Understanding the Conceptualization and Operationalization of Trauma‐Informed Care Within and Across Systems: A Critical Interpretive Synthesis

Abstract

Policy Points.

• In order to achieve successful operationalization of trauma‐informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration.

• Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level.

Context

Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma‐informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC.

Methods

Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information‐rich websites. We used a coding tool, adapted to the TIC literature, for data extraction.

Findings

Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information‐rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider “buy‐in,” have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma‐affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language.

Conclusions

Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

The seminal adverse child experiences (ace) study of the late 1990s was the first large‐scale study to link adverse childhood experiences to later development of a multitude of risk factors associated with several leading causes of morbidity and death in adulthood. ¹ Findings identified in the ACE study prompted further investigation into the impact of childhood trauma, which has led to increased awareness of the widespread prevalence of trauma experienced across the lifespan. ² , ³ , ⁴ Epidemiological trauma trends become even more revealing when viewed within various human service delivery systems. Individuals with significant trauma histories are disproportionately represented in child welfare, criminal and juvenile justice, mental health and addictions, and social services systems. ⁵ , ⁶ , ⁷ , ⁸

Rising awareness of the prevalence of trauma over the last several years has coincided with recent advancements in neuroscience, particularly regarding the neurobiology of trauma. A growing body of research has shown how childhood trauma can disrupt normal neurocognitive development resulting in long‐term negative outcomes in behavioral, physiological, cognitive, and interpersonal functioning. ⁹ , ¹⁰ , ¹¹ Responses to traumatic exposure can include anger, aggression, and risky and self‐destructive behaviors, as well as engagement in criminal activity, particularly in the adolescent and young adult years. ¹² , ¹³ Understanding the link between trauma, neurocognitive function, and behavioral outcomes holds significant implications for how various human service systems design service delivery. In addition to increased understanding of how trauma affects the brain, scientific discovery regarding neuroplasticity, specifically the brain's ability to rewire stress responses, and opportunity for post‐traumatic growth also hold significant implications for service delivery, particularly with regard to trauma‐informed care. ¹⁴ , ¹⁵

The concept of trauma‐informed care (TIC) emerged from increased awareness of the pervasiveness of trauma and a growing understanding of how it can negatively impact structural and functional brain health. Various human service delivery systems such as child welfare, education, health, justice and social services, have begun to recognize that a significant proportion of service users have trauma histories. ⁶ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ Additionally, the education system has started to respond to the neuroscience implications of how trauma can impact student learning and academic performance. ²¹ , ²² , ²³ An emerging body of empirical literature has shown promising evidence regarding the effectiveness of trauma‐informed services in comparison to traditional services. ²¹ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ Various concerns about the conceptualization and operationalization of TIC, however, have also begun to surface. ³³ The concept of trauma‐informed care (TIC) remains poorly defined in the current literature and several contested definitions can be found on the understanding and application of TIC in diverse contexts. Some literature exists regarding the use of TIC in human service delivery systems, but consensus is lacking in both the definition and application of TIC within and across these systems. The purpose of this paper is to systematically review the literature on TIC within and across systems of care and to create a conceptual framework, informed by analytical findings of the review, that outlines how TIC can be defined and operationalized.

Methods

Design

Our study design follows the methodological approach of a critical interpretive synthesis. ³⁴ , ³⁶ We selected a critical interpretive synthesis (CIS) design as it is most suitable for emerging literature that remains poorly conceptualized due to limited understanding and empirical research. In addition to elements of a traditional systematic review guided by an iteratively developed compass question, a CIS typically generates a conceptual framework resulting from qualitative analysis of synthesized evidence. ³⁶ After a preliminary survey of existing literature on TIC, we formulated the following compass question, consisting of three components: How is trauma‐informed care (1) defined and (2) operationalized vertically in the clinical setting, at the organizational level, and at the health system level, and horizontally across other systems of care including child welfare, education, the judicial system and social services; and (3) what factors explain whether and how TIC is operationalized at these levels and in these systems?

Literature Search and Article Selection

Drawing on traditional elements of a systematic review, we formulated a search‐term strategy in consultation with an expert librarian to guide a structured, systematic literature search utilizing Boolean key phrases for both empirical and nonempirical articles. We initially piloted the search‐term strategy in select databases and revised it several times in consultation with the librarian. We systematically searched the following health and nonhealth databases: Campbell Collaboration, Cochrane, Econlit, Embase, ERIC, HealthSTAR, Health Systems Evidence, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstract, Sociological Abstracts, and Web of Science (Figure 1). We used the following iteratively developed line‐item key‐term searches for health databases: (1) “trauma informed” OR “trauma sensitive” OR “trauma expos*” OR “trauma specific” (2) “health practi*” OR “health prof*” OR clinician (3) “health polic*” OR “policymak*” (4) “health sys*” OR “health org*” OR healthcare with the subsequent line combinations: 1 and 2; 1 and 3; 1 and 4. Nonhealth databases utilized the following bounded search terms: “trauma informed” “trauma sensitive” “trauma resilienc*” “trauma specific” “trauma expos*” “trauma aware.” We slightly modified key search terms to ensure best fit for specific databases. In addition to the bibliographic databases, we manually searched gray literature and reference lists of high‐value articles.

Figure 1.

Literature Search Results and Study Flow [Colour figure can be viewed at wileyonlinelibrary.com]

We conducted the searches between March and May of 2017 and conducted a repeat of the search strategies outlined above in March 2021. Abstracts were exported into an Excel spreadsheet and coded according to three categories: Include, Assess Further, and Exclude. Included documents addressed the topic of trauma‐informed care at any of the three levels within the health system—program, organization, or system level—and that addressed the conceptualization and/or operationalization of TIC in other systems of care. In order to achieve a fulsome understanding of the emergence of TIC as a concept, no restrictions were placed on the publication date of included articles. We excluded documents if they primarily focused on treatment modality and efficacy studies or the development of clinical tools. We then exported the Included and Assess Further titles and abstracts into a separate excel spreadsheet and reviewed again the Assess Further articles. After this second phase, documents were identified as eligible for inclusion based on a title and abstract review. A third and final assessment phase consisted of full‐text review. An Excel tracking sheet was created with documents organized into six different tabs: (1) child welfare, (2) education, (3) health, (4) justice, (5) social services, and (6) multiple systems of care. The sixth tab was created to accommodate articles that discussed TIC across more than one system. The five included systems of care were not determined a‐priori, but rather emerged at the third assessment phase when all the Included and Assess Further documents were organized according to system to help manage the review process.

In the third phase, the first author carried out a full‐text scan of each document and assessed according to the inclusion/exclusion criteria in order to generate a purposive sample of the most information‐rich documents. Purposive sampling is the recommended sampling strategy for CIS methodology ³⁶ and it is defined as “strategically selecting information‐rich cases to study; that is, cases that by their nature and substance will illuminate the inquiry question being investigated.” ^{37 (p265)} Information‐rich documents were included if they provided in‐depth insights and understanding regarding the research question at hand as determined by the data extraction tool (see Online Appendix 1). Documents which provided only scant data in the tool were not included in the purposive sample.

