Gray’s Trauma‑Informed Care Services Corp (GTICSC) has used Efficiency, Efficacy, Empathy and Equity, the 4 Es, as a guiding formula since its inception in 2017. This demonstrates how the 4 Es can be used to build trauma‑informed systems of care for victims of violence, including survivors of domestic violence and “dark triad” abuse.
Trauma & Violence‑Informed Care
Trauma‑informed care (TIC) views service provision through a lens of trauma, requiring an understanding of trauma’s impact, awareness of triggers and vulnerabilities, and a commitment to avoid re‑traumatization (Ferencik & Ramierz-Hammond, 2017). It places the survivor’s experience at the center and emphasizes trust, safety, collaboration and empowerment. Trauma and violence‑informed approaches expand this lens to recognize how systemic violence and discrimination intersect with trauma, calling for organizational changes that increase safety, control and transformative behaviors, while fostering choice and collaboration (Canada’s Public Health Agency [CPHA], 2025). The 4 Es operationalize these principles within GTICSC’s integrated healthcare and educational programs.
Efficiency: Streamlining Processes to Minimize Harm
Trauma‑informed services must be delivered efficiently so survivors do not face unnecessary delays or bureaucratic burdens. Lean Six Sigma (LSS) and similar improvement methods are useful in this context. A quality‑improvement study in ophthalmology clinics showed that implementing Lean Six Sigma reduced median patient in‑clinic time from 131 minutes to 107 minutes and increased the number of patients seen per clinic session by 9 % (Kam et al., 2021). The study explained that Lean techniques reduce “waste” and Six Sigma reduces variation by defining, measuring and improving processes (Kam et al., 2021). A systematic literature review found that understanding challenges, readiness and critical success factors is essential for deploying LSS in healthcare and that such deployment can improve operational efficiencies and enhance patient and staff outcomes (McDermott et al., 2022). GTICSC applies these approaches to reduce wait times for services, streamline intake, and ensure survivors receive care without repeated trauma narratives.
Efficacy: Evidence‑Based & Outcome‑Oriented Care
Efficacy refers to the effectiveness of interventions in promoting healing and organizational wellness. The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that trauma‑informed approaches improve patient engagement, treatment adherence, health outcomes and staff wellness (SAMHSA, 2025). Trauma‑informed nursing research shows that when nurses adopt a trauma‑informed lens, job satisfaction increases, risk of burnout decreases and patient experiences improve (Fleishman et al., 2019). Implementing organizational and clinical changes, such as staff training, safe environments and patient empowerment, helps transform systems (SAMHSA, 2025). GTICSC’s programs integrate Lean Six Sigma with trauma‑informed competencies, monitoring outcomes to ensure interventions remain effective and adopting continuous improvement cycles.
Empathy: Understanding Survivors’ Experiences
Empathy is the heart of trauma‑informed practice. In domestic violence settings, trauma‑informed care requires advocates to respond with supportive intent and to avoid re‑traumatization (Ferencik & Ramierz-Hammond, 2017). Services should respect individual choices, form partnerships that minimize power imbalances and focus on trust and safety. Empathic care is particularly important for survivors of “dark triad” abuse, a term describing relationships with individuals high in Machiavellianism, narcissism and psychopathy. These traits involve manipulation and a lack of empathy (Ferencik & Ramierz-Hammond, 2017). Machiavellianism is associated with controlling behavior, emotional abuse, and psychopathy (Furtado et al., 2024). It is linked to a higher propensity for intimate partner violence. Understanding these dynamics helps providers validate survivors’ experiences and design interventions that prioritize safety, and psychological healing. Education and reflective practice, such as GTICSC’s Transformation Through Education: The Impact of Trauma‑Informed Education on Victim Services Providers, foster empathy by helping providers recognize their own responses and avoid secondary trauma (Gray, 2025).
