Introduction
Methods
Study design
Eligibility criteria
Population
Setting
Intervention
Outcomes
Types of studies
Search strategy
Study selection
Charting and organising the data
Data synthesis process
Results
Authors Region, Country | Study Title | Type of report Purpose of study/ study aims | Date of data collection / service delivery | Name of and type of service/ setting/ context | Sample recruitment Response rate | Procedure | Qualitative or qualitative data Analysis |
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Aremu, Hill, McNeal, Petersen, Swanberg, Delaney (2018) (94) Illinois, USA | Implementation of trauma-informed care and brief solution-focused therapy A quality improvement project aimed at increasing engagement on an inpatient psychiatric unit | A quality improvement project The purpose of the quality improvement project was to educate staff on methods to incorporate TIC into day-to-day practice | Initial training: January 2017 2nd wave training: April 2017. Data were collected on the number of injectable medications dispensed by pharmacy to the unit per week between 20/10/13–14/12/13 and 01/07/15–5/10/15. | No name Adult inpatient psychiatric unit | Sample recruitment: N/A Response rate: Not stated. | A 2- hour patient engagement training was extended to all staff members. Process evaluation involved reviewing data collected 1 month after the initial training and every 3 months post-training and measuring staff attendance at each mandatory training. Outcome evaluation involved assessing staff comfort of patient engagement before and after training, reviewing shift documentation and nurses’ reflective notes on engagement, and monitoring medications administered. All participants completed the ‘Management of Aggression and Violence Attitude Scale and Combined Assessment of Psychiatric Environments – brief version’ before attending the training, and one month after. | Quantitative Pre-/post-test scores on the CAPE and MAVAS were examined for differences using the Wilcoxon signed rank test for paired data. Changes in rates of PRN IM medication administration, and rates of evidence of patient engagement in clinical notes, were described but not statistically analysed. |
Azeem, Aujla, Rammerth, Binsfeld, and Jones (2011) (68) USA, region not stated | Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital | Retrospective pre/post study To determine the effectiveness of Six Core Strategies in reducing the use of seclusion and restraints with hospitalised youth. | All medical records were reviewed for youth hospitalised between July 2004 - March 2007 | No name Mixed- and single-gender child and adolescent (ages 6–17) hospital psychiatric unit | N/A | Information on restraint and seclusion use was gathered on a standard form completed when a service user was placed in a restraint or seclusion. In March 2005, staff at the hospital were trained on the Six Core Strategies in national training. The data collected were shared in all staff meetings, regularly with clinical teams, and were posted on the respective units monthly. | Quantitative Demographic and clinical variables were reported. Outcomes were described but no statistical analyses performed. |
Azeem, Reddy, Wudarsky, Carabetta, Gregory & Sarofin (2015) (69) USA, region not stated | Restraint reduction at a pediatric psychiatric hospital: A ten-year journey | Service description To reduce the number of restraints and to provide TIC in a 52-bed paediatric psychiatric hospital. | 2005–2014 | No name Mixed- and single-gender child and adolescent (ages 6–17) unit at a psychiatric hospital | N/A | N/A | Quantitative Described some changes in quantitative measures (e.g., rates of restraint) but no statistical analyses reported. |
Beckett, Holmes, Phipps, Patton, & Molloy (2017) (95) Sydney, New South Wales, Australia | Trauma-informed care and practice: Practice improvement strategies in an inpatient mental health ward | Service evaluation To improve the quality of care provided to consumers on a mental health ward within an acute inpatient service by establishing TIC on the ward. | The study evaluates the programme over a 3-year period. Specific study dates are not stated. | No name A psychiatric inpatient ward, with a high dependency unit and an acute unit | N/A | Study procedures not stated. | Mixed Not stated |
Blair, Woolley, Szarek, Mucha, Dutka, Schwartz, Wisniowski & Goethe (2017) (86) Connecticut, USA | Reduction of seclusion and restraint in an inpatient psychiatric setting: A pilot study | Pre/post implementation of intervention pilot study To describe and evaluate the effectiveness of a quality and safety initiative designed to decrease seclusion and restraint on an inpatient psychiatric service | Pre-intervention data: October 2008–September 2009 Post-intervention data: October 2010 –September 2012 | No name A mixed gender psychiatric inpatient service of a large urban hospital | Baseline - all consecutive admissions during the year prior to the intervention: n = 3884 Study sample - all consecutive admissions after the full intervention implementation: n = 8029 | Baseline data (e.g., the number and duration of seclusion/restraint events and demographic data) were from all consecutive admissions during the year prior to introduction of the intervention (October 2008–September 2009). The study sample consisted of all consecutive admissions after the intervention was fully implemented (October 2010–September 2012). | Quantitative Chi-square tests to compare differences in seclusion/restraint incidence in the study versus baseline periods t tests to compare seclusion/restraint duration in the study versus baseline periods |
Boel-Studt (2017) (77) Midwest, USA | A quasi-experimental study of trauma-informed psychiatric residential treatment for children and adolescents | Service evaluation To examine the effectiveness of a trauma-informed approach implemented in the psychiatric residential treatment facilities of a Behavioural Health Agency serving trauma-affected children and adolescents compared to a traditional psychiatric treatment approach previously used. | The programme commenced in 2012. Data collection for youth in the trauma-informed psychiatric residential treatment group began 12 months following implementation to allow for training and full integration of the model. Data collection occurred over 9-months. | No name Psychiatric residential facilities of a large Behavioural Health Agency | N = 205 Data for this study were extracted from the case records children and adolescents who received either traditional PRT (n = 100) or TI-PRT (n = 105) services. Records that contained missing data on key study variables were excluded. Response rate: N/A | Data for the comparison group were extracted from the files of 100 youth who were discharged from one of the psychiatric residential treatment facilities within a 13-month period before TIC implementation. Data collection for youth in the trauma-informed psychiatric residential treatment group began 12 months following implementation. There were three separate waves over a period of nine months until an adequately powered sample size was achieved. Functional impairment was assessed by master’s-level clinicians employed by the agency at the time of admission and again at discharge using the Child and Adolescent Functional Assessment Scale. | Quantitative Repeated measures analysis of variance examined differences between groups on change in functional impairment from admission to discharge. Multivariate regression examined differences in average length of time in treatment. Logistic regression examined differences in the probability of discharging to a community-based placement versus an institutional placement. Zero-inflated Poisson (ZIP) regression examined group differences in restraint and seclusion. |