In order to ensure the inclusion and exclusion criteria were consistently applied and a reliable sample was generated, a second reviewer independently assessed a random generation of 15% of the initial titles and abstracts and then independently reviewed another random generation of 15% of the selected full‐text documents. Any discrepancies in coding were mutually discussed to reach consensus. Inter‐rater reliability was assessed through a Kappa statistic, which was calculated to be 0.82 for the initial title and abstract review and 1.0 for the full‐text review.

We generated a master list of the selected documents and entered it into a central database in Excel, including a unique identifying code and a brief article descriptor for each document. This centralized database assisted with data extraction by providing a high‐level overview of each system and contributed to the emerging conceptual framework. Throughout the article selection process and purposive sampling, the first author recorded emerging themes and concepts in a reflexive journal.

Data Analysis and Synthesis

We used a data extraction tool (see Online Appendix 1), derived from a preexisting and well‐established health and social system arrangements taxonomy, which we contextualized to the TIC literature in the data collection phase .^38,39 Health and social systems arrangements consist of three types of arrangements and three levels of implementation strategies. First, governance arrangements describe various levels of decision‐making authority and how consumers and stakeholders are involved in the decision‐making process. Second, financial arrangements describe how various levels of the system are financed, how providers are remunerated, and whether and how consumers are financially incentivized. Third, delivery arrangements describe how care is designed to meet consumers’ needs, who provides care, where it is provided, and with what supports. Implementation strategies target consumers, providers, and organizations. ³⁸ , ⁴⁰ We also used the taxonomy to extract data about programs and service areas, trauma, TIC, and study design. We then synthesized and deductively analyzed the data through the “3‐I” framework, which outlines how policy development and choices are influenced by institutions, interests, and ideas. ⁴¹ The “3‐I” framework is a helpful analytical tool that allows for exploration of how variables within each of the three “I's” can either facilitate or hinder policy development and implementation. ⁴² The first of the 3 “I's”—institutions—can be defined as the informal and formal rules, norms, and organization factors that constitute political behavior. There are three components of institutions, the first of which is government structures, or the specific political arrangements of individual countries as well as the mandate and accountability mechanisms between the government and its agencies. Policy networks are the second component of institutions and they can shape policy development and choice by uniting governments with actors outside the formal government process. Policy legacies are the final component of institutions and they both shape and limit policy development and choices based on previous policy decisions and the country's constitution. The second “I” is interests, which represents a range of actors who either benefit or bear the cost of policy decisions. The third “I,” ideas, refers to knowledge and beliefs about what is and values or opinions about what ought to be. ⁴²

We piloted the data extraction tool during the final article selection phase and subsequently revised and finalized the format. The first author then systematically applied the extraction tool to each purposively sampled article by reviewing the article in full and coding it via the tool. We then extracted the data and uploaded into NVivo12 and further analyzed the coded data utilizing constant comparison methodology, which provided greater elucidation into how TIC can be defined as well as what factors explain whether and how TIC is operationalized. A reflexive journal was maintained throughout this process capturing central themes emerging from the data. Members of the research team were consulted at various stages throughout the data collection and analysis process to ensure methodological rigor and analytical comprehensiveness.

We developed the conceptual framework depicted in Figure 2 based on analytical findings from synthesized data regarding TIC, which we identified and further refined through an iterative analytical process. Through use of thematic analysis in accordance with CIS methodology, ³⁶ the conceptual framework maps out variables that are required to conceptualize and operationalize TIC. The three categories of outcomes—service user, service provider, and service user/provider—were created based on outcome themes identified in data analysis. Once data analysis was complete, the conceptual framework was reviewed by the research team for comprehensiveness. Mutual consensus within the research team regarding analytical interpretation was established via group discussion. We presented the study findings and conceptual framework to a group of clinicians and researchers affiliated with an internationally reknowned multi‐disciplinary institute with clinical expertise in psychiatry and psychology, and established research expertise in developmental trauma, behavioral sciences and research methodology. We then revised and finalized the framework in accordance with received feedback.

Figure 2.

Conceptual Framework: How Trauma and Trauma‐Informed Care are Defined and Operationalized

Results

The results are presented in three sections to reflect the sequencing of this study. Using the data extraction tool, we synthesized the results of the systematic review to address the following questions: (1) How is TIC defined? (2) How is TIC operationalized? (3) What factors affect operationalization? Synthesized data in (1) were analyzed to generate our definitions of trauma and TIC. Synthesized data in (2) were analyzed to generate the conceptual framework outlining the core components of TIC and how it can be operationalized. Synthesized data in (3) were analyzed to generate the theoretical framework depicting factors that can affect the operationalization of TIC by acting as either barriers or faciltators.

Systematic Review Search Results

Comprehensive electronic database searches and gray literature/hand searches initially identified 2,467 documents (Figure 1). After duplicates were removed (n = 678), 1,789 titles and abstracts were reviewed in accordance with inclusion/exclusion criteria and 316 documents were selected for full‐text assessment. After full‐text review, a purposive sample of 98 high‐quality, information‐rich documents was generated. The repeated search in March 2021 yielded 2,069 documents. After duplicates were removed (n = 628), 1,441 titles and abstracted were reviewed according to the same inclusion/exclusion criteria and 129 documents were selected for full‐text assessment. None of the documents added additional conceptual insight and thus were not included for additional analysis. Nine articles were, however, included in the discussion with regards to implications for future areas of research.

Of the 98 included documents, almost three‐quarters (n = 73) were published after 2012, whereas 14% (n = 14) were published between 2006 and 2012 and 11% (n = 11) were published between 2000 and 2006. None of the included documents were published prior to 2000. Thirty‐five documents were from the health system, seventeen from child welfare, seventeen from education, ten from justice, nine from social services and ten from multiple systems. These five systems were selected after the full‐text review, as they had the most information‐rich data. Several specific systems of care, such as the military, veterans’ services and refugee‐specific services were captured and reviewed in the original search results, but the available data lacked both depth and comprehensiveness, thus, they were not included. In total, across all systems, sixty documents (61%) were theoretical papers and 38 documents were empirical studies. Within health, there were 12 empirical studies (34% of documents). Child welfare had ten empirical studies (59%), education had seven (41%), justice had four (40%), social services had four (44%) and one empirical study was found in multiple systems (10%). Included in the empirical studies were systematic reviews (n = 3), other qualitative approaches (n = 3), experimental ‐ unspecified design (n = 11), case studies (n = 11), and mixed methods (n = 10). Nonempirical papers consisted primarily of commentaries, editorials, or theoretical applications of TIC.

All documents in which the country setting was identifiable were generated from high‐income countries, with 84 documents from the United States, 8 from Australia, 3 from Canada, and 1 from the United Kingdom. Two documents did not identify the country setting. Documents specific to individual systems of care also touched on varied settings. Within health, the reviewed TIC literature encompassed care across the lifespan and specialty services ranging from neonatology and pediatrics to diagnostic imagery, and obstetrics and gynecology to geriatrics, as a few examples. TIC literature in health also focused on specific professions, including nursing and allied health, primary care physicians, dentists and emergency room physicians. Included literature pertinent to the health system also encompassed mental health services (inpatient, outpatient and community services) as well as all mental health professionals working within the health system, including psychiatrists, psychologists, nurses, social workers, therapists, and counselors. Included documents within the education system focused heavily on primary education, with some literature on secondary education and only one article addressing tertiary education. Within justice, the reviewed TIC literature has been applied to juvenile justice and family court, as well as specialized courts, such as mental health and addictions. Police services, various types of law enforcement, and corrections facilities are also included in the TIC justice literature. The social services TIC literature spanned broad population groups and issues, including veterans, homelessness and marginal housing, domestic violence, intellectual disabilities, immigrants, and refugees.

