EE and NVL identified 50 documents and selected 25 including policies at the national, local, and organisational level and contextual documents (Table 1). Documents included in analysis either mentioned TI care or discussed closely related concepts.
In total, 21 professionals expressed interest, 2 did not have direct experience of TI approach at the system level, 8 did not respond by the deadline, 11 provided consent and were interviewed. Interviews lasted between 32 minutes and 68 minutes (mean 52 minutes). We achieved a maximum variation sample representing diversity of gender (4 men, 7 women), organisations (public, private, third sector), professional role (frontline to leadership positions), and direct experience of developing and/or implementing TI approaches in healthcare (from 2 to 25 years). Most participants developed and implemented TI approaches in England, at the level of organisations and local authorities (Table 2).
Our framework analysis has produced seven analytical themes: policy landscape of TI care, interpretations of TI care, TI care as a remedy to health system challenges, not every TI approach is the same, factors that facilitated or hindered implementation of TI approach, the future of TI care in the UK, and why TI approaches are represented and implemented in this way. We report themes under the research questions which they answered.
How are TI approaches represented in UK health policies?
We found endorsement of TI approaches in documents at a national level, as well as in NHS and non-NHS organisations, local authorities, and some devolved nations; however, there was no specific or agreed UK-wide, England-wide, or NHS-wide strategy and leadership, nor was there an agreed terminology and framework, or a robust evidence base in the UK. Despite growing endorsement of TI approaches in policy documents, positive statements were not backed up with legislation, funding commitment, and resource allocation. Documents and interviews revealed disconnected and piecemeal implementation, as well as differing understanding of TI care between geographical areas and services. This suggested a need for joint and coordinated working. Although TI care was endorsed in UK policy, robust research evidence from the UK context was needed.
Policy landscape of TI care
The 25 documents were published over nine years (2012–2021) and considered all UK nations, multiple sectors, and government policy as well as service-user voices (Table 1). Documents spanned a range of health sectors, although mental health and services for women were most commonly included. The category with the greatest number of documents was ‘guidance on how to do TI care’ (n = 6) and fewest was ‘patient/service-users and carer perspectives’ (n = 1). Seven documents focused on a region or devolved nation while 18 took a UK-wide or NHS-wide focus. High-level documents included NHS planning and strategy documents, as well as parliamentary and legislative articles. The UK government has commissioned evidence reports and guidance on TI care including reports which involved engagement with third sector organisations and service-user groups. Most high-level policy documents, such as the NHS five-year plan, mentioned TI approaches only in passing without discussing definition or detail. In contrast, we found multiple local or organisation level guidelines and reports which were focused specifically on TI approaches. Overall, there was a shortage of UK-based, methodologically robust, evidence.
Mirroring the historical development of TI approaches from mental health services[8, 17], most documents and interviews referenced mental healthcare (n = 24), followed by women’s health (n = 11), criminal justice sector/policing (n = 8) and DVA services (n = 10), as well as multi-agency application (n = 8). Other areas referenced included education (n = 2), healthcare for rough-sleepers (n = 7) and primary care (n = 4). Of sectors referenced, major incident management was referenced the least (n = 1).
The level of the TI approaches varied across the dataset: from application at one organisation, to a public health board, to NHS-wide[31, 32]. Variability in the geographic coverage ranged from UK wide (n = 6) to regional application (n = 15), with Scotland emerging as a leading region with the nation-wide TI knowledge and skills framework for the Scottish Workforce. There was one document which considered how TI care could be applied across sectors in Northern Ireland, and in supporting literature there was a strong national focus on responding to ACEs in Wales[35, 36], including within the police and criminal justice sectors.
The timeline of TI approaches and related concepts in the UK showed a steady growth between 2012 and 2021 with parallel developments from top-down and bottom-up (Fig. 1). We identified few documents prior to 2012, with the Health and Social Care Act published in 2012. Although the Act did not specifically use the term TI care, it discussed related concepts of a greater voice for patients, enabling patient choice and safety of services. We found a noticeable clustering of documents in 2018 and 2019. Potential contributions could be the release of key contextual documents such as the US SAMHSA guidance and the National ACEs Study in the preceding year[8, 10]. Other possible reasons could be the high-profile metoo and Black Lives Matter movements and tragedies like Grenfell fire. Relevant news articles, including calls for rape victim support and professional training on trauma, came to the fore in 2018–2021. These events and activities have brought the issues of trauma, vulnerable populations, intersectionality, and racial justice to the foreground and may have helped achieve a focus on TI approaches as a responsive system-level framework.
