Abstract
Aims
To explore youth, caregiver and staff perspectives on their vision of trauma‐informed care, and to identify and understand potential considerations for the implementation of a trauma‐informed care programme in an inpatient mental health unit within a paediatric hospital.
Design and Methods
We applied the Interpretive Description approach, guided by complexity theory and the Implementation Roadmap, and used Applied Thematic Analysis methods.
Findings
Twenty‐five individuals participated in individual or group interviews between March and June 2022, including 21 healthcare professionals, 3 youth and 1 caregiver. We identified two overarching themes. The first theme, ‘Understanding and addressing the underlying reasons for distress’, related to participants’ understanding and vision of TIC in the current setting comprising: (a) ‘Participants’ understanding of TIC’; (b) ‘Trauma screening and trauma processing within TIC’; (c) ‘Taking “a more individualized approach”’; (d) ‘Unit programming’; and (e) “Connecting to the community”. The second theme, ‘Factors that support or limit successful TIC implementation’ comprises: (a) ‘The need for a broad “cultural shift”’; (b) ‘The physical environment on the unit’; and (c) ‘Factors that may limit successful implementation’.
Conclusion
We identified five key domains to consider within trauma‐informed care implementation: (a) the centrality of engagement with youth, caregivers and staff in trauma‐informed care delivery and implementation, (b) trauma‐informed care core programme components, (c) factors that may support or limit success in implementing trauma‐informed care within the mental health unit and (d) hospital‐wide and (e) the importance of intersectoral collaboration (partnering with external organizations and sectors).
Impact
When implementing TIC, there is an ongoing need to increase clarity regarding TIC interventions and implementation initiatives.
Youth, caregiver and healthcare professional participants shared considerations important for planning the delivery and implementation of trauma‐informed care in their setting.
We identified five key domains to consider within trauma‐informed care implementation: (a) the centrality of relational engagement, (b) trauma‐informed care programme components, (c) factors that may support or limit successful implementation of trauma‐informed care within the mental health unit and (d) hospital‐wide and (e) the importance of intersectoral collaboration.
Organizations wishing to implement trauma‐informed care should consider ongoing engagement with all relevant knowledge user groups throughout the process.
Reporting Method
Standards for Reporting Qualitative Research (SRQR).
Patient or Public Contribution
The local hospital research institute's Patient and Family Advisory Committee reviewed the draft study methods and provided feedback.
Keywords: child nursing, focus groups, mental health, patient perspectives, psychiatric nursing, qualitative approaches, quality of care, research implementation
1. INTRODUCTION
Trauma‐informed care (TIC) is a philosophy of care that goes beyond trauma‐specific interventions to attend to the needs of individuals with histories of trauma, whether they are the ones receiving care or staffing the care system (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014). While varying definitions of TIC exist, commonly agreed upon assumptions include the four R's: realizing the prevalence of trauma, recognizing manifestations of trauma, responding appropriately to trauma and resisting re‐traumatization as well as the six principles of (a) safety, (b) trustworthiness, (c) support, (d) collaboration, (e) empowerment and (f) cultural, historical and gender considerations (e.g. SAMHSA, 2014). Furthermore, the notion of ‘universal precautions’ suggests that services regard every patient and staff member with trauma‐informed sensitivity, acknowledging that anyone encountering the organization may have a trauma history (Elliott et al., 2005).
2. BACKGROUND
2.1. Trauma‐informed care in paediatric inpatient mental health settings
Decades of research have demonstrated the association among trauma, morbidity and healthcare usage (e.g. Felitti et al., 1998). Youth with histories of trauma and adversity are at increased risk for a range of emotional, social and cognitive difficulties, and associated inpatient psychiatric and residential care admissions (e.g. Briggs et al., 2012; Keeshin et al., 2014). Individuals may not disclose a trauma history or even consider their experience to be trauma, therefore TIC involves treating all patients, caregivers, and staff with the recognition that we often do not know what has happened to them. While there are growing efforts to better serve this population with numerous published accounts of TIC implementation in paediatric inpatient mental health settings (e.g. Bryson et al., 2017; Stokes et al., 2023), there is an ongoing need to increase clarity regarding TIC interventions and implementation initiatives (Stokes et al., 2023).
2.2. The current study: Context within the Implementation Roadmap
This study was a part of a larger integrated knowledge translation (IKT) project of planning the implementation of a TIC approach on an inpatient mental health unit, within a Canadian tertiary‐care paediatric hospital. Departmental leadership was interested in implementing a TIC approach (operationalization of TIC principles), which they would refer to as a TIC programme, within an initiative to re‐design the model of care of the unit and wished to do so in an implementation science‐informed manner. At the time of the study, the unit was implementing initiatives that aligned with TIC (e.g. Safewards, Emotion‐Focused Skills Training and Safety Pods) but no structured TIC programme was in place. As described by Stokes et al. (2022), researchers and site knowledge users (those who are likely to use or be affected by the research) collaborated within a multi‐disciplinary TIC Advisory Committee (TIC AC) to design a project using principles of IKT (Banner et al., 2019) and the Implementation Roadmap (Harrison & Graham, 2021). This Roadmap identifies three phases of implementation: (a) identify and clarify issues; (b) build solutions and field test them; and (c) implement, evaluate and sustain. To address the first phase, we conducted a scoping review that examined the current state of the literature relating to TIC interventions in paediatric mental health inpatient and residential settings (Stokes et al., 2023), and an environmental scan that identified TIC interventions currently used in the Canadian context. The findings from the review and environmental scan informed the TIC AC's selection of a TIC programme. This current study targeted the second phase of building solutions: customizing the best practices to the context and discovering barriers and drivers for best practice implementation. While a few studies have explored knowledge user perspectives on TIC to broadly inform TIC implementation across settings (e.g. Isobel et al., 2021), we are not aware of any studies that engaged with knowledge users to inform the implementation of TIC on a paediatric inpatient mental health unit.
3. STUDY METHODS
3.1. Aims
We sought input from youth, caregivers and staff about (a) their vision of TIC and (b) potential implementation considerations related to their vision of TIC, including facilitators and barriers, and the contextual setting. While this study focused on the local context of a paediatric inpatient mental health unit, the issues identified hold relevance for those planning the implementation of TIC in similar settings.
3.2. Design
We applied the Interpretive Description (ID) approach to guide this qualitative study. ID is inductive and suitable for exploratory research, with an emphasis on the clinical application of the data and findings within a disciplinary context (Thorne, 2008). Complexity theory guided this study (Clark, 2013) in considering not only the TIC clinical programme but also factors relating to individuals and groups receiving and providing the intervention, the physical setting, the implementation process and the context within and beyond the target unit. As described above, this project was also informed by principles of IKT and the Implementation Roadmap. We used the Standards for Reporting Qualitative Research (O'Brien et al., 2014) to guide the reporting of this study (Appendix S1).
3.3. Positionality of research members
Our research team consisted of a doctoral student (YS), who was also a part‐time nurse on the inpatient unit where this study was focused, five university‐based researchers who formed the thesis advisory committee of the aforementioned doctoral student (IDG, KBL, JDJ, EH and ACT) and 17 additional site knowledge users (the TIC AC). The five thesis advisory committee members hold expertise and interest in trauma, mental health care and/or implementation science. The thesis advisory committee was external to the hospital allowing for impartial feedback relating to the study. The TIC AC included members representing leadership, nursing and allied health, medicine and research, who provided input and expertise related to the local setting and helped to ensure relevance and applicability of the study findings.
3.4. Knowledge user contribution
The TIC AC members were involved in deciding the types of participants, recruitment and data collection strategies, participant compensation and interpretation of the findings within this manuscript. After the initial planning stage, YS also reviewed the study methods with the hospital research institute Patient and Family Advisory Committee, who provided feedback regarding youth and caregiver recruitment and compensation.
3.5. Study setting
The inpatient mental health unit set within the paediatric hospital is an acute care stabilization unit that holds 19 beds for youth up to age 18, with an average length of stay of approximately 10 days.
3.6. Eligibility criteria
The eligibility criteria for participating are presented in Table 1.
TABLE 1.
Participant eligibility criteria.
| Participant group | Criteria |
|---|---|
| Youth |
|
| Caregivers |
|
| Staff |
|
| Exclusion criteria (All participants) |
|
3.7. Recruitment
We recruited a convenience sample and interviewed all eligible volunteers. All participants received a $5 gift card. Youth were also offered high school volunteer hours. Management offered support for interested staff by facilitating coverage for those working a shift during a scheduled interview, and by compensating staff who were not working for their time. Interested participants emailed the study email address and the first author screened participants for eligibility and obtained informed consent.