Borckardt et al. (2011) (87) South-eastern USA | Systematic investigation of initiatives to reduce seclusion and restraint in a state psychiatric hospital | Cluster-randomised, controlled, cross-over trial To examine the effect of systematic implementation of behavioural interventions on the rate of seclusion and restraint in an inpatient psychiatric hospital | Baseline phase: January 2005 – February 2006 Implementation phase: March 2006 – March 2008 Follow-up period: April 2008 – June 2008 | No name Five inpatient psychiatric wards at one hospital: an adult unit, a geriatric unit, a general adult unit, a substance abuse unit, and a child and adolescent unit at one large state-funded psychiatric hospital | Response rate: Not stated. | A multiple baseline design, implementing an engagement model with four components. Each unit was assigned to implement the four components in a different, randomly determined order. Each unit was assigned two separate implementation periods dedicated to making physical changes to the therapeutic environment. Each unit served as its own control from intervention to intervention. Number of seclusions and restraints per patient day for each unit and each period of implementation were routinely collected. Mean length of stay and mean illness severity rating were collected at each phase of the implementation schedule. The patient form and staff form of the Quality of Care measure (Danielson et al.) was taken before and after each phase of the intervention rollout. There was an observation-only phase at the beginning of implementation. This was extended for most units into the second phase of the implementation schedule before full randomisation of the order of the intervention across units. | Quantitative Descriptive statistics of key variables were presented. The effects of the interventions on rates of seclusion and restraint in the units were measured over time. Rate of seclusion and restraint were permitted to cluster over time. Independent t-tests examined changes in patient-reported factors pre- and post- implementation of TIC across all units. Paired-sample t tests examined changes in staff members’ Quality of Care ratings pre- and post- each stage of implementation. Non-parametric Wilcoxon’s rank-sum test examined the overall change in mean monthly rate of restraints and seclusions from the baseline to the follow-up phase. |
Brown, McCauley, Navalta, & Saxe (2013) (78) Boston, USA | Trauma systems therapy in residential settings: Improving emotion regulation and the social environment of traumatised children and youth in congregate care | Description of service implementation To provide an overview of the successful adaptation and implementation of trauma Systems Therapy (TST) at three residential facilities | BOSTON Intensive Residential Treatment Program: Between September 2000–2007 The Children’s Village: Between January-August 2008 KVC Health Systems: 2008–2009 | Names: - Boston Intensive Residential Treatment Program - The Children’s Village - KVC Health Systems, Inc Three residential treatment units for young people with severe psychiatric disorders | Response rate: Not stated. | TST was implemented in three residential programs and different sets of outcomes were tracked in each. Each of these programs is described in the article in turn. | Quantitative Outcomes were described and some presented graphically. No statistical analyses were conducted. |
Cadiz, Savage, Bonavota, Hollywood, Butters, Neaery & Quiros (2004) (80) New York, USA | The Portal Project: A layered approach to integrating trauma into alcohol and other drug treatment for women | Cross-site study, including process evaluation To test the Portal model of integrated, gender-sensitive, culturally competent service that considers the multiple domains of trauma, alcohol and other drug problems, mental health and parenting. | Not stated | Names: - Starhill Residential Drug Treatment Program - Dreitzer -Women and Children’s Residential Treatment Center Residential treatment programme for women with alcohol/ drug issues, mental health problems and trauma histories. | People entering treatment at either of Palladia’s two residential drug treatment programs. Response rate: N/A | Client interviews, case record reviews and fidelity studies based on observations of treatment groups were developed for the Portal Project evaluation. | N/A - Service description Not stated |
Chandler (2008) (65) Massachusetts, USA | From traditional inpatient to trauma-informed treatment: Transferring control from staff to patient | Qualitative descriptive study design To describe experiences of staff who successfully transitioned from traditional inpatient care to TIC. They aimed to describe and compare (i) the experiences of staff in reducing patient symptoms in a traditional inpatient model and in TIC and (ii) how the staff created a trauma-informed culture of safety. | Not stated | No name An inpatient psychiatric unit | Purposive sampling: Staff who worked on the unit for more than 12 years were invited to take part because they spanned the transition between the traditional program and TIC. Response rate: 10/36 | After participants gave written informed consent, individuals were interviewed. Interviews ranged from 60 to 90 min. Narratives were tape-recorded or handwritten, depending on the interviewees’ preference. Participants were asked to describe the symptoms that brought patients into the unit. They were then asked to describe changes in patient care over the previous 12 years. The staff narratively described their experience, reflecting on the traditional approach and the transition to TIC. Participants’ tape-recorded responses were transcribed verbatim. | Qualitative Verbatim transcripts were analysed by a nine-step inductive content analysis. This step-by-step analysis, an iterative process, occurred following each interview. Confirmability, as a measure of scientific rigor, was determined by auditability, credibility, and fittingness. |