How is TIC Defined?

An important finding showed that in order to define TIC, the phenomenon of trauma itself must first be conceptually established. Analysis of the reviewed definitions found the current literature lacks conceptual clarity and definitional consensus for both trauma and TIC. In the reviewed literature, trauma has been defined in myriad ways, ranging from very narrow biomedical diagnostic criteria to broad definitions encompassing psychosocial, cultural, and historical components (see Online Appendix 2). Based on analysis of the reviewed definitions and for the purposes of this study, we define trauma as when an event, or series of events, overwhelm an individual's capacity to psychologically self‐regulate and can negatively affect the individual's internal well‐being, inter‐personal relationships, and functioning in society.

The conceptual definition of TIC has also been discussed in a wide‐ranging manner (see Online Appendix 3). Upon iterative analysis of extracted data from the reviewed literature, we define trauma‐informed care as a bidirectional relationship between the trauma‐affected individual (who can be a consumer or provider of services) and a provider of human services (who can also be affected by trauma) within a culture fostering mutual resilience supported by an integrated referral network which allows the bidirectional relationship to occur vertically, within one system of care, and horizontally across other systems of care if needed.

How is TIC Operationalized?

During synthesis of the systematic review results it became apparent that the reviewed literature lacked a comprehensive description of how TIC can be operationalized. To better understand the operationalization of TIC we (1) summarized the operationalization of TIC as described in the literature and (2) analyzed the synthesized literature on TIC operationalization in order to generate an original conceptual framework.

How TIC is Operationalized as Described in the Literature

A common theme in the results of the systematic review related to the orientation of how TIC is operationalized. ⁶ , ³³ , ⁴³ , ⁴⁶ We have termed this vertical TIC and horizontal TIC, meaning TIC can be operationalized vertically within systems of care and horizontally across systems. Within systems, TIC can be operationalized at three levels—programs/services, organization, and system. ¹⁷ , ⁴⁷ , ⁵³ We identified specific barriers and facilitators to the operationalization of TIC at each of these levels (see Table 1). Additionally, the context of the system has particular implications for how TIC is implemented. For example, TIC implemented within the child welfare system includes addressing foster placement instability whereas TIC in the criminal justice system encompasses recognizing how the experience of trauma can impact an individual's court testimony. ³¹ , ⁵⁴ , ⁵⁶

Table 1.

How Trauma‐Informed Care is Operationalized Vertically Within Systems of Care and Horizontally Across Systems of Care

Level Within and Across Systems	Barriers	Facilitators	Sources
Program and services level Universal trauma precautions—treating everyone as though they have a trauma history (e.g., In health, allowing patient to collect vaginal swabs; in social services, providing service users with as much choice as possible) Universal context‐adapted trauma assessment on trauma exposure and resilience skills	Uneven commitment from front‐line staff to change in practice (TIC perceived by some providers as latest hot topic) Ambiguity of TIC—unclear to providers when TIC is actually being implemented (versus good care with a trauma lens)	Growing awareness among pockets of front‐line service providers regarding need for TIC Growing body of empirical research is beginning to demonstrate positive gains of TIC in service delivery	6,7,17,20,22,46,47,49,60,62,65,76,79,84,86,87,94,106,107,110,113,118,119
Organizational/systems level Trauma education and training for all staff Trauma‐informed policies/procedures across all organizational levels Incorporating consumer/stakeholder input into policy decisions regarding systems arrangements, including program/service delivery Visible senior management/executive support for TIC	Service providers resistant to trauma awareness (screening) if system unable to respond appropriately to trauma by providing effective and accessible trauma services	Emerging evidence demonstrates education/training can act as strong facilitator in TIC implementation Use of trauma champion(s) and/or leadership team identified as central to operationalization	6,28,30,43–47,49,52,55,62,63,65,66,76,86,88,91,92,96,106,107,111,113,120–127
Inter‐sectoral level Recognized need to create common TIC language across all systems Clearly identified roles/responsibilities across systems Integrated funding across systems for TIC Established referral networks with increased access to mental health providers specializing in evidence‐based TIC	Lack of vertical preparation within systems and horizontal preparation across systems can limit infrastructure required for TIC as distinct approach to care (e.g., establishing referral networks to ensure trauma services readily available) Financial infrastructure needed to support intersectoral collaboration (e.g., identifying how sustainable funds can be generated and by whom) Current lack of resources/services for positive trauma screens	Increasingly widespread recognition of prevalence of trauma has demonstrated gap in current care across all systems Service providers across systems recognize need for TIC and some awareness that TIC presents viable solution	6,7,18,43–47,60,62,65,76,85,88,106,113
System‐specific
Child welfare Universal trauma screening/assessment Provider training on TIC including foster parents Reduce placement instability Close collaboration with trauma‐informed mental health services (traumatized children being mis‐diagnosed or under‐diagnosed due to symptomology overlap with other childhood disorders)	Institutional policy legacy: standard operating procedures (e.g., child removal/placement instability) High staff turnover Heavy caseloads	Recognition of high trauma prevalence among children involved in child welfare services Some regions/countries actively working on reducing re‐traumatization of child welfare children, particularly harm caused by instability of out‐of‐home placements	7,19,28,43,44,51,55,63,64,76,86,87,128,129
Education Incorporate TIC into educational curriculum (primary, secondary and tertiary)—students taught emotional regulation and resiliency Create trauma‐sensitive classrooms (with sensory stimulus activities to de‐escalate triggered students and equip teachers to deal with vicarious trauma)	Institutional policy legacy: traditional pedagogical approach Some provider resistance that TIC is beyond scope of teachers	Recognized link between trauma exposure and student academic difficulties Increased acknowledgement that stability and structure of daily school routine is the ideal setting for creating trauma‐informed education	22,29,45,50,58,60,108,112,119,123,130–132
Health Trauma screening becomes normalized, particularly in gatekeeper settings such as emergency departments and primary care Trauma‐informed approach, particularly for invasive procedures and necessity for exposure of body parts, which can be difficult and triggering for patients with trauma histories Provider actions unique to health include full explanation of appointment in advance, granting options for patient to sit or stand during exams, inquiring about patient preferences if possible, provider acknowledgement that exam/procedure may be upsetting with information provided regarding emotional regulation skills	Institutional policy legacy: pathology of symptoms and limits of diagnostic criteria Insufficient provider time Lack of physician billing codes for TIC	Growing body of scientific evidence correlating trauma exposure and negative health outcomes, particularly chronic disease (e.g., ACE studies) Empirical studies demonstrate effectiveness of TIC particularly in mental health/addictions services	18,19,47,48,57,62,70,75,78,79,82–84,88,91,95,103–105,110,111,118,121,133–137
Justice Judicial staff, particularly police, prosecutors and judges, trained to recognize and respond to trauma symptoms in victims, especially children/youth Courts minimize triggers for trauma‐affected individuals, particularly victims/witnesses being cross‐examined Prisons/corrections facilities aware of high trauma prevalence amongst offenders and respond appropriately	Institutional policy legacy: punitive justice; traditional court‐room proceedings ‐ mechanisms of cross‐examination and failure to acknowledge traumatic memory recall differs significantly from neutral memory recall; infrastructure of corrections facilities	Acknowledgement of system barriers for victims of crime and potential for victim re‐traumatization in justice system Growing awareness of high prevalence of trauma amongst offenders and need to provide TIC in corrections services Some justice systems setting precedence through incorporation of specialized mental health/addictions courts and integration of mental health/trauma services in corrections facilities	6,30,31,49,61,65,66,80,96,138
Social services Trauma‐informed case management, which focuses on preventative measures (crisis interventions planned in coordination with service user) and moving past symptom management/reduction to focus on skills‐building and resiliency	Institutional policy legacy: siloed services TIC least developed conceptually in comparison to other systems – in current literature TIC is not clearly distinct from good care	Increasing recognition of high trauma prevalence amongst social services populations including those experiencing homelessness, veterans, refugees and immigrants, domestic violence and intellectual/developmental disability populations	8,17,32,53,59,94,124,139–141

Two types of barriers to the operationalization of TIC were noted across systems of care in the reviewed literature. These are categorized as infrastructural barriers, meaning physical or organizational obstacles, and ideological barriers, meaning opposition to TIC on the basis of ideas, perspectives, and understanding. Infrastructural barriers include inadequate resources such as insecure funding and lack of validated trauma screening tools as well as system design barriers such as lack of established referral networks and insufficient availability of trauma services. ³¹ , ⁵⁵ , ⁵⁷ , ⁵⁹ Ideological barriers include provider resistance to TIC due to poor understanding of trauma, perceptions of TIC as weak or ineffective, and lack of adequate training and education on what, precisely, is TIC and how to operationalize it both vertically and horizontally. ²⁸ , ⁴⁶ , ⁶⁰ , ⁶² These barriers are explored in greater detail in the section titled “What Factors Explain Whether and How TIC is Operationalized?”.

Conceptual Framework

The conceptual framework (see Figure 2) was developed based on thematic analysis of the synthesized documents included in the systematic review. This framework was intentially developed as a generic model denoting what variables are required to operationalize TIC, which allows the framework to be applied across contexts and systems. The language of trauma‐informed care is intentionally used in Figure 2 in relation to both health and nonhealth systems to capture the essence of human service delivery systems, which is to provide some type of care to members of society in need. The concept of care is not exclusive to clinical care and it is important to recognize that nonhealth systems also provide care through services that seek to enhance the general welfare and well‐being of individual members of society or communities as a whole. For this reason, the phrase trauma‐informed care is used in the conceptual framework and throughout this paper. It is also important to note that while this study focuses exclusively on five systems, TIC is not limited to these systems.

Defining Key Concepts of the Framework

Several concepts outlined in the conceptual framework require definitional clarity. Definitions of the italic terms below were derived from thematic data analysis as described above. Vertical TIC is defined as TIC that is operationalized at the following three levels within one specific system: program (or service), organization, and system. The bidirectional arrows linking these three levels indicate that vertical TIC can start from a bottom‐up approach (beginning with programs or services), a top‐down approach (beginning with the system) or a combination of both bottom‐up and top‐down approaches. Horizontal TIC is defined as TIC operationalized across systems that are unified by an integrated referral network. An important aspect of horizontal TIC is clear role delineation for service providers across different systems of care and to ensure non‐clinical service providers are able to implement TIC while remaining within their scope of practice. Classroom teachers within the education system or case managers within the child welfare system, as an example, play an essential role to the operationaliation of TIC by creating trauma‐informed spaces that acknowledge trauma and seek to mitigate further harm. They are not, however, mental health professionals and an essential component of horizontal TIC is to enable front‐line staff to know when, how and where to refer an individual requiring assistance in managing traumatic experiences.

When analyzing data regarding TIC outcomes, three categories emerged. These three outcome categories are defined as (1) service user outcomes, which include reduction in trauma symptoms, behavioral issues and service user crisis, and improved service user engagement and retention in programs/services (2) outcomes for both service users and providers, which include improved overall mental health and well‐being, mutual respect, and an enhanced sense of safety (3) service provider outcomes, which include reduction in service provider fatigue and burnout related to secondary trauma, reduction in service provider injuries, improved service provider morale, lower staff turnover and greater collaboration among service providers within and across systems.

Description of the Framework

As depicted in Figure 2, TIC is oriented vertically and horizontally, with the point of intersection captured via an integrated referral system. The referral network, which links vertical TIC and horizontal TIC, allows nonhealth systems to rapidly refer service users to trauma‐specific treatment or mental health services when needed. The integrated referral network is also relevant for health systems, as different health specialities and service areas will need timely access to a trauma‐specific referral system if they identify a positive trauma screen and additional support and care are required.

The trauma‐affected individual is situated centrally within the figure, as the purpose of human service delivery systems is to improve the quality of life for the serviced population. The three concentric circles emerging from the trauma‐affected individual reflect that trauma has a three‐dimensional impact on the affected individual. First, there is the internal experience of psychological distress and emotional dysregulation due to the experience or perception of life becoming uncontrollably unsafe as a result of the traumatic event or series of events. Second, the individual's interpersonal relationships can be affected as trauma often leads to a profound sense of disconnect. Finally, the individual's role in and relation to broader society can be altered due to trauma sequelae and behavioral adaptations. It is important to note that trauma can affect one, two, or all three of these domains.

Encompassing all aspects of TIC and the individual is a culture of resilience. It is important that individuals affected by trauma are not treated simply as victims, but that their treatment or service milieu is infused with a focus on resilience, by identifying strengths, building skills, and facilitating choice. Likewise, a culture of resilience is essential for programs/services, organizations, and systems rather than a culture of control with rigid inputs and outcomes. As depicted in the figure, there are fundamental components to each level of vertical TIC. Horizonal TIC consists of intersectoral collaboration across systems, which includes mutually established and clearly defined roles for involved service providers and the creation of a common trauma language to ensure that service providers across systems are on the same page and can efficiently communicate.

Finally, on the right of the figure are the outcomes of TIC, which are divided into three categories. The circle labeled days, weeks, months, and years, which encompasses outcomes, reflects that both service users and providers fall along a continuum acknowledging that a variety of complex variables contribute to individual recovery, which looks different from person to person. Outcome measurements are not time‐limited as the healing trajectory is often not linear and can involve processing complex layers of issues over a prolonged period of time.

What Factors Explain Whether and How TIC is Operationalized?

The factors explaining whether and how TIC is operationalized are organized into two categories—political system factors and system arrangements. The theoretical framework outlined in Figure 3 was developed from deductive analysis using the 3‐I framework and the health and social system arranagements taxonomy.

Figure 3.

Factors That Affect the Operationalization of Trauma‐Informed Care

Political System Factors

Political system factors are divided into three components – institutions, interest groups and ideas (see Table 2).

Table 2.

Political System Factors That Influence How Trauma‐Informed Care is Operationalized

Political System Factors	Relevant Themes	Relationships With Other Factors	Key Examples From Literature		Sources
			Barriers	Facilitators
Institutions	Limited evidence on how TIC is affected by institutions	Limited government support may reflect lack of substantial empirical evidence detailing effectiveness of TIC	• Cyclical nature of elected parties within government structures can be barrier to achieving sustainable, long‐term government support, particularly as TIC very new and relatively untested concept • Policy legacies related to past decision‐making in siloed structure of public bureaucracies creates significant challenge to implementing cross‐sectoral approach to TIC	The government structure of federal states can more easily facilitate uptake of TIC given the partial self‐governing of states or provinces, such as the US in which certain states have already begun implementing TIC at the state level	21,31,45,55,61,63,65,75,76,80,142
Interests	Professional organizations can act as either facilitators or barriers to TIC implementation depending on if they support or resist TIC	Some interest groups are using empirical evidence (ideas) to demonstrate need for TIC within workplace or service area, including evidence on prevalence of vicarious trauma amongst providers	Some professional groups resistant to TIC's call for role expansion (e.g., teachers implementing trauma interventions in classroom)	• When relevant interest groups (e.g., professional organizations) “buy‐in” to implementation of TIC and are adequately supported (management, personal support services to address vicarious trauma) they can act as a facilitator	22,30,33,45,46,49,51,53,55,59,61,63,65,66,75,76,78–80,82,86,87,96,108,110,112,124
				• Interest groups recognize service providers can benefit from TIC as evidence outlines prevalence of vicarious trauma amongst service providers across systems and specific providers have begun advocating for workplace TIC to support staff
Ideas	Knowledge and beliefs • Rationale for TIC uses empirical evidence to demonstrate need (epidemiology of trauma) • Empirical studies in field of neuroscience suggest need for trauma‐informed services • Routine screening for trauma exposure/impact identified as essential across systems Values and mass opinions • Perspective shift from pathologizing behavior to recognizing role of trauma in behavior	• Increased awareness of empirical evidence on trauma has generated interest group support for TIC • Lack of substantial empirical evidence on effectiveness of TIC likely contributing to limited government support (institutions)	• TIC lacks conceptual clarity (divergent values regarding what TIC ‘ought to be’ reflected in projection of implementation strategies)	• Research evidence suggests population need for TIC	21,28,43,44,92,123,125,143 6,8,28,33,46,61,69,70,75,84,94,96,110,112,124,133,135,139,143

Institutions

With regard to institutions, institutional policy legacies were identified across all systems as a significant barrier to TIC. In child welfare, the legacy of standard operating procedures, which include child removal from the home and heavy reliance on use of foster homes are a deterrent to change, despite wide recognition that both procedures can be significantly traumatic for the child, particularly the instability of foster home placements. ¹⁹ , ⁵¹ , ⁶³ , ⁶⁴ In education, the legacy of educational policy and pedagogy, particularly as it defines the scope of a teacher's role in the classroom, has created resistance to TIC amongst some educators. ²⁹ , ⁴⁵ In justice, the legacy of punitive justice and traditional courthouse and corrections facilities procedures has challenged TIC, particularly as some judicial staff have identified TIC as “soft” and excusing bad behavior. ⁶¹ , ⁶⁵ , ⁶⁶ , ⁶⁷ The health system has a strong legacy of pathologizing symptoms and providing care based on diagnostic criteria. ⁶⁸ Lack of trauma awareness and understanding amongst health providers has been linked to the dismissal of trauma symptoms and narrow diagnostic criteria regarding trauma has limited perceived medical validity of trauma symptomology. ¹⁸ , ⁴⁶ , ⁶⁹ , ⁷⁰ Finally, the legacy of social services as siloed programs present a challenge to TIC. ¹⁷ , ⁵³ , ⁵⁹ , ⁶² As one example, service providers in a housing program felt the inclusion of TIC was beyond their scope.⁵⁹ Addressing the impacts of policy legacies across systems of care as they relate to the operationalization of TIC will be critical moving forward.

As noted above, an identified facilitator of TIC under institutions is the government structure of federal states, which allows for easier facilitation of TIC due to the partial self‐governance structure of states or provinces. This is particularly evident in the United States, where several states have already begun implementing regional and state‐wide TIC initiatives. ²¹ , ⁵¹ , ⁵⁵ This can also be seen in Canada, where certain provinces have developed regional or provincial TIC initiatives. ⁷¹ , ⁷² , ⁷³

Interest Groups

Interest groups, as a political system factor, had significant influence in the operationalization of TIC. Service provider resistance to TIC surfaced repeatedly as a common theme across all systems. ⁴⁵ , ⁴⁶ , ⁵³ , ⁵⁹ , ⁶¹ , ⁶³ , ⁷⁴ , ⁷⁵ , ⁷⁶ , ⁷⁷ Service providers represent a powerful interest group and their perception that TIC will create direct and diffuse costs for providers has resulted in significant resistance. The various reasons service providers are resistant to TIC include lack of time, paucity of resources, inadequate training, concerns that trauma screening will cause distress in the service user, fear of not being equipped to deal with trauma disclosure, resistance to provider exposure to trauma, concerns about vicarious trauma, perceptions that TIC is ineffective and beyond the scope of practice, and insufficient financial infrastructure to ensure provider remuneration for services provided. ³³ , ⁴⁵ , ⁴⁶ , ⁵² , ⁵³ , ⁵⁹ , ⁶⁵ , ⁷⁵ , ⁷⁶ , ⁷⁸ , ⁷⁹

Ideas

The final component of political system factors is ideas, which includes both knowledge and beliefs about what TIC is, as well as values and mass opinion about what it ought to be. Established knowledge regarding the epidemiology of trauma as a facilitator for TIC was a common theme across all systems, with widespread recognition that trauma is pervasive and impacts all human service delivery systems. ²¹ , ²⁸ , ⁴⁴ Additionally, the literature suggests that advancements in neuroscience have also helped facilitate TIC by dispelling the pathology of trauma symptoms as “bad behavior” thus, making TIC more tenable to providers. ¹⁸ , ²¹ , ⁸⁰ , ⁸¹

There are two barriers under ideas that hinder the operationalization of TIC. The first involves a paucity of empirical research regarding the effectiveness of TIC, which has just started to emerge within the last few years. Second, as discussed above, the lack of conceptual clarity and definitional consensus regarding both trauma and TIC can negatively influence the acceptance of ideas about TIC. In the absence of widespread agreement on what is TIC, the current status of TIC literature primarily consists of value‐statements regarding what TIC ought to be. ⁴³ , ⁴⁷ , ⁸²

System Arrangements

The results of how systems arrangements affect TIC operationalization are outlined within the four system components—governance arrangements, financial arrangements, delivery arrangements, and implementation strategies (see Table 3).

Table 3.

System Arrangements That Influence How Trauma‐Informed Care is Operationalized

System Arrangement Factors	Relevant Themes	Relationships With Other Factors	Key Examples From Literature		Sources
			Barriers	Facilitators
Governance arrangements	Policy authority
	Centralization/decentralization of policy authority	Policy (and funding) support from relevant levels of policy authority identified as critical for sustainable implementation of TIC (C6)	Coordinating policy authority across systems may be challenging	Decentralization of policy authority can enable more efficient implementation of TIC, as seen in some states in the US	6,21,28,43,44,46,49,62,85,88,106,113
Organizational authority
	Management approaches	Senior management “buy‐in” for TIC identified as critical, particularly in relation to staff support; Management engagement with front‐line staff seen as important for sustained commitment by staff to TIC	Front‐line staff feel less supported in TIC and less motivated to embrace TIC implementation if regular management presence lacking	When administrators/executives provide strong leadership for TIC, increases feasibility and sustainability of implementation	18,28,47,62,63,78,84,95,110,111,122,125
	Networks/multi‐institutional arrangements Collaborative, intersectoral training argued to be more cost‐effective and practical (establishing common language, clear roles/responsibilities amongst agencies) Continuity of care/collaboration across systems	Intersectoral collaboration, particularly close collaboration between mental health providers and relevant systems (justice, social services, education, child welfare) identified as central element of TIC	Lack of common language Lack of timely referral process (to mental health services) Lack of integrated funding	Increased recognition within systems of need for trauma‐informed, mental health services	6,43–46,49,62,76,85,86,88,106,144
Consumer & stakeholder
	Consumer participation in policy and organizational decisions	Consumer participation at this level allows critical insight from service users to contribute to service delivery design	Service users invited to participate in decision‐making might hesitate out of concern that involvement may impact their care	Increasing awareness across systems at the system level of importance in facilitating service user feedback to monitor system performance Can be personally meaningful and empowering for service users	6,62,84,87,88,106,107,110
	Consumer participation in system monitoring	Participation of service users on advisory boards reviewing user feedback can provide important insight for providers into contextual factors regarding feedback	Inherent power dynamics can allow for easy dismissal of service user input	Increasing awareness across systems at the system level of importance in facilitating service user feedback to monitor system performance Can be personally meaningful and empowering for service users	6,106,107
	Consumer participation in service delivery	Appropriate use of peer support/mentorship in TIC is cost‐effective and helps mitigate current shortage of service providers trained in TIC	Paucity of research examining use of peer support/mentorship in TIC	Use of peer support/mentorship in TIC can empower service users and minimize power imbalance between provider and consumer	65,87,88,106
	Stakeholder participation in policy and organizational decisions or monitoring	Stakeholder participation in policy/organizational decisions regarding operationalization of TIC created better provider “buy‐in” increasing effectiveness of provider delivery/implementation of TIC	Importance of stakeholder participation not widely recognized in literature	Participation via feedback in provider training provides built‐in opportunity to incorporate stakeholder participation	87,91,106,144
Financial arrangements	Financing systems
	Private insurance in health has been the only system‐level, revenue‐raising mechanism identified in the literature	Financial arrangements are an integral component to sustainable TIC delivery arrangements and implementation strategies; without established TIC financial infrastructure for system financing, the delivery and implementation of TIC is weakened	Developing a financial system for TIC will be challenging given TIC operationalization remains inchoately understood More rigorous evaluation of TIC outcomes likely needed first to justify opportunity costs of TIC system‐level financing	The financial cost to systems in not providing TIC has been identified in the literature Cost‐sharing across systems can increase efficiency and reduce overlap (shared funding of combined staff training across systems when appropriate, such as justice and mental health/addictions)	33,46,47,79,90,106
Funding organizations
	Prospective payment	Adequate prospective payment for TIC directly relates to feasibility of delivery arrangements and implementation strategies; lack of established financial arrangements currently poses significant barrier to sustainability of TIC	Anticipated implementation costs, such as staff training and development, consultation fees, costs related to creation of trauma tool kits etc., have not been widely incorporated into organizational funding mechanisms and lack of funding has been cited across systems as a barrier		31,52,145 62,146–148
Remunerating providers
	Fee‐for‐service	Health care providers are much less likely to provide TIC if they are not able to be reimbursed for services provided	The lack of an established billing codes for TIC is a significant barrier, even when training and consultation is provided free of charge	Research indicates a growing awareness and willingness amongst providers for TIC if they are paid/reimbursed	19,91
Purchasing products & services
	Scope & nature of insurance plans	Service providers across systems will likely not provide TIC if mechanisms lacking for remuneration of TIC services	Partial or absent insurance coverage for TIC and trauma‐specific services has been identified as central barrier across the systems for both service users and providers		46,90,106,149
	Restrictions in coverage/reimbursement rates for organizations, providers, & services		Only certain psychiatric diagnoses qualify for reimbursement and not all psychiatric services are eligible for full reimbursement		150,151
Delivery arrangements	How care is designed to meet consumers’ needs
	Availability of care	Expanding availability of TIC requires stable funding infrastructure and sufficient workforce	Current lack of funding for staff training and TIC service delivery Providers reluctant to assess for trauma when low availability of and accessibility to trauma services and care	Increasing awareness within and across systems of need for TIC	28,33,43–45,51,52,57,60–63,65,76,96,104–106,118
By whom care is provided
	System—Need, demand, and supply	Identified need for more MH professionals trained in evidence‐based trauma‐informed treatment; providers reluctant to complete universal trauma screening if they are unable to refer/provide adequate supports/treatment to respond to positive screens	Lack of established, secure financial arrangements for provider training and remuneration will continue to be barrier, despite increasing recognition for more professionals to be trained in TIC	TIC being incorporated into the curriculum of some university‐level provider training programs	28,33,43,44,49,51,52,63,76,106
	Skill mix—Role expansion or extension	Clear delineation of service provider roles within and across systems needs to be outlined in governance arrangements and incorporated into provider training	Some service providers outside health system concerned that providing TIC is beyond their scope of practice	Intersectoral collaboration, including a referral network to appropriate services for positive trauma screens, has been outlined in literature to support non‐health service providers in TIC	92,113
	Staff—Training	Sufficient workforce with appropriate training is essential to adequate service delivery	Empirical research identifies some providers are uncertain as to how TIC differs from “good care” due to current ambiguity of TIC conceptualization Evaluation tools to measure TIC outcomes remain poorly defined and tested, which limits feedback to staff regarding impact of TIC	Service providers cross‐trained in TIC are better equipped to identify and handle the complex etiology of trauma Increased TIC awareness through staff training can enable providers to more readily identify trauma symptoms and facilitate referrals to necessary services	6,18,44,45,55,62,65,66,75,78,83–85,87,88,91,92,106,107,110,113,123–125,127,144,152
	Staff—Support	Recognition of prevalence of vicarious trauma amongst service providers holds implications for governance arrangements (policies, management approaches) and financial arrangements (providing medical benefits)	Denial or rejection of vicarious trauma acts as barrier to TIC (staff burnout, retention problems, resistance to TIC when staff not supported in dealing with vicarious trauma)	Acknowledgement of vicarious trauma is becoming more culturally acceptable in systems, such as justice, where traditionally it was seen as weak Need for adequate support services for providers dealing with vicarious trauma emerging as prominent theme in literature	6,63,75,87,96,106,127,153
Implementation strategies	Consumer‐targeted
	Information or education provision	Intention of human service delivery systems often includes helping individuals in need through provision of information/education and skills	Service users have identified insufficient provision of information/education on self‐management of trauma symptomology due to lack of TIC or poorly trained staff	Studies in neuroscience indicate the brain can recover from trauma when the right tools and skill‐set are provided Emerging empirical research suggests information/education and skills development can empower service users to better manage trauma symptoms	44,88,107
	Skills and competencies development				88,107
	Culturally appropriate care	Recognizing unique needs across diverse population groups is a critical component of TIC and directly relevant to design of governance and delivery arrangements	Some service providers have indicated high‐volume caseloads limit time needed to establish and provide for specific cultural needs	The principles of TIC provide a platform for culturally sensitive care by addressing power imbalance and attentiveness to unique needs	44,62,88,94,107
Provider‐targeted
	Educational material	Directly relates to staff training and sufficient workforce for service delivery	Conceptualization and operationalization of TIC currently poorly defined and established	Growing body of empirical research on operationalization of TIC across different settings is providing important insight	17,30,55,60,78,80,85,86,88,91,92,107,108,110,111,113
	Organization‐targeted
	Organizational policies/procedures incorporating TIC reflect serious commitment by senior leadership/management, which acts as impetus for increased staff compliance in TIC implementation	Lack of organization‐targeted implementation strategies acts as barrier as it isolates front‐line staff in bearing full responsibility for TIC	Organizational self‐assessment tools (e.g., agency walk‐throughs and various toolkits) for TIC Align policy and practice to principles of TIC Increased recognition of organizational role in re‐traumatization of service users when TIC not provided	6,18,28,30,44,47,52,65,76,78,83,86,92,95,96,103,106,107,110,111,123,125,127,132,152,154

