Hcmp, Ipsum

Trauma Informed Care, from Policy to Practice

Introduction

This paper aims to guide the potential implementation of trauma-informed practise (TIP), also

known as trauma-informed care in a local psychiatric hospital. TIP is a framework that acknowledges

the prevalence and impact of trauma and considers that mental health clinicians are best positioned

to identify and respond to trauma in consumers (Hurley, Hutschnison, Lakeman & Wilson 2017). The

Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) guidelines advocate

recognition and response to trauma by addressing failures and collaborative, clear health

communication and delivery among diverse stakeholders such as families, the federal government,

and the frontline workers.

TIP employs a collective impact approach to garner support for a shared vision and long-term

action plan that communicates critical messages about organisational goals and priorities (Kotter,

2012). Its primary goals are to raise awareness of trauma through data-driven actions and a

commitment to provide compassionate, safe, sustainable, and supportive environments for all trauma

survivors (Fallot & Harris, 2001). Fallot and Harris (2001) proposal to respect for safety, trust, choice,

collaboration, and empowerment as core principles in addiction treatment remain the most debated

in TIP research (Wilson et al., 2021). The background information that follows serves as a reference

guide for tailoring the depth of the discussion for TIP implementation. Emphasis is placed in the early

stages of implementation when challenges are most prevalent and achievements may mean the

most.

Background

The alarming and destructive effects of trauma, such as interpersonal violence,

discrimination, significant child abuse, and sexual assault, are slowly being recognised by Australian

health policymakers and practitioners (Lovell, Greenfield, Johnson, Eljiz, & Amanatidis 2022). Faced

with the constant inpatient admissions and readmissions of trauma survivors, trauma care has

developed a mystique that leaves clinicians apprehensive of addressing it (Palfrey et al., 2019).

Trauma stories often cause vicarious traumatization in therapists, leading to therapeutic nihilism,

exhaustion with lack of management support (Leonard & Tiller, 2015). Clinical responses have been

reported to range from disbelief, rejection, stigma, fascination, and over-involvement in patient care

(Leonard & Tiller, 2015). Patient poor treatment responses remain attributed to a lack of trauma

training, scepticism and outdated clinical practices (Leonard & Tiller, 2015).

The rigidity of structures and the use of coercive policies and procedures in acute care are

usually experienced as countertherapeutic by trauma patients (Allison, Bastiampillai & Goldney,

2016). Similarly, ward rules, ward rounds, mixed-gender patient populations, involuntary

confinement as well as seclusion and restraint are perceived as emotionally unsafe and

disempowering for trauma patients (Lovell, et al., 2022). The protocol to do no further harm drives

ongoing discussions about TIP in inpatient services (Allison et al., 2016).

The most articulated policy to emerge from Australia's TIP movement is the understanding

that seclusion and restraint should be reduced and, where possible, eliminated (Lovell et al., 2022).

Otherwise, TIP implementation remains academic resting on principles and general guidelines (Isobel,

2021). Its adoption is slow to take off and difficult to sustain (Wilson et al., 2021). What research

may lack is concrete information on what typically drives the implementation process. This task

will identify the factors that motivate, limit, and enable TIP implementation in acute care using

Kotter’s eight step organisational change model (Kotter, 2012).

Implementation of evidence to practice

Implementing organisational change requires a systematic, intentional planning, strong

leadership support, reinforcement and a robust methodology to evaluate care gaps (Kotter, 2012).

Organisational change refers to any configuration, dissemination, and adoption of elements that

result in a cognitive roadmap to improve the capacity and effectiveness of implementing change

(Kotter 2021). Kotter's steps involve: increasing urgency, forming a coalition, clarifying vision,

communicating, focusing on short-term goals, embracing change, and never giving up (Kotter 2012).

In addition, TIP implementation requires expertise in patient safety, healthcare system changes,

patient-centred care, complex care management, and collective leadership that considers the macro,

meso, and micro levels of integrated care (Palfrey et al., 2019). Proactive, agile, bold and perseverant

leadership has the ability to change the status quo and outdated models of care, giving trauma survivors hope

for sustainable mental health care (Kotter, 2012). Integrated care has been shown to improve outcomes

for trauma survivors (Kotter, 2012).

