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

Section 7: Analysis

This section focuses on the analysis of the effectiveness of the key predictors identified in terms of improving people's experiences of services, organisations, systems and outcomes for people with lived experience of trauma.

Following the criteria descibed above in Section 1.3 Methodology, the decision-making tree (see Appendix B) was used to evaluate the evidence about each of these predictors or enablers, leading to the following classification:

Effective: workforce development.

Promising: pre-intervention strategies, trauma-informed leadership, training and education for other stakeholders, use of trauma screening or routine enquiry, evidence-based trauma-informed treatments.

Inconclusive: promoting positive relationships and effective communication with stakeholders, creativity and flexibility, longer implementation periods, adoption of proactive approaches.

Effective: workforce development

There is evidence of a positive link between workforce development and positive short- and medium-term outcomes for those involved with different services, systems, and organisations. These positive outcomes refer to those with lived experience of trauma and to staff working on those services, systems, and organisations.

Workforce development is the most common component used in the trauma-informed interventions covered in this evidence review. More specifically, it covers strategies such as staff training (Diggins, 2021; Racine et al., 2021), staff coaching and support (Barnett et al., 2018; Hales et al., 2019; Damian et al., 2017; Tabone et al., 2021), or the use of reflective practice (Barnett et al., 2018; Galvin et al., 2021; Hales et al., 2019).

Within workforce development, training is the most accepted and widely used strategy, present in nearly all the studies and literature reviews covered here. Therefore, there is strong and shared support that staff training is an essential part of the implementation and delivery of trauma-informed initiatives within different services, systems, and organisations such as education (see Diggins, 2021; Tabone et al. 2020), child welfare (see Jankoswki et al., 2019; Murphy et al., 2017), or community-based interventions (see Racine et al., 2021; Singh et al., 2020). However, training can take many different forms, and it depends on the chosen intervention, population, objectives, etc. (see Bunting et al., 2019). Some like Avery et al. (2021) believe that allowing staff, such as teachers, to have control over the training received could enhance its positive impact.

Other areas of what it is defined as workforce development include staff coaching and support or promoting reflective practice. In these cases, the focus was sometimes on providing staff with support as many times as necessary when working in environments that make them prone to secondary traumatic stress (see Connell et al., 2019). Additionally, some interventions aimed at ensuring staff had the tools to provide supports specific to the populations they work with (see Singh et al., 2020), or that they have the skills to effectively implement trauma-informed approaches within their settings (Galvin et al., 2021).

One of the main challenges of this reviewwas the difficulty in determining the direct effect of each of the specific strategies on the overall intervention outcomes as they are not measured separately. However, there is quantitative (Azeem et al., 2017; Baetz et al., 2021; Connell et al., 2019; Murphy et al., 2017) and qualitative (Barlett et al., 2016; Damian et al., 2017; Singh et al., 2020; Tabone et al., 2020) evidence supporting the positive influence of trauma-informed workforce development on staff and service user outcomes. In the case of service users, these benefits include reductions in violent incidents in juvenile facilities (Baetz et al., 2021), children's behavioural difficulties (Diggins, 2021), and in the use of restraints and seclusions in a child and adolescent psychiatric hospital (Azeem et al., 2017), as well as improvements in the wellbeing of children involved with the child welfare system (Murphy et al., 2017). For staff, improvements include professional satisfaction (Damian et al., 2017; Perry and Daniels, 2016), increased trauma-informed knowledge, competency, or capacity to support the people with whom they work (Singh et al., 2020). Staff training also had a positive impact on staff skills to use trauma screening, which increased the frequency this strategy was used (Bartlett et al., 2016; Jankoswki et al., 2019), something that could help maximise the capacity for assessment and referrals (see Bunting et al., 2019).

Therefore, despite the weaknesses and inconsistencies in the literature available, there is an extensive evidence base supporting the positive effect of workforce development, with a particular focus on staff training, in the short- and medium-term outcomes of those involved with different systems, services, and organisations.

Promising:

• Trauma-informed leadership;
• Organisational readiness / pre-intervention;
• Training and education for parents, carers and people with experience of trauma;
• Use of trauma screening or routine enquiry.

These four strategies appear to aid the implementation of trauma-informed initiatives, also being linked with positive outcomes for staff and service users. Findings about these strategies were positive, but not to the extent that they constituted evidence that an intervention was 'effective'. This is because while authors noted a positive change, there was limited evidence regarding whether these strategies could confidently be said to have contributed to the changes in a more consistent way. These strategies are considered promising because of their positive impact on the successful implementation of trauma-informed initiatives and because of their mediating role in promoting positive short- and medium-term outcomes for staff and service users.

