leading and managing change: implementing trauma …...leading through change 2 introduction...

Running Head: LEADING AND MANAGING THROUGH CHANGE 1

Leading and Managing Change:

Implementing Trauma-informed Practice in Health Care Settings

Karen Custodio

University of British Columbia

Social Work 524

LEADING THROUGH CHANGE 2

Introduction

Implementing a trauma-informed practice (TIP) model of service delivery within health

care settings can be a complex change process for organisations and institutions. Literature

suggests key factors that will increase the likelihood that the process will result in constructive

change. This paper identifies four key factors within trauma-informed practice literature and

examines them further through a semi-structured interview with a community leader in the TIP

field. For the purpose of this paper, trauma is defined as “experiences that overwhelm an

individual’s capacity to cope” (Trauma-informed Practiced Guide, 2013). The literature

reviewed and the findings from the interview suggest these key factors have a significant

impact on the outcome of the TIP implementation process.

Literature Review

Research suggests that exposure to trauma can have a longstanding, pervasive impact

on individual’s lives (Ardino, 2014; Bloom, 2008; Bloom, 2010; Elliot, Bjelajac, Fallot, Markoff, &

Reed, 2005; Fallot & Harris, 2006; Kusmaul, 2015; & Trauma-Informed Practice Guide, 2013).

Trauma is known to have an impact on children and adult alike. A well-known study called the

Adverse Childhood Experiences (ACE) study found that children with a history of adverse

experiences are more likely to have negative experiences with substance use, alcohol,

depression and suicide attempts (Felitti et al., 1998). Studies in the area of post-traumatic

stress disorder have highlighted the significant role trauma exposure has on adults (Gersons &

Carlier, 1992). Trauma can also create barriers to accessing supportive services for individuals

with a history of trauma (Trauma-Informed Practice Guide, 2013). As a result, the concept


trauma-informed practice (TIP) was created as a direct response to the need for services to be

responsive to the unique needs of individuals with a history of trauma (Fallot & Harris, 2006).

TIP has garnered a significant amount of attention in recent years and has developed into an

accepted practice model for healthcare providers supporting individuals with mental health and

substance use issues in British Columbia (Trauma-informed Practice Guide, 2013). It is used to

inform services and staff on how to offer safe, supportive environments for individuals who

have a history of trauma.

Trauma-informed organisations adopt a culture of learning, nonviolence and

collaboration between employers, employees and clients (Bloom & Sreedhar, 2008). This

translates to having staff that are aware of the impact trauma has on clients, the need to

provide a safe and trusting environment and support clients to build skills and strategies to

cope with their triggers (Trauma-informed Guide, 2013, p. 13-14). As more organisations move

towards officially adopting TIP as a component of the service delivery model, there seems to be

a large amount of literature explaining the complexities that can arise during the transition and

adoption of this model. Within this literature, TIP is referred to as trauma-informed care (TIC).

As a result, this section of the paper will use TIC when reviewing literature findings.

Literature suggests key factors exist that can influence the likelihood of a successful

implementation of a trauma-informed practice model (Ardino, 2014; Bloom, 2010; Doherty &

Horne, 2002; Elliot, et al., 2005; & Rouse, & Parsons, 2014; Trauma-Informed Practice Guide,

2013). Four key factors emerged from the TIP change management literature reviewed. The

first factor identified in the literature is the integral role or leadership and management during

a change process (Ardino, 2014; Bloom, 2010; Elliot et al., 2005, & Jacobs et al., 2014). The role


of leadership is discussed in almost all of the literature reviewed. A second factor identified is

the awareness of staff emotions during this transition (Bloom, 2010; Elliot et al., 2005; &

Doherty & Horne, 2002). TIC literature suggests it is important to consider the possibility that

staff work in the helping profession may have experienced past trauma and may also be at risk

of vicarious trauma or burnout (Bloom, 2010 & Trauma-Informed Practice Guide, 2013). A third

factor identified in literature is the importance of communication between management and

staffing in order to reflect the kind of communication that needs to take place between staff

and clients (Ardino, 2014; Bloom, 2010, Trauma-Informed Guide, 2013). The final factor

identified in this paper is the importance of providing training for all staff that come in contact

with clients accessing services (Ardino, 2014; & Kusmaul et al., 2015).