TIP Evidence effectiveness

Kotter's change model has been extensively studied and proven effective as a framework for

healthy safety initiatives and health communication improvement (Carman, Edmiston, Stradman &

Vanderpool 2019, Kotter, 2012). A systematic review of 31 articles found that safety, empowerment,

and support improved patient satisfaction and TIP implementation (Fleishman et al., 2019). This study

also found that nurses who used a trauma-informed lens in their practice reported increased self-

efficacy, confidence in discussing trauma, higher job satisfaction, reduced risk of burnout, leading to

higher employee retention (Fleishman et al., 2019). Leonard and Tiller (2015) emphasized that

consumers' therapeutic relationships improved when traumatic experiences were acknowledged

rather than dismissed.

Kotter’s Model

Establishment of urgency, coalition, and vision

The three key principles of Kotter’s model include: establishing a change system, enabling,

implementing, and sustaining change (Kotter, 20120). The first phase of organisation change involves

creating a sense of urgency, forming a leading coalition, developing a vision and strategy (Kotter,

2012). (Carman et al., 2019). Kotter's model posits that people and organizations often resist and

prevent the steps required for effective and sustainable change (Kotter, 2012). The awareness-

raising process prompts employee to recognise that changing practise requires their effort to improve

care. The key leadership role for this stage is to eliminate complacency (Carman et al., 2021).

Being trauma informed involves active trauma learning, strengths-based trauma care planning,

consumer empowerment and de-escalation measures (Allison et al., 2016).

Guiding coalition

TIP has been discussed differently in social epidemiology, biostatistics, behavioural and

environmental health sciences (Johnson-Lawrence & Parker 2022). Interdisciplinary expertise allows

bi-directional collaboration, mutuality and trust (Carman et al., 2019). implementation that respects

local expertise, cultural considerations and employee buy-in has been proven successful (Carman et

al., 2019).

A Strengths, Weaknesses, Opportunities and Threats (SWOT) and stakeholder analysis could

be conducted to identify the organization's concerns, interests in adopting TIP and what motivates

different behaviours and people’s levels of cooperation (Johnson-Lawrence & Parker 2022). Preparing

for and dealing with adversity offers a chance to innovate, overcome challenges and change the pace

(Fleishman et al., 2019). Early investment in person-centred integrated care, trauma specialisation,

and certification can strengthen TIP implementation (Isobel, 2021).

Empower and enable

TIP begins and ends with the empowering nature of the therapist-client relationship and the

importance of client-cantered care in services. Employee involvement, good planning,

communication and training engagement have all been identified as critical factors for successful

implementation (Carman., 2019). Consumers are more likely to receive TIP from staff who feel safe,

respected, supported, empowered and rewarded (Fleishman et al., 2019).

Creating a Vision, short term wins and program evaluation

Creating a vision and a change strategy empowers, motivates and inspires TIP

implementation. The second phase describes communicating the vision for change, inspiring

employees for a change movement and achieving future goals (Kotter, 2012). Short-term wins

improve employee engagement and help evaluate change as it occurs (Kotter, 2012). Quick wins

demonstrate milestones reached and the importance of change and how to avoid failure (Carman et

al., 2019; Isobel, 2021). Negotiation, planning, risk evaluation, critical reasoning, incentivisation and

effective communication are critical skills for implementing change (Allison et al., 2016). The last

phase is about integrating gains, bringing about further change and re-establishing changes in the

culture (Kotter 2012).

Barriers to translate research

Traditionally, multiple health restoration decisions have been made without real

consideration of their impact on various stakeholders, and subsequently require significant

investment to correct (Johnson-Lawrence & Parker 2022). To this day, nurses have adapted to several

systemic changes over the past 20 years, and more recently our roles have tended to be limited to the safety of

care (Wilson et al., 2021). TIP lack fidelity measures, well-defined strategies, and a standardised

definition of trauma. Competing demands, a lack of time, clinical uncertainty, negative staff attitudes,

information overload, and a lack of culture with passive, avoidant leadership, widens this practise gap

(Allison et al., 2016).

