Trauma-informed care in UK: where are we? A qualitative study of health policies and professional perspectives

doi:10.21203/rs.3.rs-1459547/v1

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Research Article

Trauma-informed care in UK: where are we? A qualitative study of health policies and professional perspectives

https://doi.org/10.21203/rs.3.rs-1459547/v1

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Background: Trauma-informed (TI) approach is a framework for a system change intervention that transforms the organisational culture and practices to address the high prevalence and impact of trauma on patients and healthcare providers and prevent re-traumatisation in healthcare services. Our systematic review of TI approaches in primary and community mental healthcare identified limited evidence for its effectiveness in the UK, despite endorsement in various policies. We aimed to explain the evidence-policy gap by analysing how and why TI approaches are represented, understood, and implemented in the UK.

Methods: A qualitative study comprising of a document analysis of UK health policies followed by semi-structured interviews with key informants with direct experience of developing and implementing TI approaches. We used the Ready Extract Analyse Distil (READ) approach, and framework method.

Results: We analysed 25 documents and interviewed 11 professionals from healthcare organisations and local authorities. Policies from healthcare organisations, local authorities, and Scottish and Welsh governments recommended TI approaches. However, there was no UK-wide strategy, agreed terminology and framework, or robust evidence base. Despite growing endorsement of TI approaches in policies, positive statements were not backed up with legislation, funding or resource allocation. Documents and interviews revealed differing understandings of TI approaches between geographical areas and across services, with disconnected, piecemeal implementation. Professionals explained the current landscape of TI approaches by the lack of high-level strategy and leadership, a need for adequate evaluation funding, and a lack of understanding of the term, existing frameworks and evidence available. They wanted more coordination and collaboration between organisations and regions. We identified factors that affected implementation of TI approaches at the level of organisation (leadership support, bottom-up and top-down development, presence of systemic thinking, organisational culture, resource allocation, competing priorities) and wider context (government support, funding, impact of the COVID-19 pandemic). Professionals had conflicting views on the future of TI approaches, however all agreed that government backing is essential for implementing policies into practice.

Conclusions: A coordinated, centralised strategy on TI approaches in health systems, improved funding for evaluation, and education through professional networks about evidence-based TI health systems can increase value and reduce waste in research and implementation of TI approaches in the UK.

Psychological trauma

mental health

primary health care

public health

qualitative research

policy making

health policy

Individual, collective, and systemic trauma is a highly prevalent and costly public health problem[1]. The WHO World Mental Health Survey identified that 70% of participants had experienced lifetime traumas, including physical violence, intimate partner sexual violence, and trauma related to war[2]. In England, a household survey found that nearly half of adults had experienced at least one adverse childhood experience (ACE), including childhood sexual, physical or verbal abuse, as well as household domestic violence and abuse (DVA)[3]. The 2020 Crime Survey for England and Wales found that 29% women and 13% men experienced DVA throughout their lifetime; 7.7% women and 3.6% men reported experiencing DVA in the last year[4]. The cost of DVA to the UK economy is currently estimated at £14 billion a year, with £2.3 billion focused on health services[5]. Individual and collective traumatic experiences occur in the context of structural violence such as racism, and economic and gender inequalities. People experiencing socio-economic disadvantage, women, minoritised ethnic groups, and the LGBTQ + community are disproportionally affected by violence and trauma[6, 7].

A high proportion of patients in healthcare services, have lived experience of trauma and are at risk of the long-term negative health and social sequelae, translating into increased health service use. Many healthcare staff themselves have lived experience of trauma. Individuals and families who have experienced violence and trauma seek support from healthcare and other services for the physical, psychological and socioeconomic impacts of trauma[1, 8]. Patients with four or more ACEs are at higher risk of a range of poorer health outcomes including cardiovascular disease and mental ill health, versus those with no ACEs history[9]. In the household survey in England and Wales, adults who had experienced four ACEs were twice as likely to attend their general practice repeatedly, compared with those with no ACEs history. Incidence of health service use rose as the ACEs experiences increased, with the effects of ACEs on health service use established in early adulthood[10]. In a systematic review 47% of patients in mental health services had experienced physical abuse and 37% had experienced sexual abuse[11]. A recent systematic review of healthcare providers’ own experience of DVA, reported a pooled lifetime prevalence of 31.3%[12].