Governance Arrangements

First, within governance arrangements, both policy authority and organizational authority were identified as central to TIC. ⁶ , ²⁸ , ⁶² Regarding policy authority, successful operationalization of TIC requires clear policies and procedures at the program, organization, system, and inter‐sectoral level. Lack of consistent policies and procedures across all levels has been demonstrated to significantly impede meaningful operationalization of TIC. ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ Regarding organizational authority, management approaches, particularly ongoing and visible support from top leadership, is noted to be essential. ⁷⁵ , ⁷⁸ , ⁸⁷ , ⁸⁸ , ⁸⁹

Financial Arrangements

Lack of financial infrastructure supporting TIC has hindered operationalization, both within health and across other systems. For example, insurance plans rarely provide coverage for trauma services, which decreases accessibility to trauma services for individuals with constrained financial resources. ³³ , ⁴⁶ , ⁹⁰ Additionally, physicians often lack billing codes for TIC, which limits their ability to provide TIC services. ¹⁹ , ⁹¹ Furthermore, many providers have to pay out‐of‐pocket for TIC training and are inadequately compensated for their work, which contributes to human resource shortages in trauma services. ¹⁹ , ⁸⁸ Lastly, sustainable funding at the organization, system and inter‐sectoral levels has yet to be established in many systems. ³¹ , ⁴⁴ , ⁹² This lack of financial infrastructure exists despite the existence of some evidence that suggests TIC is more cost‐effective, particularly within the health system. ⁹³

Delivery arrangements

A precursor to effective delivery is adequate provider training in TIC that encompasses trauma awareness, understanding trauma impacts and adopting appropriate responses to individuals with trauma histories. ²² , ⁷⁹ , ⁹⁴ At the same time, support to providers delivering TIC was frequently discussed in the reviewed articles. ²⁸ , ⁶² , ⁷⁵ , ⁹⁵ This literature recognizes that service providers may be affected by their own personal trauma histories, and/or through the effect of repetitive professional exposure to trauma, which is particularly common in child welfare and justice services. ³⁰ , ³³ , ⁵¹ , ⁸⁶ , ⁸⁷ Experiences of vicarious trauma, burn‐out and compassion fatigue have been identified by service providers as significant barriers to TIC that require adequate mitigation and support. ⁶ , ⁴⁴ , ⁸⁷ , ⁹¹ , ⁹⁶ , ⁹⁷ The COVID‐19 global pandemic has further heightened awareness of vicarious trauma amongst service providers and led to the recognition of TIC as a necessary support for providers amid the crisis. ⁹⁸ , ⁹⁹ , ¹⁰⁰

The reviewed literature often recommended the use of multidisciplinary or intersectoral teams that integrate a health care provider who specializes in trauma into nonhealth services. This delivery approach featured most prominently in child welfare, education and justice services, but also surfaced in health and social services. ³¹ , ³³ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁶⁰ , ⁷⁶ , ⁸² , ¹⁰¹ , ¹⁰² A related theme was the need for rapid referral systems that provide timely access to trauma services. ⁷ , ⁴⁶ , ⁶² , ¹⁰³ , ¹⁰⁴ Across all systems, there was discussion of provider resistance to trauma screening in the absence of a clear protocol for how to respond to positive screens and when the appropriate treatment and resources were not readily available. ⁴³ , ¹⁰⁵ , ¹⁰⁶

Implementation Strategies

The reviewed literature discussed a range of TIC implementation strategies that were targeted to different groups: consumers, providers, and organizations. Lack of access to clearly defined and pragmatic TIC educational training was a barrier for both service users and providers. ⁴⁴ , ⁸² , ⁸³ , ⁸⁴ , ⁹⁶ Consumer‐targeted implementation strategies focused primarily on education and skills development related to emotional regulation and self‐management of trauma symptoms. ⁴⁴ , ⁸⁸ , ¹⁰⁷ Provider‐targeted strategies were focused on staff training regarding trauma awareness and the provision of TIC. ¹⁷ , ³⁰ , ⁵⁵ , ⁶⁰ , ⁸⁵ , ¹⁰⁸ The use of organizational self‐assessment tools and ensuring policies and procedures were aligned to the principles of TIC were key strategies targeting organizations. ⁶ , ³² , ⁵⁵ , ⁸⁸ , ¹⁰⁹ , ¹¹⁰ Across all strategies, the use of evidence to inform strategies was found to be a significant facilitator of TIC implementation. ⁷⁸ , ⁸⁰ , ⁹² , ¹¹¹

Discussion

The concept of TIC has yet to achieve widespread consensus in the literature regarding definitional understanding. Furthermore, TIC remains difficult to operationalize consistently and in a comprehensive manner, in part, because the concept of trauma, which TIC seeks to address, lacks an established and accepted definition and is neither consistently recognized or understood within systems of care. Thus, if the concept of trauma, itself, remains contested, it is not surprising that emerging solutions to address trauma (TIC), will also lack definitional consensus and clarity. It is important to acknowledge, however, that TIC is a newly emerging phenomenon and the majority of empirical studies have been published within the last few years. Additionally, published TIC literature is disproportionately theoretical and of the 98 included articles for this study, only 38 were empirical research papers. While one type of document or methodology was not more heavily weighted than another, the comparative paucity of TIC empirical studies in relation to theoretical commentaries is noteworthy. It is not surprising, given the complexity of trauma and the newness of empirical research on TIC, that the scientific literature is still working towards establishing consensus regarding what is TIC and how best to operationalize it. While the conceptual framework developed in this study provides a robust and comprehensive definitional understanding of both trauma and TIC, it will need to be tested within and across systems of care.