Paralysed trauma approach

TIP is ambiguous, and efforts to implement it have been driven by corporate culture

engagement and participatory priorities (Johnson-Lawrence & Parker 2022). Change in inpatient acute

care is primarily driven by emerging crises, but is often reactive and piecemeal (Allison et al., 2016.)

TIP implementation characterizes key leadership and employee culture challenges and highlights the

implications of navigating a difficult financial context. Employees can make a significant contribution

to building and maintaining the reputation of the company (Kotter, 2012). Cynicism, resistance to

change, and exhaustion within the workforce can provide valuable insights to support the accuracy of

the goals and plans that serve as the basis for TIP implementation (Kotter, 2012). A workplace culture

that discourages employees from raising significant but potentially divisive concerns dominates

organisational change failure (Isobel, 2021).

Unevaluated TIP model

One of the most cited in the TIP implementation literature is Fallot and Harris’s (2001) model.

Although it appears plausible for TIC implementation, its validity has rarely been empirically evaluated

(Wilson et al., 2021). Investing in organizational change should fulfil the ethical obligation to do no

harm (Leonard & Tiller, 2015). However, this is complicated by the macro systems of healthcare

organizations and the micro systems of patient care teams. The disconnection between one part of a

system can lead to disaster elsewhere (Allison et al., 2016). Suffice to say, the governance of mental

health care in Australia is shaped by the repeated restructuring of public mental health services,

paraprofessionals and fragmented trauma delivery that often fails to meet individual consumer needs

(Allison et al., 2016).

High occupancy and acuity can overwhelm the clinician’s ability deliver therapeutic care or

drive the change needed for TIP (Isobel 2021). Risk may also emerge from intricate interdisciplinary

services, poor design of physical spaces, clinical work practises, technology and devices, our patient

preferences, and dominant models of treatment (Wilson et al., 2021).

Political Realities

Change in mental health systems is difficult to implement (Allison et al., 2016). Both social

and professional stigma impedes TIP implementation (Leonard & Tiller, 2015). Change in the mental

health environment do not have broad public support and is not considered top political priority

(Johnson-Lawrence & Parker 2022). Reforms are primarily driven by cost considerations (Allison et al.,

2016). TIP is well supported in research and science, but is underfunded at the ward level (Allison et

al, 2016). Political realities are complex and dynamic (Johnson-Lawrence & Parker 2022). After tragic

events such as suicide or abuse, energy is spasmodically focused on the traumatic event but soon

fades (Allison et al., 2016). In some jurisdictions where politicians and their significant others have

experienced a traumatic event, policy and political support for mental health strengths-based case

management and initiatives ensues (Johnson-Lawrence & Parker 2022). There is a gap between the

politician's departure and seizure of power and the need to implement mental health system reforms

(Allison et al., 2016). Instead of influencing public policy, many excellent TIP recommendations are not

followed up (Allison et al., 2016).

Kotter (2012) described policy formation as a process involving research, stakeholder

dialogue, community and media interest pressures (Johnson-Lawrence & Parker 2022). A paralysed

trauma-practice approach is often the result of too many stakeholder managers and passive, avoidant

leaders (Allison et al., 2016). Negotiating changes, obtaining approvals, and ideology all have a strong

influence on funding, which negates the potential impact of TIP implementation (Allison et al., 2016).

Workforce recruitment, retention and staff shortages

Staff shortages and lack of resources complicate trauma care (Palfrey et al., 2018). Time

constraints make teaching, coaching and mentoring health professionals difficult (Allison et al., 2016).

Poorly resourced facilities to provide consumer room occupancy or staffing preferences, limit TIP

implementation (Isobel, 2021).