If the high prevalence and negative impacts of trauma are not recognised and addressed in healthcare services, there may be negative consequences for patients and healthcare providers. Patients may not disclose trauma or recognise the impact of trauma on their presentation. Patients may also be at risk of re-triggering and re-traumatisation through invasive procedures and coercive practices. Examples include the removal of choice regarding treatment or judgemental attitudes following a disclosure of abuse, seclusion and restraint[13, 14]. Re-traumatisation within health services can affect both patients and staff, with the latter experiencing vicarious trauma[15], and the resulting chronic stress may impact on staff members’ ability to empathise and support others[16].

Over last 20 years, the framework of a trauma-informed (TI) approach at the health systems level has been developed. This aims to prevent re-traumatisation in healthcare services and mitigate the high prevalence and negative effects of violence and trauma on patients, and also on healthcare providers. A TI approach (synonyms TI care, TI service system) starts from an understanding that trauma can impact all people directly or indirectly[8], and recognises that patients and healthcare providers may have experienced a traumatic event or have on going trauma, with these experiences affecting their behaviour and health. The most cited frameworks for a system-level TI approach are those by Harris and Fallot[17], and the US Substance Abuse and Mental Health Services Administration (SAMHSA)[8]. These frameworks highlight that it is necessary to, firstly, change organisational culture and environments (organisational domain) and then change clinical practices (clinical domain) by integrating the key assumptions and principles throughout all system levels. The SAMHSA framework suggests four R-assumptions, six key principles, and ten implementation domains. ‘A program, organisation, or system that is trauma-informed realises the widespread impact of trauma and understands potential paths for recovery; recognises the signs and symptoms of trauma in clients, families, staff and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures and practices, and seeks to actively resist re-traumatisation’ [8]. The key principles comprise: 1) safety, 2) trustworthiness and transparency, 3) peer support, 4) collaboration and mutuality, 5) empowerment, voice and choice and 6) cultural, historical and gender issues[8]. The 10 implementation domains recommend incorporating the above assumptions and principles throughout system governance and leadership, written policy, the physical environment, when engaging with people with lived experience, cross sector collaboration, screening, assessment, and treatment services, training and workforce development, progress monitoring and quality assurance, financing, and evaluation[8]. Other authors proposed similar constructs for the framework of TI approach, often using slightly differing terminology[17, 18]. The authors consistently highlighted that the framework of TI approach is not a protocol but rather high-level guidance applicable to any human service system and should be tailored to the organisational and wider contexts. The process of becoming a TI system is described as a transformation journey rather than a one-off activity. TI care is also distinct from related concepts such as psychologically informed environments, which has gained prominence in services for rough sleepers, and is focused on individuals’ complex vulnerabilities and ‘building’ skills[19].

Despite a 20-year history of the TI approach framework, several reviews have found limited evidence for their effectiveness in health systems[20–22]. However, UK policies and guidelines recommend implementing TI approaches at the health system level. This study addresses the evidence-policy gap identified in our systematic review on trauma-informed primary care and community mental health care[20]. We aimed to understand the reasons for the evidence-policy gap by answering the following research questions:

How are TI approaches represented in UK health policies?

How are TI approaches understood and implemented in the UK?

Why are TI approaches represented and implemented in this way?

To answer our research questions, and consider perspectives from different standpoints, we conducted a multi-method qualitative study comprised of a document analysis of UK health policies followed by semi-structured interviews with key informants. Document analysis explored how TI approaches are represented in UK health policy while interviews explored professional views on how they are understood and implemented, and why they are represented and implemented in this way. We used the READ approach[23] and framework method[24] suitable for applied health research conducted by multi-disciplinary teams with varied experiences of qualitative analysis.

Data collection

Data collection occurred between October 2020 and June 2021.