In line with documents, our interview data suggested both the bottom-up and top-down development of TI approaches in the UK. Three out of ten interview participants had been involved in developing and implementing TI approaches prior to the release of the first document in 2012, with the rest becoming involved in 2017, just prior to the clustering of documents in 2018 and 2019 indicating a pivotal wave of popularity of the TI approach framework at this time. Participants explained that their clinical practice facilitated interest in the topic. They had already been working towards TI care without knowing about the framework of a TI approach:
“I was doing training to teams, trying to raise awareness, and seeing slowly over time, more referrals and things coming through for people with trauma, which all suggested that something was happening and changing. But at that point, I didn’t even know there was something called, “Trauma informed care”….it was one of my colleagues actually, talked to me and introduced me to some documents. I was just like, “This is it. This is what I have been thinking that we need.” Participant 9
How are TI approaches understood and implemented in the UK?
Some documents and interviewees demonstrated differing understanding of the TI approach framework; some further developed the original SAMHSA framework by tailoring it to the organisational and wider contexts. We found evidence of piecemeal implementation of TI approaches in the UK driven mainly by dedicated passionate leaders at the level of organisation, local authority and devolved nation.
Interpretations of TI care
Documents and interview participants provided differing interpretations of TI approaches indicating a need for a shared vision on how the high-level frameworks should be implemented in the real world of health systems. We found marginally differing definitions of TI approaches in documents with authors proposing new terminology and concepts. While high-level policy documents recommended TI care without defining it, the contextual documents used slightly differing defining terminology. However, our deductive coding showed that they all in general mapped onto the philosophy and constructs of the widely cited SAMHSA framework, with some further developments of this. For example, the Women’s Mental Health Taskforce report, included principles similar to the SAMHSA framework, with additional focus on governance and leadership, gender inequalities, equality of access, holistic and effective care.
We found evidence of divergence when interview participants tried to unravel the meaning of a TI approach versus ACEs and one-off TI initiatives. One participant unified concepts such as TI care, ACEs and Psychologically Informed Environments in recognising past traumatic experiences, calling for an overarching approach which values all these aspects. Another participant detached the terms ACEs and TI care, reflecting that ACEs have become well known in research whereas a TI approach is a pragmatic way of supporting those who have experienced trauma. Documents and most interviewees differentiated a TI approach from a good clinical practice, acknowledging that the former extends and enhances principles of the latter. However, one participant felt there was little to distinguish a TI approach from good clinical practice suggesting that TI principles “are pretty standard”, with ‘co-production, collaboration and empowerment’ already being considered good practice in Mental Health Trusts (Participant 9). On the other hand, the same participant felt that the 4R’s of the framework of TI approach are key to its definition: “it is mainly about the principles. It is about those four Rs”. Others thought that service commissioners “want quick fixes… they are not actually understanding [that] it [TI approach] is much, much deeper than that” (Participant 10).
Interviews confirmed the piecemeal implementation of TI approaches in the UK that mirrored the patchy representation in policy documents and variety of understanding. Several participants gave examples of initiatives at the clinical practice level branded as TI approaches including routine enquiry about ACEs in isolation, without additional elements of a TI framework and one-off training events about ACEs or TI care without any changes at the system level. Other participants did discuss the value of routine enquiry about ACEs when part of TI systemic change and to enable conversations about trauma.
Not all participants had a clear overview of the national landscape regarding TI care, having their attentions focussed on the development of their own organisation. However, among those who expressed an opinion on the wider UK picture, there was general agreement that a shared national vision would be beneficial. We found that different regions and organisations reinvented the TI approach wheel at times, with interviewees expressing a need for national harmonisation and coordination. Participants expressed the need for adequate allocated resources and a more unified approach across organisations and sectors:
“But it is difficult because I couldn’t agree more that it is so patchy across England. And actually, it makes work very difficult. It makes it very challenging because you are doing something, and then all of a sudden you find out that somebody else in the south is doing the same piece of work. But actually, you could have been working together on it if the resources were there and you could all have- If there was a hub for us to be able to do this work, then things would be a hell of a lot easier.” Participant 10
One participant from England suggested that whilst the SAMSHA definition of TI approach was widely cited, they did not feel there was an agreed set of components and activities for implementing the framework in practice. This participant felt that a consensus on shared practice standards was a necessary next step for TI care in the UK.