Trauma-informed leadership

Effective leadership appears to be essential in the implementation and delivery of trauma-informed initiatives. Many of the studies and literature reviews covered in this report highlighted the role of leadership buy-in and of leadership teams to ensure the effective adoption of these initiatives. More specifically, assigning roles of trauma-informed leadership. Creating leadership teams seems to help promote wider staff buy-in, drives policy and practice change, protects the effective delivery of the intervention, and helps address implementation challenges (see Bartlett et al., 2016; Bunting et al., 2019; Barnett et al., 2018).

Trauma-informed leadership appears to be a key predictor or enabler of the effective implementation of trauma-informed approaches in different systems and services. Although there are no direct evidence of its impact on staff and service users' outcomes, trauma-informed leadership seems to act as a mediator to ensure the implementation of the key components (such as staff training; see Bartlett et al., 2019; Hales et al., 2019) that are more directly linked to these positive outcomes and to ensure the quality of delivery and sustainability of the intervention. For example, having Trauma Informed Leadership Teams (TILTs) helped create a shared language between different agencies involved in a trauma-informed initiative implemented state-wide within the child welfare system, which improved the referral process (see Bartlett et al., 2016). TILTs can also help improve communication between child welfare systems and external partner agencies, and help address secondary trauma stress among staff.

Implementing trauma-informed leadership roles and teams is a promising strategy that can help promote positive outcomes for those working in different services, systems, and organisations and for those with lived experience of trauma.

Organisational readiness / pre-intervention

Having pre-intervention strategies, such as conducting a needs assessment, appear to be another predictor that supports the successful implementation of trauma-informed initiatives in different sectors, promoting positive outcomes for staff and service users.

The aims of these pre-intervention strategies include defining the needs and values of the organisation, determining readiness for change or predicting potential challenges to implementation. Therefore, pre-intervention strategies can help develop tailored trauma-informed interventions that address the needs of the systems and organisations and align with their values (see Avery et al., 2021; Barnett et al., 2018; Jankowski et al., 2019; Perry and Daniels, 2016). Although these pre-intervention strategies appear to have potential to aid service delivery and promote positive outcomes for staff and service users, the evidence reviewed is limited. Therefore, this strategy is also considered promising.

Training and education for parents, carers and people with experience of trauma

Some interventions focus on providing training and education to staff and to other stakeholders such as children, young people, or families who are service users, or part of service user's support network. Although this is another case where the is evidence limited and impact has not been directly assessed, initial findings are promising regarding impact on overall outcomes. Baetz et al. (2021) conclude that their education-based intervention, adopted by two juvenile detention facilities, was most effective when, together with staff training, young people had also been involved in a skills-development programme. The effectiveness here lies in the reduction of violent incidents within one of the two facilities, where more youth had participated in the programme. Additionally, a six-week training programme delivered to foster parents had a positive effect on their understanding of effective trauma-informed fostering, or tolerance of children's perceived negative behaviour (Lotty et al., 2020). It also had a significant effect, although smaller, on the reduction in children in care's emotional and behavioural difficulties (ibid).

Therefore, expanding the training efforts to stakeholders, and not limiting to staff, might be adding benefits to trauma-informed initiatives. There are different ways of involving stakeholders, such as providing trauma-informed parent training (see Tabone et al., 2020), or sharing information with clients about the trauma-informed changes taking places in the services they use and their purpose (see Hales et al., 2019). However, the extent and quality of the evidence reviewed means that these initiatives can only be classed as promising.

Use of trauma screening or routine enquiry (where appropriate)

Trauma screening or routine enquiry where appropriate is an approach that can help identify those at higher risk of developing a negative reaction because of their exposure to trauma (see Connell et al., 2019). Despite the challenges linked to its adoption (see Connell et al., 2019), it is a strategy widely used in systems (e.g. child welfare), and has been positively perceived by staff (Bunting et al., 2019). However, its impact is not always assessed or discussed.

One example of the positive impact of using trauma screening or routine enquiry is Racine et al.'s (2021) study, where 3.5% of the pregnant women attending a prenatal care clinic who participated in the study were refereed to mental health services. Additionally, in their school-based literature review, Avery et al., (2021) conclude that implementing trauma screening and assessment, together with other TIC interventions led to improvements in children's trauma symptoms.