Factor 1: The role of Leadership and Management

Leaders and managers need to be open to becoming trauma-informed and must be

committed to the implementation of TIC in order for the services to become trauma-informed

(Ardino, 2014; Elliot et al., 2005; & Bloom, 2010). Literature suggests that organizational

administrators need to be engaged with their staff throughout this process (Bloom, 2010).

Leaders and managers need to demonstrate to their staff that they are open to listening to

their needs, taking their feedback into consideration, acting on the feedback, and being open to

changing the process as needed. In an organisation that is implementing TIC, it is particularly

important for leadership and management to flatten the hierarchy that exists in order to

decrease the power imbalance that can exist between front line staff and supervisors (Bloom,

2010). This is because TIC models recommend that power is shared among individuals within


the organisation as it helps to provide a feeling of safety and empowerment for clients

accessing services (Bloom, 2010; & Elliot et al., 2005).

Victims of trauma can be re-triggered in environments where hierarchical structures

dominate the organizational culture (Ardino, 2014; Bloom, 2010; & Elliot et al., 2005). These

individuals are less likely to be triggered if an environment has shared power which extends to

the patients. Management and leadership are encouraged to embrace change and be a model

for others as they can often set the tone of the organisation (Ardino, 2014). When leaders are

able to set the tone, to do the work needed to foster real change, and change processes in a

manner that embrace TIC principles, the TIC transition is more likely to be a success (Bloom,

2010).

Factor 2: Responding to Staff’s Emotions

Models of trauma-informed practice often identify the need to be aware of staff’s

emotional reactions because they may have experienced trauma in their past and they are

exposed to trauma regularly in their day to day work (Bloom, 2008, Bloom, 2010, Elliot et al.,

2005; Trauma-nformed practice guide, 2013). Whether or not staff have a history of trauma,

they may be triggered by client’s histories, experiences, and behaviours. The safety and needs

of staff must be taken into consideration within a TIC process because of the importance of

maintaining safety for clients. Staff that may be experiencing emotionally instability may

unintentionally create an unsafe environment for their clients (Bloom, 2010, Elliot et al., 2005;

Trauma-Informed Practice Guide, 2013).


Some TIC model’s adopt the belief that the majority of staff working in the social

services profession have experienced trauma in their past. Bloom’s Sanctuary Model (2008)

suggests that many staff working in the helping profession have experienced trauma. She

suggests that their experience with past trauma can be one of the main reasons they work in

this field. She argues that organisations need to pay attention to this and potentially respond

to it. A trauma-informed organisation needs to respond to the impact of trauma on their

clients and staff. A trauma-informed organisation also has to be aware that exposure to trauma

can also traumatize staff therefore there needs to be supports in place for these staff should

they experience vicarious trauma.

Factor 3: Communication is Key

The communication between management and staff in a TIC organisation should reflect

the kind of trauma-informed communication that would take place between staff and clients

(Ardino, 2014; Bloom, 2010, & Trauma-Informed Practice Guide, 2013. The communication

should be respectful, clear, non-confrontational and managers should be able to take

responsibility for miscommunication (Trauma-Informed Practice Guide, 2013). Research

suggests that communication can be a struggle during the implementation of TIC (Kusmaul et

al., 2015). It is important that leadership engage in this style of communication with staff

during the change process in order to create a trauma-informed environment (Ardino, 2014).

The TIC literature places emphasis on the importance of communicating with staff about

the processes that are being implemented by management (Ardino, 2014). Allowing staff

feedback and acting on the feedback received is a way of decreasing the power imbalance


between management and front line staff (Ardino, 2014, & Elliot et al., 2005). It also allows

organisations an opportunity to develop communication processes that provide a safe platform

for staff to share ideas. Creating a culture of safety is integral within a TIC process (Bloom,

2010; & Trauma-Informed Practice Guide, 2013). When the people working in an organisation

feel safe to share feedback without fear of persecution, it helps to set the stage for client

feedback to also be received in the same manner. The ability to share feedback and be open to

client feedback is an integral aspect of open communication. Open communication is integral

in organisations that embrace a trauma-informed practice model (Bloom, 2010).