Chandler (2012) (51) Massachusetts, USA | Reducing use of restraints and seclusion to create a culture of safety | Qualitative single case study To describe the structure that empowered staff of a locked community hospital unit to reduce the use of restraints and seclusion to create a culture of safety. | Not stated | No name An inpatient psychiatric unit | Researchers attended a staff meeting to explain the study. Following the meeting, individual staff volunteered for the study directly with the researcher. Patients were told that the researchers were visiting to observe a community meeting. Patients asked to recount their experience of the difference between this unit and others they have experienced. Response rate: Not stated. | The PI interviewed staff and leadership; reviewed unit policies on restraint and seclusion; and used participant observation. Individual interviews about restraint, seclusions and safety were arranged with staff in a private location. Voluntary informed consent was obtained, anonymity was maintained through numerically coding digitally recorded and transcribed interviews, and data was stored in a locked location which was only accessed by the PI. Bracketing was used prior to data collection to note the investigators’ preconceptions and biases. | Qualitative An eight-step inductive content analysis was used with the verbatim interview transcripts following each interview and for field notes. This step-by-step analysis was an iterative process that occurred after every interview. Confirmability of the findings was established by auditability, credibility, and fittingness. |
Duxbury et al. (2019) (70) North-west England, comprising five counties; Cheshire, Greater Manchester, Merseyside, Lancashire and Cumbria, UK | Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). | Non-randomised controlled trial To test the hypothesis that restraint use would be 40% lower on intervention wards after the introduction of REsTRAIN YOURSELF | January 2015 -February 2016. The total study duration was 16.7 months on all wards. | No name 11 mixed-gender and 3 single-gender adult, acute mental health wards from seven mental health hospitals | Two acute care wards were targeted from all eligible acute wards within each participating Trust. Matched wards were allocated for each Trust, taking into account restraint use, number of beds and patient demographics. Some Trusts were limited in the wards they could use due to competing interventions being introduced; therefore, non-matched samples had to be used in some instances. Response rate: Not stated. | Within all participating Trusts, a range innovations were implemented on the implementation wards within a ‘Six Core Strategy’ framework. A dedicated improvement adviser worked on the wards one day a week to support the implementation of the approach. There were three study phases during the course of the project. These were baseline, implementation and adoption. The implementation phase referred to when the REsTRAIN YOURSELF adviser was active on the ward (duration mean per ward = 5 months, range = 3.5–5.5 months). The baseline phase (mean duration = 13.6 months, range = 8.1–18.3 months) referred to the study period before implementation. The adoption phase (mean duration = 7.9 months, range = 2.4–13.1 months) referred to the improvement stage when advisor stopped visiting the ward. Staff were encouraged to carry on REsTRAIN YOURSELF implementation without external support from the project and the continued use of their local champions. | Mixed (this paper only reports quantitative results) Restraint event rates per 1000 bed-days with 95% confidence intervals were calculated for the intervention and comparator wards across the study period. Chi-squared tests were used to analyse associations between exposure to the intervention and restraint frequencies. This paper reports only on outcomes of physical restraint reduction. |
Farragher & Yanosy (2005) (74) New York, USA | Creating a trauma-sensitive culture in residential treatment | Service change description To explain how their staff used the Sanctuary Model to bring about significant changes in the children, staff, and organisation as a whole. | They began the process of learning about and implementing TIC in 2001 | Andrus Children’s Center Residential mixed-gender youth treatment unit for children with severe emotional problems | N/A | N/A | N/A |
Forrest, Gervais, Lord, Sposato, Martin, Beserra & Spinazzola (2018) (79) Massachusetts, USA | Building communities of care: A comprehensive model for trauma-informed youth capacity building and behaviour management in residential services | Service evaluation To conduct a preliminary evaluation of two programs investigating whether Building Communities of Care’s (BCC) unique approach to embedded behaviour management in treatment of youth results in reduced restraint, improved safety, and shortened length of stay | Introduction of BCC: Program 1 - December 2013. Program 2 - March 2016. Retrospective, naturalistic, aggregate data was collected from 2012–2017. Data on length of stay, number of restraints, and worker’s compensation claims was included from January 2012 to September 2017. Data on position of restraints, number of client restraint-related injury, and number of staff restraint-related injuries was included from January 2014 when available. | No name Residential mixed-gender treatment programmes for young people (ages 12–22) with mental disorders | N/A | Length of stay data was recorded by program directors in months and reported to quality improvement and management personnel monthly. Number of restraints was routinely collected internally by the agency as part of its critical incidents tracking and risk reduction efforts. Program directors reported the data in aggregate to quality improvement and management personnel at the end of each quarter. The programs’ insurer provided number and total yearly monetary value of worker’s compensation claims. Data on position of restraints, and number of client and staff restraint-related injuries were collected from annual reports to an overseeing government agency. Position of restraints data was collected immediately after restraint occurrence in a mandatory report of the incident. Similarly, data on client restraint-related injury and staff restraint-related injury was collected immediately after the incident, with injuries categorised as either minor (requiring on site medical treatment) or major (requiring further medical assistance). | Quantitative Quantitative measures are described and presented graphically, but no statistical analyses were conducted. Total yearly monetary value of worker’s compensations claims was averaged per claim and per quarter for this evaluation. Length of stay was averaged across all clients by year for examination. |