Conclusion

TIP delivery is composed of complex systems. (Kotter 2012) proposed that TIP must be

designed and implemented by clinicians and policymakers using systems thinking. Systems thinking is

not automatic, it must be informed by knowledge and competent skills. (Kotter, 2012). Most

managers fail because they prefer simplicity to complexity and certainty over unpredictability (Kotter,

2012). Evaluation and research into TIP and its impact on acute care nurses is extremely limited

(Wilson et al., 2021). This essay revealed that the dynamic challenges of acute care, myriad systems,

and the biomedical treatment approach are contextual challenges may impede TIP implementation

(Johnson-Lawrence & Parker, 2022).

The targeted application of TIP in acute care and re-traumatization practices in this area need

to be studied with the same enthusiasm and consideration shown to trauma users. Staff burnout,

vicarious trauma and therapy delivery risks with the demands of a ward level, should highlight the

complex nature of providing TIP in acute mental health. Unless the parallel practices are carefully and

critically analysed, a fully integrated trauma-informed mental health system would remain

oversimplified and may not thrive

References

Allison, S., Bastiampillai, T., & Goldney, R. (2016). McGorry et al. debate on the “National Mental

Health Commission Report: Evidence based or ideologically driven?” Australian & New

Zealand Journal of Psychiatry, 50(3), 290–290. https://doi.org/10.1177/0004867416631831

Carman, A. L., Vanderpool, R. C., Stradtman, L. R., & Edmiston, E. A. (2019). A Change-Management

Approach to Closing Care Gaps in a Federally Qualified Health Center: A Rural Kentucky Case

Study. Preventing Chronic Disease, 16(E105). https://doi.org/10.5888/pcd16.180589

Leonard, D., & Tiller, J. (2015). Dissociative identity disorder (DID) in clinical practice – what you don’t

see may hurt you. Australasian Psychiatry, 24(1), 39–41.

https://doi.org/10.1177/1039856215604481

Lovell, R. C., Greenfield, D., Johnson, G., Eljiz, K., & Amanatidis, S. (2022). Optimising outcomes for

complex trauma survivors: assessing the motivators, barriers and enablers for implementing

trauma informed practice within a multidisciplinary health setting. BMC Health Services

Research, 22(1). https://doi.org/10.1186/s12913-022-07812-x

Fallot, R. D., & Harris, M. (2001). The Trauma Recovery and Empowerment Model (TREM): Conceptual

and Practical Issues in a Group Intervention for Women. Community Mental Health

Journal, 38(6), 475–485. https://doi.org/10.1023/a:1020880101769

Fleishman, J., Kamsky, H., & Sundborg, S. (2019). Trauma-Informed Nursing Practice. Online Journal of

Issues in Nursing, 24(2), N.PAG–N.PAG. https://doi.org/10.3912/OJIN.Vol24No02Man03

Isobel, D. S. (2021). Is trauma informed care possible in the current public mental health

system? Australasian Psychiatry, 103985622110286.

https://doi.org/10.1177/10398562211028625

Kotter, J. P. (2012). Leading change. Harvard Business School Press. (Original work published 1996)

Palfrey, N., Reay, R. E., Aplin, V., Cubis, J. C., McAndrew, V., Riordan, D. M., & Raphael, B. (2018).

Achieving Service Change Through the Implementation of a Trauma-Informed Care Training

Program Within a Mental Health Service. Community Mental Health Journal, 55(3), 467–475.

https://doi.org/10.1007/s10597-018-0272-6

Parker, S., & Johnson-Lawrence, V. (2022). Addressing Trauma-Informed Principles in Public Health

through Training and Practice. International Journal of Environmental Research and Public

Health, 19(14), 8437. https://doi.org/10.3390/ijerph19148437

SAMHSA. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

Prepared by SAMHSA’s Trauma and Justice Strategic Initiative.

https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf

Wilson, A., Hurley, J., Hutchinson, M., & Lakeman, R. (2021). ‘Can mental health nurses working in

acute mental health units really be trauma‐informed? An integrative review of the

literature. Journal of Psychiatric and Mental Health Nursing.

https://doi.org/10.1111/jpm.12717