Systems arrangements also affect whether or not TIC is operationalized. From a governance perspective, service user participation to inform policy decision‐making can be an important facilitator of TIC implementation. ⁶ , ⁶² , ⁸⁷ , ¹⁰⁷ Similarly, from a delivery perspective, improving provider access to TIC training, greater availability of TIC treatments for consumers, and the use of multidisciplinary teams encompassing TIC‐trained healthcare providers in non‐healthcare services can be important facilitators. ⁶⁰ , ⁶² , ¹⁰⁷ The lack of comprehensive financial arrangements such as inadequate insurance coverage, lack of physician billing codes, and non‐sustainable funding, compound siloed and poorly coordinated cross‐sectoral delivery system structures that act as barriers to TIC. ¹⁸ , ²¹ , ⁸⁸ , ⁹¹

Strengths and Limitations of the Study

There are three major strengths to this study and one limitation. First, the methodology of a CIS is most suited to an emerging concept, which lacks comprehensive understanding in the literature. Given that TIC is a newly emerging phenomenon with limited empirical research, the use of a CIS is a methodological strength in that it best fits with the challenges of TIC, particularly the lack of conceptual clarity and widely‐agreed upon definition. Additionally, use of a CIS allowed for broad data collection, including empirical research, theoretical papers and information‐rich grey literature, which was important given the scope of data required across systems, some of which were just beginning to evolve in the TIC discourse. Second, the research team held considerable clinical experience and understanding of the cross‐sectoral issues of trauma and TIC. Additionally, the research team also held extensive experience in political system analysis and health and social systems arrangements, which allowed for rigorous data analysis and the development of several iterations of the conceptual framework to ensure rich conceptual insight. Third, to our knowledge, this is the first study to examine trauma and TIC both vertically within health and horizontally across child welfare, education, justice and social services. The inclusion of data across various aspects of the health system, as well as other systems, allowed for comprehensive data collection and analysis, which resulted in the generation of a conceptual framework that provides foundational insight into definitional understanding and operationalization of TIC.

The emerging nature of TIC posed a limitation to the study as various labels and descriptors were found in the literature regarding TIC. Generated search terms were intentionally extensive in attempts to capture as much data on TIC as possible, but it should be noted that data may be missing given that at times TIC is discussed in the literature without express use of common descriptors or labels. In attempts to mitigate this, the first author maintained a documented list of various conceptual definitions related to TIC in the pilot phase of the search strategy, which was used to inform the finalized list of search terms. Additionally, the first author collaborated with an expert librarian on several occasions to test and revise the search terms and strategies in attempts to allay risk of missing data. It remains possible, however, that not all relevant data was included, particularly in light of the wide‐ranging descriptors of TIC and lack of definitional consensus within and across systems in the literature.

Implications for Policy and Practice

As outlined above, TIC requires clear and coordinated policies both vertically, within systems, and horizontally across systems. These policies will need to address political system factors, such as the role of interest groups, and system arrangements, such as the mechanisms of intersectoral collaboration, adequate financial infrastructure, and accessible resources for positive trauma screens. Specifically, clear policies need to be established outlining the roles and responsibilities of service providers and how TIC can be practiced at the program and service level as well as what TIC means at the organizational and system level. Additionally, there is some recognition in the literature that service‐user input should be included in the development of TIC policies, but there has been no acknowledgement regarding how to address the inherent power imbalances that exist between service user and service provider and between service user and system that allow for service user input to be easily discarded. This is important to address as TIC policy development and implementation continues to evolve. Finally, TIC implications for practice across systems will need to consider the bounds of various service providers’ scope of practice and how to utilize multidisciplinary teams to address this concern.

Regarding implications for practice, there are two important considerations. First, in order to successfully implement TIC in practice, particularly at the program and service level, it is imperative that issues stemming from provider resistance to TIC, namely lack of time, resources and support for providers, are addressed. Emerging empirical studies have shown that providers are receptive to TIC when they first fully understand what trauma is and how TIC can address trauma and, second, when they are adequately provided with the tools, resources and support to successfully implement TIC. Regarding the second consideration for practice, it is important to note that positive outcomes have already been achieved resulting from changes to practice at the grass‐roots level across systems. For example, despite the policy legacies of pedagogy within the education system, several American primary and secondary schools have been able to implement TIC, which has produced significant benefit to both staff and students. ²¹ , ⁵⁰ , ¹¹² Similarly positive results have been achieved in the health system, specifically in mental health services, and in child welfare and the criminal justice system. These studies demonstrate that despite the power of policy legacies, strong leadership and provider buy‐in within programs and organizations can create positive change. ⁶ , ⁵¹ , ⁵⁵ , ⁶¹ , ⁶⁶ , ⁷⁰ , ⁸³ , ⁸⁶ , ¹¹⁰

Implications for Future Research

As noted above, TIC is an emerging and inchoate concept and a paucity of empirical research exists on how TIC can be operationalized. Several gaps in the literature have been identified and need to be further explored. Specifically, virtually no empirical research has been generated regarding the financial infrastructure needed to support TIC. Viable financial arrangements are essential to addressing a number of current barriers to TIC, including provider training and support as well as mechanisms for rapid referral systems. The financial aspects of all of these issues need to be studied in greater detail. Additionally, much of the current research is siloed into specific systems, despite the repetitive call for inter‐sectoral collaboration, and this needs to be examined further. ³³ , ⁴³ , ⁴⁴ Intersectoral collaboration will require a multifaceted approach with buy‐in within and across systems. ⁴⁵ , ⁶⁵ , ¹¹³ Greater understanding is required regarding how to facilitate this. Furthermore, TIC represents an intricate response to a complex issue and requires collective problem‐solving and the rigorous testing of postulated solutions to address system barriers, particularly institutional policy legacies. Finally, the proposed conceptual framework requires further validation both within and across systems as the field of TIC continues to evolve.

Recently, TIC has been recommended as a response to improve patient care and address front‐line staff burnout as related to the COVID‐19 global pandemic. ⁹⁸ , ⁹⁹ TIC has also been recommended to address health inequities and social justice issues specific to certain population groups, such as ethnic minority communities ¹⁰⁰ , ¹⁰⁹ , ¹¹⁴ and the LGBTQ community. ¹¹⁵ , ¹¹⁶ , ¹¹⁷ It is unclear, however, how and to what extent TIC can address these issues—a global pandemic, social justice and human rights issues—and rigorous empirical research is required to further understand the role of TIC in crisis situations, such as the global pandemic, as well as applicability to specific population groups and broader societal issues.

Funding/Support: None.

Potential Conflict of Interest Disclosure: All authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. No conflicts were reported.

Supporting information

Appendix 1. Data Extraction Tool

Appendix 2. Various Definitions Conceptualizing Trauma

Appendix 3. Various Definitions Conceptualizing Trauma‐Informed Care