Factor 4: Staff Training

During a change process, staff may need re-training in order to be better prepared to

work within a changing environment (Bloom, 2010, Elliot et al, 2005, & Trauma-Informed

Practice Guide, 2013). Staff benefit with the training provides information about TIC and how

they can implement TIC in their daily work (Ardino, 2014; Bloom 2010, Elliot et al., & Trauma-

Informed Practice Guide, 2013). When it comes to implementing a TIC process, training is seen

as a way to prepare staff to manage client’s potential trauma responses (Trauma-Informed

Practice Guide, 2013). Training is also meant to provide staff with opportunities to work on

resiliency and self-care skills to help them manage their own responses to working in an

environment that exposes them to trauma (Bloom, 2010; & Trauma-Informed Practice Guide,

2013).

It is recommended that training be offered to all staff throughout an organisation

(Ardino, 2014; Bloom, 2010; Kusmaul et al., 2015; & Trauma-Informed Practice Guide, 2013).


Any staff that have direct contact with service users need to be included in TIC trainings. This

ensures that all staff have a shared knowledge and can support each other in this process.

Literature also suggests it is important to respect the prior knowledge and experience of staff

(Trauma-Informed Practice Guide, 2013). Not all staff need to receive the same level of training

because some already have work experience and training on trauma-informed services and

practice. It is important to avoid minimizing staff’s previous knowledge by forcing them to

attend trainings they will feel are redundant (Trauma-Informed Practice Guide, 2013). Kusmaul

et al. (2015) found that staff identified training needs varied depending on the training topic

and the staff person’s position within the organisation (p. 33). Providing staff with training

during the change process helps staff feel as though their organisation was invested in their

learning and providing opportunities for success (Ardino, 2014). It is important to note that

organisations need to provide time for staff to be trained and the support to implement what

was learned in the training (Bloom, 2010).

Interview with Community Leader

An interview was conducted with a community leader who has been involved in the

implementation of trauma-informed practice (TIP) at a provincial and organisational level. She

identified herself as having extensive experience with the change process that surrounds the

implementation of TIP within programs, organisations, and provincial-level initiatives. The

questions posed to this community leader were developed from the literature explored in the

previous section of this paper. The interview lasted an hour and took place in a public venue

near the interviewee’s home.


Factor 1: The Role of Leadership and Management

The interviewee shared stories from her work experience. Within these stories, she

identified the importance of leadership and management in the change process. She shared

that when working to implement TIP on a provincial initiative, it was important to identify TIP

champions that help leadership positions at the provincial level of management. She explained

that in order provincial-wide change to occur, a person in a position of power willing to drive

the change must be on board with change. She found that the key principles of TIP resonated

with direct service staff, but leadership were not always aware what it meant or how their

leadership had to change in order to compel organisation’s leadership to explore and engage in

TIP models.

She shared a story of an institution in the lower mainland that hired her to oversee a TIP

change management process. She stated that prior to hiring her, the institution attempted to

implement TIP without leadership buy in. She explained that the process had not gone well and

many staff were upset with the change process because of the moral distress they faced. The

staff had received TIP training on the key principles of trauma-informed care, but they were

unable to make changes in their practice because of the lack of management support. The

managers did not provide time or support for the staff to make changes in their daily practice

and to their work space. This led to staff feeling as though they were potentially re-

traumatizing clients because they knew that they were responding to their needs incorrectly.

