutes 'effective training':

While staff training has been identified as key to implementing TIC, it is unclear what can be deemed as "effective trauma-training" in terms of length, impact, or key elements of that training (Purtle, 2020).

Content and characteristics of the training delivered varied across different studies, ranging from two-hour sessions to year-long programmes, targeting different stakeholders, and using different resources such as National Child Traumatic Stress Network (NCTSN) or the Child Welfare Training Toolkit (see Bunting et al., 2019).

Difficulties related to trauma screening or routine enquiry:

After being involved in the CONCEPT initiative, Connell et al (2019), focused on enhancing system capacity to deliver trauma-informed care, staff reported being less familiar with efforts to implement new practices such as trauma screening. There are some challenges associated with the implementation of trauma screening as it can become an additional burden to the workforce, which might lead organisations to seek support from external agents (Connell et al., 2019). This might also be linked to additional barriers such as staff showing lack of awareness if they are not directly involved in the screening process. Additionally, there seems to be a lack of validated tools that can assess exposure to trauma and symptomatology related to trauma, particularly for younger children (ibid). Additionally, Lang et al. (2016) highlighted that the implementation of trauma screening processes can be more complex and challenging than the implementation of other approaches such as providing staff training. The challenges associated with these difficulties range from systemic problems (number of staff, high demands), the cultures of the different teams, and limited staff engagement or buy-in. Therefore, these findings highlight the need to ensure professionals are invested, aware, and convinced about the benefits of trauma-informed approaches.

Length of time required for implementation

Akin et al. (2017) described that the three projects they reviewed experienced implementation delays. The most common reasons for these postponements related to implementing or modifying information systems, creating sharing agreements, lengthy bureaucratic times or staff turnover.

In the literature review carried out by Zhang et al. (2021), many of the TIC initiatives reviewed were implemented for one year or less. However, not all areas of psychological wellbeing can be addressed in the same amounts of time, and some of them, such as PTSD, might need a longer period to show improvements (see Zhang et al., 2021). Murphy et al. (2017) reported that while some improvements could be seen within three months of intervention (for instance emotional regulation), others were gained over a longer time period, including functioning and behavioural regulation.