Trauma-Informed Care, from Policy to Practice
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 consumer trauma (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 selfefficacy, 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 awarenessraising 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