Document analysis

We defined policy as ‘a statement of the government’s position, intent or action’[25], and considered this definition at the level of a nation, local authority or organisation. NVL and EE identified policy and related contextual documents through: (i) searches for peer reviewed and grey literature in our earlier systematic review on TI primary care and community mental health care[20], (ii) snowballing of references from included documents, (iii) signposting by interview participants and experts in the field of TI care. EE and NVL retrieved documents meeting the inclusion criteria: adult healthcare, UK-focus and discussion of TI approaches. We excluded documents on child healthcare, trauma-specific interventions and non-UK focus.

Qualitative interviews

We conducted virtual semi-structured interviews with healthcare professionals at decision making levels who have direct experience of developing and implementing TI approaches in the UK. We aimed to recruit up to 10 professionals from national and local governments and healthcare services. Researchers sent an expression of interest letter via email and Twitter to: (i) individuals and professional networks of policy makers, (ii) authors of included policy documents, (iii) individuals recommended by interview participants. Interested individuals contacted study researchers who checked their eligibility, sent participant information leaflets, answered questions, and arranged interviews with those eligible and willing to proceed. Interviews were conducted over the Zoom video call platform. Researchers obtained verbal informed consent, asked demographic questions, and followed a flexible topic guide to ensure primary issues were covered during all interviews but allowing participants to introduce unanticipated issues. The topic guide explored participant experiences of developing and implementing TI approaches and their views on how and why TI approaches have come to be represented in policy and implementation (Additional file 1). The interviews were audio-recorded with consent, professionally transcribed verbatim, and anonymised.

Analysis

We followed the four-step READ approach to document analysis in health policy research: 1) ‘Ready your materials’ which involves agreeing the type and quantity of documents to analyse, 2) ‘Extract data’ whereby key document information such as basic data and concepts are organised, 3) ’Analyse data’ when data is interpreted and findings are developed, 4) ‘Distil your findings’ which involves assessing whether there is sufficient data to answer the research question and findings are refined into a narrative[23].

Step 1. Ready your materials

EE and NVL agreed to use purposive sampling to gather 25 documents representing a broad range of document categories including primary legislation, parliamentary documents, NHS and Public Health England strategy and planning documents, service-user perspectives, evaluation reports, and guidance on ‘how to do’ TI approach[26]. EE ordered included documents chronologically.

Step 2. Extract data

EE read and re-read all included documents and used a customised Excel form to extract data on document title, authors, year, source, objectives, target audience, focus, key messages, referenced evidence and policies/guidelines, recommendations. During data extraction, EE made notes about how each document answered the following questions: What is TI care? TI care for whom? Why TI care? EE and NVL met regularly to discuss preliminary ideas for analysis.

Step 3. Analyse data

We imported all included documents and interview transcripts into NVivo R project and applied the framework method[24]. To address variability in definitions and terminology regarding TI approaches, we included key concepts from the well-known SAMHSA system-level framework[8], as a basis for our coding frame, for example the six TI principles. First, researchers read four documents (EE, NVL) and two interview transcripts (NVL, EE, JS, DM) and independently manually coded text relevant to our research questions using a combination of inductive and deductive coding[27]. Deductive coding helped to identify concepts related to TI care, even if the document itself did not specifically use the “trauma-informed” term. The researchers then met to compare initial thematic codes and agree on a ‘working analytical framework’ which was imported into NVivo and applied to the documents (EE) and interviews transcripts (JS, DM, EE, NVL). We refined the framework by adding and merging thematic codes identified subsequently, ran matrix coding queries by data sub-sets (documents, interviews), and combined codes into final analytical themes that answered our research questions. During analysis stage, researchers met bi-weekly to finalise the dataset, develop and refine coding frame and themes. We wrote reflective diaries and analytical notes and discussed how our clinical backgrounds in general practice and psychiatry, and varied experiences of qualitative research, could have influenced the analysis.