Interestingly, this interviewee worked for an organisation that attempted unsuccessfully

to implement the Sanctuary Model of trauma-informed care developed by Sandra Bloom. This


is interesting because the Sanctuary Model is prevalent in literature and was explored for this

literature review. She attributed the lack of success of this process due to the lack of leadership

engagement and knowledge on what TIP entails. She shared that managers were not willing to

support their staff in implementing the process because they did not seem to understand that

TIP is an organisation-wide procedural and cultural shift, and not something that can be quickly

implemented into programs with little leadership involvement. She shared that the

organisation has since changed leadership, and the new executive director has adopted the

principles of TIP within her leadership style. When compared to the literature, it reinforces the

notion that leadership must be bought into the TIP change process in order for it to succeed.

I found her comments regarding the identification of a champion interesting because it

was not something explicitly covered in the literature reviewed for this paper. I am not sure if

this is due to the fact that the reviewed articles did not explore provincial or state-wide system

change. Another interesting point she made was about the added complexity a

multidisciplinary healthcare environment played in the TIP implementation process because it

was difficult to engage the leadership from all the different service areas. This was touched

upon in literature (Elliot et al., 2005), but was not emphasized to the extent it was emphasized

in this interview. She identified the multidisciplinary environment as a significant barrier

because of how challenging it was to create an implementation plan with all service areas

involved. In fact, the complexity resulted in the plan moving forward with little clarity at the

leadership level. The end result was not positive. In Summary, the role of leadership was

identified as integral to change management in both literature and by this leader. Both


literature and this interviewee argued that leadership needs to embrace the principles of TIP as

their management style must set the tone for the organisation to adopt the TIP principles.

Factor 2: How do Organisations Respond to Staff Emotions Through this Process

The community leader shared that it has been her experience that organisations are

aware that staff are regularly exposed to trauma in their work environments on a regular basis.

She shared that it is important for organisations to be aware that staff can be emotionally

strained by the change process and that may cause an increase in emotional reactions. She

stated that the institution she worked with attempted to identify staff’s need for a trauma-

informed work environment by embracing the concept of “we” for the TIP training. This meant

that the trainings explored the trauma-informed principles from both a client and staff

perspective. The trainings provided information on how the work environment can trigger both

staff and clients, plus it explored other factors that may cause trauma responses.

The community leader did not identify any specific reasons why individuals may

experience emotional reactions beyond the fact that they may be exposed to trauma as a result

of working with individuals who have experienced past trauma. There was no mention of the

possibility that staff working in the field have a history of trauma. I found this interesting given

that the very nature of a TIP process is founded in being aware of potential emotional

responses. Bloom (2010) and others identify there is a high likelihood that staff working in the

helping profession have past trauma. Trauma-informed practice cannot be implemented in an

unhealthy, stressed, traumatized, demoralizing work environment where staff experience

unresolved grief, anger, disempowerment and helplessness (Bloom, 2010). When asked if


there was specific trainings regarding any possible impact of staff personal experience trauma,

the interviewee explained that the concept of “we” within the training allowed for them to

explore their past trauma. It was clarified that the staff were considered professionals and

should be able to access services outside the trainings to explore their past trauma. I believe

the interviewee was identifying the importance of professionalism when working within a

demanding field. Even though this answer is understandable as staff need to have some

competencies regarding trauma and their personal triggers, this response does not fully align

with Bloom’s (2010) model.

Factor 3: What is the Role of Communication?

The community leader identified that communication was integral to the TIP change

processes she was involved in. The interviewee shared that the institution she worked with

struggled with keeping staff informed about the change process. She stated the staff felt

confused and were unclear as to what the change was attempting to achieve. Staff reported in

feedback surveys that they did not know how change was going to be achieved, and the

changes meant for their daily work responsibilities. She expressed that the lack of

communication was a significant barrier to the process. She identified that staff needed to

inform staff about the process before it happens instead of after it happens.

The institution that had unsuccessfully implemented the Sanctuary Model really

struggled with communication between leadership and direct service staff. She shared that

things began to shift when new leadership implemented processes where staff were able to

give feedback on how the process was going without fear of retribution. She stated that a town


hall format was adopted and it took a long time before staff started voicing concerns at these

meetings. She shared that the turning point was when a staff member shared a negative

experience and the executive director worked with the staff person to implement change that

rectified the situation. After that, staff felt more comfortable sharing.