3.7.1. Youth and caregivers
Youth and caregivers were recruited in several ways. A youth‐run in‐house mental health advocacy and support programme invited eligible youth who were currently affiliated with their programme. The hospital communications department posted the recruitment invitation on their social media platforms. A local non‐profit, peer support organization for caregivers of youth facing mental health challenges advertised the recruitment message among their members. A local knowledge institute on child and youth mental health forwarded the recruitment poster to community partner agencies. Finally, to boost recruitment, we placed posters for youth and caregivers at the entrance to the inpatient mental health unit and included posters in patient and caregiver discharge packages.
3.7.2. Staff
Staff were invited to participate via emails (two emails, one in February 2022 with a reminder in March 2022) and through posters placed in the staff areas in the hospital in‐patient unit.
3.8. Data collection
Data collection spanned March–June 2022 and included a short online demographic questionnaire and a virtual focus group or individual interview. Demographic data were collected prior to the interviews via REDCap (Research Electronic Data Capture) and were not linked to interview data. Interviews took place through Zoom facilitated by two team members (YS and PC; individual interviews were facilitated by YS). Sessions were recorded through Zoom, with live transcription. YS reviewed the recordings and edited the transcripts in Microsoft Word.
To gain an understanding of the implementation context, the facilitators prompted participants to share: (a) their perspectives and understandings of TIC and what TIC meant to them and (b) their vision of TIC in the inpatient mental health unit, including any important race, culture and gender considerations, as well as implementation factors. The demographics forms and interview guides were designed with TIC AC based on literature (Stokes et al., 2023), piloted with two of its members and revised for minor grammar changes. This article focused on a subset of interview items (Appendix S2).
3.9. Data analysis
3.9.1. Demographics
We descriptively analysed demographic data for each of the participant groups (youth, caregiver and staff) in Microsoft Excel.
3.9.2. Focus groups and interviews
We used Applied Thematic Analysis methods initially following the structure of the interview guide to assist in segmenting and coding the data (Guest et al., 2012). To enhance trustworthiness, two research team members (YS and PC) independently reviewed each transcript, creating memos and highlighting text to reflect thematic similarities and differences. During analysis, we guided our thinking by asking questions such as ‘What am I seeing?’ and ‘Why am I seeing that?’ (Thorne, 2008, p. 158). After reviewing and coding each transcript, YS and PC met to compare coding and notes, identifying disparities in interpretations, coming to a shared consensus on each code and aggregating codes into initial themes and sub‐themes. Once three transcripts were coded and agreed upon, we aggregated the individual transcript summary files together into files by theme and developed a structural code book (based on Guest et al., 2012, p. 57). After analysing five transcripts, YS, PC and additional team members (IDG, KBL and JDJ) met to review the analysis and discuss the emerging themes. Themes and sub‐themes were continuously re‐evaluated to ensure that they remained internally homogenous (grouped codes were aggregated appropriately, creating a coherent theme) and externally heterogeneous (themes were mutually exclusive). Throughout the analysis process, we regularly returned to the initial transcripts to ensure that the findings were grounded in the data. Once we completed the initial analysis, YS presented the findings to the thesis advisory committee and the TIC AC, with the purpose of refining the themes and sub‐themes and determining how the findings informed the organization's decision‐making goals, and how the TIC AC would proceed. All research team members agreed upon the study findings.
3.10. Ethical considerations
This study was approved by the Research Ethics Board at the participating hospital (Protocol No. 21/103X) and the University of Ottawa (Protocol No. H‐01‐22‐7691). All participants provided electronic informed consent prior to participating. To minimize any possible perceived coercion, participants were recruited through posters, emails and social media initiated by the hospital and local organizations. The first author did not communicate with any potential participants regarding participation unless they initiated contact through the study email address.
4. FINDINGS
4.1. Characteristics of participants
Twenty‐five individuals volunteered for individual or group interviews; 21 staff, who were all healthcare professionals, 3 youth and 1 caregiver (Table 2). We conducted five staff focus groups (ranging from two to six participants per group), two staff individual interviews, one youth focus group, one youth individual interview and a caregiver individual interview. Most participants self‐identified as women, with one staff member identifying as a man. All youth were under age of 21 and had been admitted to the unit between 2019 and 2022. Staff participants ranged in age from 21 to 60 years and had worked in the mental health in‐patient unit for 1 to 25 years. The majority of healthcare professionals were direct‐care providers (Registered Nurses or Child and Youth Counsellors). The sample included people who self‐identified as Black, Caucasian, First Nations, Ashkenazi Jewish and Filipino.
TABLE 2.
Participant demographics.
| Youth (N = 3) | Caregivers (N = 1) | Healthcare Professionals (N = 21) | |
|---|---|---|---|
| Self‐identified Gender: n (%) | |||
| Woman | 3 (100) | 1 (100) | 20 (95.2) |
| Man | 1 (4.8) | ||
| Age range: n (%) | [data suppressed] | ||
| <21 | 3 (100) | ||
| 21–30 | 3 (14.3) | ||
| 31–40 | 5 (23.8) | ||
| 41–50 | 9 (42.9) | ||
| 51–60 | 4 (19.0) | ||
| Rural/Urban: n (%) | |||
| Rural | 1 (33.3) | 7 (33.3) | |
| Urban | 1 (33.3) | 1 (100) | 14 (66.7) |
| Missing | 1 (33.3) | ||
| Role: n (%) | |||
| Direct care a | 16 (76.2) | ||
| Clinical care a | 4 (19.0) | ||
| Management/Leadership | 1 (4.8) | ||
| Youth | 3 (100) | ||
| Parent | 1 (100) | ||
|
Years worked on unit Range (Median) |
NA | NA | 1–25 (6) b |
|
Year youth last admitted to unit Range |
2019–2022 | [data suppressed] | |
Direct Care (Registered Nurse and Child and Youth Counsellor) and Clinical Care (MD, Psychologist, Occupational Therapist and Social Worker).
n = 19.
4.2. Themes
All participants voiced enthusiasm for TIC as an approach that fit with their values, and a strong desire to see TIC operationalized in the unit. We identified two overarching themes. The first theme, 'Understanding and addressing the underlying reasons for distress', which related to participants' understanding of TIC and their vision of TIC on the unit, comprises five sub‐themes: (a) 'Participants' understanding of TIC' encapsulates participants' perceived definitions of TIC. The remaining sub‐themes address core elements of participants' visions of TIC on the unit: (b) 'Trauma screening and trauma processing within TIC'; (c) 'Taking "a more individualizedapproach" '; (d) 'Unit programming'; and (e) "Connecting to the community" ). The second theme, 'Factors that support or limit successful TIC implementation', contains sub‐themes that participants deemed necessary to successfully implement a TIC programme and elements that may hinder it. These sub‐themes include: (a) 'The need for a broad "cultural shift"' , which incorporates a need to improve staff support and multi‐disciplinary team collaboration; (b) 'The physical environment on the unit', making the unit more visually comfortable and engaging and creating more therapeutic spaces; and (c) 'Factors that may limit successful implementation', including staff buy‐in, delivery of training and maintenance and sustainability concerns. Themes and sub‐themes are summarized (Table 3) with additional illustrative quotes.
TABLE 3.
Themes and additional illustrative quotes.
