Evaluation of a trauma-informed care (TIC) training program across community health centers in Texas: a qualitative study

Abstract

Background

In April 2019, Texas Association of Community Health Centers launched the Trauma-Informed Care (TIC) program in community health centers across Texas. This initiative aimed to transform organizational culture for consistent delivery of TIC by providing training and coaching opportunities for Trainers and Champions in each health center. This study is an interim qualitative evaluation to gain participants’ insights into their experiences of and perceptions about TIC training as part of the TIC initiative.

Methods

We conducted semi-structured key informant interviews via Zoom with Trainers across four cohorts of participating health centers between February 2020 and April 2023. We used rapid assessment procedures to conduct analysis in tandem with data collection given the ongoing TIC training. We present salient quotes to illustrate the emergent themes.

Results

We interviewed a total of 36 Trainers and identified the following emergent themes from the interviews: (1) Perceived need for the TIC training, (2) Perspective shift in patient care, (3) Increased support for staff wellness, (4) Importance of equal involvement of staff at all levels, (5) Need for leadership buy-in, and (6) Lack of self-efficacy and empowerment to train others.

Conclusions

A trauma-informed environment in a healthcare setting can bolster patient-centered care as well as a culture of staff wellness. This qualitative evaluation revealed that after TIC training, Trainers had improved attitudes and behaviors to commit to organizational TIC transformation to prevent unintended consequences of trauma for both patients and staff. Trainers’ experiences with and suggestions for enhancing the TIC training should be considered for training future cohorts as they continue to strive for TIC transformation in their health centers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11813-3.

Background

Trauma-informed care (TIC) is an approach to organizational transformation centered on understanding the widespread impact of trauma at all levels and potential coping strategies [1]. It recognizes the signs and symptoms of trauma and responds to the well-being of involved individuals by fully integrating knowledge about trauma responses into policies, procedures, and practices [2]. TIC seeks to minimize re-traumatization in all individuals with histories of trauma, including secondary trauma of staff, and encourages their participation in the development, delivery, and evaluation of services [2]. Research has shown that TIC is effective in improving patient health outcomes, establishing good patient-provider relationships, and significantly ameliorating provider knowledge, attitudes, and confidence to identify and work with patients experiencing traumatic stress [3, 4].

In April 2019, Texas Association of Community Health Centers (TACHC) launched the Trauma-Informed Care program in federally qualified health centers (FQHCs) and one look-alike. The TACHC TIC initiative aimed to shift the culture of the participating health centers to one in which direct patient care is provided in a trauma-informed environment as part of the patient-centered medical homes. The program centered primarily on training and technical assistance via facilitation calls for Trainers in each health center using the “Train-the-Trainer” model (Fig. 1). The training curriculum was developed by TACHC adapting the Substance Abuse and Mental Health Service Administration’s domains of TIC and focused on concepts generated by TACHC that would be applicable to all organizations, including FQHCs. Through the TIC training and facilitation calls from the TACHC TIC program coordinators with content expertise, Trainers obtained additional strategies to overcome challenges or barriers to implementing the standards they had selected from organizational assessments conducted as part of their goalsetting. Following their TIC training, Trainers selected and disseminated the same training to Champions in their health centers. Working in tandem, Trainers, Champions and health center leadership aimed to implement TIC within their health centers and created a long-term plan to commit to sustained transformation.

Fig. 1.

Overview of the Train-the-Trainer model

The TIC program is still in progress with consecutive cohorts of health centers in different phases of implementing their TIC training. The aim of this preliminary study is to understand experiences of, and perceptions about the TIC training from the accounts of Trainers in the participating health centers.

