Mixed Methods Case Study of Domains for Implementation of Trauma-Informed Care in England: The Need for Cultural Transformation

Trauma-informed care (TIC) is increasingly promoted in mental health systems, yet its implementation frequently stalls when reduced to discrete training events that follow policy directives. Our study examines how mental healthcare providers support the implementation of TIC. wWe draw on implementation science applied to the case of TIC and organisational change scholarship, through mixed methods (survey, interviews, environmental audits) in a single case study of a community mental health provider in the English NHS, to examine domains for successful implementation of TIC within mental healthcare provision. Our survey highlighted that a training intervention can build shared awareness, its effects remain short-lived without staff engagement to implement TIC. Our interviews showed distributed leadership as central to engaging staff in implementation of TIC, and also to align strategic priorities towards meaningful outcomes. They also highlighted that authentic co-production with Experts-By-Experience and Voluntary, Community and Social Enterprises (VCSE) representatives supported implementation, but risked tokenism without genuine power-sharing. Finally, raised in interviews, and followed up through environmental audits, implementation was also supported by the physical environment, with poor estates constraining efforts to create predictable, dignifying spaces central to TIC. Overall, informed by implementation science and organisation change scholarship applied to healthcare, our study suggests that TIC implementation is better conceived not as a technical training or compliance exercise mandated by policy, but rather as a complex cultural transformation within health and care systems. As such, we both extend and nuance insight into the domains underpinning implementation of TIC. • Training alone is insufficient for implementation of trauma-informed care • Distributed leadership supports implementation of trauma-informed care • Staff engagement supports implementation of trauma-informed care • Co-production enhances wider cultural change toward trauma-informed care • Poor physical estates limit implementation of trauma-informed care