| Theme | Explanation of themes as derived from participant quotes | Illustrative quotes a (Y = Youth; C = Caregiver; and HP = Healthcare Professional) |
|---|---|---|
| Theme 1: Understanding and addressing the underlying reasons for distress | ||
| 1.1 Participants' understanding of TIC | Participants defined as TIC as:
|
‘Instead of saying what's wrong with the person, it's more of, this is where they're at and how can we help them be a better version of themselves’ C‐1 ‘They might be there for depression, yet they have all these traumas, and they're only dealing with the depression… And if you don't take care of the traumas, what's the point in taking care of the depression… It's part of the puzzle… like the traumas are the biggest piece of the puzzle, because usually those are the things that are causing the other things’. HP‐4 |
| 1.2 Trauma screening and trauma processing |
|
‘I think the screening needs to happen…early detection starting right from when you walk in the door …but also understanding that people aren't going to talk to a bunch of strangers…so I think it's about starting early, and providing that open space to talk about it, but also following up and not assuming that what they say the first time is the hard facts’. Y‐2 ‘And then the screening and identifying piece…. my opinion is that that's not necessary, because … we just walk in with this notion that most individuals have experienced trauma. I feel like the early screening and comprehensive assessment…has the potential to re‐trigger and retraumatize’. HP‐3 ‘And standard screening for trauma…can we recognize also that there are going to be things that are not reported…Not just screening, but what this tells us, how will this impact our care’. HP‐20 ‘The early screening and comprehensive assessment, kind of depends on what that is right, I'll find that if we force people to open up when they're not ready, that's traumatizing in itself, depending on the environment….’ HP‐19 ‘It does take a long time, meaning you can't just walk in and say what's bothering you, and walk back out… it's a way of approaching them and letting them talk’. HP‐4 ‘I myself am pretty cautious about unpacking someone's trauma in the context of an inpatient admission or on the inpatient ward, because I can't control the variables to create the safety for a kid over an extended period of time, for them to actually work to truly heal their trauma, it's just it's a noisy loud unit, you just can't do that’. HP‐2 ‘Because they're scared of the patient escalating, but you know, this is a safe space for patients to be able to deal with that…’ HP‐13 ‘Sometimes people aren't ready to work on them or to talk about it, or this isn't the right place for them to start building those attachments to have that discussion about the in‐depth trauma work; [however] we can start the foundations, and that's normally the goal of the safety plan, that we're a part of the process…’ HP‐19 |
| 1.3 Taking ‘a more individualized approach’ [Y‐2] |
|
‘Retelling what happened every single time to each person… it should just be told to everyone that's coming to check on the person, so that they don't have to keep bringing it up, because it could be traumatizing for some people…Because for me, I felt really overwhelmed when everyone kept asking me the exact same questions’. Y‐3 ‘We've got this standard one pager that you do; communication needs, sensory needs…. And it gets shared in an easy format right on the chart, and where the kid goes, it's easy to pull that up and go: Oh, quiet environment, kid does well with having this, I need to communicate expectations in this way…. But more aspects then these… the strengths profile; because these kids get brought in, and you look immediately to their deficits and their challenges. The strengths profile is so important because that's what you tap into to help the kid get through’. HP‐20 ‘To have a more individualized approach, that one treatment doesn't fit all, and I think that just needs to be taken a lot more seriously…Because you can't just approach everyone with the same kind of idea of what people have gone through… you can't think that this set of circumstances is going to work for everyone….’ Y‐2 ‘If it were a more trauma‐informed care based approach, I feel like questions would have been asked, like do you prefer male or female staff….And I wouldn't have been triggered and I wouldn't have been crying and screaming…So those kind of things would have been much different if people have asked me what my experiences were and how they could better help me while I was there’. Y‐2 ‘“Blanket restrictions”; which is just rules that we put on the unit for the entire unit that don't necessarily make sense [for every patient]…But I'm always questioning… how do we balance that on our unit… Sometimes we get into literally like restraints over the silliest things that literally when you look back, it makes zero sense, if you could have just let them have xyz you probably wouldn't have gotten to a restraint; was it really worth it… but again there's reasons why we don't allow blankets [and other safety restrictions], but does it need to be for everybody, probably not, how do we balance that…’ HP‐18 ‘Is there room in this model to look to incorporate elements that can serve the population with developmental needs [e.g. autism]’ HP‐20 Cultural considerations in the delivery of TIC: ‘I think just specific to each individual…Religious beliefs and values may need to be respected to a higher level than what is being done’. Y‐2 ‘I think we need to do better. We see so many kids coming in from different cultures and I don't think we're very sensitive to the fact that certain cultures look at mental health differently…’ HP‐21 ‘Recognizing that we've got our biases, we don't want to have them, but we have to recognize that we have them…’ HP‐20 |
| 1.4 Unit programming |
|
‘Nipping these problems in the bud and not letting them get to the point where people are being like physically aggressive … you don't often go from being completely calm to hitting your staff within 5 seconds, there are things that lead up to that. There are experiences, there are feelings, and trying to express those feelings. So, I think it would be really dishonest if someone were to say “Oh well, they just they just got angry, they just started hitting me, I have no idea why”. But, did you look back, an hour earlier when you told them that they couldn't see their family that day, and you didn't stay with them to help through that distress? Or were you there when their parents called and said “Oh hey I can't come today,” did you sit with them through that? Did you help them when they had to be taken out of groups because they had harmed themselves or something they were being punished for, were you there to help them? Or did you let that anger built up, and that frustration, and those horrible feelings built up to the point where this [happened]? Then you're like “Oh well, we're just going have to sedate them and restrain them, I mean there's nothing we can do.” But there was something you could do, you know’. Y‐1 ‘The more we can do to get people moving and not sitting in their rooms all day…’ Y‐2. ‘Our patients can be a very high‐risk to be out in the community, but wouldn't it be great if we somehow cut a door out to the roof and create a nice park area where we could grow things, and have a secure area that they can be outside and experience nature, and programming possibilities would be endless…we could have a garden out there, we could grow food, we could grow trees, we could grow flowers… have a purpose to be out there…’ HP‐6 ‘The somatic awareness… we first start working with them to help them understand the autonomic nervous system and regulation. We often will help clients to orient to the things that are working for them… the shirt that you chose today, notice that it's a comfy cozy hoody, and did you pick it because of the colour, did you pick it because it was sitting on the couch or the chair beside you, just notice what it feels like. Or that warm cup of tea that you have, and there's the sensory piece, notice the smells and notice the warmth of the mug … they know what dysregulation feels like, they're in hospital for dysregulation, so helping to notice what a little bit of regulation in a really small and titrated way feels like, and having them start to attune to that. And then that helps to expand their awareness that there is another place, there is that more balanced state in the nervous system’. HP‐3 ‘I think it would be great if we had …the ability to play music in kids rooms or white noise… it would be fantastic if it was set up to speakers or something in the ceiling, where we could let kids choose preferred music or white noise…just something so that they can have their own safe place’ HP‐19 ‘It's a family‐based situation it's not just a patient‐based’ HP‐15. ‘Hopefully in the future we could have some parent–child groups, maybe even on the unit in evenings during family time, coming together to learn about co‐regulation, learning simple tools like how to practice validation, how to practice empathy…if we're going to bring in that trauma‐informed piece, it's usually generational trauma …so the parents have trauma and then the kids subsequently are passed on that trauma, with the insecure attachments and all, that so how does that parent training look’. HP‐1 |
| 1.5 ‘Connecting to the community’ [HP‐3] |
|
‘That idea of connecting to the community… around trauma, as opposed to…dealing with the depression and not naming the trauma’. HP‐3 ‘Connecting them to things in the community where they would be doing something together along those lines, like a yoga class or a drumming circle…’ HP‐2 ‘She's met the criteria to be discharged, but everything falls on the parents or the caregivers to then continue on the journey… I was kind of surprised because I was like okay so [patient] becomes an outpatient right, and she gets to come back a little bit. And they were like no, there is no outpatient [follow‐up], and I was like, what do you mean there's no outpatient [follow‐up] for [patient], usually [after] someone's in the hospital, there are some type of a, come back, let's evaluate…’ C‐1 ‘You're discharging my daughter. We've done everything that you've told us….what's the next piece to help us. And there wasn't really a next piece.…I think one of my recommendations or suggestions would be an aftercare for the parents, just a check‐in a week later. “How are things going, have you tried [the recommendations] from her the recommendation page…have you managed to achieve any of this… what's working really well, what can I help you with, what else can we tweak for you”…[We would] have felt validated… out of your seven recommendations we've done the first five. This one has been a really tricky one, what do you recommend we can do instead….’ C‐1 |
| Theme 2: Factors that support or limit successful TIC implementation | ||
| 2.1 Need for a broad ‘cultural shift’ [HP‐10]. |
|
‘I feel like that is a huge cultural shift, like large, it's not just, here's a programme and let's all follow it, it's a culture that we have to change…If we're going to truly embody trauma‐informed care, that it has to be top down, like everybody’. HP‐10 ‘We really need to incorporate some of those values into our discussions, into the whole process, right from admitting on…’ HP‐21 |
| 2.1.1 Need to improve staff supports and multi‐disciplinary team collaboration |
|
‘When we look at implementing a trauma‐informed care model, the first part that goes to my mind is, okay trauma‐informed for the patients, but I think we need to actually start at the base‐ and that's trauma‐informed for the staff, because we're not going to be able to appropriately, safely, trauma‐informed‐ly, if that's a word, support our patients, if our staff aren't even at that. So I think the best way for this to be successful, is starting at the roots and the basics, with the staff’. HP‐7 ‘How do you make an environment where people are talking in a non‐pathologizing way about the experiences we go through, as well as our patients' experiences…’ HP‐9 ‘If that person is feeling it's trauma it's trauma. It doesn't matter what it was, because that person's experiences need to be validated and supported. Rather than dismissed, because we do lose staff because of that sometimes’. HP‐8 ‘The recognition that reducing trauma in kids will probably correlate with reducing trauma in staff…They [direct care staff] need to know that they can turn around and go, “Listen this isn't working” and somebody's got their back…What kind of a culture, what kind of support do staff need to have so they can show up all the time?…Staff need that to feel secure… What happens can influence whether you walk away from a difficult situation feeling like, that was hard but I'm okay, versus, that was hard and I'm not okay, and I still have to keep going back into that situation, even though I'm not ok’. HP‐20 ‘I've seen over the pandemic signs of clinical leaders burning out… But I also see…and recognize, that's because you have no idea what to do, and you don't feel supported, and you feel at the end of your rope …So, the support also needs to be at the upper clinical levels, in the managerial levels… at every level. We can slip into negative practices, or we can put in the supports that we need to keep ourselves framed in positive and therapeutic stances. So yes, multi‐tiered support’. HP‐20 ‘And it's hard to [provide] ‘trauma‐informed care’ if you have too many tasks in a day, because you can't just tick off‐ I was trauma‐informed today… it's a much bigger thing’. HP‐8 ‘My other concern is that a lot of that will again fall to frontline [staff]…how can we kind of give pieces to all of the team members….’ HP‐10 ‘Recognizing people's roles, and understanding how trauma‐informed care can be impacted by us working in silos, or our roles not being clearly defined or respected, or our roles not fitting into each other's' properly or accurately’. HP‐5 ‘The allied health team; because I feel it's very “frontline staff versus others” and if we are going to work towards trauma‐informed care, it has to be everyone right. Social work, OTs [occupational therapists] everyone, psychiatrists’. HP‐19 ‘We also need to show that we are a team, and we work together…that culture of working together’. HP‐7 ‘As frontline I feel like we're often not always involved in the decisions of things and the rollout…we didn't really get a say in how it was going to change our day‐to‐day lives… so I am really enjoying being able to give my input, and hope that we can keep these kinds of discussions going’. HP‐13 |
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‘I would like to see…regular refreshers and ongoing training, not just a one‐off…I've had all of those introductions to CBT and DBT but I don't feel that I've had accurate time to be able to practice the little bits that I did learn…’ HP‐7 ‘My concern… if we are to get trauma‐informed training, introductions are good, but they can't fully support a patient by only having little bits of training, here and there, and not [be] fully competent in anything’ HP‐12 ‘Things like that are really difficult when you don't have that simulation‐based practice…then you're learning in a crisis situation where we don't learn well…’ HP‐19 |
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‘I would love to see more time made for debriefing after a significant event. That could be more time to debrief with the patient…but not just one‐on‐one with the assigned staff…[also]with the physician present or with social work present, but done in a way that it's not intimidating for the patient. I think that oftentimes it falls on just frontline to review what happened with the patient, one‐on‐one…I think that to come together would be helpful for staff to feel supported…And it comes across as more supportive [for the patient], “We're your team…what can we do differently”’ HP‐14 ‘Oftentimes the debriefs turn into everybody pointing out what went wrong, which isn't really supportive for that staff…’ HP‐14 ‘A lot of the times our debriefs are rushed because there's not enough staff to cover the floor… people aren't given the time or opportunity to talk…We still have to attend to patient care, so then whoever is involved in that situation is once again just forced to get back onto the floor and continue on with their day and not really have a safe space to process anything that just happened’. HP‐14 ‘I honestly wonder if it could be someone outside of management and leadership, a third party to come in or to review it with us…I think sometimes it's hard to be completely honest with how you're feeling to management and leadership…. that would give you, or someone who's just been through a significant event, a contact person to be able to say, “This is what happened, like this is how I'm feeling”…because if they can tell, well, this one person came to me about it, and this person and this person, this seems to be a significant thing, why don't we liaise with management or whoever to escalate this further, because it seems to be affecting a lot more staff than we thought’. HP‐13 ‘In these group debriefs, the few times that we have been able to do them, we say what went well, what didn't go well, but there's not really any follow‐up. Yes, you can say what didn't go well…or what we could do better next time, and then somebody writes it on a paper, and then nothing comes of it… contributes to staff not feeling supported, and to re‐traumatization of staff. And I also think that…it's not good for the patient either …’ HP‐14 |
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2.2 Physical environment on the unit |
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‘If there was a way to make it less hospital‐y… a way to make it a little bit less horrifyingly scary when you first walk in the door’. Y‐2 ‘Recognizing that the right physical space has to be there, and it has to be there for the kid yes, and it has to be there for the staff; to know that they can do what the kid needs, while keeping themselves safe. So, the right physical setup is key’. HP‐20 ‘To help either burn off energy or do something that gets them outside of the walls [of their room] where they're just stewing in their emotions’ HP‐13 ‘Even staff spaces don't seem to be places where people can sit and talk…just to sit down and debrief with somebody…’ HP‐9 |
| 2.3 Factors that may limit successful implementation | ||
| 2.3.1 Staff buy‐in |
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‘I wonder about the receptiveness of staff [to being vulnerable about their own emotions and needs]’ HP‐6 ‘I think there is this culture of…if I don't feel like I can trust you, I'm not going to let my guard down and really be vulnerable and let you know how my feelings are… I think that our unit would be very reluctant to participate’. HP‐21 ‘It can't even get off the ground, because you have strong voices that are just not going to be a part of it. And they impact other people, and then the whole thing gets sabotaged by the strong voices that have been around for years’. HP‐21 ‘We obviously do [need] the trauma‐informed care, but we are also responsible for maintaining physical safety of the patient and staff, so I think it's going to be that delicate dynamic… [and] is where I feel there might be difficulty [with] buy‐in, is maintaining the trauma‐informed [care] and maintaining safety’. HP‐8 |
| 2.3.2 Delivery of training |
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‘When you rely on people [current staff] to do that training [train‐the‐trainer], what happens is all of those feelings of frustration, having no job satisfaction, it all siphons through. And so now, even though you had a brand‐new staff, who was motivated…is a really skilled person, now they become tarnished … And we need to address that before we can bring something in …, I don't have a whole lot of hope’. HP‐21 ‘They try with the education and half the time people can't even attend …’ HP‐8 |
| 2.3.3 Maintenance concerns |
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‘Since we got all the training, or since we said this is what we're starting, there hasn't been any follow‐up, and we're all just kind of trying to stay afloat at this point, and doing what we think is right in the moment, versus being able to have the time or have the check‐ins to say, are we on the right track’. HP‐14 ‘It was so many little things that all got implemented at the same time, and sometimes I don't really remember what's in the new care model ‐what am I supposed to be doing…’ HP‐13 |
Not all the dimensions of the themes are represented due to space constraints.
4.2.1. Theme 1. Understanding and addressing the underlying reasons for distress
Participants' understanding of TIC
All three groups (youth, caregivers and healthcare professionals) understood TIC as looking beyond ‘what's wrong with the person’ (Caregiver 1) to focusing on the underlying reasons for the person's distress, informing how they can be helped. One youth summarized the essence of TIC as the process of understanding and addressing the ‘why’ behind the symptoms that present before jumping to diagnoses and pharmacological interventions. Accordingly, participants noted that TIC should involve assessing and addressing the ‘deeper’ holistic factors related to a youth's mental health presentation. All youth specified that avoiding creating further trauma from care should be a priority within a trauma‐informed approach.
I think to me it means coming from a place of why people are feeling how they're feeling, instead of coming from a diagnosis‐based place. Instead of saying, ‘You're depressed so here's a bunch of drugs’, saying, ‘What factors are contributing to your depression, or what factors led to you being suicidal’. Looking how things arose, instead of just putting a band‐aid on it, working at those deeper set of issues. (Youth 2)
The caregiver described TIC as an approach where instead of pathologizing, providers acknowledge and meet the patient where they currently are and identify how they can support healing and growth. In addition to changing from a deficit‐based approach to a more supportive stance, the caregiver highlighted incorporating principles of safety and connection.
Healthcare professionals emphasized the importance of acknowledging the prevalence of trauma in their patient population and developing an awareness of the neurological and developmental changes caused by trauma. They spoke about orienting to how these trauma‐based changes affect the processes of providing and receiving care, with trauma considered as potentially the most critical issue at the core of a patient's presentation. They noted the importance of the emotional regulation capacities of patients, caregivers and staff that are providing care and creating a healthcare system that is responsive to everyone's needs. Healthcare professionals echoed youth in prioritizing the avoidance of further trauma through care, and the caregiver's emphasis on safety and connection, as well as managing emotions. They suggested that adopting a ‘universal precautions’ approach would ensure that each person is approached with trauma‐informed sensitivity.
In discussing their vision of patient care on the unit within a TIC approach, participants identified a number of core considerations (sub‐themes): (a) whether trauma screening and trauma processing should be a part of TIC, (b) taking ‘a more individualized approach’ to care that incorporates the patient's trauma history and their sociocultural identities, (c) making changes to unit programming and (d) ‘connecting to the community’ including for post‐discharge follow‐up.