Goetz & Taylor-Trujillo (2012) (82) Midwestern USA | A change in culture: violence prevention in an acute behavioral health setting | Service evaluation To describe the development of the patient-focused intervention (PFI) model and its impact on the reduction of patient violence and staff injuries at a behavioural health service hospital | The PFI model was initiated in 2005 | No name Four psychiatric services: a residential treatment program for female adolescents (ages 12-18), an acute inpatient adolescent unit (ages 12–18), an adult inpatient unit (age 19>), and a sub-acute unit for adults with substance use and mental health problems. | N/A | The data on seclusion and restraint, Code Gray episodes, and staff injuries were collected by the hospital as part of their routine monitoring. The staff safety survey (is a biannual survey with 10 Likert-style questions focusing on staff’s perceptions of the environment, their training and patient aggression management) was developed by the hospital leadership. | Quantitative Descriptive statistics describing the data for each indicator were reported and presented graphically. The staff survey was scored by averaging staff scores for each question, and then aggregate scores on each question were compared across previous years. |
Gonshak (2011) (66) Louisville, Kentucky, USA | Analysis of trauma symptomology, trauma-informed care, and student-teacher relationships in a residential treatment center for female adolescents | Pre-post study To investigate (i) the extent to which student trauma symptomology, staff beliefs about TIC, and staff quality interactions with students in the classroom, related to students’ perceptions of their relationships with their staff member; (ii) the extent to which training staff in a trauma-informed framework is associated with increased staff knowledge about trauma, increased beliefs about the effectiveness of TIC, and increased quality staff classroom behaviours; as well as improved student perceptions of staff relationships and decreased student report of trauma symptoms. | Data were collected from January 2009 – May 2009 Risking Connection teacher training was implemented in mid-March 2009 | Maryhurst Inc. residential treatment center Female adolescents in a residential treatment centre for children who have severe emotional difficulties | Response rate: Not stated. | Procedures included classroom observations and the administration of surveys to both teachers and students. Student observations and surveys examined student change associated with the teacher changes after the implementation of the Risking Connection training intervention. Data were collected at four time points from students and two time points from teachers in late January 2009 and over the next five months. Teachers were given surveys and were observed once pre-intervention and once post-intervention. Service users were given surveys twice pre-intervention and twice post-intervention. Data collection was completed by university faculty researchers and graduate research assistants with the assistance of Maryhurst direct-care staff. Standardised instruction was provided to the participants at each time point of data collection. | Quantitative Multiple regression analyses determined the extent to which students’ trauma symptomatology, teacher beliefs about trauma-informed care, and teachers’ emotionally supportive behaviour were associated with the students’ perception of the student-teacher relationship. Descriptive statistics were provided following teacher scores: Risking Connection Curriculum Assessment, Trauma-Informed Care Belief Measure, Teacher Fidelity to Risking Connection, and CLASS-Emotional Support subscale before and after the intervention. Paired sample t-tests compared the four teach measure scores pre-test and post-test, and effect sizes were calculated. Pre- and post-test changes in student attributes were conducted comparing change between the two pre-tests and change between the two post-tests. Trends across time were also examined using means at all student time points. |
Hale (2019) (59) Illinois, USA | Implementation of a trauma-informed care program for the reduction of crisis interventions | Pre-post study To test the hypothesis that implementation of the Six Core Strategies in a child and adolescent behavioural health hospital would lead to a 25% decrease in rates of physical holds and seclusion for patients 6 months after implementation, and reduce the risk of re-traumatisation | May-November 2018 | No name Child and adolescent (ages 3-17) inpatient behavioural health hospital | Response rate: Not stated. | Implementation of TIC took 3 weeks as each staff member has an opportunity to attend weekly educational sessions that focused on each of the six core strategies. Department leaders were aware of the time commitments this project initiative would take and agreed to let their team members participate. The leadership team was provided TIC training first. Once training was complete, the researcher obtained routine data on use of holds and seclusions at the end of each month. Deidentified information was provided to the researcher. | Quantitative Descriptive statistics were provided for the numbers of physical holds and seclusions in the six months prior to implementation of TIC, and in the six months after. Data were also presented graphically. No statistical analyses were performed |
Hale & Wendler (2020) (67) USA, region not stated | Evidence-based practice: Implementing trauma-informed care of children and adolescents in the inpatient psychiatric setting | Description of service implementation, and pre/post intervention study To investigate the impact of implementation of TIC in an inpatient psychiatric setting versus routine care was on rates of use of physical holds and seclusion at 6 and 12-months post-implementation among children and adolescents (ages 3–17). | October 2017 - April 2019 | No name A child and adolescent (ages 4–17) psychiatric hospital | N/A | The problem of too many uses of physical restraint and seclusion interventions was communicated to staff over 2 months before educational interventions focusing on TIC (with a focus on de-escalation techniques) were implemented. Multidisciplinary discussions and retooling of patient treatment and care plans began following the educational interventions. Implementation of video review debriefings followed 2 months later. The entire process took 6 months. Culture change was in place by the end of the 12 months. | Quantitative The number of uses of restraint and seclusion events 6 months before and after implementation were reported, and the changes in these figures described. No statistical analyses were performed. |