“So, you'd have to find a set of practice standards that everyone agreed on that, 'This represents what good trauma-informed practice looks like, let's assess organisations against it’… All of those things would have to be measured against a set of practice standards, to work out whether you were getting close to it.” Participant 7
Interviewees gave examples of the bottom-up initiatives aiming to create a shared vision and resources on TI approaches. One participant cited a UK-wide Trauma Informed Community of Action and several participants mentioned local working groups on TI care “with the leaders, or managers, or commissioners, or whatever, can come together in these groups, and really ensure that we are sharing the learning, and we are coming together to create a more streamlined approach to things” (Participant 10).
Interview participants agreed that the implementation of TI approaches varied across the UK, with Scotland having more strategic coordinated implementation:
“They [Scotland] have a national programme for this that cuts across all of the services. I think that’s a much better way of doing it. They’ve outlined the skills that are necessary for various staff groups. They’re looking at it much more systemically and making sure that the training is happening systemically and the learning is happening systemically.
In England, at best, it’s piecemeal, it’s seen as relevant for that group but not this group. I hear very little conversation about it in relation to systems. I hear very little real depth of understanding. People use the word, now, lightly, without really knowing the implications of what they’re saying. I think that’s creating a lot of frustration with certain service users or service user advocates, because they are saying, “You’re packaging the same old thing up but it’s not really changing.” I think, sometimes, they have a point.” Participant 3
TI care as a remedy to health system challenges
In all policy documents and in nine interviews, TI approaches were presented as a remedy to a variety of problems within health systems, although a gap between policy recommendations and implementation was identified in interviews.
Sixteen of twenty-five documents justified TI approach as a way for addressing the high prevalence and negative impact of violence and trauma on patients, with at least eleven documents considering its impact on staff. The growing international evidence base for the impact of psychological trauma and the need for service response was used in documents and interviews to justify TI approaches as a pragmatic solution to these concerns. However, the documents and interview participants justified the need for TI care by citing US and Welsh epidemiological studies on ACEs, DVA and patient accounts of being re-traumatised in services. We found no references to UK studies that demonstrated effectiveness, safety, or acceptability of TI approaches.
TI care has been presented as an answer to several health system challenges from integrated care to recovery from the COVID-19 pandemic. For example, in the NHS Long Term Plan, TI care was identified as a component of a new model of integrated care, linking primary and community mental health care, alongside personalised care. A TI approach has also been presented as a solution to addressing the collective trauma of the COVID-19 pandemic for patients and staff. One participant felt that the pandemic had highlighted “people’s understanding of collective trauma and the individual trauma”, bringing a TI approach to the forefront (Participant 6).
However, interview participants highlighted that although high-level policies recommended TI approach as a remedy, they did not provide enough detail and commitment to be implemented in practice:
“They [policies] don’t really define what it means in practice to be trauma-informed. In the NHS 10-year plan around the community transformation it says that it’s needed but it doesn’t say what is needed. So how, then, it’s interpreted is then very different and often at a really low level.” Participant 3
Not every TI approach is the same
In line with the SAMHSA guidance, document and interview data showed that the high-level framework of a TI approach needs to be tailored to the organisational and wider context. Policy documents advised organisations to clarify what TI care means for them, and that application of the framework should depend on the organisational needs. Although five documents recommended frameworks for a TI approach with specific implementation fields for example staff training, policy and practice and organisational structure, they advocated tailored application to the needs of service-users and organisations[28, 33, 34, 40, 41]. One document advised that the application of their TI approach framework should specifically depend on organisational gaps needing to be met. An interview participant shared awareness of the development of a UK trauma training framework which would provide workplaces a ‘bespoke training package that fits their specific needs’ (Participant 3). Several documents suggested that specific organisational needs should be informed by service-users through co-production and co-design of services[28, 29, 34, 38, 40–44]. One document representing voices of service-users, explained that although protocols can be helpful in TI care implementation, a responsive and flexible approach is necessary for an organisation to effectively listen to their patients. When applying the framework of a TI approach to their organisational and wider contexts, services used different activities that mapped on the SAMHSA implementation domains, to varying degrees; however most did not cover all ten, as we outline below.
Training and workforce development
Recognising the impact of vicarious trauma, at least 8 documents supported related workforce development, including staff wellbeing and “robust systems for supervision and debriefing; education about self-care; a culture of trust in which staff are able to say when they are struggling to cope, without fearing that they will be judged or penalised; and sufficient resources to ensure that staff are not expected to shoulder unrealistic workloads”. One interviewee highlighted the importance of incorporating TI principles in the hiring process, advising an ‘upstream’ approach, potentially at a job interview stage, to recruit those ‘who have a desire to work in a trauma-informed way’ (Participant 9). Similarly, one document recommended a values-based hiring policy to ‘ensure that the professionals recruited hold the necessary values to deliver trauma-informed care’.