Implementation of the TIC program

Each health center’s training team comprised three Trainers employed in different professional roles. Training teams were required to include a healthcare provider (i.e., physician or dentist) and a behavioral health specialist, while the third team member could be from any role including any clinical or non-clinical staff member, such as an administrator. Although many of the behavioral health specialists, given their profession, were already aware of TIC, Trainers generally did not have previous knowledge about TIC prior to the training. Trainers were existing staff, who volunteered to take on the role in the TIC program or were recommended to participate by their health center leadership. Eighty-seven Trainers from 29 health centers received one-year TIC training from the TIC program coordinators between 2019 and 2024. To discuss the application of TIC concepts in the health centers, Trainers participated in ten monthly learning community sessions that were developed specifically for the purpose of the TIC training. Several months into the training, Trainers selected and began to provide the same training to Champions, who would subsequently disseminate the training to other staff in their respective health centers. The number of Champions in each health center varied based on health center size. The TIC program also leveraged the Project ECHO^® (Extension for Community Healthcare Outcomes) model; behavioral health specialists and subject matter experts from all practice settings, including rural and underserved areas, were connected to bridge knowledge gaps and build capacity using tele-mentoring and case-based learning.

Methods

Study design and setting

We qualitatively examined TIC Trainers’ experiences, opinions and perceptions about the TIC training. Between February 2020 and April 2023, we conducted semi-structured key informant interviews with Trainers across four cohorts of participating health centers. To recruit participants, we sent out an invitation email to all Trainers in the program, and those who responded to the invitation participated in the interview. All interviews were conducted remotely via Zoom.

Data collection

All study participants provided informed verbal consent at the commencement of the interview. A semi-structured interview guide (see Supplementary File) developed by the research team was used for this study, and included these central questions: What is your overall thought about the TIC program so far? What successes have you had in training Champions to disseminate the TIC approach in your health center? What challenges or setbacks have you faced as Trainers? What activities or resources do you think were missing or would be valuable to improve the training that you provided? If you could do one thing to improve trauma-informed practice in your health center, what would you do? Additional notes were taken during and after each interview and incorporated into data analysis. The interviews lasted an average of 30 min and each of the study participants received a $25 electronic gift card following completion of the interview. Although one person conducted the interviews, the research team held regular debriefing weekly meetings to discuss certain findings from the interviews, clarify any uncertainties, make necessary modifications to the interview guide, and ensure the accuracy and completeness of the qualitative data collected.

Data analysis

We used rapid assessment procedures (RAP) [5] to conduct data analysis in tandem with data collection, as the TIC training was in progress during the entire data collection period. Applying RAP is appropriate in rapidly evolving health care settings to generate preliminary data and evaluate the implementation of new programs in a timely manner [6]. RAP balance research rigor, timeliness, and utility of the findings to inform intervention development. We first summarized each transcribed interview using a standardized template organized by interview questions, instead of using traditional line-by-line coding methods. We aggregated the data to create matrices that provided a view of information for each interview question across interviews, which allowed comparison of information across respondents and identification of emergent themes. We extracted contextually meaningful, rich responses using direct quotes.

Ethics

The study was approved by The University of Texas Health Scienter at Houston Committee for the Protection of Human Subjects (HSC-SPH-19-1019; 11/25/2019).

Results

We conducted key informant interviews with a total of 36 Trainers across four cohorts of health centers. Our analysis of the interviews revealed six salient themes: (1) Perceived need for the TIC training, (2) Perspective shift in patient care, (3) Increased support for staff wellness, (4) Importance of equal involvement of staff at all levels, (5) Need for leadership buy-in, and (6) Lack of self-efficacy and empowerment to train others. Below we present key findings in greater detail, supported by anonymized narrative accounts.