Isobel & Edwards (2017) (64) Sydney, New South Wales, Australia | Using trauma informed care as a nursing model of care in an acute inpatient mental health unit: A practice development process | Mixed methods case study To describe the process and effects on the nursing workforce of implementing a trauma-informed model of care in an acute mental health inpatient unit using a Practice Development process. | Practice development project commenced in October 2012. Interviews were conducted in May 2014, 18 months post-implementation. | No name An acute mental health inpatient unit | A purposive, convenience sample of nurses participated as determined by length of experience, involvement with the project and availability at time of interview. Response rate: Not stated. | Semi-structured interviews with nurses were conducted on the unit by a research assistant. Nurses were asked about how they felt about the changes occurring within trauma-informed care framework, the effects on their day-to-day work, consumers, the team and how they felt about their roles. Interviews were audio-recorded and transcribed. | Qualitative Transcripts were analysed using an inductive conventional content analysis. Transcripts were examined to identify themes and emerging expressions of experiences. These themes and expressions were compared to identify similarities and differences. |
Jacobowitz, Moran, Best, & Mensah (2015) (54) New York, USA | Post-traumatic stress, trauma- informed care, and compassion fatigue in psychiatric hospital staff: A correlational study | Cross-sectional correlational study To explore whether there is a correlation between inpatient psychiatric health care workers’ (i) experience of traumatic events, (ii) resilience to stress, (iii) attitude/ confidence in managing violent patient situations, and (iv) compassion fatigue with respect to post-traumatic stress symptoms. | Data collection occurred between November 2011 - May 2012 | No name A psychiatric hospital, providing short-term acute care in the following units: general adults, child and adolescents, older adults, chemical dependency | Convenience sample of inpatient psychiatric health care workers, consisting of registered nurses, psychiatric aides, assistant counsellors, psychiatrists, case coordinators and therapeutic rehabilitation specialists. Response rate: Out of a total of 250 direct patient-care employees working at the hospital, 172 returned surveys (68.8% return rate). Of the returned surveys, 158 had complete information (8.1% of returned surveys had missing information). | Two trained research assistants met with the hospital staff to explain the study and solicit their participation. A semi-structured questionnaire asked participants to identify their job title, usual shift, age, gender, years of psychiatric work experience, education level, height, build, living arrangement, when they last participated in patient aggression management training, and when they last participated in a TIC meeting. Each question provided between two to seven answer choices from which participants selected the best response. Participants received a token of appreciation (a pen) for placing their questionnaires in a locked box. Only the PI had access to the contents of the box while it was at the research site. | Quantitative The data were screened for outliers. 7% of the data were excluded. The data also were examined for missing values. 8.1% of participants failed to complete at least one of the questionnaires. There were no significant patterns the missing data. Missing data were replaced using the SPSS function for linear interpolation. Normality of continuous variable distributions was assessed using the Kolmogorov-Smirnov Test. Only the Burnout subscale of the Professional Quality of Life Scale met the assumption of normality. The alpha level was set at 0.05, and two-tailed analyses were used for all of the tests. The Post-Traumatic Checklist variable was transformed and adjusted using the scores on the Life Events Checklist. Correlations between the adjusted PCL-C scores, the demographic variables and standardised measures were analysed using Spearman correlation coefficients. The Kruskal-Wallis H-Test and the Mann-Whitney U-Test compared the Adjusted PCL-C scores to the demographic variables. Significant relationships were entered into a Hierarchical Linear Regression Analysis to determine a best-fit model. |
Jones (2021) (88) Nottinghamshire, UK | How distress is understood and communicated by women patients detained in high secure forensic healthcare, and how nurses interpret that distress: An exploration using a multi-perspective interpretative phenomenological analysis | Qualitative study To explore how women patients in high secure healthcare understand and communicate their distress, as well as how nurses interpret the women patients’ distress. The study seeks to provide profound and meaningful insights into the lived experience of psychological distress on thoughts, emotions and behaviours for women patients in the National High Secure Healthcare Service for Women (NHSHSW). | Not stated | National High Secure Healthcare Service for Women (NHSHSW) National high secure inpatient psychiatric service for women | Each team was approached independently, and each patient considered in terms of capacity to consent. The study was explained to the patient group and nurses via community and multidisciplinary team meetings. Named nurses of patient participants were approached. Informed consent was gained from all participants. All named nurses agreed to take part. Response rate: Not stated. | This study adopted a co-production approach and used feminist principles as a framework. A working party, including the researcher and voluntary patients (n = 8–13 depending on availability) facilitated the research process. Patients used the Personal Distress Signature (PDS) to record descriptions of their experience of distress and associated protective factors. Twenty patients volunteered the written content of their PDS to form the basis of interviews. Contents of these PDSs were thematically analysed to develop the semi-structured interview guide to explore patients’ perspectives on distress. Speech and language specialists were consulted to adapt the questions and prompts to make them accessible to people with communication difficulties. Themes were presented back to the patient group for validation. Pilot interviews were conducted. Individual semi-structured interviews were conducted with volunteer patients and participating nurses. Focus groups were facilitated by facilitators. Not all participants agreed to audio-recording so handwritten notes were made on flip chart paper. Patients and staff facilitating took turns taking notes. Information from the focus groups was presented to individual patients who did not attend the focus group (e.g., due to being in seclusion) and they contributed. Their contributions were fed