Transforming Together through Trauma-Informed Care (TTT): Preliminary Outcomes of a Trauma-Informed Organizational Change Intervention

Background: People living with HIV experience high rates of trauma, posing a significant barrier to successful progression through the HIV care continuum. While most trauma-informed interventions are individual-level, research increasingly points to the important role of a holistic organizational culture in shaping staff and client outcomes (Goering, 2018). To address this, trauma-informed organizational change (TIOC) interventions aim to enhance safety, collaboration, empowerment, and healing among clients and staff through alterations to organizations’ culture, policies, and practices. TIOC interventions can result in service systems that are responsive to trauma, resist retraumatization, and improve client outcomes. However, scant literature operationalizes TIOC or examines TIOC implementation outcomes. This study examines pilot evaluation outcomes of a TIOC intervention that enrolled organizational leaders and provided in-depth group trainings and implementation coaching to support organizational changes.

Methods: This study uses a concurrent triangulation mixed methods design. To measure participants’ pre/post TIOC-related knowledge, attitudes, and skills, the authors developed a 28-item, 10-point Likert scale survey based on TIOC principles (N=9 participants). To measure organizational-level TIOC, authors used the TICOMETER, a 35-item instrument of five TIOC domains (N=3 organizations). Authors conducted t-tests of both measures (one-sided p<0.05). Authors also conducted N=8 in-depth, semi-structured qualitative individual interviews to understand a) intervention impact, b) intervention acceptability and appropriateness, and c) barriers and facilitators to implementation. Interviews were transcribed verbatim and analyzed using thematic analysis.

Results: 9 participants attended 11 monthly cohort learning sessions, 25 monthly individualized coaching sessions, and 2 in-person convenings over the course of the 12 month intervention. T-tests revealed statistically significant increases for the TIOC knowledge (MD=3.62, p<0.05), but not attitudes (MD=0.502, p=0.62) or skills (MD=-0.53, p=0.61) subscales. T-tests also revealed no statistically significant increases across TICOMETER organizational domains. However, thematic analysis revealed practically significant organizational changes, including changes to 1) policies and procedures (e.g., improving workflows, increasing service accessibility by offering appointments on evenings/weekends), 2) staff training and onboarding (e.g., hiring additional staff, all-staff TIOC trainings), 3) physical environment (e.g., parking lot signage, adding art and plants to waiting areas), and 4) the meaningful involvement of people living with HIV (e.g., co-designing services and client spaces with community advisory board). Thematic analysis also indicated that the intervention was feasible, acceptable, and appropriate across diverse organizational settings, though each organization experienced unique barriers and facilitators to TIOC implementation.

Conclusions: Despite limitations of small sample sizes, pilot results indicate promising changes in the hypothesized direction at both the individual and organizational levels. Quantitative analyses demonstrate changes in participants’ TIOC knowledge, while qualitative analysis provides insight into the types of organizational changes able to be enacted in the TIOC process and preliminary support for intervention feasibility and appropriateness. These outcomes support the case for a future, fully powered examination of the TIOC intervention and its impact on organizational staff and clients.