Theme 1. Perceived need for the TIC training

Trainers acknowledged that the TIC training was much needed and valuable in the healthcare setting. TIC approaches in the health centers were particularly impactful after they underwent difficult times, including the COVID-19 pandemic, staff turnover, aftermath of shooting incidents, and clinic-related complaints from patients. Even during such adversity, Trainers could be conscious about how they communicated amongst themselves and with the patients, “finding that sweet spot between being safe but also not triggering people” (Cohort 1, Trainer 13) “because we had the training on the back of our brains” (Cohort 1, Trainer 5). Trainers increasingly realized the need for the training as they noticed different stressors and triggers from physical environments to the daily language and signage used in the health centers. One Trainer stated: “it was apparent to me when we started the program that this was really lacking in our clinic and that it would really improve patient care and patient outcomes” (Cohort 3, Trainer 4). Another Trainer added: “As the TIC language is becoming more universal, it’s like creating this culture where they knew they were missing out on something that would be helpful to their work” (Cohort 1, Trainer 11). One Trainer commented:

When we went through the TIC training, and I started looking at these policies on patient termination, I recognized some of the verbiage and how harsh some of our letters were. You’re possibly traumatizing them again for rejection. And there’s so many other ways that we can write those letters (Cohort 1, Trainer 4).

Trainers agreed that staff turnover, a persistent issue especially during the pandemic, hindered the culture shift to TIC as those who were trained frequently left their health centers. To improve staff retention, Trainers recognized the need to integrate the TIC training into the onboarding process. They pointed out that TIC implementation would be more effective with “more concentrated time to introduce TIC during the onboarding process” (Cohort 2, Trainer 3), whereby “everybody gets the training from the very beginning” (Cohort 3, Trainer 4) rather than a select few being trained at the commencement of their employment. Two Trainers indicated:

It would be good to have TIC training as part of our onboarding process. That way they can hear it firsthand, “This is something that we do as a center and this is how we operate, this is how things go.” They can come into the center already trained for it, to have those TIC approaches under their belt. (Cohort 3, Trainer 1)

Incorporate TIC into new employee orientation, introduce the whole topic of TIC, the definition, what it is, and how it fits into the culture…this is exactly what we want to happen without shoving, without pushing…you’ve got to let it happen naturally and purposefully. So that as staff are coming in, this is the ingraining of becoming part of the culture that we want to happen. (Cohort 1, Trainer 7)

Theme 2. Perspective shift in patient care

Critical to TIC is the understanding that past experiences might still influence current patient well-being in a myriad of ways. The TIC training facilitated a perspective shift for Trainers in approaching and treating patients. They reported that regardless of their departments, they were equipped to practice their daily work being mindful of patient perspectives. The training prompted Trainers to communicate among themselves as to what led patients to exhibit particular behaviors or what crisis they may have experienced. Trainers became more cognizant of the possibility of past trauma and thereby committed to ensuring that patients were not retraumatized when coming into the clinics. In doing so, Trainers saw themselves as prudent healthcare professionals with a greater sense of responsibility for “understanding of the patient side and ways to incorporate TIC when working with patients” (Cohort 4, Trainer 5). Another Trainer mentioned that their “language with patients improved” (Cohort 2, Trainer 3). Two Trainers noted:

TIC has informed how I respond to our patients and their concerns…it definitely broadened my understanding. It’s also helped me in how I investigate those complaints from our patients who could be potentially traumatized and other incidents. I’ve learned to treat trauma in a universal precaution kind of way. You just don’t know who has trauma. (Cohort 1, Trainer 11)

For me personally, that training gave me a more responsible role in patient care and the opportunity to look at things from a clinical standpoint as well as from a patient standpoint. It was a lot of learning information that we could apply to not retraumatize them based off of some of the assessments we do to determine the baselines of their current mental status. (Cohort 2, Trainer 7)

Theme 3. Increased support for staff wellness

In addition to focusing on patient care through a trauma-informed lens, the TIC training positively impacted staff with its emphasis on supporting a culture of staff wellness and minimizing vicarious trauma. The training connected staff in the workplace, facilitating inter-departmental communication and offering opportunities to deliberate over how staff, who may also have experienced trauma, treated one another. Cross-sectional training served as an opportunity for staff to hear how different departments manage diverse situations. It gave them alternative ways to meet the needs of their clients and implement TIC more effectively. One Trainer found the training “well-rounded in the way that it takes into consideration people’s environment, staff’s own trauma experiences, and how it affects staff and customer service” (Cohort 3, Trainer 5). Moreover, having a safe space for self-care was critical in preparing them to serve patients. Three Trainers described:

What we found was that because TIC also affects people in our workforce, there was a connection in there from our maintenance staff all the way to our doctor(s)…we have similarities in some way with experiences involving TIC. And so all of a sudden, the label of my job title had nothing to do with it anymore. We were now connected based on experiences that were affected by trauma. (Cohort 1, Trainer 7)

The TIC training had to do with not only the way we deliver services, which is important, but the way we treat one another as colleagues. It encouraged staff to have that piece of being aware of the need for self-care. (Cohort 3, Trainer 6)

One major improvement I have noticed is staff having a safe space, where we say, “this is a space where you can let it all loose.” We remind them of self-care so they can be healthy mentally, physically, and spiritually to help patients. (Cohort 2, Trainer 1)

Theme 4. Importance of equal involvement of staff at all levels

The majority of Trainers voiced that staff at all levels should receive the training to achieve TIC transformation. Clinical Trainers expressed the importance of having providers as Trainers. However, it was challenging for providers to be actively involved in the training. This challenge was often attributed to lack of time and capacity primarily due to being occupied with patients. Non-clinical fellow Trainers also expressed that “it’s very difficult to train the doctors but they’re the ones that see the patients” (Cohort 2, Trainer 11), emphasizing that providers are vital members of their training teams. While acknowledging providers’ barriers to commit to the training, non-clinical Trainers believed that “it’s a burden on the whole system just trying to work around the complex schedules of providers” (Cohort 1, Trainer 5), when they had competing priorities that deterred their participation in the training. The busy schedules inherent in healthcare settings inadvertently waned Trainers’ initial enthusiasm regardless of their roles. To overcome this obstacle, one Trainer suggested designating staff “in charge of trauma informed care…and deliver information regarding TIC for providers” (Cohort 1, Trainer 10). Two Trainers elaborated on their constraints:

I’m a practicing physician, so it’s like I have to divide my time in training others and seeing my patients. So that’s one of the barriers. It’s just us trying to deal with other issues that are not better or more important, but not taking more of our time right now. (Cohort 1, Trainer 8)

We really set it up as peer training. I think the challenges are the competing projects and consequently lack of time to commit to TIC. I feel like sometimes we meet to meet and people dread going to meetings, which means the attendance may not be as good as it could. (Cohort 4, Trainer 3)

Theme 5. Need for leadership buy-in

Trainers believed that staff perception of the value of TIC implementation and their proactive participation in the training were contingent on the behavior and attitudes of leadership and administration. This belief included the extent to which leadership and administration understand TIC, as well as their levels of buy-in and involvement in TIC implementation. Some health centers had consistent support from their leadership. One Trainer shared that “leadership has stood behind TIC, believes in it, and wants the clinic to change” (Cohort 2, Trainer 5). However, others struggled to secure buy-in because the training need “can be easily forgotten” (Cohort 1, Trainer 7) and “leadership had a misunderstanding of TIC at the organizational level” (Cohort 1, Trainer 10). Minimal support from directors and supervisors for training dissemination attenuated staff engagement that was critical for TIC transformation. For example:

I did struggle with bringing in the leadership and getting their buy-in into the work with TIC. I feel that in order for something like this to work, our leadership has to have 100% buy-in, otherwise it’s only going to get carried down to a certain extent. I think this does need to be a more intentional tiered approach. (Cohort 3, Trainer 2)

Definitely have the higher hierarchy of administration more involved, because the more the top is involved, the more the people below them will be active in the TIC program. We also have a board membership and I would love to have one of them participate. (Cohort 3 Trainer 5)