back to the group. Individual patient interviews lasting 30 min or less were conducted in a private room. Participants were given the option for the interview to be audio-recorded. The interview could be conducted over two sessions if preferred. Nurse interviews took place in the same interview room or in a staff room. They were also given the option for the interview to be audio-recorded. There was regular liaison with operational managers to ensure that practical support for women was provided to attend groups. Nurses were briefed to check-in with and provide emotional support to participants if needed. | Qualitative The audiotaped interviews and handwritten notes were transcribed by the researcher. Multi-perspective Interpretative Phenomenological Analysis (IPA) was used to analyse semi-structured interviews. Analysis of the data was presented to the women patients for in-depth review and were also subject to peer review. Quality of analysis was ensured via independent reviews completed by practitioners familiar with IPA methods |
Korchmaros, Greene & Murphy (2021) (72) South-western USA | Implementing trauma-informed research-supported treatment: Fidelity, feasibility, and acceptability | Longitudinal study The study examined programme fidelity and the feasibility and acceptability of implementing trauma-informed research-supported treatments (TI-RSTs) at an adolescent residential substance misuse treatment agency over time. | Not stated | No name A mixed-gender adolescent residential substance misuse treatment agency | At all time points, all agency staff were invited via email to complete an online survey or to complete paper copies of the survey. Staff held diverse roles. Response rate: Not stated. | Survey data was collected from agency staff at: 4 months (Time 1) 1.25 years (Time 2) 2.25 years (Time 3) into implementation of the TI-RSTs. An independent research assistant set up a laptop in a private area at the treatment agency for staff without computer access and made attempts to encourage completion of the survey. Staff completed surveys anonymously and privately. No demographic information was collected on individual surveys to preserve anonymity. | Quantitative Single-sample, 1-tailed t tests were used to test whether staff, on average (i) agreed that the TI-RSTs were implemented with fidelity and they agreed that the TI-RSTs were implemented correctly (ii) agreed that implementing the TI-RSTs was feasible such that staff agreed that their agency was capable of making and sustaining change; their agency was ready to implement the TI-RST, and agency leaders were prepared to implement the TI-RST (iii) agreed that implementing the TI-RSTs was acceptable and the TI-RSTs improved client outcomes, (iv) there were greater than moderate attitudes towards RSTs and being more than slightly satisfied with the TI-RSTs. ANOVAs assessed changes over time, differences across type of TI-RST, and differences across related types of fidelity and feasibility measures, or indicators. The data collected at Times 1, 2, and 3 were treated as independent in analyses. |
Kramer, Michael George (2016) (57) USA, region not specified | Sanctuary in a residential treatment center: Creating a therapeutic community of hope countering violence | Qualitative, data included: group observation; content analysis of agency documents and quantitative data; focus groups; and individual interviews To determine how and why the Sanctuary model works in decreasing trauma symptoms with a population of court-committed youth. | The Sanctuary Model was implemented over a three-year period (exact dates not provided). Group observation took place over a year and a half. | No name Forensic male adolescent residential treatment unit. | Participants were introduced to the researcher, provided with information about the study and invited to participate. Response rate: Not stated. | The researcher began as a non-participatory observer of administrative and clinical team meetings, individual service plan meetings, and community meetings over a year and a half. Field notes were kept and general themes were extracted. The researchers obtained access to organisational records and documents, and minutes of Core Team, and Red Flag Review meetings, covering the three-year period of implementing Sanctuary. The researcher examined their content for emergent themes. Focus groups (30–60 min) were conducted; two for staff and three for service users. The groups were recorded and transcribed verbatim. They were held in an administrative conference room. For service users, focus groups were held in residential conference rooms. Three 30–60-minute individual interviews were conducted: two impromptu and one planned with staff. Two interviews occurred after chance meetings (not transcribed as the researcher did not have the audio-recorder). The interviews were conducted in an office, with the third interview requested in lieu of being a staff focus group participant. This interview was audio-recorded and transcribed, conducted in an administrative meeting room. | Qualitative The digital audio-recordings of focus groups and the planned individual interview were transcribed verbatim. Grounded theory and utilisation-focused evaluation were used to analyse the data. |
Niimura, Nakanishi, Okumura, Kawano & Nishida (2019) (93) Tokyo, Japan | Effectiveness of 1-day trauma-informed care training programme on attitudes in psychiatric hospitals: A pre–post study | Pre-post study To evaluate the effects of a TIC training programme on attitudes towards TIC practice in mental health professionals, using standardised measurement instruments | March 2018 - June 2018 | Tokyo Metropolitan Institute of Medical Science 29 inpatient psychiatric hospitals across Tokyo, Japan | All hospitals with psychiatric beds in Tokyo and its suburban prefectures (Kanagawa, Saitama, Chiba, and Yamanashi) were approached. The invitation letter included information regarding a 1-day TIC training programme. Mental health professionals voluntarily responded to the research team to participate in the TIC training programme. Response rate: Not stated. | Participants attended the 1-day TIC training programme. The programme was run and co-facilitated by some of the authors. After the TIC training programme, participants received a gift card worth 100 yen ($9.03 USD) for attending. Self-rated questionnaires, including the Attitude Related Trauma-Informed Scale (ARTIC-35) and a self-rated questionnaire developed by the study authors, were administered at pre-training, post-training and 3-month follow-up. | Quantitative Participants characteristics were summarised, including sex, age, job category and year sin the psychiatric field. Missing values for each item in the ARTIC-35 were imputed using the multivariate imputation. Longitudinal data structure was considered using the predictive mean matching technique for two-level data. Twenty imputed data sets were generated with 10 iterations per imputation. For each of the imputed data sets, the following analyses were repeated: (1) the sum of the items on the ARTIC-35 for each participant were divided by the number of items, (2) means and standard deviations for the average scores for each time point were obtained, (3) mean differences and 95% confidence intervals for the average scores between time points were estimated. Analyses were repeated using the complete case method. Using data from 56 participants in the analysis, the proportion of TIC implementation at the 3-month follow-up was calculated. |
