Trauma-Informed Approaches in Primary Healthcare and Community Mental Healthcare: A Mixed Methods Systematic Review of Organisational Change Interventions

Abstract

A trauma-informed approach is a framework for organisational (synonym system) change interventions that address the universal prevalence and impact of trauma. This mixed methods systematic review assessed the effects of trauma-informed approaches on psychological, behavioural, and health outcomes in health-care providers and adult patients in primary care and community mental healthcare. We searched five databases and grey literature and consulted experts for reports published in January 1990 to June 2021. The quantitative descriptive and qualitative framework syntheses were integrated through a line of argument and mapped onto a logic model. We included six nonrandomised studies that evaluated eight interventions with varied theoretical developments, components, and outcomes. The most common components were budget allocation, workforce development, identification/response to violence and trauma, and evaluation. Evidence for intervention effects was limited and conflicting. Four studies reported improvement in provider readiness and sense of community, while three reported conflicting effects on provider behaviour regarding delivery of trauma-informed care. Four studies reported some improvement in patient readiness for disease management and access to services; however, the evidence for patient satisfaction was conflicting. Two studies found that patients and providers felt safe. While one study reported improvement in patient quality of life and chronic pain, another found no effect on substance use, and three studies reported conflicting effects on mental health. Intervention mechanisms included a package of varied components, tailoring to the organisational needs, capacities and preferences, staff education and self-care, creating safe environments, and shared decision-making. Intervention effects were moderated by contextual (health system values, policies, governance, business models, trauma-informed movement, organisational culture, and social determinants of health) and intervention factors (buy-in from all staff, collective learning through conversations, equal attention to staff and patient well-being, and sustainable funding). No studies measured adverse events/harm, cost effectiveness, or providers’ health. We need more methodologically robust evaluations of trauma-informed organisational change interventions.

Unpacking complexity in addressing the contribution of trauma to women’s ill health: a qualitative study of perspectives from general practice

“…Primary care practitioners held women's distress whilst they waited for specific therapies or supports, and yet the practitioners did not have adequate formal support systems to take care of their own wellbeing. This finding resonates with Pereira Gray et al 25 who suggest that the UK shortage of GPs, erosion of continuity of care, sustained increase of remote consultation methods and lack of structural support in the system may exacerbate challenges faced by practitioners to provide high quality care 26,27,28 .…”

“…A co-ordinated systems approach should support an integrated and holistic approach, rather than encouraging a dichotomising split between physical or psychological services. Our findings suggest that this model would also support the wellbeing of practitioners delivering care, and may have an impact on staff retention, making this a critical consideration at all system and service levels, from individuals, to practices, to funders and commissioners 28,29 . However, less is known about how to enact or enable trauma-informed care at a systems level 16 .…”

“…This includes learning how to actively nurture equitable care within services, practices, and within Primary Care Networks. At a funding and commissioning level, autonomy and equitable work need to be valued and enabled and this requires policy attention; simplistic metrics of care like numbers seen or a narrow focus on numerically quantifiable access will not capture either the impacts on patients or practitioners 28 . Nor will this capture the contacts and appointments that did not happen.…”

U.S. Physicians’ Training and Experience in Providing Trauma-Informed Care in Clinical Settings

“…Routine screening for trauma history identifies patients who can benefit from individualized trauma-sensitive support services and resources [15]. In contrast to the traditional "trauma-blind" delivery of services, TIC incorporates the four R's: (1) realizing the impact of trauma and helping the individual recover, (2) recognizing the signs and symptoms of trauma, (3) responding by utilizing TIC principles in all areas of services, and (4) resisting re-traumatization [16,46]. Thus, in a trauma-informed approach, the provider asks, "What happened to you?"…”

“…Basic to trauma-informed care is recognizing how trauma affects the patient. Rather than following a traditional treatment protocol, a trauma-informed approach serves as a comprehensive framework of interventions [46] directed at multiple levels: medical education and training, professional practice, and institutional/organizational levels to address the prevalence and impact of trauma on both patients and healthcare providers.…”