Inner setting
Culture
Norms, values, and basic assumptions in an environment related to its mission and purpose.
Organizational environments were described as inclusive, nonjudgmental, and patient-centered with compassionate staff who build trust through accountability, appropriate language/tone, protection of confidentiality, efforts to combat stigma/discrimination, and a trauma-sensitive service lens. Participants described a mission-driven culture where patient autonomy is promoted. Staff diversity was believed to be prioritized through hiring practices, with staff demographics often mirroring populations served. Some participants reported that representation is still a barrier, especially among clinicians, therapists, and leaders, with a perceived lack of value for diversity within upper management, which was experienced as re-traumatizing.
“Folks living with HIV […], showing them that they can trust us […] by just having the amazing staff that we have and building rapport and building relationships with people, and knowing that we have resources.” -Transcript 32: CBO provider
Networks and Communications
Nature and quality of internal social networks influencing work and patient care.
Overall, effective systems of internal communication were perceived to be in place for deescalating crises and supporting client relationships. Patient perspectives, needs, and feedback were informally captured during routine visits and shared in team meetings. Detailed intake assessments, advanced care plans, and mental health screenings were seen as important means of gathering and sharing patient information to provide the best care. Some participants reported fragmented teams and communication around crises. The degree of visibility of clients’ electronic medical records among providers garnered mixed perspectives, some advocating for greater visibility to avoid duplicative history-taking as potential re-traumatization, while others advocated for less visibility to protect confidentiality. Patients were nominally involved in organizational decision-making through community advisory boards (CABs) and ad hoc feedback surveys, which were cited as having unclear language, low client engagement, and poor representation among clients most difficult to reach. Similarly, CABs faced limitations such as scheduling conflicts, lack of client compensation, and insufficient policy and management support. Some noted feedback was often garnered from a few cherry-picked clients. The need for systematic and comprehensive consumer involvement and representative feedback was highlighted as necessary for a successful TIC program.
"Sometimes the peer team [is] overlooked in terms of what's really happening with the clients. […] clients may tell the case managers or even their therapists one thing and then we know an entirely different story, which usually we will tell the therapists if we refer them. […] just because the clients feel more comfortable with us, they will really tell us a lot more, which would help with helping them with their issues..." -Transcript 29: CBO leadership
Implementation Climate.
Tension for Change
Degree to which stakeholders perceive the status quo as intolerable and that change is necessary to improve care quality, client services, and staff wellness.
Difficulties in building client trust were connected to clients' past negative experiences with providers, unaddressed mental illness, high staff turnover due to burnout, client disengagement related to provider apathy, racial tension between client and provider, provider perception that patients often do not progress, and a lack of client privacy with too many assigned providers. Participants reported that trauma screenings were not provided comprehensively, universally, or routinely, and that there is a need for better trauma screening tools and documentation of results. Most identified a need for more trauma support services to better address client trauma.
"They don't trust people as a big umbrella. People may often come to us with a history of not being able to trust medical people. And so how do you establish that trust very quickly? I always tell a nurse, you get about 15 seconds when you walk in the room with that patient to establish a good relationship with them." -Transcript 8: Clinic leadership
"So, us being well educated about the topic is pretty vital in helping people feel a little more comfortable.[…] but support system barriers and stigmas and self-stigma are huge." -Transcript 32: CBO leadership
Compatibility
Alignment of intervention with personnel norms, values, perceived risks and needs, and fit with workflow and systems.
Participants reported that in addition to providing “excellent” clinical care, they work to destigmatize mental health services, foster trauma-sensitive spaces, and enrich interpersonal care by offering peer support groups among PWH. Participants unanimously recognized trauma as an issue affecting clients (e.g., trauma of HIV diagnosis/serostatus, childhood adversity, racial trauma) and acknowledged the need for TIC to optimize patient care. All supported the idea of working with a TIC coordinating program to improve TIC adoption. Many staff participants described current services as inherently trauma-informed but stated a need to prioritize staff wellness to improve retention of staff who work directly with traumatized patients while coping with their own trauma.
“[W]e could use trauma-informed care here to help the clients and measure client psychological wellbeing throughout the process. But also assist in supporting staff psychological wellbeing throughout the project. […] it would be very valuable for clinics across the board.” -Transcript 10: clinic leadership
Learning Climate
Leadership transparency and collaboration in decision-making; personnel’s perceived value; safety of environment; time and space for reflective thinking and evaluation.
Participants reported several facilitators to address implicit bias in the workplace including open and honest communication in staff meetings, comfort with healthy disagreements, and a climate of continued learning through conversations and reflection. Past trauma trainings were described as culturally inclusive and well-explained in comfortable environments, which were seen as facilitative of meaningful discussions that helped providers feel more confident at work. Having supportive, available supervisors who value discussion and feedback and are familiar with staff responsibilities were noted as ways for personnel to feel heard and valued. However, some participants cited leadership issues in engaging staff, including a lack of follow through on suggestions, change-resistant leaders who are disconnected from frontline work, and a lack of leadership diversity. In some organizations, engagement in TIC was disincentivized as uncompensated work.
"One area where I struggle is when I see unconscious bias happening. They're my coworker. So calling it out affects that relationship […] the best way to enact change in that is not just having trainings, but also calling it out when you see it.” -Transcript 1: clinic provider
Readiness for Implementation.
Leadership Engagement
Leadership commitment and involvement in TIC and prioritization of staff wellness.