Step 4. Distil your findings

We stopped document review when we reached the pre-specified number of documents and discussed common findings. First, we illustrated how TI approaches have developed in the UK over time by creating an integrated timeline with document publication dates, the years when interview participants began working in this area, and broader contextual factors from national news and related media. Then we integrated findings from the analysis of documents and interviews through three iterative cycles of developing final analytical themes cutting across documents and interviews. Researchers produced written accounts of the themes, and tables with illustrative quotes that explained the landscape of TI approaches in the UK with underlying reasons and explanations.

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.

Table 1

UK policy documents included in analysis, ordered by publication date and category
Document category	Document title and year
Primary legislation, white papers, and consultation reports	2012 Health and Social Care Act 2019 Transforming the response to domestic abuse: consultation response and draft bill 2021 Integration and Innovation: working together to improve health and social care for all
Government and parliamentary documents	2016 Ending violence against women and girls. Strategy 2016–2020 2018 Public Health Priorities for Scotland 2018 HM Government: Serious Violence Strategy 2019 Ending violence against women and girls 2016–2020: refresh strategy 2021 COVID-19 Mental Health and Wellbeing Recovery Action Plan
NHS/Public Health England strategy documents	2014 Five year forward view 2018 Strategic direction for sexual assault and abuse services – Lifelong care for victims and survivors: 2018–2021
NHS/Public Health England planning documents	2019 NHS Long Term Plan 2019 NHS Mental Health Implementation Plan
Patient/service-users and carer perspectives	2019 Engaging with complexity: providing effective trauma-informed care for women
Evaluations and evidence reported to Department of Health or local government	2018 The Women’s Mental Health Taskforce. Final report 2019 A sense of safety: trauma-informed approaches for women 2019 Developing trauma informed practice in Northern Ireland: key messages Successes and struggles keeping trauma in mind: development of a trauma informed adult mental health service Ten evidence-based reasons for embedding values-based ‘Enabling Environments’ in health care
Guidance on ‘how to do’ trauma-informed care’	2017 Transforming psychological trauma: a knowledge and skills framework for the Scottish Workforce 2018 Trauma-informed approaches. Trauma-informed care: implications for practice 2018 Trauma-informed care in response to adverse childhood experiences 2018 Adverse Childhood Experiences, Resilience and Trauma-informed care: a Public Health Approach to Understanding and Responding to Adversity. The Annual Report of the Director of Public Health 2019 Developing real world system capability in trauma informed care: learning from good practice 2021 A good practice guide to support implementation of trauma-informed care in the perinatal period

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).

Table 2

Characteristics of interview participants
Participant ID	Gender	Geographical area	Organisation	Current role	Role in developing and/or implementing trauma-informed approach	Years of direct experience
1	Male	Wales Northwest England	Local authority Charity	Freelance public health practitioner	Training, consultancy	5
2	Male	East Midlands, England	NHS Mental Health Trust	Clinical lead for trauma service	Research, clinical work, training.	4
3	Female	North England	NHS Mental Health Trust	Clinical director of a service	Led implementation	21
4	Female	Southeast England UK-wide	NHS Mental Health Trust National charity	Women's services lead Trainer, consultant	Chose and managed implementation, training	4
5	Female	Southwest England	Charity for people with complex needs and substance misuse	Senior manager	Wrote organisation's policy, chose and managed implementation, training	17
6	Female	Southwest England	Mental health and housing charity	Senior psychologist	Led the design and implementation of trauma-informed approach in the organisation	2
7	Male	Northwest England	Private consultancy	Company director, consultant clinical psychologist, visiting professor	Designed and delivered training, supported organisations to develop trauma-informed approach	25
8	Female	UK-wide	UK body of the international charity delivering mental health and support services	Senior psychosocial practitioner	Developed organisation's trauma-informed approach, developed national policy, produced educational material for a national body	-
9	Male	Southwest England	NHS Mental Health Trust	Trauma-informed care lead	Developed trauma-informed approach for mental health trust, led implementation	10
10	Female	Northwest England	Third sector organisation	Trauma-informed care lead	Research, implemented town-wide trauma-informed approach across various services, member of international network on trauma-informed care	7
11	Female	East Midlands, England	Local authority	Public health manager	Managed commissioning of training for several groups of healthcare professionals within local authority	4
Note. NHS, National Health Service.

