This study is an examination of the motivators, barriers and enablers to the implementation of TIP in a multidisciplinary, multi-service type, non-acute, outpatient, community health setting. It has identified ten key factors motivating, restricting and enabling the implementation of TIP in practice. These factors may be conceptualised as related to the organisational or service context, or individual professional. Seven factors are related to the organisational or service context, including: supportive and informed management; flexibility of service models; levels of service demands; resource availability; education opportunities; good client outcomes; and reporting requirements. Three factors are associated with the individual professional delivering the service, including: philosophical approach; team orientation; and vicarious trauma/stress management. Critically, alignment in two ways was deemed necessary for successful TIP implementation, that is: in knowledge and understanding across organisational role levels from clinicians, to managers, to executives; and, in professional philosophy and team orientation of individual clinicians.
This study confirms previous research in other health settings, including drug and alcohol, mental health, emergency medicine, and paediatric and trauma nursing [11, 24, 25, 33]. Additionally, it supports findings from discipline specific studies in nursing, social work, medicine and midwifery [2, 24, 25]. In particular, as seen in studies in emergency medicine and paediatric nursing, participants across disciplines consistently spoke about their services’ existing capacity for TIP, in multiple service entry points, ensuring clients had choices, collaborative goal setting and treatment processes, with seamless referral pathways, and open and transparent communication [24, 25]. They also noted successful implementation of trauma informed systems, such as supporting peer debriefing, case discussion, clinical review and cross disciplinary learning. This was consistent with study findings and best practice documents in the mental health setting [18, 21, 28, 34].
As seen in studies examining the implementation of TIP within emergency medicine, mental health, paediatric and trauma nursing, a number of barriers were noted. In particular, lack of trauma informed practice at a leadership level, limited opportunities for wide-spread staff training, and the need to better inform decision makers about complex trauma [11, 24, 25]. Recommendations were made to increase opportunities to manage vicarious trauma across disciplines and to increase opportunities for trauma specific training [11, 24, 25]. It is important however to note that the limited access to trauma-specific training and supervision reported by the participants in this study, may be a result of trauma-specific training not being prioritised for this workforce due to a lack of awareness by planners/managers regarding its applicability across disciplines and service types. This has been highlighted by Hoysted and colleagues (2017)  as a common barrier across the health system, noting that trauma related training and supervision is traditionally the territory of social work and for this reason may be overlooked in service planning for other professional groups .
The study’s significant contribution to the knowledge base is demonstrating that effective implementation of TIP is achieved through attending to the inseparability between the motivators, barriers and enablers. To phrase this in the terms used above, the study highlights the ways in which the organisational or service context promotes, or restricts, the use of TIP for individuals and teams, both individually and collectively. Furthermore, it emphases the impact the orientation of the individual professional or team involved has in supporting or being hesitant to TIP implementation. In a positive or negative reinforcing cycle, organisational context influences individual and team motivation for TIP, and, in return, individuals and teams shape the context by advocating for or against TIP.
Despite the demonstrated compatibility of TIP with the majority of identified organisational and individual professional contexts within the community health setting, barriers related to funding pressure and the bio-medical model were commonly identified. Whilst this has not been explicitly highlighted in previous research on implementing TIP, it does align with the drive to use minimal resources, which was identified as a barrier in a number of TIP studies, particularly within the mental health and emergency medicine settings [11, 25]. It also aligns with findings outside of the TIP research field, whereby the ways in which health systems are financed is frequently reported as a barrier across the healthcare setting [2, 7]. This is particulary evident in regrds to providing accessible and appropriate prevention, treatment and recovery services for those who experience disadvantage, including complex trauma [35, 36].
Public health services are traditionally based on a bio-medical model delivered within a complex, large scale organisation . In this context executives, managers and front-line professionals often consider service delivery differently, resulting in an inbuilt tension and diverging focus between roles. Typically, those in managerial and planning roles focus on whole populations who seek access to services, while front-line clinicians’ attention is directed to the needs of the individual.