Theme 6. Lack of self-efficacy and empowerment to train others

Despite the training materials and the availability of the TIC program coordinators to facilitate the training process, a number of Trainers did not feel confident or empowered to train others. The curriculum was designed for diverse audiences, but the lack of self-efficacy was pronounced among those who did not have behavioral health or psychology backgrounds and were new to TIC. Trainers were apprehensive towards training their peers because they found the concepts nebulous and felt unprepared to process the curriculum themselves. One Trainer stated: “the curriculum was perceived as theoretical…not feeling empowered to take the time to be connected with others and try new things or creative with the curriculum” (Cohort 2, Trainer 9) for effective training dissemination. Two Trainers expanded on these points:

We’re having a hard time grasping everything, and we don’t feel very confident in training other people. I think for people with psychological clinical background they might be immersed in this topic but for others who have not had this information before, it’s a lot of material for sure. (Cohort 2, Trainer 4)

I think some last-minute clarifications are important because for example, the last time everything was sent out for the next meeting, there were 7 to 10 attachments. So, I was not sure how much do I need to share with them during that meeting and how much can I hold back so I can have a more fluid meeting. (Cohort 4, Trainer 9)

One Trainer drew attention to the pitfalls of being part of the first cohort to roll out the training in the absence of insights and experiences of a prototype clinic. The unique ways in which each clinic operates and an inability to confer with other clinics for those in Cohort 1 added ambiguity regarding how the training should have been disseminated.

Even though we were given all the information that we needed to train, it’s just doing the footwork and getting the job done, and that was pretty difficult honestly. Once you do something for the first time, it’s always difficult. It’s cumbersome. And it was ambiguous to us because it was not done before and every clinic is so different. (Cohort 1, Trainer 2)

Aside from monthly facilitation calls, Trainers sought an in-depth understanding of what the training would entail, what was expected of them in their role, and the level of commitment required prior to the training to alleviate their lack of confidence as trainers. They also anticipated guidance in the form of “consulting with a TIC contact person” (Cohort 3, Trainer 3) to help them develop future plans and envision the growth of the participating clinics as the training continued. Structured guidance would give Trainers reassurance about their performance and motivation to consistently incorporate TIC in their health centers. This was clearly illustrated by two Trainers:

If they could come up with an information packet or something that says this is the commitment you’re going to make, this is the work that’s going to be involved… I’m somebody that appreciates as much anticipatory guidance as possible. (Cohort 1, Trainer 10)

Some people are already good at motivating themselves. But if we just had some more hands-on in the guidance area to say “Hey, you guys are doing excellent. This is where I see you in the future.” I definitely see a community need for trauma informed care for us to grow as an agency but I think some kind of guidance would be good to let us know if we’re on the right track. (Cohort 2, Trainer 7)

Discussion

This qualitative study sought to gain a deeper understanding of Trainers’ perspectives on their training for TIC implementation in Texas community health centers. Trainers gained heightened awareness of TIC as necessary “universal precautions” [7] because they were able to apply TIC concepts during unforeseen, taxing circumstances in their health centers. They held favorable views to integrating TIC not only into their practice but also in their onboarding process. Trainers’ perceived value and need for the TIC training proposed introduction of TIC to all incoming staff. Notably, agencies in rural Pennsylvania participating in a learning collaborative for TIC implementation observed improved outcomes when they had standard training policies for incorporating TIC into their onboarding procedures [8]. Effective communication with patients across a broad range of socioeconomic and cultural backgrounds is key, especially in FQHCs [9]. As the TIC training elaborated on this important idea, Trainers in our study increasingly used assumption-free, trauma-informed language when treating patients to forestall possible verbal triggers and retraumatization. Furthermore, the training cultivated a culture of staff wellness, including efforts to promote self-care and minimize secondary traumatic stress for staff. In addition to disseminating TIC-related knowledge and skills, the training helped mitigate traditional compartmentalized silos and form a sense of unity in the workforce by encouraging cross-disciplinary communication and collaboration. An evaluation of a statewide train-the-trainer intervention on TIC knowledge transfer in Australia also delineated the strength of training beyond mere didactic educational methods [10]. Their intervention used interactive strategies to provide TIC knowledge and opportunities for reciprocal communication.