Most participants could not elaborate on the extent of leadership’s support for TIC but noted there had been trainings, workshops, and/or discussion of TIC in meetings. Some noted that for a TIC program to be successful, leadership support and initiative was necessary, as was greater inclusion of community and personnel voice program design (i.e., versus leaders either designing programs without input or not being transparent about reasons or basis for changes). Participants in leadership roles, however, expressed support for TIC, along with barriers to implementation (e.g., lack of capacity/funding). Some leaders indicated their support of staff wellness, yet some personnel participants felt that their work-related trauma was not acknowledged by leadership and attributed high turnover rates to poor staff wellness. Some felt unheard and noted a need for more transparency in organizational decision-making.
“Like leadership, […] they're not really on the front, so they don't really know what's going on. […] they'll make a decision and you're like, why did you make that decision that doesn't work for us […] because we see X amount of patients […] I think sometimes leadership that aren't directly here and see what goes on every day, they can make decisions […] and trying to put that into practices isn't that feasible because they don't know the process.” -Transcript 12: health department provider
Available Resources
Resources dedicated to TIC.
Many participants credited their confidence in providing client care to a wealth of organizational resources and ongoing trainings. Some organizations provide a comprehensive “one-stop-shop” approach with several services available to clients within the same site. Participants viewed integrated onsite behavioral health services as a major benefit to staff when guiding patients through trauma and crises. Methods for promoting client safety included onsite services (e.g., security, mental health) and policies and procedures to promote respect and confidentiality. Some participants credited the work of committees, agency equity statements, and policies as assets for delivering culturally responsive services. Most participants identified capacity issues (e.g., short session times) as barriers to building trust, providing information, and empowering clients. Participants mentioned the need for onsite behavioral health, printed TIC materials, training to handle mental health crises for all staff, and increased staffing (especially Spanish speaking and therapists of color). Participants suggested TIC trainings should be reoccurring and incentivized (e.g., compensation or continuing education credits).
“One of the biggest challenges in working [as a provider] with our population is managing the effects of trauma that develop into behaviors […] Sometimes 30 minutes isn’t enough to deal with some of those behaviors, but also get the information that I need to plus being therapeutic…” -Transcript 1: clinic provider
Outer Setting
Patient Needs and Resources
Extent to which patient needs are assessed, known, and prioritized across systems.
A collective awareness existed about the need to screen and treat trauma, coupled with a recognition that mental health resources were lacking. Some viewed telehealth and online counseling as facilitators to meeting needs and increasing engagement, especially for those with transportation barriers. Barriers to providing care include clients’ unstable/unsafe home environments (e.g., intimate partner violence and challenges finding housing for clients with felonies), perceived judgement about medical adherence lapses, HIV stigma, and misinformation about HIV and sex education among family, friends, and PWH themselves.
“If a person doesn't go to the doctor on a regular basis, for whatever reasons, lack of trust of the provider, we look at that as a failure, versus really trying to understand that. […] but I think that a lot of people that have been lost care, if we unpack that, there's more to just them not being able to have transportation to go to see their provider.” -Transcript 27: CBO leadership
Cosmopolitanism
Degree to which organizations are networked to support clients and TIC.
Many participants feel confident in providing services due to their knowledge of referral networks and relationships with community partners. However, some mentioned an overreliance on community partners, feeling ill-equipped to make referrals due to a lack of familiarity with external services, and the perception that institutions operate in silos from another. System-wide barriers to care include long wait times for external mental health support and insufficient HIV prevention resources. With federal regulations (i.e., HIPAA) complicating patient referrals and follow-up with community partners, many suggested a universal release of information. Collaboration among different organizations and across disciplines was seen as essential to the success of TIC adoption and EHE goals.
…[I]ndividualized training and cultural humility is an incredible step, but we’ve got to get our systems and processes smoothed out because we re-traumatize our patients when they have to re-disclose everything that they had just disclosed […] We have to grow from TIC to better systems, and processes, and handoffs.
-Transcript 4: clinic leadership
Intervention Characteristics
Relative Advantage
Perceived impact of TIC on staff wellness and client services versus the status quo.
TIC and cultural humility trainings have helped participants respond to clients more confidently, but some TIC trainings have not adequately focused on vicarious and primary trauma among personnel. Some believe a city-wide effort to adopt TIC should be balanced with other priorities such as meeting clients’ basic needs. Some cautioned that the success of TIC programs rests on its relevance to the local community and needs appropriate, diverse, and representative developers, facilitators, and providers.
“You need to listen to the people when you’re developing programs […] You have to make it unique to this metro community, and I think that we make a lot of mistakes where we think something works somewhere else, certain facilitators, certain people, and then we bring them and we apply them, and we think that’s going to take care of the problem.” -Transcript 27: CBO leadership
Complexity
Perceived difficulty of implementation (navigating systems for trauma service provision).
Participants anticipated experiencing challenges related to working within large, bureaucratic institutions, given the complexities of implementing a multi-level intervention. They saw hierarchies as barriers to collaborative decision-making, with financial and political considerations potentially being prioritized over patient-centered care. In some institutions, racism and inequity was described as part of leadership hiring practices and organizational structures of privilege. Some participants noted difficulties related to systems-level change, efforts to alter deep-seated beliefs, and stigma complicating client confrontation of trauma.
“We're a clinic that operates within a larger corporate structure. […] And so, there're extreme limitations on what we can do, what authority patients have over this clinic […] I have extreme limitations in my ability to initiate new programs.” -Transcript 4: clinic leadership