Prchal (2005) (73) North-eastern USA | Implementing a new treatment philosophy in a residential treatment center for children with severe emotional disturbances: A qualitative study | Qualitative focus groups To describe the process of implementation of the Sanctuary Model of treatment in a residential treatment centre for youths with severe emotional disturbances, from the viewpoint of staff who volunteered to participate in focus groups about the model and its implementation. | January 2002 - March 2002 | No name Three residential, youth therapeutic services specialised to treat youths with conduct disorders and other serious emotional disturbance | All staff who worked in the Sanctuary Model units were invited to participate in focus groups. Response rate: Not stated. | Ten focus groups were conducted. Three involved clinicians and administrators/ supervisors (7–12 participants in each group) and seven involved milieu counsellors (3–10 participants in each group). Each group session was recorded, and the recordings were transcribed. Notes were taken and then compared with the transcripts. When participants did not consent to recording, extensive notes were taken and then typed by the transcriptionist. All training on the Sanctuary Model took place prior to this initial implementation stage. | Qualitative A mid-range, inductive, coding scheme was used to analyse the qualitative focus group data, with some structure imposed by the research questions and overall goals of the study. A multi-step approach to coding was used. The coding process was undertaken by the PI and a doctoral student. Consensus on finalised code definitions was reached through discussion between the PI and student. |
Prytherch, Cooke & Marsh (2020) (28) North London, UK | Coercion or collaboration: service-user experiences of risk management in hospital and a trauma-informed crisis house | Qualitative To explore service-users’ experiences of risk management in both hospital services and a trauma-informed crisis house | Not stated | No name A residential female crisis house | Five current residents were approached by crisis house staff, two of whom participated. Six previous residents volunteered to take part. Response rate: 2/5 | Interviews took place at the crisis house and lasted approximately 1 h. Participants were asked about their experiences in the crisis house and in hospital services. All interviews were audio-recorded. Pseudonyms were used to protect confidentiality. | Qualitative Thematic analysis within a critical realist framework was used. Data was analysed iteratively. An inductive approach was used. Rather than aiming for “theoretical saturation,” the findings are presented as one interpretation that is “far enough along to make a contribution to our evolving body of understandings.” The analysis was sent to all participants to validate the analysis. |
Rivard, McCorkle, Duncan, Pasquale, Bloom & Abramovitz (2004) (75) North-eastern USA | Implementing a trauma recovery framework for youths in residential treatment | Service evaluation To describe an intervention designed to address the special needs of youths with histories of maltreatment and exposure to family and community violence. To describe the main components of the evaluation, the evaluation design, and initial impressions of staff during the course of implementing the intervention. | The first round of focus groups was conducted during late January – early March 2002. | No name Three residential youth therapeutic services (each composed of smaller residential units) specialised to treat youths with conduct disorders and other serious emotional disturbances | N/A | The Sanctuary Model was first piloted in five residential units that self-selected to participate in the initial phase of the project. Following the pilot, four additional residential units were randomly assigned to implement the model. Eight other residential units, where the model was not being implemented, served as the usual services comparison. A comparison group design (Sanctuary versus Standard Residential Services) with measurement at five points (baseline, 3, 6, 9, and 12 months) examined change in the two conditions. Several standardised instruments were used to measures changes in the therapeutic community environments and change in youths’ functioning and behaviours. Change in the frequency of critical incidents (e.g., harm to self, others, or property) and use of physical restraints was measured by accessing and analysing data from the agency’s management information system. Implementation adherence to the original model was measured through consultant’s process notes, periodic review of a Sanctuary Model Milestones Checklist, and a Psychoeducation Group Fidelity Checklist. Perceptions of the course of implementation, and challenges in implementing the model were collected through focus groups, convened every 6 months. Ten clinician and administrator/supervisor focus groups were conducted (n = 7–12 per group). Seven focus groups involved counsellors (n = 3–10 per group). Participants were also asked about factors facilitating and inhibiting their ability to implement the model. | Qualitative Focus groups were audiotaped, with permission of participants, and transcribed. Responses to each of the focus group questions were compiled across the groups. The aggregated responses to each question were then coded and displayed in matrices by major themes, categories, and sub-categories. The major themes that emerged across all focus groups were narratively described. |