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[28]. 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[29], to a public health board[30], 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[33]. There was one document which considered how TI care could be applied across sectors in Northern Ireland[34], 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[37].

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[8], with some further developments of this. For example, the Women’s Mental Health Taskforce report[38], included principles similar to the SAMHSA framework, with additional focus on governance and leadership, gender inequalities, equality of access, holistic and effective care[38].

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[33]. 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[31]. A TI approach has also been presented as a solution to addressing the collective trauma of the COVID-19 pandemic for patients and staff[39]. 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[8], 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[30]. 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[33]. 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[28]. 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[8], 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”[28]. 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’[28].

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[42]. 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”’[28].

Physical environment of the organisation

Implementing TI approach may involve reviewing workspaces where trauma-related conversations occur to reinforce safety for patients and staff[46].

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[42]. 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[28].

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[38]. One interviewee also called for a united parliamentary leadership recognised by government and capable of influencing policy.

Our qualitative analysis of 25 UK policy documents and 11 interviews with key informants demonstrated the steady development of TI approaches in health systems in recent years. Despite endorsement of TI approaches in documents, we found evidence-policy and policy-implementation gaps with more centralised implementation in Scotland and Wales versus piecemeal implementation in England. Interview participants explained this landscape by the lack of national strategy and leadership, adequate funding, and shared understanding of TI approaches within and across healthcare systems. While policy documents recommended TI approach as a remedy for addressing challenges like integrated care and the impact of the pandemic, they did not guarantee adequate provision or clarify how it should be implemented. The implementation of TI approaches in England was driven from the bottom-up by passionate dedicated leaders at the level of organisation or local authority, who called for more coordinated implementation. They either applied existing frameworks of a TI approach through contextual tailoring or invented bespoke models that addressed local needs. The common implementation domains included workforce development, cross-sector collaboration, screening and treatment services, progress monitoring and adapting the physical environment. We identified factors that facilitated or hindered implementation of TI approaches at the level of organisation (leadership support, bottom-up and top-down development, systemic thinking, organisational culture, adequate resources, competing priorities) and wider context (government support, funding, the pandemic). Key informants had conflicting views on the future of TI approaches, however all agreed that without political backing at the government level, policy endorsement will not translate into meaningful implementation.

Our first important finding is a marked difference in the landscape of TI approaches in healthcare systems between the devolved nations, with evidence of a unified national strategy emerging in Scotland and Wales and notably absent in England. Possible explanations include smaller territories, populations, and governments, with clear buy-in from government-level leadership in Scotland. Our analysis highlighted the initiatives of local decision-makers in England who have developed and implemented TI approaches in their own organisations and local authorities. The absence of a national strategy in England contributed to the piecemeal implementation, with some regions leading the way, and others silent. As local TI leads have been left to ‘find their own way’, they may not always have been aware of similar initiatives in other organisations and regions, and instead had to ‘reinvent the wheel’. A proposed solution was bottom-up initiatives aiming to bring the local TI leads together to share resources and good practice. This finding indicates the need for a leader on TI approaches within or linked to the UK government who can support and strengthen the bottom-up initiatives.

Our second important finding is confirmation of the evidence-policy gap, with proposed reasons emerging in the analysis. Interview participants explained an absence of UK evidence on the effectiveness of TI approaches by a need for more interest from commissioners and funders, as well as a lack of physical and methodological capacity to evaluate system-level TI approaches. The former can be resolved through funding calls and comprehensive, transparent evaluation. The latter can be addressed by funding external evaluations and raising awareness regarding available methodologies and tools for evaluating TI system change interventions[21, 22].