Although the training was overall effective and well-received by Trainers, they encountered some inherent challenges of healthcare settings in committing to the training. Frequently mentioned concerns were limited time for the training, especially for providers. Healthcare professionals’ lack of protected time for continuing education or intermittent attendance to any training alike restricts their ability to apply the intended knowledge while managing rapidly changing situations in healthcare settings [11]. Additionally, strong leadership buy-in for the program and reminders about efforts to adopt TIC practices can bolster all-level Trainers’ participation in the training and sustainability of the training [12]. Such strategies are prerequisites to drive organizational change and build TIC into the DNA of organizational culture [13]. Trainers in our study also recommended that leadership and administration engage in the training to the same extent as the other staff. Provision of training to staff at all levels, which reflects the TIC principle of collaboration, can minimize power differentials among employees, enhance knowledge transfer, and help establish trauma-informed practices efficiently [14].

Due to some Trainers’ low self-efficacy and readiness to disseminate the training, they requested more guidance and periodic feedback about their performance in the training. Trainers’ initial lack of confidence may be natural, especially for those without previous exposure to concepts of TIC. Even for those familiar with TIC, perceptions of self-efficacy can diminish as a function of gradually removing initial training supports. For example, in a large service system’s learning collaborative approach for cognitive therapy implementation, clinicians’ perceived skill level declined from the training period to the initial implementation interval after training [15]. In the current study, a suggestion to allay Trainers’ discomfort about training peers is to hold a series of teach-back sessions, a procedure originally used in healthcare to enhance provider-patient communication and applicable for staff training. To increase their levels of readiness, Trainers can review the learned concepts and ‘rehearse’ how they would deliver the training to other staff in the presence of the training coordinators. To this end, facilitation calls may need to consider increased supervision for Trainers.

This study has several limitations. First, interviewee demographics were not collected, which may have affected the generalizability of the study findings. We had intended the interviews to be succinct to be mindful of busy schedules of staff and to maximize the use of the interview time. In addition, because the TIC initiative is ongoing, and here we present interim results, current successes may no longer persist or challenges may be resolved over time. However, conducting analysis in tandem with data collection allowed us to inform future implementation strategy development.

Conclusions

Early detection of and long-term responses to trauma are pivotal given that its consequences can manifest as adverse health outcomes in later years. As secondary and tertiary strategies of disease prevention, a core tenet of public health, TIC fosters a safe environment for the provision and receipt of compassionate care for all individuals who may have experienced trauma and are vulnerable to retraumatization or vicarious trauma. This qualitative evaluation revealed that after the TIC training, Trainers had improved attitudes and behaviors to commit to organizational TIC transformation to prevent unintended consequences of trauma for both patients and staff. Trainers’ experiences with and suggestions for improving the TIC training should be considered for training future cohorts as they continue to strive for TIC transformation in their health centers.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

TIC

Trauma-informed care

RAP

Rapid assessment procedures

TACHC

Texas Association of Community Health Centers

FQHC

Federally qualified health center

Authors’ contributions

PMC and RC conceived the study. JC collected, analyzed, and interpreted the data and wrote the original draft of the manuscript. All authors critically reviewed and edited the manuscript. All authors approved the final manuscript as submitted.

Funding

This work was supported by Direct Relief, Texas Mental Health/Behavioral Health Funders Collaborative, and Texas Association of Community Health Centers (TACHC unrestricted funds).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The data are not publicly available as it contains information that could compromise the privacy of research participants.

Declarations

Ethics approval and consent to participate

The study was approved by The University of Texas Health Scienter at Houston Committee for the Protection of Human Subjects (HSC-SPH-19-1019; 11/25/2019). Informed verbal consent was obtained from all subjects involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.