Rivard, Bloom, McCorkle, Abramovitz, (2005) (58) North-eastern USA | Preliminary results of a study examining the implementation and effects of a trauma recovery framework for youths in residential treatment | Non-randomised control design (with nested process evaluation) To examine the implementation and short-term effects of the Sanctuary Model as incorporated into residential treatment programs for youth | The Sanctuary Model was first piloted with four residential units. During this phase, the staff training protocol and manual was developed and piloted between February and August 2001. Four additional residential units were randomly assigned to implement the Sanctuary Model in the fall of 2001. | No name Three residential youth therapeutic services (each composed of smaller residential units) specialised to treat youths with conduct disorders and other serious emotional disturbance s | Four units self-selected to participate in the initial phase of the project. Four additional residential treatment units were randomly assigned to implement the Sanctuary Model in 2001. The youth sample consisted of all youths for whom full informed written consent was obtained from custodial agencies, legal guardians, parents, and youths. The staff sample was composed of staff that worked in the programs and who voluntarily elected to participate in surveys and focus groups through a process of fully informed, written consent. Response rate: Not stated. | The Sanctuary Model was first piloted in four residential units that self-selected to participate in the initial phase of the project. The staff training protocol and manual was developed and piloted between February-August 2001. Four additional residential treatment units were randomly assigned to implement the Sanctuary Model in autumn 2001. Eight other units, providing the standard residential treatment program, served as the usual services comparison group. Progress in implementing the model was documented through consultants’ notes and periodic reviews of the Sanctuary Project Implementation Milestones checklist. Qualitative data on staff perceptions of implementation, and challenges in implementing the model, were gathered through focus groups. The Community Oriented Programs Environment Scale was administered to staff four times at 4–6-month intervals. Youth demographics, historical data, history of abuse and neglect were abstracted from client records at baseline. Other measures of youth outcomes included: the Child Behaviour Checklist, the Trauma Symptom Checklist for Children, the Rosenberg Self Esteem Scale, the Nowicki-Strickland Locus of Control Scale, the peer form of the Inventory of Parent and Peer Attachment, the Youth Coping Index, and the Social Problem Solving Questionnaire. | Mixed A comparison group design, with measurement at three points (baseline, 3 months, 6 months), was used. Group differences in outcomes were explored using independent t-tests. Repeated measure analyses were used to assess differences over time and by group. Qualitative analysis method was not stated. |
Stamatopoulou, (2019) (52) Northern England, UK | Transitioning to a trauma informed forensic unit: Staff perceptions of a shift in organisational culture | Qualitative evaluation of implementation of a TIC intervention To provide a description of the impact of transitioning to a trauma-informed service model on staff working in an inpatient forensic unit in England and the factors that influence the progress of this transition | Implementation of the TIC programme: February 2018 Focus groups were conducted in January 2019 and February 2019. | No name Inpatient female forensic mental health unit (comprised of four wards ranging between low-medium security) | The field supervisor made contact with the forensic unit. Response rate: Not stated. | The researcher visited the unit in December 2018, after project approval. During this visit, locations, dates and times for the focus groups were agreed with the service. Paper copies of the participant information sheets were provided to interested staff and left in staff rooms and with the local contact for the researcher. An open-ended interview schedule was devised. The questions asked about the incorporation of choice, trust, empowerment and safety within the programme of change. All interviews were recorded. Data collection was conducted in four 45–90 min focus groups (n = 3–7 staff members). Two focus groups were conducted with senior staff members. Two focus groups were conducted with staff in lower pay grades. The researcher was available following the focus groups for debriefing. Quality of the project was assessed using the Eight “Big-Tent” criteria for Excellent Qualitative research (Tracy, 2010). | Qualitative Focus group data was analysed using thematic analysis. Inductive analysis was applied. Data was coded through a social constructionist epistemology lens. Themes and subthemes were presented narratively. |
Tompkins & Neale (2016) (53) UK, region not specified | Delivering trauma-informed treatment in a women-only residential rehabilitation service: Qualitative study | In-depth case study approach To explore factors that affect the delivery of trauma-informed treatment in one women-only residential rehabilitation service and to identify any challenges experienced by staff (in delivering the programme) and clients (in receiving the programme). | April 2015 - August 2015 | No name A female residential substance use treatment unit | Purposive sampling which aimed to encompass those likely to have varying experiences of the trauma-informed treatment. Response rate: Not stated. | Thirty-seven semi-structured interviews were conducted. Two researchers approached potential participants and provided them with study information. Participants volunteered to take part. Interviews were conducted in private. All interviews followed a topic guide that explored participants’ personal circumstances and views and experiences of TIC. Staff were provided information on their experiences of delivering TIC, whilst clients were asked about their experiences of receiving it. Staff received no compensation for taking part; clients received a £10 high street gift card. All interviews were audio-recorded and transcribed. | Qualitative Data were analysed using iterative categorization, involving participants. The two coding systems were developed by researchers. The authors revisited the coded data to identify patterns, similarities and differences within and between different participant groups. Emerging findings were refined following discussions between the authors, two of the key stakeholders, and peer review. |
Zweben et al. (2015) (81) Oakland, California, USA | Enhancing family protective factors in residential treatment for substance use disorders | Pre-post study To compare outcomes for women and children on a trauma-informed dual diagnosis residential treatment program versus treatment as usual | Not specified | Project Pride, East Bay Community Recovery Project Residential treatment program for women who are pregnant or have young children | Residents at Project Pride who volunteered to participate in CF! Response rate: N/A | The ‘Celebrating Families!’ (CF!) program was implemented. There were 44 women who participated, and 51 women who were in Project Pride but who did not take part. Participants were assessed at baseline, discharge and 6-month follow-up. | Quantitative Quantitative outcomes were reported but no statistical analyses conducted. |