Accelerating Organizational Change for Health Justice: Implementation Outcomes of Trauma-Informed Organizational Change Among Southern HIV Service Organizations

Background. ‘Trauma-informed care’ (TIC) has become ubiquitous in health and social services. TIC initiatives initially privileged individual-level trauma-focused services but more recently have considered trauma-informed organizational change (TIOC). TIOC interventions alter organizations’ climate, culture, and specific strategies to promote implementation of TIC principles, ideally resulting in a system that is responsive to trauma and resists retraumatization. Anticipated outcomes include enhanced organizational justice-orientation, reduced staff burnout and improved client retention, engagement, and clinical outcomes. The research on TIOC, however, is nascent and scant literature examines the practical operationalization of TIOC implementation. Our multidisciplinary team implemented a pilot TIOC intervention with Southern HIV service organizations consisting of in-depth TIOC training and implementation coaching. This intervention was collaboratively developed by a team of academic researchers and experts in HIV-specific TIC, including people living with HIV. Preliminary evaluation indicated significant changes in participant TIOC knowledge, skills, and attitudes and systemic trauma-informed organizational change. The current study examines implementation outcomes of the TIOC intervention to accelerate the uptake and potential social impact of TIOC.

Methods. Authors conducted a content analysis of programmatic documentation from the 7 organizations who received the intervention (i.e. site-specific TIOC implementation action plans, final reports) to operationalize adoption of TIOC. Authors then employed thematic analysis of in-depth interviews with representatives from sites’ organizational ‘change teams’ (n= 14), using Proctor and colleagues (2011) implementation outcomes as an a priori coding structure.

Results. Adoption of TIOC was operationalized through changes in 6 domains: organization-wide training; policies and procedures, staff onboarding, physical and/or digital space, decision making structures (including the meaningful involvement of people living with HIV), and new services. Fidelity to TIC was evidenced by how organizational changes aligned with SAMHSA-recognized TIC principles. Appropriateness was indicated by participants’ expressed need for TIOC at their organizations. Acceptability was impeded in some cases by staff resistance to change, but was facilitated by committed implementation champions and a TIC approach to implementation. The intensive time commitment of the intervention strained feasibility, but participating organizations ultimately deemed the change worth the cost. Feasibility was enhanced by flexibility and collaboration on the part of interventionists. The intervention led to system-wide penetration of TIC organizational changes. Intervention reach extended beyond participating organizations through participant diffusion of TIC knowledge and TIC advocacy within regional organizational networks and systems. Finally, sustainment required ongoing vigilance to maintain TIC organizational culture.

Discussion. Research indicates the critical importance of TIC to support the safety, self-determination and empowerment of communities served by social workers. Increasingly, the field is recognizing that the social impact goals of TIC must be realized through system-wide change, not simply the isolated efforts of individual programs and providers. Our study offers clear operationalization of TIOC adoption in HIV service settings, as well as insight into practical implementation of TIOC, thereby creating a roadmap for other health and social services committed to TIOC. Authors will additionally discuss the important role of our collaborative, interdisciplinary team and our use of community-based participatory methods throughout intervention development, implementation, evaluation and dissemination.