As seen within the multi-service, non-acute, outpatient community health context, the complexity of implementing TIP across the health system is shaped by a range of factors, including: organisational inertia to change; the rigidity of the traditional biomedical model; caution with the use of resources; adherence to strict privacy requirements; limited opportunity for wide-spread staff training; and inadequate or inconsistent knowledge and understanding of TIP across professionals at all levels [2, 11, 37]. Implementing system-wide strategies to overcome these challenges is essential as service delivery which fails to take into account complex trauma impacts, risks continuing to provide fragmented, ineffective and harmful services . System-wide changes to further facilitate the necessary organisational and professional cultural shift towards TIP, include changes to the way health services are funded, organised and measured [18, 19], and in the way health professionals (across disciplines) are trained, developed and supported [7, 19, 39].
Balancing health service funding criteria and performance targets, so to deliver a service accessible for a population, and the needs of individuals affected by complex trauma remains an ongoing challenge . Depending on the position of the professional – executive, manager, planner or clinician – a different emphasis is focused upon. This study however demonstrates that these need not be mutually exclusive, as participating managers recognised the imperative for balancing funding and performance targets with effective care for high risk populations and workforce.
Clients with experience of complex trauma can fail to attend appointments, or when they do find it difficult to engage with clinicians and may require flexible or longer appointments, and additional case management or care coordination [18, 28, 35]. Front-line clinicians and managers therefore argue for increased flexibility in service delivery and greater attention to the needs of disadvantaged or minority populations . Funding and reporting requirements focused on client numbers however remains a high priority for managers and executive for ensuring service capacity; however, these requirements limit value for individual clients and increase clinician stress levels.
Hence, the critical question: how to develop organisational systems which support trauma survivors and staff wellbeing, whilst delivering timely, effective and efficient care to the entire population? It is important that executive, managers, planners and clinicians continually address this question in a collaborative, cooperative manner, so as to avoid potential tension, conflict, and mistrust that can arise between roles with competing priorities. In the absence of trauma informed changes in health service funding models; identifying, evaluating and researching how to effectively address this challenge beyond reducing TIP to aesthetic changes, one-off training sessions and brief interventions is a future task. This is of particular importance within the COVID-19 context which continues to create stress and uncertainty, for both clients, their families and clinicians .
There were several limitations to this study. Firstly, there was a potential for selection bias, as participants self-selected to participate, and therefore it is possible that those who were supportive of moving toward the implementation of trauma informed practice were more likely to opt-in. In addition, the relatively small sample size limited the scope for statistical analysis, as well as the generalisability of the findings more broadly. However the cross-discipline approach and high level of participation from the selected sample helps to mitigate this.
Secondly, it is important to note that the data collection tool (questionnaire) for determining the level of use of TIP by the workforce does not provide comprehensive coverage of all the elements of trauma informed practice, as it was designed with the intention of providing education and capturing a snapshot only. The definitions provided on the tool, were limited as was the time allocated to tool completion. Furthermore, whilst the tool was validated for relevance, clarity, simplicity, and low ambiguity, by two TIP experts, it was not a validated instrument. This is identified as an area for future research. Additionally, potential exists for user bias towards over reporting based on what the user would prefer to be doing (or considers the right thing to do) rather than what they are actually doing (in their practice). However, the study helps to reduce the limitations of the questionnaire tool by completing in-depth explorative focus groups and mini-focus groups which were independently transcribed and analysed by the Principal Investigator (RL), who immersed themselves in the data, and completed the qualitative analysis with consultation and support from a senior academic, and a senior health manager, who assessed the findings for accuracy, truth value, neutrality, relevance and applicability.
Finally, the study was conducted within an outpatient community health setting, and therefore cannot be considered as indicative of the motivators, barriers or enablers within the inpatient, and/or hospital setting.