Therefore, due to the inconsistent results and limited evidence of positive impact, the effectiveness of trauma screening or routine enquiry is deemed promising. There are gaps in the evidence relating to its impact and role in the implementation of trauma-informed approaches across different systems, services, and organisations. However, it is important to consider that not all systems or services aim to identify people with lived experience of trauma. Instead, they assume these people are part of the general workforce or population with whom they work. However, other services take a more focused approach working at "trauma-specialist" levels, meaning that trauma screening would be more appropriate. Therefore, these factors must be taken into consideration when looking at the limited evidence about trauma-screening or routine enquiry available in the body of literature reviewed here, bearing in mind that it might not be an appropriate strategy for all systems and organisations.

Inconclusive:

• Adopting a strengths-based approach;
• Flexibility;
• Positive relationships and effective communication with stakeholders;
• Extended implementation

Insufficient evidence to make a judgement on impact. Although these strategies were linked to positive outcomes for staff and service users, it is not possible to determine their effectiveness, mainly due to a lack of evidence concerning their impact.

Promoting involvement, positive relationships and effective communication with stakeholders

Building positive relationships with families and communities was one of the key elements of certain interventions. Avery et al. (2021) concluded that respecting students' and families' cultural values are important to promote empowerment, safety, or to strengthen the commitment to avoid re-traumatisation.

These strategies seem to be particularly common within school systems. Perry and Daniels (2016) focused on using the resources schools already had instead of looking for external support from trauma-based services. Therefore, they focused on identifying existing needs and supports available and on strengthening the relationships between staff and students and involved families via Care Coordination teams. These strategies helped improve communications and bring together resources and coordination to assess stakeholders' overall needs. According to Avery et al. (2021) Care Coordination teams and improving communication with stakeholders boosted TIC implementation.

Other positive examples include the ReLATE model, where daily community meetings helped school children increase emotional communication, setting goals, and promote a sense of safety that can help those who need clear routines (see Diggins, 2021).

In the case of the child welfare system there seems to be an interest in involving services users as part of the TIC implementation (see Bunting et al., 2019). Examples of how to promote this involvement include trauma-informed training for parents and carers, or the creation of community partnerships by promoting consultation and planning with stakeholders (ibid). Additionally, some projects followed a "grassroots" strategy, focused on community networks and collaboration, assessment and consultation, supported by specific TIC implementation tools and consultation with relevant stakeholders (Bunting et al., 2019).

While there seem to be indications of the positive impact of this strategy in the implementation of trauma-informed approaches within different settings, and its promising impact on the short- and medium-term outcomes of staff and service users, the lack of clear and solid evidence means its effectiveness can only be deemed inconclusive.

A creative and flexible approach

Adopting a creative and flexible approach in the implementation of trauma-informed approaches could help systems adapt these strategies to meet their needs and values, as well as those of service users. This approach can lead to tailored service delivery (see Barto et al., 2018), ensure service users engage with the interventions' programmes and activities in their preferred way (see Galvin et al., 2021), as well as avoiding strategies that might negatively affect the overall trauma-informed initiative (see Akin et al., 2017). However, studies discussing creativity and flexibility or assessing their impact are scarce. Therefore, their role in the implementation of trauma-informed approaches and their impact to bring about positive outcomes for service users and staff is unclear, deeming effectiveness inconclusive.

Extended implementation periods

Although not always assessed, longer implementation periods seem to be a facilitator for promoting positive outcomes, particularly amongst service users. Avery et al.'s (2021) observed a relationship between longer implementation periods and a reduction in school children's behavioural difficulties. Similar effects were observed with child welfare trauma-informed interventions, where the effect size is largest when implementation t runs for a longer period, in this case at least 7 to 12 months. Finally, Murphy et al. (2017) defended the importance of longer implementation periods based on the principle that not all areas of intervention react equally, and some, like emotional difficulties, will only emerge over the longer-term.

However, the impact of longer implementation periods, or even the definition of what "longer" constitutes is not widely assessed in the literature reviewed for this report. Therefore its effectiveness is deemed as inconclusive due to the lack of evidence.

Adopting a strengths-based approach

Making changes to policies and practice to ensure the adoption of proactive perspectives seem to be a facilitator to promote the comprehensive adoption of trauma-informed approaches, as well as having a positive mediating impact on service user outcomes. One example is strategies to respond to critical incidents or individualised safety plans for students (Diggins, 2021). Another is replacing punitive approaches with strength-based and "skill-building" ones (Avery et al., 2021). These changes to policies and practice seem to support the implementation of trauma-informed initiatives and can contribute towards positive results such as reductions in emotional and behavioural difficulties (see Diggins, 2021). However, the evidence available is limited, and their effectiveness inconclusive.