Trauma screening and trauma processing within TIC
Participants expressed conflicting views about whether trauma screening and trauma processing (i.e. discussing and treating the trauma) should be components of a TIC programme.
One youth asserted that trauma screening is essential, with the caveat that it must be done sensitively, and recognizing that disclosure is dependent on trust and rapport with healthcare professionals, which can take time to build. Yet, some healthcare professionals voiced that with the assumption of ‘universal precautions’, formal trauma screening would not be needed. Others stated that trauma screening, in addition to universal precautions, is essential to TIC because information gathered would inform the provision of care. Healthcare professionals who supported screening noted important considerations for its timing, nature and environment. All participants who spoke about trauma screening alluded to its complexity and stated the importance of a context of therapeutic rapport built on trust. There were also different views about discussing and processing a patient's trauma in the context of the inpatient mental health unit. Some healthcare professionals perceived the unit environment as an unsafe and unpredictable environment to discuss trauma, while others described it as a safe place for patients to work through issues that may evoke high levels of distress. Others saw the inpatient unit as an opportunity to build foundations of safety towards trauma processing, depending on the patient's readiness. Many healthcare professionals voiced concerns about the acute care nature of unit, such as whether they will have follow‐ups to continue processing the trauma.
At the end of the day, the challenging part…is that we're crisis stay, and if we know that we're not going to get that kiddo when they're discharged therapy right after; it's really hard to open up to tell me about all of this trauma, but yet you're not going to have supports once we've opened this up for you…. (Healthcare Professional 13).
Taking ‘a more individualized approach’
All participants conveyed the necessity to individualize care to specific needs of the patient, considering any known trauma history as well as acknowledging and addressing the youth's individual sociocultural needs and identities.
Regardless of views relating to trauma screening, participants across groups spoke about the importance of having a consistent way to document and communicate a patient's known trauma history to other providers on the team, as well as to integrate the patient's specific needs related to the trauma into a care plan that is readily accessible to all team members. This was in response to participants' mention of the detrimental effects of requiring patients to continuously repeat aspects of their history to new providers. Moreover, participants emphasized taking a strengths‐based lens when developing the care plan as most congruent with TIC.
She was tired of always retelling her story and I felt the same way…We bared our soul. I was like, okay what else do you need to know, because I knew it was helping [the patient], but I felt like it's the same story that I'm going to tell you again that you can read… (Caregiver 1)
Participants identified the imperative for an individualized approach that considers individual patient experiences, perspectives and characteristics, including developmental, cultural and gender factors, to inform planning and delivery of care. One youth described how being more directly involved in her care and treatment planning could have improved the trajectory of her stay on the unit.
Several healthcare professionals spoke about the necessity to proactively identify when patient needs are best served by integrating multi‐disciplinary team members (e.g. social work, occupational therapy and psychology) into their care and promptly involve those disciplines. Healthcare professionals suggested an initial intake with youth and caregivers, including multi‐disciplinary representatives, to explore how the team could best meet this youth's needs with the available resources:
In my wildest dreams we would have at intake a meeting with that full team and that youth and family… then each discipline would be able to explore with that family what their possible role would be. (Healthcare Professional 6)
One healthcare professional reflected on the need to consider individual patient needs in the context of general unit restrictions while balancing the eminence of safety. Another healthcare professional gave precedence to considering the distinct needs of patients with developmental disabilities (e.g., autism) within TIC.
When asked to reflect on any cultural, racial or gender considerations that would be important in planning the implementation of TIC, youth supported that an individualized approach is key. One youth and healthcare professional suggested it would be vital to ensure patients can access an appropriate prayer space. The caregiver raised the importance of offering care in the preferred language of the youth and family, preferably through having staff with diverse language skills, a sentiment shared by healthcare professionals who suggested having interpreters readily available so as to provide assessments and care in a congruent language for patients and families without delay. The caregiver also raised the value of offering more culturally diverse food menu options. The caregiver and healthcare professionals both echoed the need for a clear plan on how to cohort patients who identify as transgender, further noting the need for education to better support transgender patients. Several healthcare professionals spoke about the need to learn more both about specific cultures and about the intersection of mental health and cultures, and to be able to reflect on societal and personal biases to provide more culturally sensitive care.
Unit programming
In articulating their vision of TIC, all groups of participants touched on aspects of unit programming to be developed. Participants discussed the fundamental need for therapeutic engagement, as a form of engagement that is intentional and empathetic and that fosters relational safety, trust and emotional regulation. They also suggested unit programming content such as dialectical behaviour therapy (DBT), more physical activity, outdoor/nature activities, somatic and sensory approaches and caregiver education and engagement.
The primacy of engagement was underscored by youth participants in contrast to unfavourable consequences of a lack of engagement. Youth described the necessity that healthcare professionals be present with patients in their distress, rather than leaving them alone. Another youth described how consistent therapeutic engagement is vital in supporting distress tolerance and emotion regulation, and how a paucity of engagement can lead to accumulation of unexpressed distress that may present in more disruptive and even violent ways. The caregiver similarly endorsed that their youth's affect and level of engagement in therapeutic tasks fluctuated, depending on whether their assigned healthcare professionals on that shift were present and engaged. Healthcare professionals congruently voiced relational presence and engagement as essential to TIC, and many explicitly expressed a wish that the unit context be more conducive for providers to offer this ideal.
I don't know why there's this common thought that to put a person with mental health issues in a room thinking all day is going to fix them. But it's not, I promise you it's not… just sitting there thinking will not fix my depression, it won't fix the issues that I have, and there needs to be more engagement. Engagement is a big thing…Eliminating the social isolation punishment…Just having people be there with you in distress, instead of leaving you alone… (Youth 2)
Participants also brought up a desire to incorporate specific types and content of programming on the unit, which they saw as congruent with TIC. Youth referred to the value of dialectical behaviour therapy (DBT) and advocated for more DBT components in the unit. Youth and healthcare professionals also identified the need to integrate physical activity into programming. Similarly, three healthcare professionals spoke about the value of finding creative ways to integrate nature‐based programming within the setting of a locked unit. Some healthcare professionals suggested incorporating more body‐based somatic awareness programming to increase patients' sense of internal safety, which they saw as a prerequisite to trauma processing and a feasible task in an acute care unit. One healthcare professional highlighted that patients are already familiar with the experience of emotional dysregulation and that the providers' task is to gradually expose and familiarize the youth with emotionally soothing and safe experiences. Several healthcare professionals and one youth echoed the value of offering more sensory soothing resources and interventions.
While youth had mixed perspectives on the extent to which caregivers should be involved during the admission, healthcare professionals and the caregiver participants agreed that caregiver engagement and needs must be considered. Participants noted that focusing solely on the youth in treatment may overlook the needs of the caregivers in fostering their capacity to support the youth when they are discharged home. Some healthcare professionals suggested building caregiver programming within the unit schedule, acknowledging that trauma is often passed down inter‐generationally through interpersonal dynamics resulting in insecure attachments.
Trauma‐informed; yes, you're looking at [the patient], but…a piece has to be done for the caregivers as well. Because if the whole purpose is to have a patient learn the strategies…vocalize and get to a point where they have a safety plan in place and discharge can happen, as the caregivers you have to make sure that we are okay in doing what's being said in this, and that we have the tools to do it. (Caregiver 1)
‘Connecting to the community’
Caregiver and healthcare professional participants spoke about the importance of linking the inpatient unit—including providers, youth and caregivers—with community resources. Healthcare professionals agreed upon the need to offer patients the option of referral to trauma‐specific providers, as appropriate, post‐discharge. Some healthcare professionals specified the value of facilitating sensory regulation‐related referrals, with particular value on joint caregiver and youth participation in sensory co‐regulation activities. The caregiver participant expressed surprise that upon discharge her child had not been provided with any direct referrals or follow‐up appointments. Given the significant safety concerns that led to the hospital admission, the caregiver assumed that some follow‐up support would be offered. Healthcare professionals spoke about a desire to become more familiar with the community resources where youth may be referred or transferred to, to better support and prepare youth for discharge and follow‐up.
I think it would be helpful if we could have the opportunity to go to visit other agencies or talk to other agencies. Our kids will often express being fearful or sad or anxious about being transferred to a different place or having to start a new program. And other than what's available within [our agency], none of us have ever really seen what these other places are like right… how much trauma‐informed care can you deliver if, you have no idea what you're talking about, how much reassurance can you give a patient…(Healthcare Professional 14)
4.2.2. Theme 2: Factors that support or limit successful TIC implementation
Need for a broad ‘cultural shift’
To achieve TIC, participants spoke about the need for a ‘cultural change’ (Healthcare professional 20)—more than simply a care intervention but a shift in everyone's approach to care and to working together. Healthcare professionals emphasized that TIC needs to be implemented not only in the inpatient mental health unit but also hospital wide and across all levels of staff. They rationalized that this would provide a consistent approach for patients as they travel through the hospital system, particularly in the emergency department, typically the point of entry to admission to the inpatient units.
