Trauma-informed care (TIC) has emerged as a vital framework aimed at transforming human service systems to better recognize, respond to, and prevent the impacts of trauma. Its holistic, multifaceted approach seeks to create safe, empowering environments for both service users and providers, addressing complex organizational cultures across various sectors. As TIC continues to gain momentum, understanding how it is defined, implemented, and evaluated across different contexts is crucial for fostering systemic change and improving mental health and social outcomes worldwide.
Traumatic experiences are pervasive and can have enduring adverse effects on individuals, organizations, and society at large. If left unaddressed, trauma can foster unsafe environments characterized by heightened arousal, mistrust, and the frequent use of coercive practices. Implementing TIC offers a pathway to mitigate these harmful consequences, yet the specific methods and strategies for effective adoption remain diverse and often inconsistent. This review systematically maps the existing research, highlighting key concepts, interventions, and measures used in TIC across a broad spectrum of settings.
1. Introduction
Trauma can result from various distressing events, such as violence, neglect, abuse, disasters, or systemic injustices, which threaten an individual’s sense of safety and well-being. Most populations experience at least one traumatic event in their lifetime, with psychiatric and vulnerable groups experiencing higher rates of trauma exposure and PTSD [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. For example, in mental health populations, trauma exposure often goes underdiagnosed, compounding the risk of poorer health outcomes [https://medappinsider.blog/how-is-canadas-healthcare-system/]. These traumatic experiences can impair quality of life, increase substance use, homelessness, suicidality, and lower social functioning, especially in those with severe mental illness (SMI) [https://medappinsider.blog/what-type-of-healthcare-system-does-canada-have/].
Professionals working within these systems—nurses, psychologists, teachers—are also at risk of secondary trauma and burnout, especially when exposed to violence or harassment. When trauma remains unaddressed, organizations risk fostering cultures of mistrust, excessive arousal, and coercive practices, which can further victimize vulnerable populations. This underscores the urgent need for frameworks that shift organizational cultures toward trauma sensitivity.
Trauma-informed care (TIC) was first conceptualized by Harris and Fallot in 2001 [https://medappinsider.blog/what-are-data-sets-in-healthcare/], emphasizing a comprehensive, strength-based approach that acknowledges trauma’s prevalence and its influence on individuals’ lives. The core principles—safety, trustworthiness, peer support, collaboration, empowerment, and cultural sensitivity—aim to foster environments where trauma survivors feel respected and in control. Implementing TIC involves a profound cultural shift, affecting policies, staff training, and organizational practices [https://medappinsider.blog/how-is-canadas-healthcare-system/].
Unlike trauma-specific treatments (TST)—such as prolonged exposure or trauma-focused cognitive therapy—TIC is a systemic organizational approach designed to embed trauma awareness into all levels of service delivery. This broad application helps prevent re-traumatization and promotes recovery by modifying organizational cultures, practices, and relationships [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
Research suggests that successful TIC implementation may also reduce violence and coercion within mental health settings. Public health strategies, like the six core strategies model, combine leadership, data utilization, workforce development, reduction of seclusion and restraint, peer involvement, and debriefing techniques to promote organizational learning and trauma awareness [https://medappinsider.blog/how-is-canadas-healthcare-system/].
Despite growing interest, the literature reveals considerable variability in how TIC is conceptualized and operationalized. Over 23 systematic reviews explore its application across settings like schools, juvenile justice, and healthcare, yet these often focus narrowly on specific populations or interventions [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. Many highlight the lack of consensus on definitions, inconsistent methodologies, and the diversity of implementation strategies, which hinder the ability to synthesize findings or establish best practices.
Aims and Objectives
This review aims to systematically map the current landscape of TIC research, identifying how it is defined, implemented, and evaluated across settings. We seek to answer: “What is known about implementing TIC?” Specifically, we examine study characteristics, interventions applied, measures used, and conceptual understandings of TIC to identify gaps and guide future efforts [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
2. Methods
This scoping review was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/RZSKQ) and followed established guidelines [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. The methodology involved five steps: formulating research questions, identifying relevant studies, study selection, data mapping, and synthesis.
Stakeholder engagement was integral, involving a Danish National TIC Network comprising service users, clinicians, managers, researchers, and NGO representatives. Their insights helped shape the questions and ensure relevance to practice and policy [https://medappinsider.blog/how-is-canadas-healthcare-system/].
2.1. Formulating the Research Questions
Guided by the Population, Concepts, and Context framework, the questions focused on those utilizing services (patients, staff), the methodologies and interventions applied, and how TIC principles are defined and operationalized in different settings. Stakeholders emphasized issues related to empowerment and systemic change, leading to a broad scope that included healthcare, social services, education, and juvenile justice.
2.2. Identification of Relevant Studies
A comprehensive literature search was conducted across multiple databases (CINAHL, Cochrane, Embase, ERIC, Medline, PsycINFO, Web of Science) in June 2019, with updates in February 2022. Search terms included variations of trauma-informed strategies and service settings. Gray literature sources were also explored but prioritized peer-reviewed articles for quality assurance.
2.3. Eligibility Criteria
Inclusion criteria encompassed studies reporting on TIC implementation, quality improvement, or organizational change from 2000 onward, published in English or Scandinavian languages. Gray literature was excluded after initial screening, focusing on empirical research studies. The criteria emphasized descriptions of interventions, measures, and definitions, excluding purely theoretical papers or those focusing solely on trauma-specific treatments.
2.4. Study Selection
Using Covidence, two reviewers independently screened titles, abstracts, and full texts, resolving disagreements through discussion with a third reviewer. A total of 157 empirical studies were included, along with 23 systematic reviews for supplementary context, as summarized in a PRISMA flowchart.
2.5. Data Mapping
Data extraction involved categorizing study characteristics, methodologies, definitions, interventions, and outcome measures. Discrepancies were resolved through consensus meetings, ensuring consistency and rigor [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
2.6. Data Synthesis
Numerical summaries and narrative descriptions captured the diversity of approaches, settings, and conceptualizations of TIC across the included studies [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
3. Results
3.1. Study Characteristics
Most studies originated from the USA (n=107), reflecting longstanding efforts to embed trauma awareness in health and social systems [https://medappinsider.blog/how-is-canadas-healthcare-system/], with others from Canada, Australia, and the UK. A minority were from Germany, Finland, Greece, and Japan, highlighting geographic disparities.
Organizations ranged from regional to national levels, with about 44% conducted regionally and 13% at hospital or community levels. Settings included child welfare, schools, mental health, emergency departments, and social services. The diversity of contexts underscores the broad applicability of TIC but complicates comparisons.
Methodologically, most studies employed quantitative designs (44%), followed by qualitative (23%) and mixed-methods (20%). Quality improvement initiatives, often using routine data, accounted for 13%. These variations reflect the ongoing exploration of how best to operationalize TIC principles [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
3.2. Definitions of TIC
Definitions varied but commonly referenced SAMHSA’s framework [https://medappinsider.blog/what-are-data-sets-in-healthcare/], which emphasizes six core principles. Many studies incorporated Harris and Fallot’s description [https://medappinsider.blog/what-are-data-sets-in-healthcare/], Bloom’s sanctuary model, or adaptations thereof.
Despite this, the application of principles like safety, trust, collaboration, and empowerment differed significantly. For example, some focused solely on physical safety, others on psychological safety, and some conflated principles or used their own formulations. This ambiguity in definitions hampers consistent measurement and implementation, emphasizing the need for clearer, more universally accepted terminology [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
3.3. Interventions
Interventions ranged from educational programs—training staff on trauma concepts—to organizational strategies such as environmental modifications, trauma screening, and policy changes. Over half of the studies focused on education, with durations from short online modules to multi-year training.
Some implemented comprehensive approaches guided by frameworks like SAMHSA’s six principles, combining training with environmental and policy reforms. Others used unique curricula tailored to specific populations, such as school-based trauma curricula or residential care programs. A subset of studies (around 28%) examined measurement tools or organizational assessments without implementing specific interventions [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
3.4. Outcomes and Measures
Measures targeted three groups: service users (trauma survivors), providers, and organizations. For service users, validated trauma and PTSD scales—such as the UCLA PTSD Reaction Index—were common, alongside broader wellbeing and quality-of-life measures [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. Some studies relied on administrative data or self-generated questions.
For providers, assessments often focused on attitudes, knowledge, and competencies, frequently using the validated ARTIC scale [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. Organizational outcomes included organizational readiness, principles adherence, and barriers, often measured with tailored or unvalidated tools.
Many studies evaluated the impact of TIC training on provider attitudes and knowledge but less frequently on client health outcomes or systemic change. The inconsistency in measurement tools underscores the importance of adopting standardized, validated instruments to advance evidence-based implementation [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
4. Discussion
This comprehensive mapping reveals that TIC is a broad, adaptable, but often ambiguously defined framework. While most studies reference core principles like safety and trust, application varies widely, affecting comparability and the accumulation of robust evidence. The diversity of settings—from child welfare to adult mental health—demonstrates TIC’s flexibility but also highlights the challenge of establishing standardized practices.
Implementation often relies on staff training, environmental changes, or policy reforms, with varying durations and intensities. Evidence suggests that leadership commitment, staff support, and policy alignment are critical for success [https://medappinsider.blog/what-are-data-sets-in-healthcare/], yet the lack of consensus on operational definitions complicates evaluation.
Measurement inconsistency remains a significant barrier. The adoption of validated tools like the ARTIC scale [https://medappinsider.blog/what-are-data-sets-in-healthcare/] is recommended to facilitate systematic assessment of provider attitudes, while trauma and PTSD measures should be chosen carefully to capture symptomatology and wellbeing holistically.
The cultural shift demanded by TIC involves changes at multiple organizational levels, requiring intentional strategies informed by implementation science frameworks such as RE-AIM [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. Future research should focus on long-term outcomes, cost-effectiveness, and systemic impacts, including survivor participation in research—aligning with principles of trauma sensitivity [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
The variation in definitions, interventions, and measurement tools indicates a need for international consensus and clearer conceptual frameworks. Such standardization would promote more effective implementation, evaluation, and scaling of TIC practices globally [https://medappinsider.blog/what-are-data-sets-in-healthcare/].
5. Conclusions
Trauma is a widespread phenomenon with profound health and social consequences. TIC offers a comprehensive approach to transform organizational cultures into trauma-sensitive environments that prioritize safety, trust, collaboration, and empowerment. Despite its promise, the field remains fragmented, lacking a unified definition and standardized implementation strategies. Establishing clearer conceptual frameworks, validated outcome measures, and systematic methodologies is essential for advancing TIC’s evidence base and practice.
Implementing TIC requires collaboration among policymakers, practitioners, and trauma survivors, fostering systemic change rooted in human rights and dignity [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. As the concept continues to evolve, future research must focus on long-term impacts, scalability, and sustainability, ensuring that trauma-informed principles become embedded in health and social service systems worldwide [https://medappinsider.blog/what-are-data-sets-in-healthcare/]. Embracing this approach may ultimately lead to safer, more effective, and more compassionate service environments for all.
This review underscores the importance of a unified, trauma-sensitive language and approach to guide effective implementation across diverse settings and populations, aligning with global human rights principles and best practices.