Cross sector collaboration
Establishing cross-sector collaboration with partner organisations, for example by supporting routes to specialist care in cases of complex trauma and engaging with allied agencies such as social care and housing, was advocated in two documents[42, 45].
Screening, assessment, and treatment services
One document recognised that patients may be reluctant to be signposted to services where they previously had negative experiences. Some interview participants suggested that routine enquiry or screening for a history of psychological trauma is an important activity of TI care, encouraging professionals to ask about “things that might be contributing to somebody’s disease or illness or condition” (Participant 7), noting that “if we wait for people to tell us what’s happened to them, we’ll wait a very long time”.
Progress monitoring and quality assurance
Although a degree of organisational flexibility and responsiveness was recommended, a regulatory body guaranteeing certain standards of TI approach was proposed to “ensure that trauma informed care is a meaningful label that guarantees certain ways of working, not an empty “buzzword”’.
Physical environment of the organisation
Implementing TI approach may involve reviewing workspaces where trauma-related conversations occur to reinforce safety for patients and staff.
Factors that facilitated or hindered implementation of a TI approach
Both documents and interview participants discussed barriers and enablers for implementing TI approaches in the UK, with these factors considered at the level of the organisation and wider context.
At the organisation level, some participants felt high level leadership support was needed, and if lacking is a barrier to implementing TI approach. We found conflicting perspectives on who these leaders should be. There was contradiction between whether leaders with power i.e., “somebody at the top” (Participant 2), or those with passion i.e., somebody who “must have really wanted to do it and has been in the right position to make this happen” (Participant 9), were more important for effective implementation. The concept of organisational champions garnered support when “champions act as influencers and their credibility within services adds to the potential for buy-in from other staff”, fostering sustainable change. One participant warned against a reliance on top-down leadership, explaining that when a senior leader leaves an organisation’s priorities can change “and then the door is closed again” (Participant 9). The participant also felt that change driven from the top-down, might lead to resistance, with support for bottom-up implementation:
“I think change is best when it comes from the bottom up. Where we can create a movement of people who want to be trauma-informed. So, we can say, “Look, this is how it is going to help. Let’s all try and do this.” I think that is the best way to do it. The more top-down things are, the more likely you are to get resistance.” Participant 9
Another enabling factor was the prioritisation of the voices of service-users and enthusiastic clinicians. However, some interviewees felt that passionate individuals alone cannot create effective change:
“The reason I think it's not been that successful...it was to do with how it was done rather than what it was about. I think it's flatlined a little here in our organisation. So, what happens is people are designated as trauma-informed champions and various things, and it's wonderful kinds of cosmetic things, and then nothing happens.” Participant 2
Collective responsibility and organisational commitment were highlighted as an essential factor to support individuals with passion:
“In my other experience with other organisations, as well, I think there’s a tendency to situate the implementation or the design of whatever you’re trying to do with your trauma-informed work within one person or a small group of people. I think a challenge is to create a sense of collective responsibility around it.” Participant 6
A suggested solution was an “orchestra” of linked TI care champions with leadership support (Participant 9), which can integrate principles into organisational culture and practice.
Unsupportive organisational culture and high-pressure environments was perceived as a barrier:
“We have this gap and this disparity because staff are saying on the ground… “I need to do this, but I can’t. This isn’t feasible. I am prioritising my wellbeing right now because I am burnt out. And I have so much secondary trauma from working in this service as it is, I can’t even begin to think about changing my practice and saying things differently”…it is not achievable for staff on the ground without the right infrastructure.” Participant 10
One document cited scarcity of resources and low staff morale, as well as a resistance to new initiatives and upheaval.
Competing demands and opportunity costs were also raised:
“How much capacity does an organisation have to work on 50 different projects at the same time?” and ‘how does trauma-informed care get to the top of the list as the most important thing to develop?’ Participant 9
At the wider context level, participants agreed that powerful and passionate people within organisations may not be sufficient for creating significant change without political support in their region or country, with differing political factors in devolved nations identified. One interviewee noted that although TI care was referenced in high level English policy documents, the term had greater visibility in Scottish and Welsh policy:
“I mean, there’s the odd reference to it in certain policy documents like the substance misuse guidelines and Public Health England have recently mentioned it a few times, but it’s not visible. It is in Scotland and Wales, it’s far more visible and they’ve got policy and legislation, in some cases, to support this, particularly in Scottish Government.” Participant 7
The value of political support capable of influencing practice nationally was highlighted in policy documents. One interviewee also called for a united parliamentary leadership recognised by government and capable of influencing policy.