When I think of trauma‐informed care… it's so much more than just the interventions that we do, it's every aspect, it touches every aspect of the hospital and the inpatient experience… (Healthcare Professional 6)
Need to improve staff supports and multi‐disciplinary team collaboration
Within this cultural shift, healthcare professionals articulated needs to be addressed to enable them to provide consistent TIC: (a) trauma‐informed support within a ‘culture of working together’ (Healthcare professional 7), (b) adequate TIC training and (c) post‐incident debrief processes to support patients and staff and to foster meaningful improvements to care.
Healthcare professionals reasoned that for TIC implementation to be successful at the level of patient care, it needed to begin with trauma‐informed support for staff. They affirmed that just as TIC involves taking a less pathologizing approach to patient experiences, so too for staff. Healthcare professionals suggested that it would require a culture shift for them to feel safe to share their own experiences with each other without stigma and that supporting staff within a culture of TIC would facilitate TIC for patients. They noted that staff may experience traumatic events at work, which may or may not be experienced by other staff as traumatic. Yet, it is the individual's experience that must be validated and supported. One participant described that when staff are well supported to face their day‐to‐day challenges and to provide TIC for patients, it will reduce trauma in staff as well as patients. They further asserted that all levels of staff, including leadership, require this consistent support.
Direct‐care healthcare professionals described a tension within their roles, with ever‐accumulating tasks to complete, while acknowledging that TIC cannot be reduced to a task or checklist. Some expressed concern that implementing TIC would result in even more ‘tasks’ (Healthcare Professional 8) delegated to the direct‐care providers. Many healthcare professionals expressed that the cultural shift is needed to include a more cohesive and collaborative multi‐disciplinary team approach. They spoke about the need for appreciation and respect of team members' roles and contributions across disciplines and of this notion in terms of cultural competence—acknowledging and respecting diverse professional cultures within a team when promoting team collaboration and cohesion.
When you say culture, I think of cultural ways of knowing. So different people experience different traumas differently, I'd also wonder about … professional cultures, so how different people see themselves as helping, and do we always recognize when people are seeing themselves as helping…And how do professionals take care of themselves, and what spaces are made for that, even if that looks different between professions… (Healthcare Professional 9)
Healthcare professionals further expressed a desire to continue to be involved in TIC implementation planning discussions to offer input into changes that would affect their daily work. Healthcare professionals highlighted the need for training about TIC. They emphasized that training is essential but must be comprehensive and ongoing. They agreed that TIC training must provide not only knowledge but also facilitate comfort in applying the knowledge and skills in practical contexts.
Furthermore, healthcare professionals spoke specifically about the need to improve the post‐incident debrief processes. Some wanted a more formal debrief process that incorporates multi‐disciplinary team members in a format that is supportive of both the patient and the staff members involved. They noted that current debriefs are often rushed due to staffing needs and the acuity of the unit, preventing full or complete participation. Others suggested that someone external to the department offer debriefs and support for staff. Within any debrief process, they spoke about the necessity to consider individual needs of staff members. For example, some staff may be ready to debrief immediately after the incident, and others may need a day to reflect before reviewing the event with others.
We all process emotions at different times right, so for some people, right after is the time where they can shift their emotions and be like okay … I'm ready to have that conversation. But not all of our staff are going to be able to do that. Some of our staff may need that time to go home to process it, to do other things to then say okay, I'm ready to hear what I could have done differently. And I think that comes at the trauma‐informed perspective that we're all very different…. (Healthcare Professional 19)
Finally, healthcare professionals emphasized that any outcomes from a debrief must not only be documented but also receive attention and follow‐up from leadership to ensure that the lessons learned result in tangible changes.
Physical environment on the unit
Every participant commented on the need to modify the unit's physical environment by (a) making the unit more visually comfortable and engaging and (b) adjusting the structure of the unit to create more therapeutic spaces.
Participants from each group emphasized a need to improve the visual appearance of the unit. Youth and healthcare professionals acknowledged the distinction ‘between making it comfortable and making it fun’ (Youth 2), with the goal of creating a therapeutic environment that fosters safety and emotion regulation and thereby engagement in treatment. Healthcare professionals voiced a need for more timely upkeep of broken areas of the unit (e.g. walls and windows), as well as visual design enhancements such as paint, artwork and furniture that is calming, soothing and friendly.
It's almost a distinction between welcoming and hospitable, so you don't want to say welcome on [the unit]… but you do want to be hospitable to people and…you want to figure out a way that they can be somewhat comfortable in the uncomfortableness of what they're going through. (Healthcare Professional 9)
Healthcare professionals expressed a need for structural changes to allow for more therapeutic spaces in the unit. They highlighted the need for more meeting rooms where staff could meet privately with youth, caregivers or colleagues.
‘We don't have the inviting places to have those one‐to‐one therapeutic conversations with whatever person or team member that might be’ (Healthcare Professional 7).
Participants noted that the entrance to the unit is far from the unit clerk, resulting in families needing to wait sometimes long periods at the unit door before being let in. They suggested that having the clerk closer to the entrance would be more welcoming. Healthcare professionals also suggested structural changes to the patient rooms and location of the patient showers that would increase patient dignity and decrease anxiety during their stay. Several healthcare professionals emphasized the need for dedicated and safely constructed unit spaces for the most acute patients. They reasoned this would facilitate a quieter space for relatively less acute patients who could benefit from unit programming and protect them from noises that could be re‐traumatizing. Youth similarly suggested the need for better‐insulated walls between patient rooms and more private spaces to provide privacy during conversations with others and to protect vulnerable youth from hearing other youth in distress. Healthcare professionals also suggested the importance of larger spaces for patient physical activity.
Factors that may limit successful implementation
Healthcare professionals identified several factors limiting their current capacity to provide TIC, as well as perceived future factors that could limit successful implementation of the TIC programme. These included (a) staff buy‐in, (b) delivery of TIC training and (c) maintenance and sustainability.
Healthcare professionals voiced concern that some staff may be reluctant to buy‐into the new TIC approach to care. In particular, they suspected that there would be resistance to a programme that required staff to share their own emotions and needs with their team members: ‘They [staff] don't want to feel like they're in therapy…’ (Healthcare Professional 21). Participants also expressed some concern about a perceived dichotomy of TIC versus maintaining physical safety of youth and staff.
One healthcare professional detailed concerns about a train‐the‐trainer model that staff who are traumatized and burnt‐out would not be effective trainers and champions for TIC. Furthermore, several healthcare professionals described challenges in supporting direct‐care shift workers to complete training, given scheduling conflicts and staffing shortages. There was a consensus that shift workers could not be expected to complete training on their days off, as that would be incongruent with a culture that fosters staff wellness: ‘Having to actually change the culture in how you deliver the education’ (Healthcare Professional 8).
Finally, many healthcare professionals expressed apprehension about maintaining a TIC programme and sustaining the benefits. They described previous experiences with rollouts of new interventions, where there was initial enthusiasm that wavered with time because of lack of forthcoming support and structure to sustain it.
It is hot in the moment and popular in the moment, and we try to live by it in the moment, and then as we get busy, as we get more kids, a lot of that is forgotten, and then we slip back into what we were doing before. And there's no accountability of where…or why did we stop, and how do we get back to it right, and it almost feels like now we're just waiting for the next new model of care all over again… (Healthcare Professional 14)
5. DISCUSSION
This study offers youth, caregiver and healthcare professionals' perspectives on TIC at a paediatric hospital and on issues that should be considered when implementing a TIC programme in an inpatient mental health unit. Participants shared their understanding of TIC, their vision of how TIC would ideally be operationalized in the current setting and their perceptions of factors that would enable or limit the successful implementation of TIC. Our findings lead us to four main discussion points: the centrality of relational engagement in TIC and in the implementation of TIC, core TIC programme components, mental health unit and hospital‐wide factors for success in implementing TIC and the importance of intersectoral collaboration (partnering with external organizations and sectors).