Equity: Addressing Systemic Violence & Disparities
Equity means ensuring all survivors, regardless of race, gender, sexuality or socioeconomic status, have access to trauma‑informed services. Trauma and violence‑informed approaches emphasize understanding how violence and trauma intersect with systemic conditions. Some of these conditions include poverty and discrimination (CPHA, 2025). They call for creating emotionally and physically safe environments, fostering choice, collaboration and connection, and providing strengths‑based support (CPHA, 2025). Domestic violence often leaves victims feeling powerless; recovery requires helping survivors regain control over the areas of their lives impacted by abuse (Ferencik & Ramierz-Hammond, 2017). GTICSC incorporates cultural humility and equity into all programs, courses, projects, and educational materials. This ensures that services for marginalized groups (e.g. immigrants, LGBTQ+ individuals) address unique barriers, as well as, the fact that staff reflect the communities served.
Applied Practice: Integrating the 4 Es
Applying the 4 Es in practice involves aligning efficiency, efficacy, empathy and equity. Organizational leaders should: Assess and streamline workflows using Lean Six Sigma or similar methodologies to minimize re‑traumatization and improve service capacity (Kam et al., 2021). Organizations need to learn how to implement evidence‑based interventions and train staff in trauma‑informed principles to enhance outcomes and reduce provider burnout (Fleishman et al., 2019; SAMHSA, 2025). In practice, providers working with victims of violence should foster empathetic relationships with victims by understanding trauma responses, recognizing dynamics of dark triad abuse, and empowering survivors through collaborative decision‑making (Ferencik & Ramirez-Hammond, 2017; Furtado et al., 2024). Providers can also embed equity by addressing systemic violence and ensuring culturally competent care recognizing that trauma intersects with race, gender and socioeconomic status. Dr. Gray’s work highlights the role of integrated healthcare solutions and education in transforming services. By combining process improvement, trauma‑informed training, and cultural humility, organizations can deliver high‑quality care to victims of domestic violence and dark triad abuse, improve provider satisfaction, and build transformative systems that prioritize Efficiency, Efficacy, Empathy and Equity.
Keywords: Trauma‑informed care, Lean Six Sigma, Efficiency, Efficacy, Empathy, Equity, Domestic violence, Dark Triad, Integrated healthcare, Provider education
References
Public Health Agency. (2025). Trauma and violence-informed approaches to policy and practice. Government of Canada. Retrieved on 17 November 2025. https://www.canada.ca/en/public-health/services/publications/health-risks-safety/trauma-violence-informed-approaches-policy-practice.html.
Fleishman, J., Kamsky, H., Sundborg, S. (2019). Trauma-Informed Nursing Practice. OJIN: The Online Journal of Issues in Nursing, 24(2).
Ferencik, S.D. and Ramirez-Hammond, R. (2017). Trauma-informed approaches promising practices and protocols for Ohio Domestic Violence Network. Retrieved on 18 November 2025. https://www.odvn.org/wp-content/uploads/2020/05/ODVN_Trauma-Informed_Care_Manual_2020.pdf
Furtado, B. F., Anacleto, G. M. C., Bonfá-Araujo, B., Schermer, J. A., & Jonason, P. K. (2024). Conflict in Love: An Examination of the Role of Dark Triad Traits in Romantic Relationships among Women. Social Sciences, 13(9), 474. https://doi.org/10.3390/socsci13090474
Gray, A. D. (2025). Transformation Through Education: The Impact of Trauma-Informed Care Training on Victim Services Providers [Doctoral Dissertation]. ProQuest
Kam, A.W., Collins, S., Park, T., Mihail, M., Stanaway, F.F., Lewis, N.L., Polya, D., Fraser-Bell, S., Roberts, T.V., Smith, J.E.H. (2021). Using Lean Six Sigma techniques to improve efficiency in outpatient ophthalmology clinics. BMC Health Serv Res 21(38). https://doi.org/10.1186/s12913-020-06034-3
McDermott, O., Antony, J., Bhat, S., Jayaraman, R., Rosa, A., Marolla, G., & Parida, R. (2022). Lean Six Sigma in Healthcare: A Systematic Literature Review on Challenges, Organisational Readiness and Critical Success Factors. Processes, 10(10). https://doi.org/10.3390/pr10101945
SAMHSA. (2025). Advancing trauma-informed care issue brief key ingredients for successful. Retrieved on 18 November 2025. https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf


