How is trauma-informed care conceptualised in UK mental health services? Systematic scoping review protocol.

Strengths and limitations of this study

Population

Inclusion. Documents that described service providers (with or without healthcare professional registration) delivering TIC included paid or unpaid volunteer workers, administrators, occupational therapists, social workers, psychologists, nurses, psychiatrists, physical health coordinators, support workers, allied health professionals, or students carrying out formal healthcare roles as part of their placement for their university degree.

This review included documents related to patients who have experienced traumatic events, who were receiving care from a mental healthcare team, and who exhibit mild to major mental health conditions, as diagnosed via clinical descriptions and diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders 5th edition or Text-Revision, and the International Classification of Diseases 10th or 11th version.

Exclusion:

Documents that covered traumatic brain injury, dental trauma studies, editorials, or orthopaedic trauma were excluded. This was to ensure the review's relevance to psychological trauma. Documents that discussed physical trauma, including fractures, cuts, burns, concussions, dislocations, and injuries from car collisions or falls, were excluded. Documents that did not meet the inclusion criteria and were irrelevant to psychological trauma.

Intervention

None

Comparison

None

Outcome

The review's primary outcome included eligible documents of those reported with relevant principles, implementation, or evaluation of TIC. Documents that described the enablers or challenges of using TIC in implementing and embedding it in a mental health care setting. Documents could show bullet point statements or objectives contributing to trauma information. This covered overall concepts, including synonyms of TIC. MC (student researcher) explored the overall progression of the TIC and assessed the document's quality in the UK context.

Study design

Included study design. Empirical studies in listed UK-specific mental health care settings available in English that used qualitative methods, including but not limited to designs such as grounded theory, phenomenology, ethnography, feminist research, action research, mixed-methods approaches or qualitative descriptions⁴². This review also considered descriptive observational study designs, including individual case reports, case series and descriptive cross-sectional studies, as part of inclusion. Nonempirical documents included training materials, such as a handbook or county policy statement. The study design included letters or public handbooks covering trauma screening. Documents that described TIC practices, TIC guidelines, assessments, and training applied in a UK setting were included. Although TIC was a universal concept, for this systematic scoping review, the study type was specific to the UK setting, with documents publicly available for the UK workforce.

Excluded study design. Studies with quantitative methods, such as experimental or quasi-experimental study designs, randomised controlled trials, non-randomised controlled trials, interrupted time series studies, or before-and-after studies, were not included⁴³. Analytical observational studies, such as case-control studies, analytical cross-sectional studies, and prospective and retrospective cohort studies, were not included. Documents that focused on service providers (with or without healthcare professional registration) outside the UK. This was to maintain the focus on the UK context and qualitative research. Documents that described systematic literature reviews or scoping reviews, blog formats, or conference abstracts were excluded.

Database searches for empirical research papers

Three electronic database search terms were used: Medline, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search strategy was developed with a specialist University of Nottingham librarian. The text words contained in the titles and abstracts of relevant articles and the index terms describing the articles were used to develop a full search strategy for PsycINFO via OVID with the syntax of the following:

The search strategy, including all identified keywords and index terms, was adapted for each included database and/or information source. The complete search strategy used for Medline via Ovid and CINAHL was registered on the Open Science Framework (OSF) registries as a repository of Extended data⁴⁴.

Citation tracking

Forward and backwards citations were repeated until no added documents were included.

Grey documents

Grey documents were defined as eligible policy documents under the relevant NHS policy document in the UK or by contacting the Human Resources Department of the Trust. Eligible training materials were obtained from e-academy online, face-to-face training, or from reading the trust bulletin board. MC liaised with the learning and development team of the healthcare trust or related mental health professionals, such as a clinical director, division lead or manager, for appropriate resource guidance across the region.

Filtering of journal articles

The relevant studies were imported into the Covidence systematic review software and merged into a single list. Data duplicates, such as identifying and deleting duplicates, were manually eliminated from the main search. MC then screened for titles and excluded non-relevant titles. Once MC narrowed down her relevant titles, she read the abstract. MC analysed whether the abstract was relevant and excluded irrelevant abstracts. The relevant sources were retrieved in full and uploaded into Mendeley. MC verified the full texts of the selected papers against the PICOS criteria. Forward and backwards citations were then completed. The retrieved documents were stored in the University of Nottingham computer software and securely protected with a username and password⁴⁵.

Selection of grey documents

MC actively searched through this by contacting three National Healthcare Trusts and searching web pages to assess whether they met the eligibility criteria for trauma-informed practice. MC then screened the contents to explore whether they meet TIC practice principles and working definitions. Titles and contents that did not meet the criteria for the PICOS section were removed. MC verified the full text from selected documents against the PICOS criteria. If MC remained unclear, it was resolved by discussion with a second researcher.

To address objective 1, we used criterion sampling⁴⁶ to select documents with direct experience working with mental health care services and to determine the TIC principles. This included mental health professionals such as psychologists, psychiatrists, social workers, and nurses. We ensured the diversity of this sample by selecting documents from various roles within mental health care settings, such as frontline clinicians, policymakers and administrators, and ensuring a comprehensive review of the multitude of perspectives on TIC tenets. For objective 2, we used typical case sampling⁴⁶ to focus on recognised experts in the field of TIC in the mental health care system. Objective 3 used criterion sampling and maximum variation⁴⁶. Using criterion sampling enabled us to explore documents covering experts in developing TIC initiatives. In contrast, maximum variation sampling ensured diversity within the sample to capture a range of perspectives and experiences related to TIC implementation and evaluation. Diversity was defined as different organisational contexts within mental health care, including public sector organisations, integrated care systems, and specialised mental health care facilities, related to TIC implementation and evaluation. This included selecting documents from different geographical locations, types of mental health care settings, and levels of involvement in TIC initiatives in the UK. The retrieved documents were stored in the University of Nottingham computer software and securely protected with a username and password⁴⁵.

Patient and Public Involvement

Patients and members of the public were not involved in any stage of this project, as its focus was on synthesising literature rather than conducting primary research. However, future dissemination efforts will include engagement with patient advocacy groups and public engagement to ensure findings are actionable and accessible.

Data extraction

Following a pilot test, MC extracted and checked the data from the included studies and then placed the eligible documents on a table. The full texts of all remaining studies were screened independently for inclusion. Data were systematically described from each document, including article characteristics (author(s), reference, year of publication, region in the UK, design, population setting, sample size, and outcomes of TIC). The same procedure was repeated with the grey documents. MC extracted relevant documents independently from each evidence source, and a second researcher cross-checked that 10% of the documents extracted from the data were accurate and complete. The discordant opinions that MCs found were resolved during team supervision. For this review, the concept was service providers' challenges in practising TIC principles. Enablers were factors that made implementing and embedding TIC principles easier. Further follow-up might be necessary. The data extraction sheet and data extraction table form can be found in the Open Science Framework (OSF) registries as a repository of Extended data⁴⁴.

Data synthesis and presentation

Both the documents extracted from the electronic databases and the grey documents collected were imported into NVivo 14 software for coding and validation⁴⁷ via thematic analysis. For example, this was completed by creating and defining attributes, focusing on subgroups such as age. These attributes were then assigned to cases in the population. The data were then coded to identify relevant themes. MC ran matrix coding queries to analyse the intersections between attributes and codes. MC assessed relevant patterns or differences in how the themes are presented across the classifications. The first reading provided preliminary codes from the extraction. This then progressed from narrowing the preliminary codes to the final codes, which were developed upon thoughtful consideration and reflexivity. The final codes from the search and inclusion process were explored visually in word clouds, mind maps, charts, diagrams, matrices, coding stripes or graphs for deeper immersion in the findings⁴⁷. Only the most useful and appropriate visualisation tool was tabulated into relevant units of text, which was established a priori as a guide for deeper immersion in the findings⁴⁸.

To address objective 1, the existing framework, which described the principles of TIC, was used deductively to define the codes of one framing of TIC principles. An inductive approach was used to define codes that do not fit the framing of TIC principles. Any overarching themes identified from the careful, patient and imaginative life studies of electronic and grey documents served as the foundation for a conceptual model to understand the review objectives and were presented in a table. This approach provided a sense of reference when approaching empirical instances that do not have definitive concepts to make sense of the empirical world being studied⁴⁹.

To address objective 2, MC used an inductive approach to identify important concepts that meet the TIC framework criteria from electronic and grey documents. A concept can be understood as an intermediate level of knowledge contribution in design research that bridges the gap between theories and specific instances (such as user interfaces)⁵⁰. Strong concepts were artefacts of constructive analysis, a critique and generative practice that occurs at a constructive level of removal from specific instances⁵⁰. For example, this was applied by a collective of generative, evaluative and substantive approaches to the artefacts⁵⁰ when refining TIC theory to increase research design and accumulate coherent knowledge. This was when qualitative data patterns, themes and categories were identified to form conceptual frameworks⁵¹ to explain the TIC phenomenon. Findings from this study were presented via the most appropriate visual tool. Moreover, this included a subgroup analysis of documents to highlight the important concepts related to 14–65-year-olds. This age range aligned with the standards of early intervention in psychosis services in the UK⁵². The findings from this analysis were presented in a table. By conducting a subgroup analysis tailored to this age range, we identified important concepts, best practices and trends pertinent to this demographic. This leads to more effective tailored support and services for this specific service.

Finally, with objective 3, MC used an inductive approach to explore the types of content by which the TIC is applied in practice. This considered typologies of shared characteristics such as guidelines, handbooks, and mandatory or compulsory training applied in a UK setting and was presented in a diagrammatic form. By grouping these resources into a typology, patterns can be identified and organised⁵³ to define TIC and create a meaningful impact in the research field. This was used to identify the characteristics of the document and distinguish how it was delivered in a mental health care setting. All evidence sources used were investigated for similarity, and if the items included were identified as representing the same purpose, they were combined. MC and a second researcher reviewed and discussed the items used for data synthesis.

Ethics and consent

Ethical approval and consent were not required.