Our finding of the variable understandings, and at times misunderstandings, of TI-approaches is in keeping with those of prior literature[47]. For example, standalone practices like ACEs enquiry and one-off training activities are sometimes occurring in isolation without the preceding organisation level changes which are central to a TI approach. Authors of the ACEs study explained that the ACEs score is not a diagnostic tool at an individual level, therefore care should be taken if used as part of community-wide screening, with rigorous evaluation of its use[48]. Recent reviews also found limited evidence for outcomes from routine enquiry, identifying a need for further research and evaluation [49, 50]. Several systematic reviews demonstrated that standalone awareness raising did not result in change in behaviour and practices among healthcare providers[51, 52].

These misunderstandings can be explained by the conceptual mutability of a TI approach framework, lack of awareness about existing frameworks, and a need for coordinated and centralised working. The evidence of emerging local working groups and UK-wide professional networks on TI care is promising. However, these initiatives require adequate funding and coordination to sustain momentum and develop further. These professional networks can become the platforms for education about evidence-based TI approaches contributing to increasing value and reducing waste in research and implementation in this field.

This study is methodologically robust with perspectives drawn from UK policy documents and professionals, who have direct experience of developing and implementing TI approaches. The limitations include no professional informants from devolved nations and no participants at the level of UK government. Due to time and funding restrictions, we did not interview patients including those with lived experience of trauma. Future research should recruit informants from these groups to draw a complete picture of the landscape of TI approaches in the UK.

Despite recommending TI approaches as solution to the impact of trauma on patients and staff and as a means of achieving integrated care; UK policies are not supported by adequate evidence, legislation, funding, and guidance for implementation. The implementation of TI approaches in Scotland and Wales is driven from top-down in contrast to the bottom-up development across NHS and non-NHS organisations and local regions in England. A coordinated, more centralised strategy on TI approaches in health systems, increased funding for evaluation, and education through professional networks about evidence-based TI health systems can increase value and reduce waste in research and implementation of TI approaches in the UK.

ACEs – adverse childhood experiences

COVID - coronavirus disease

DVA – domestic violence and abuse

NHS – National Health Service

SAMHSA - Substance Abuse and Mental Health Services Administration

TI - trauma-informed

UK-United Kingdom

US – United States of America

All methods were performed in accordance with relevant guidelines and regulations as detailed here: https://www.biomedcentral.com/getpublished/editorial-policies#research+involving+human+embryos%2C+gametes%2C+and+stem+cells.

Consent for publication

Not applicable.

Acknowledgements

We would like to thank all the interview participants and those with an interest in TI approaches who kindly shared policy documents and background literature with the study group. We would like to acknowledge the contributions of Dr Sandi Dheensa in reviewing the paper manuscript.

Funding

This report is independent research funded by the National institute for Health Research, Research Capability Funding stream via NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Availability of data and materials

Data are available at the University of Bristol data repository, data.bris, at https://doi.org/10.5523/bris.2awc5pqkavac12d6jm1qp9wetm.

For reference: Lewis, N. (2022): TAPCARE policy review study. https://doi.org/10.5523/bris.2awc5pqkavac12d6jm1qp9wetm

Ethics approval and consent to participate

Ethical approval was obtained from the Faculty of Health Sciences Research Ethics Committee at University of Bristol (Ref 114665, 11 February 2021). Interview participants provided verbal informed consent.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

NVL conceived, designed, and led the study. EE, NVL, JS, DM collected and analysed documents and interview data. EE and NVL wrote the first draft of the manuscript with input from DM and JS. All authors contributed to subsequent revision and approved the final version.

Authors’ details

¹Centre for Academic Primary Care, Bristol Medical School, University of Bristol, UK.

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No competing interests reported.

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Trauma-informed care in UK: where are we? A qualitative study of health policies and professional perspectives

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Abstract

Figures

Background

Methods

Results

How are TI approaches represented in UK health policies?

How are TI approaches understood and implemented in the UK?

TI care as a remedy to health system challenges

Not every TI approach is the same

Factors that facilitated or hindered implementation of a TI approach

Discussion

Conclusions

Abbreviations

Declarations

Consent for publication

Acknowledgements

Funding

Availability of data and materials

Ethics approval and consent to participate

Competing interests

Authors’ contributions

Authors’ details

References

Competing Interests

Supplementary Files

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