The interviewee’s experiences and expressed opinions on the importance of clearly

communicating the change process to staff. It was interesting to hear about a real world

example that directly reflected a key lesson identified in literature regarding the importance of

communication. It is unclear if the inability to describe the change process to staff reflected the

leadership’s lack of clarity on what the process would entail or if it was a result of a lack of

commitment to TIP. It was particularly interesting to hear how a change in leadership

significantly impacted the communication processes. The interviewee pointed out that the new

executive director seemed to have adopted the principles of TIP as her personal communication

and management style. Her experience with this new leader is an example of how one person

can have significant impact in change processes.

Factor 4: Training is Necessary

The community leader identified that training needed to be an integral component in

every TIP implementation process. She believed that organisations must adopt a culture of

learning so that they are open to providing training as well as supporting the changes that come

out of the trainings provided. She found that when management were open to learning about

TIP, they were more likely to alter the work environment in a manner that allowed staff to

implement trauma-informed principles. She stated that she supported organisations offering


trainings that educated staff on trauma-informed principles. I found that the neither the

interviewee or the literature backed one specific trauma-informed practice model. It seemed

that that the most important aspect of training is to make sure all staff receives training on

trauma-informed care principles.

She shared a story of an institution that mandated all staff to attend trauma-informed

care trainings that were provided by the employer. The mandatory trainings were not well

received. She shared that the staff reported feeling as though their past experiences and

learnings were invalidated because there were being forced to attend trainings that were below

their skills and abilities. This feedback from staff reflected the literature as it identified the

importance of respecting staff’s pre-existing knowledge. The institution responded to this

feedback and implemented a staff process group where staff could discuss different processes

introduced by management and provide feedback. This allowed staff to give feedback on what

trainings would be helpful to staff. The findings in the literature suggest that the decision this

organisation made to respond to the feedback most likely helped increase the safety within the

work environment (Bloom, 2010, Ardino, 2014, & Elliot et al., 2005).

Self-Reflection

As a social worker working in a hospital setting, I witness on a regular basis the impact

trauma has on individuals accessing healthcare services. My work experience is very relatable

to the stories the interviewee shared about the moral distress that individuals may face when

attempting to implement TIP in organisations in unsupportive environments. I have found it

very frustrating at times to respond to patients struggling to remain in hospital because the

environment re-traumatizes them. I have seen patients reject healthcare treatments they need


because they are too triggered to remain in hospital. This has been a source of frustration for

me and I have experienced moral distress as a result of watching these situations unfold. Part

of the distress comes from knowing about trauma-informed practice and not being able to

practice using TIP principles. Another part of this distress is observing people working in the

health care system talk about TIP as though they implement the principles in their daily practice

when their actions show they clearly are not trauma-informed.

It was exciting to hear about an organisation that had attempted to embrace a TIC

model from the top down. It was encouraging to hear that one person in the leadership

structure created significant change and directly affected the trauma-informed practice of

direct service staff. I wonder if the leader’s change in management style is in line with Bloom’s

(2010) concept of the dual process because it seemed that she was able to create change on

the management and program level. This dual process suggests that changes to services must

be reflected in organizational structure changes so that both management and staff adopt the

principles of trauma-informed practice. Bloom (2010) suggests it that the change process must

occur on both levels because stressed staff and frustrated administrators create pressured

organizations that ultimately provide services that often reflect the very traumatic experiences

that damaged our clients to begin with.

I found it interesting to learn about a specific work environment that implemented TIP

from a best practices perspective. It sounded like the experience was filled with successes and

challenges. It seemed that the closer their implementation came to replicating best practices,

the more successful the process became. This was apparent in the example about the new

executive director and her how ability to embrace TIP principles led to systemic changes. It


sounded as though she identified herself as a trauma-informed leader and therefore emanated

those practices in her management style. It sounded like she provided the support and

structure for her managers to do the same. I found this inspiring because my work experience

left me feeling disillusioned by the healthcare system. I have found the system to be rigid and

often very slow to respond to emerging needs of clients. The examples the interviewee

provided of times when the institution identified a problem in their TIP implementation that

was related to their personal management styles and the steps they took to change their

management so that it was more reflective of TIP was truly surprising. It made me think that as

a hopeful future leader in healthcare, I may be able to create meaningful change for staff and

clients.