5.1. Centrality of relational engagement in TIC and the implementation of TIC
All participant groups described that psychologically safe, supporting and trusting engagement is core to both implementing and delivering TIC. The absence of such engagement, ‘social isolation’, was expressed by youth as unhelpful and prone to be retraumatizing. One youth described how when patients experience a lack of trust and engagement, as well as disinterest from their staff, then providers may easily misunderstand the context of patients' escalating distress. Healthcare professional participants also stated the importance of facilitating relational improvements between youth and their caregivers. Furthermore, healthcare professionals specified that to be able to provide TIC, staff must first experience safety, support and engagement within their workplace and multi‐disciplinary teams. Relational engagement is defined as engagement within a relational ethic framework that considers three transactional dimensions: power, compassion and openness to uncertainty (acknowledgement that another's truth may not be fully known or understood) (Birrell & Bruns, 2016). Our findings suggest that relational engagement is required to implement and deliver TIC.
The social and relational context is an essential mediator of individual stress response (e.g. Perry, 2009). Furthermore, trauma has been conceptualized at its essence as a relational experience of being disconnected and isolated from safe and trusting relational support before, during or after events of adversity (e.g. Badenoch, 2018). While there are differences in how individuals cope with and overcome stress and trauma, experts repeatedly observed the significance of healthy relationships in protecting from and healing from trauma (Badenoch, 2018; Perry, 2009), and assert that ‘relationships are the agent of change’ (Perry & Szalavitz, 2006, p. 230). On the other hand, those who experience very few positive relational contacts during and following traumatic events find it more challenging to manage and decrease trauma‐activated stress reactivity, resulting in a higher likelihood of ongoing symptoms and challenges (Perry & Szalavitz, 2006). With the relational environment as the facilitator of therapeutic experiences, it is those youth with relational stability and multiple secure adults invested in their lives that tend to improve in their trauma‐related symptoms. Those with a paucity of secure and predictable relationships do not improve, regardless of the therapeutic treatments they receive (Perry, 2009). Psychological safety is an interpersonally based concept, defined as the belief that the context is interpersonally safe for vulnerability and risk taking and that one can express oneself without negative consequences (Plasse, 2015). It is within an atmosphere of psychological safety that individuals and teams can learn and ‘feel secure and capable of changing’ (Edmondson, 1999, p. 354), and develop a sense of agency to live within their values (e.g. Brown & McCormack, 2016; Wanless, 2016). It is therefore congruent with current theories that the transactional nature of relational engagement impacting healing and wellness emerged in the findings as a central element of TIC. Thus, the foundation of psychologically safe and restorative relational engagement, for youth, caregivers and staff, must be considered when selecting, or developing and implementing, a TIC programme.
In addition to the prominence of relational engagement within a TIC programme, healthcare professional participants highlighted the importance of leadership relational engagement with staff throughout the implementation process to facilitate effective TIC practice changes. The healthcare implementation science literature describes successful implementation as resulting ‘from the interactions and engagement of multiple stakeholders who are a part of a complex system’ (Harrison & Graham, 2021, p. 5), stressing that the interactions and engagement with knowledge users are key determinants of success (e.g. Ozanne et al., 2017). The evidence pertaining to TIC implementation similarly points to the importance of engaging and involving patients, caregivers, staff members and community‐based partners who are affected by or may affect the TIC programme and implementation process. These knowledge users can participate in preparing for TIC implementation, including planning, adapting, implementing, evaluating and maintaining (e.g. Bryson et al., 2017; Wassink‐de Stigter et al., 2022). Healthcare professionals in this study were enthusiastic to participate and share their perspectives and expressed a strong desire to continue to be involved in the TIC implementation planning process. The implementation process itself should mirror the safe, transparent and predictable aspects of meaningful relational engagement that are prioritized within the clinical applications of TIC. This includes facilitating empowerment, voice and choice among all involved.
5.2. Core TIC programme components
Study participants identified core elements of TIC to be integrated into an acute care mental health unit, which align closely with the key domains in the TIC literature. For example, the National Child Traumatic Stress Network (NCTSN) Trauma‐Informed Organizational Assessment (TIOA) covers nine key domains to creating a trauma‐informed programme or organization, all of which were raised by participants in this study: (a) trauma screening; (b) assessment, care planning and treatment; (c) workforce development; (d) strengthening resilience and protective factors; (e) addressing parent/caregiver trauma; (f) continuity of care and cross‐system collaboration; (g) addressing, reducing and treating secondary traumatic stress; (h) partnering with youth and families and (i) addressing the intersections of culture, race and trauma (Halladay Goldman et al., 2019). The TIOA nine domains are also consistent with other reviews of TIC definitions and interventions in the literature (e.g. Bendall et al., 2021; Branson et al., 2017). Previous critiques of TIC have pointed to ambiguity about the operationalization of TIC principles and the core clinical components of TIC interventions, calling for clarity with respect to its practical application (e.g. Berliner & Kolko, 2016; Yatchmenoff et al., 2017). As Wassink‐de Stigter et al. (2022) noted, successful implementation of an innovation such as TIC depends in part on adequately defining the characteristics of the innovation, the changes to be made and the individuals who need to be involved. In selecting and adapting a TIC programme to inpatient unit settings, it will be important to consider the priorities expressed by study participants, including clarification of inclusion of trauma screening and processing, individualized approaches to care, elements of structured unit programming and fostering community connections.
5.2.1. Core TIC programme components: Including trauma screening versus clinical inquiry
Among participants in this study, there were differing perspectives on whether and how trauma screening and trauma processing (trauma‐focused treatment) should be integrated into an acute care mental health unit. Much of the TIC literature presents a generally consistent view that trauma screening and access to trauma‐specific treatments are core elements of TIC (e.g. Bendall et al., 2021; Halladay Goldman et al., 2019). Proponents of trauma screening urge that trauma‐informed organizations serving youth with acute mental health concerns need a clear process of identifying youth who may have experienced trauma and who require a subsequent comprehensive trauma‐informed mental health assessment and appropriate referrals (Halladay Goldman et al., 2019). However, other authors acknowledge that trauma screening is complex and not without risks (Bendall et al., 2021; Berliner & Kolko, 2016; Yatchmenoff et al., 2017). There is evidence that screening, particularly when it is not conducted in a trauma‐informed manner, can cause distress for a minority of youth, generating a conflict between two elements of TIC: screening and avoiding re‐traumatization (Bendall et al., 2021). Furthermore, there is evidence suggesting that universal trauma screening, such as in general paediatric settings, carries risks of harm and offers limited benefits (Loveday et al., 2022; World Health Organization [WHO], 2022). Moreover, screening in the absence of an appropriate therapeutic response and specialized referral would call into question the purpose of screening (Berliner & Kolko, 2016).
That said, in a specialized acute mental health setting, where the prevalence of trauma is relatively high, and the influence of trauma exposure on their mental health presentation is potentially significant, using methods to identify trauma‐exposed patients may be justified. Rather than screening per se, the WHO (2022) suggests taking an approach referred to as clinical inquiry when signs, symptoms or clinical history suggest the possibility of trauma or maltreatment (such as a mental health inpatient admission). In clinical inquiry, a trained professional raises the topic of trauma and inquiries about potential trauma exposure while also providing first‐line support following disclosures. Such an approach requires: a private setting, ensured confidentiality, a protocol or standard operating procedures, trained providers and a system for referrals (WHO, 2022). The clinical inquiry approach to identifying trauma‐exposed youth is consistent with literature pertaining to trauma‐informed trauma screening. It acknowledges and addresses the potential of distress, and ensures protocols are in place to reduce and manage that distress, such as fully informing participants of the purpose and results of the assessment, prompt response to the needs identified and support for youth, caregivers and staff throughout the process (Bendall et al., 2021; Halladay Goldman et al., 2019). Furthermore, as highlighted in our findings, the nuanced context of screening/clinical inquiry matters greatly, and those designated to conduct the assessment must receive specialized training, monitoring, supervision and support (Halladay Goldman et al., 2019; Yatchmenoff et al., 2017).
In considering whether to incorporate trauma screening or clinical inquiry into a TIC programme in the context of an acute care mental health inpatient unit, it will be important for decision‐makers to reflect on the purpose of the assessment, and whether there are protocols and resources in place to meet that purpose (such as follow‐up assessments and referrals for trauma‐specific treatment). Identifying diverging views that staff members may hold on to trauma screening/inquiry can assist implementation planning regarding whether screening or clinical inquiry should occur, and if so by whom, when and how.
5.3. Mental health unit and hospital‐wide factors for success in implementing TIC
Participants described elements that would need to be in place, or considered, to support successful implementation of TIC. While these elements were relevant specifically to the inpatient mental health unit, many may also have relevance to hospital‐wide implementation of TIC. As prerequisite to TIC, healthcare professional participants underscored the need for a cultural shift; that staff in all roles need to experience the trauma‐informed principles (of physical and psychological safety, trustworthiness and transparency, support, collaboration, empowerment and acknowledgement of cultural and gender considerations; SAMHSA, 2014) as individuals and teams within their work settings. Furthermore, implementation of TIC will need to incorporate comprehensive and practice‐based training for staff, as well as ongoing supervision, coaching and debriefs, all tailored to the context and delivered in a safe and supportive manner. This is consistent with literature citing that TIC training is essential but on its own insufficient for successful implementation (e.g. Bendall et al., 2021; Williams & Smith, 2017). Trauma‐informed systems of support for the safety and well‐being of all levels of staff, and a culture shift that fosters respect and collaboration across roles is essential (Halladay Goldman et al., 2019; Isobel et al., 2021; Williams & Smith, 2017). Healthcare professionals also described factors they perceived may limit successful implementation of TIC, including concerns relating to staff buy‐in and the scheduling and delivery of TIC training (burnt‐out staff training other staff within the proposed train‐the‐trainer model). Difficulties obtaining staff buy‐in is a commonly reported barrier in the implementation of TIC, linked to staff attitudes and beliefs about the need for TIC, investment in traditional behavioural approaches, a general resistance to changes and inadequate infrastructure support (e.g. Champine et al., 2022; Wassink‐de Stigter et al., 2022). Staff buy‐in may be fostered through a shared understanding of staff perceptions of relevance of the TIC programme; benefits and drawbacks of the innovation; and of outcome expectations (Fleuren et al., 2014). Implementation of TIC needs to thoughtfully address factors related to the scheduling and delivery of staff training, as well as to reluctance and vulnerability about the new TIC programme and clarify how TIC balances and addresses the physical and psychological safety of all individuals.
Participants suggested that to achieve TIC, the physical environment needs to be more visually soothing and engaging, and the structure of the unit may need adjustments to offer sufficient therapeutic spaces. Other studies have similarly reported that to facilitate TIC, the physical and architectural design of inpatient mental health units must be hospitable and support safety and relational engagement (e.g. Yatchmenoff et al., 2017). Involving youth, caregivers and staff in the process of reviewing and modifying the physical environment may help ensure that the changes are suitable and respectful of those with diverse experiences, cultures and roles (Halladay Goldman et al., 2019; Yatchmenoff et al., 2017).
Finally, participants asserted that to achieve TIC, and the broad cultural shift TIC encompasses, implementation must be not only within the mental health unit but also hospital‐wide. In particular, the emergency department, where most patients are first triaged and assessed before admission, needs to offer a consistent TIC approach, to facilitate a seamless patient experience throughout their hospital encounter. Our findings also raised concerns about maintaining the TIC programme and sustaining the gains, given healthcare professionals' experiences with previous innovations that were implemented without sufficient support to be maintained. Implementation planning will need to incorporate a comprehensive strategy to support sustainability of the TIC programme.
5.4. Intersectoral collaboration
Participants voiced that a trauma‐informed programme would need to consider how to better support youth and families in the transition from inpatient admission to discharge to the community. As Berliner and Kolko (2016) maintain, TIC ultimately only holds value if the innovation improves the lives of youth and families, and presumably their lives post‐discharge. Thus, a TIC programme would ideally transcend an episodic hospital‐based encounter and bridge youth and caregivers to ongoing, integrated, individualized and holistic care, in contrast to ongoing disenfranchisement and re‐traumatization (Halladay Goldman et al., 2019). Reviews have consistently identified interagency or intersectoral collaboration as a core component of TIC (e.g. Bendall et al., 2021; Branson et al., 2017). Intersectoral collaboration in TIC has two goals: (1) coordination, integration and continuity of care for youth and families across systems; and (2) development of partnerships with external agencies, including all levels of staff, to foster a shared understanding of TIC and to inform ongoing planning of TIC implementation and maintenance across systems (e.g. Halladay Goldman et al., 2019).
5.5. Implications
Table 4 presents the implications for implementation of TIC on an acute paediatric mental health inpatient unit, based on the youth, caregiver and healthcare professionals' perspectives reported in this study. In Figure 1, we introduce a summary of the implications. Within concentric circles, we propose five fundamental domains to consider and address in implementing TIC in a paediatric mental health inpatient setting: (a) TIC programme components that make up the clinical intervention; (b) mental health unit factors for success in implementing TIC (factors that may facilitate or hinder successfully implementation), (c) hospital‐wide factors for success in implementing TIC, (d) intersectoral collaboration and (e) we suggest that the final outer domain of relational engagement envelops each of the first four domains as a chief tenet necessary for both the implementation and the delivery of TIC.
TABLE 4.
Implications for TIC implementation.
| Implications for Policy | Implications for Practice | Implications for Education | |
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| Relational engagement (within TIC programme and TIC implementation) | Y All | ||
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Y | ||
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| Components to consider in a TIC programme | Y All | Y All | |
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| Mental health unit and hospital wide considerations for leadership | Y All | ||
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| Hospital‐wide considerations for leadership | Y All | ||
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| Intersectoral collaboration | Y All | ||
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Y |
FIGURE 1.
Domains for consideration in implementing TIC.
5.6. Strengths and limitations
This study sought the perspectives of youth, caregivers and staff to inform the implementation of a TIC programme. Twenty‐five participants volunteered to participate; however, the majority were healthcare professionals (n = 21) with few youth (n = 3) and caregiver (n = 1) participants. Therefore, most of the data came from healthcare professional input, with several sub‐themes encompassing views expressed solely by healthcare professionals (e.g. the 'need to improve staff supports and multi‐disciplinary team collaboration', and 'factors that may limit successful implementation of TIC'). However, we performed a post‐hoc analysis of data saturation (Appendix S3) and found no new themes emerged after the second interview. Further representation from youth and caregivers and gender‐diverse participants may have yielded additional findings. Nonetheless, participants who volunteered for this study each provided rich and relevant perspectives.
6. CONCLUSIONS AND DIRECTIONS FOR FUTURE RESEARCH
This qualitative study sought to explore youth, caregiver and staff perspectives on a paediatric inpatient mental health unit relating to (a) their vision of TIC in this setting and (b) what would be needed for a TIC programme to be successfully implemented within the setting. What emerged from these findings were five key domains to consider within TIC implementation: (a) the centrality of relational engagement in TIC and implementation of TIC, (b) TIC core programme components, (c) factors that may support or limit success in implementing TIC within the mental health unit and (d) hospital‐wide and (e) the importance of intersectoral collaboration. At present, we are drawing on these findings to tailor a TIC programme to the local context and to develop a customized implementation plan before field testing and launching the programme. Engaging youth, caregiver and healthcare professionals during the implementation planning process highlighted essential issues to consider in adapting and implementing a TIC programme in our local setting. We recommend future research to continue to broaden our understanding of knowledge user perspectives regarding TIC and successful implementation of TIC, including youth, caregivers and all staff members in varied healthcare settings. These perspectives may be elicited at various stages of the TIC implementation planning process and inform ongoing modifications. We also recommend careful documentation of TIC implementation activities and outputs to allow for clear and comprehensive dissemination of what was done, by whom, clinical and process outcomes and lessons learned through this experience.
AUTHOR CONTRIBUTIONS
YS, PC, DA, JDJ, EH, ACT, MKW, AK, SG, MR, RS, DM, JB, IDG and KBL: Made substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; Involved in drafting the manuscript or revising it critically for important intellectual content. YS, PC, DA, JDJ, EH, ACT, MKW, AK, SG, MR, RS, DM, JB, IDG and KBL: Gave final approval of the version to be published.
FUNDING INFORMATION
We received funding from the CHEO Psychiatry Associates Research Fund for compensation of study participants.
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest to report.
PEER REVIEW
The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16095.
Supporting information
Appendix S1.
Appendix S2.
Appendix S3.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the full Trauma‐Informed Care Advisory Committee that offered input throughout this study, including Dhiraj Aggarwal, Paula Cloutier, Emily Locke, David Murphy, Marjorie Robb, Roxanna Sheppard, Stephanie Greenham, Allison Kennedy, Sonia Lavergne, Michelle Ward, Jennifer Boggett, Catherine Landriault, Sarah Bissex, Shannon Watson and Hazen Gandy. We also thank Justine Gould for developing the recruitment materials and procedures for this study.
Stokes, Y. , Cloutier, P. , Aggarwal, D. , Jacob, J. D. , Hambrick, E. , Tricco, A. C. , Ward, M. K. , Kennedy, A. , Greenham, S. , Robb, M. , Sheppard, R. , Murphy, D. , Boggett, J. , Graham, I. D. , & Lewis, K. B. (2025). Youth, caregiver and healthcare professional perspectives on planning the implementation of a trauma‐informed care programme: A qualitative study. Journal of Advanced Nursing, 81, 6602–6624. 10.1111/jan.16095
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author, YS, upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1.
Appendix S2.
Appendix S3.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, YS, upon reasonable request.