I found her experience within the health care field beneficial because it helped me

envision how TIP could be successfully implemented in a hospital setting. I was excited about

her stories of positive shifts towards TIP within a health care setting because the health care

setting can be inherently triggering and often the opposite of what a TIP environment is

supposed to look like. For example, TIP suggests a flattened hierarchy helps create a safe

environment for staff which translates to safety for clients (Bloom, 2010). It has been my

experience that the multidisciplinary environment of the healthcare field lends itself to power

imbalances. I have found that the medical professionals hold positions of authority over other

disciplines. It has been my experience that this power imbalance causes friction within the

broader team. I have overheard other staff complain about this and issues related to the

power dynamic out in the open where clients can hear their concerns. This kind of behavior

goes against the principle of a safe environment because there is a feeling that people do not


have control over the environment around them and they are not seen as equals. I wondered if

this power shift could ever be altered. The interviewee gave me hope that it could, given the

right leadership and the will to change.

I appreciated that both literature and the interviewee placed a significant amount of

emphasis on the role of leadership. Change management literature in general identifies the

role of leadership as integral to the change process (Lewis & Thompson, 2003; Jacobs et al.,

2014; Shove & Walker, 2007). I feel that leadership is especially important in TIP change

process because leaders have to embrace TIP principles in their management style. It has to

inform how they interact with staff and how they complete their managerial tasks. For

example, TIP suggests managers need to create a culture of safety for their staff in order to

create a culture of safety within programs (Trauma-Informed Practice Guide, 2013). In general

change management, leaders tend to facilitate communication, carry the vision, and build the

organizational capital that helps sustain change efforts (Lewis & Thompson, 2003). I believe

that supporting a change process is different than adopting the model of change as part of your

management style.

My final personal learning is the importance of facilitating opportunities for power shifts

to occur between management and direct staff. In my past position as a program director, I

was responsible for completing the overall accreditation process for the non-profit

organisation. I look back and wonder if I could have done a better job flattening the hierarchy

within the agency and engage direct staff in the accreditation process. Even though

accreditation is not the same as implementing a trauma-informed practice model, it was a very

stressful process that at times created a divide between management and staff. This divide was


a result of the number of changes that had to be made that didn’t necessarily fit well with the

staff’s daily workload. Looking back, I wonder if the staff experienced moral distress because

what the accreditation standards expected from their work and what they had time to do was

possibly two different things. Maybe there were some ways to include the staff in reviewing

the processes put in place as a result of accreditation. This may have provided an opportunity

to have their opinions reflected in policy and procedures. The trauma-informed care literature

and the interviewee both identified the positive impacts a flattened hierarchy can bring to

power imbalanced environments. I think this could be an area that I could further explore in

my career as I have experienced the negatives of working within a hierarchical structure that

supports power-imbalances between direct staff and management. As I hope to return to a

leadership role within this profession, I think there will be opportunities for me to explore

different ways of setting up management structures.

Conclusion

The community leader I chose to interview was very well versed in the topic of trauma-

informed practice. I was very fortunate to interview someone who has extensive work

experience in this specific field. It seemed that the interview flowed easily because of her

extensive knowledge and experience. Her understanding of the topic made the conversation

very interesting because she had thoughts, ideas, and experience in all areas that I asked her

about. I was surprised to find that many of her experiences and perceptions on the topic were

consistently on par with literature. The reason I was surprised was because past my work

experience has exposed me to many situations where individuals and institutions are aware of

best practices but are not able to implement them for a number of reasons. I hope to follow in


the path of the community leader I interviewed and adopt TIP principles not only in my direct

practice work, but hopefully in future leadership positions I will hold.

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