Findings from a Peer Support and Learning Group pilot to support Trauma Informed Practice in Adult Social Care

3. Findings

3.1 Attendance and attrition

Initially 7 Care Homes agreed to take part in the project. Prior to delivery of the educational component, one home withdrew, and the six remaining participating homes completed the initial educational component, consisting of three full days of education and training. Unfortunately, another home dropped out prior to the delivery of the PSL groups, citing service and staffing pressures related to the impact of the ongoing COVID-19 pandemic crisis.

More detailed information re: attendance in the PSL Groups and engagement in the evaluation of the project is included in Table 1 below.

*- Care Home representative attended

3.2 Evaluation of Educational Component

The educational component was evaluated using a participant feedback form specifically designed for the purposes of this project. Feedback suggested that the educational component was well received, and reflected that participants felt that the content was pitched at an appropriate level for their needs.

Participants noted the challenge of releasing capacity to attend the educational component of this project, citing ongoing staffing pressures and unpredictable workforce capacity. To mitigate this challenge, all three training days were delivered remotely to remove the need for travel time and were recorded to allow those unable to attend to complete the session at a more convenient time. Interestingly, the participants who completed the education competent but dropped out of the project prior to the delivery of PSL Groups reported most difficulty in attending training sessions. COVID sickness absence and childcare difficulties were cited, which may reflect the importance of ensuring protected time for the attendance at initial training, which is likely to be central in supporting subsequent buy in to the PSL model.

Qualitative feedback was also sought regarding the wider issue of delivering education on TIP within the Care Home Sector. Participants acknowledged the importance of involving team leads and senior staff in the planning, delivery, and support for implementation required to ensure that knowledge and skills gained from education are embedded in routine practice. The importance of involving key staff who have a role in supporting colleagues with a client facing role was highlighted in terms of the need for, and capacity to offer specific support for implementation of trauma informed care in practice, supporting reflection, and addressing any concerns or barriers to implementation.

"…they are the eyes and ears of what happens on the floor, so if you are going to educate and change things you need people who are going to be aware and impact this on a daily basis".

The three-day programme provided within this pilot was designed to support implementation of TIP in Care Homes at a service/organisational level and it is anticipated that a different educational approach will be required to meet the needs of the wider Care Home workforce in Scotland. Two participants shared this view, suggesting that the NES Trauma Skilled Practice e-module was more likely to be appropriate in length and delivery model due to ongoing pressures in the sector.

Level of seniority of participation in the project was also raised by one participating home who dropped out following completion of the educational component. Feedback from this service highlighted concerns regarding difficulty securing senior management participation in the project, resulting in a sense from attendees that they were not in a senior enough position in their organisation to fulfil the requirements of the pilot. This may reflect a need for a tiered approach to education regarding TIP in the Adult Social Care Sector, which is in keeping with the wider National Trauma Transformation Programme approach outlined in the Transforming Psychological Trauma Knowledge and Skills Framework (NES, 2017) and associated Scottish Psychological Trauma Training Plan (NES, 2018). It is suggested that this may include an educational programme designed to improve the knowledge of, and skills in implementing, TIP and an educational programme designed to upskill senior staff in promoting implementation of TIP in their service/organisation, including supporting the practice of others.

Another key finding from the educational component of this project centred around barriers to accessing training and education in the sector. Participants routinely cited lack of protected time as a barrier to engaging with training, as well as access to, and confidence in using technology to enable engagement with education initiatives. Many attendees had difficulties accessing MS Teams due to the use of tablet or mobile devices because of limited access to desktop and laptop computers in their service or organisation. Some participants were also forced to attend remote delivery sessions from home due to lack of IT infrastructure and facilities within their employing care home. It was felt that this likely negatively affected levels of engagement due to distractions within the home environment including childcare issues, internet connection difficulties, and caring for relatives affected by COVID-19. These findings are important in considering the feasibility of digital delivery of trauma education in the wider Adult Social Care Sector.

3.3 Evaluation of the PSL Group Component

In total, five PSL Groups were delivered between September 2020 and January 2021. The final group also included some general questions about participants experiences of the pilot which are included throughout this report.

Attendance at PSL Groups was variable across the course of the pilot, with homes providing feedback that the primary driver for this was staffing pressures as the project coincided with the initial wave of the Omicron variant of COVID-19. Out of the five homes that attended PSL Groups, four homes were able to support both participants to attend a proportion of the sessions. However, unfortunately one home was only able to release one member of staff for the duration of the project. The average number of PSL groups attended by each participant was 2.2 (including the participant who was unable to attend any sessions). A session-by-session breakdown of attendance is provided in Table 2 below:

Only three care homes (50% of initial participants) were able to complete the project, attending both the educational component and having some representation at each of the PSL Group sessions. These findings reflect the ongoing workforce challenges facing the Care Home Sector, which were exacerbated by the ongoing COVID-19 pandemic crisis and highlight the need for careful consideration regarding the potential feasibility of spreading the project model more widely with the Care Home, and wider Adult Social Care, Sector.

In line with the Action Research evaluation approach adopted, any findings identified during the project could be integrated into future plans and implementation. Feedback from participants was used to amend or improve future PSL Group sessions and direct the focus of implementation coaching drop-in sessions. Examples include:

• Changing the digital platform used to host PSL group sessions from Microsoft Teams to Zoom to reduce digital barriers to access.
• Recording sessions and uploading these to video hosting site Vimeo to support participants to access content from sessions that they had been unable to attend.
• Adapting the structure of sessions to allow for a more informal environment as participants experienced increased barriers to access during the winter months due to ongoing staffing pressures. The final two sessions were set up as drop in PSL Groups to empower participants to prioritise their workload and join sessions when they were able.

Qualitative feedback regarding the experience of attending the facilitated PSL Groups was generally positive, with one participant describing this as the "best bit" of the project. The three Care Homes who were able to sustain consistent engagement with both the educational component and PSL Groups were asked to provide three words to describe their experience of the project. Responses are reflected in the Word Cloud in Figure 1, below.

Further qualitative feedback reflected a sense of initial apprehension regarding PSL Groups and anxieties regarding judgement relating to perceived lack of progress between sessions. This reflected facilitator observation that the level of reflection and discussion improved over time as trust increased within the group. This feedback highlights the importance of psychological safety within groups and a need to invest in the development of relationships between participants to facilitate the vulnerability required to reflect and learn from experiences.

A further theme derived from qualitative feedback focused on experiences of working in the Adult Social Care Sector during the COVID-19 pandemic crisis. Participants reflected on their initial scepticism regarding the project and perceived risk of criticism of the Adult Social Care Sector, which was linked to the national rhetoric regarding Care Homes and the treatment of vulnerable people during the pandemic crisis. One participant stated that they felt "Care Homes have been battered" [by inspectors, government, the media] and another referenced the impact of challenges facing the sector on motivation to engage with the current project:

"The first year [of the pandemic], everything was changing on a daily basis, policies were changing every two days, you can see why people are thinking this is not another bit of work I can buy into…the timing of the project was a shame".

A common theme among participants related to the perceived negativity surrounding inspections and quality assurance visits, acknowledging that some of these processes had been experienced as damaging in terms of relationships within the wider system. Care Home participants identified an increase in anxiety regarding scrutiny and concerns regarding the risk of negative evaluation or biased reporting of findings were shared. This feedback reinforces the importance of collaboration in creating equal and respectful partnerships when engaging with colleagues in the Adult Social Care Sector. It was suggested that any future PSL Groups should prioritise building relationships between facilitators and participants and offering clear information regarding the role of facilitators, purpose of the groups, and reassurance regarding concern relating to scrutiny of practice or assessment of performance.

A further theme identified from qualitative feedback related to the level of understanding and practical experience of policy makers and future facilitators of PSL Groups. It was acknowledged that one of the critical success factors for this project was Project Facilitation Team's in-depth knowledge of social care services and experience in working with colleagues in the Care Home Sector. Participants were clear that any staff involved in similar projects should have a comprehensive understanding of the Care Home environment and nuances in terms of models of service delivery. It was suggested that visiting a care home and spending time observing the day-to-day practice of staff should be a minimum requirement in this regard. The potential benefits of developing foundations for trusting and collaborative relationships prior to the commencement of PSL Groups was also noted. This feedback has implications for the staffing model of any potential future project in the Adult Social Care Sector.

"…it can turn on a dime in a Care Home, people often don't have that realistic experience…come and spend time here and see what it is like. To build up the relationship with the facilitators if they are coming into build training, you need that trusting relationship…"

3.4 Implementation of Trauma Informed Practice

Three Care Homes completed the educational component and were able to sustain engagement with the PSL Groups to the end of the project. All had made significant steps in their journey to implement TIP in their service.

"What seemed miles away has become a reality"

[Care Home manager]

Of the initial participant cohort (n= 10, Mean= 5.78, Range= 4.60-6.57), 5 participants (across 3 Care Homes) were still engaged in the PSL groups at the end of the pilot. Qualitative data provided evidence of progress in the implementation of TIP in all participating services/organisations. All participants reported a sense of raised awareness of the National Trauma Transformation Programme resources, including the Trauma Skilled Practice e-module, Trauma-informed Lens workshop tool, and the NES Wellbeing plan. Following the completion of the project, one participant shared their experience and a summary of their progress at a Scottish Trauma Informed Leaders Training event, which also served to raise awareness of the need and appetite for TIP in the Adult Social Care Sector. The remainder of this section details progress from the 3 Care Homes that completed the pilot project.

3.4.1 Care Home 1 – Local Authority Care Home, Remote

Care Home 1 attended all training sessions, and all but the final PSL Group (due to sickness).

Initial implementation areas identified were:

1. Identification of trauma through their service admission screening process.

2. Embed trauma training in their service/organisation training plan and disseminate trauma training to the wider workforce

3. Engaging senior management colleagues to increase organisational support for the implementation of TIP.

4. Create links and collaborate with other Trauma Informed organisations.

Progress Achieved

1. A small team was selected to work on this goal and informal conversations regarding the practicalities of working towards this were held within the workplace. However, staffing capacity pressures related to the COVID-19 pandemic crisis prevented this work from being actioned.

2. Consideration was given to incorporate the Transforming Psychological Trauma Knowledge and Skills Framework (NES) and educational resources from the National Trauma Transformation Plan into the service/organisations training strategy and plan. Due to budget restrictions, a plan was developed to provide trauma training to a small select team with the intention of gradually rolling this out to the wider community of staff within the home. Informal awareness raising, and education was successful in changing attitudes towards distressed behaviour ("Trauma as a word is being used so much more"), which increased recognition of trauma and collaborative approaches to care with several residents:

"We had a new admission into the unit… she had a diagnosis of Lewy Body Dementia and she was aware that she was coming into the unit and she was giving up everything like her home and everything and she sat and she said to me 'Do you realise how traumatic this is?'. You always know it's something that's traumatic, but for that lady… it was such a huge event in this lady's life to be leaving her home, coming into one bedroom… so it really does make you think about things."

3. Participants worked with senior management colleagues to produce an organisational Statement of Intent. This endorsement from senior management, including the Chief Executive, was a very positive outcome and it was reported to have boosted staff engagement with TIP, where concerns regarding capacity and feasibility had previously been noted:

"The chief executive, she's been in touch and we're looking at the statement of intent and she's really on board and really wants to be involved and to help move this forward … It's been so important in starting the journey to have them involved and on board, it makes it clear to everyone else we've got that senior management buy in by signing the statement of intent."

4. Opportunities to collaborate with Rape Crisis and Women's Aid were identified. However, increased workload and lack of protected time, owing to covid-related absences, were cited as major barriers to progression.

Barriers and Enablers Identified

1. Gaining informed consent in relation to information gathering and sharing was identified as a barrier to improved identification of trauma in care home residents. Accuracy of information provided by the referrer and other relevant others was also considered a barrier in cases in which clients were unable to communicate this directly.

2. Ongoing capacity issues and restrictions on the education and training budget was a barrier to implementing trauma training and education within the care home.

3. Management support was found to be influential in creating a sense of commitment to the implementation of TIP and enthusing the workforce regarding this work.

4. Ongoing capacity pressures were cited as a barrier and the lack of managerial involvement in the project created a barrier to autonomous decision making.

3.4.2 Care Home 2 – Small independent Care Home, Central Belt

Care Home 2 attended all training sessions despite only having one representative involved in the project. Initially two representatives were selected, however one did not have a direct role within a care home and was employed in a senior management position within the local authority and was unable to hold a dedicate time to the project. Initial areas for improvement identified were:

1. Creation of a 'Trauma Champions' group within the workforce to support the implementation of TIP in the service.

2. Conducting an organisational self-assessment of TIP

3. Staff education in TIP

4. Consideration of the use of policies and procedures to support implementation of TIP

Progress Achieved

1. A small working group was identified, and it was reported that members were engaged and passionate about TIP. The team involved a range of staff roles including: the activity coordinator; team leaders; deputy manager; and maintenance worker. The latter was chosen due to his regular contact with residents and the higher levels of trust and safety residents felt with this individual.

2. The 'Trauma Champions' group implemented the NES Trauma Informed Lens Tool (NES) and reported helpful discussion around the need for/how to unpick symptoms of cognitive change/progression of dementia with symptoms of trauma. A plan was developed to support the cascade of the Lens Tool with the rest of the workforce after meetings identified that staff training in relation to TIP was a priority and they planned to continue using the tool within the wider staff team.

3. The Trauma Champions group also conducted a training needs analysis and subsequent work led to an increase in routine enquiry and the use of behaviour monitoring approaches to identify trauma. It was reported that after trauma training, they were "looking at it all with a different vision… assumptions should never be made no matter how well you know your ladies and gentlemen". They had started more routinely asking their residents about trauma and were finding, "The more you use it the more familiar I get with it."

4. The Care Home Manager undertook work on the organisational infrastructure and reviewed local policies and procedures, while the Depute Manager was responsible for the implementation of these in practice. One significant outcome included taking steps to increase recording of trauma and it's impact in resident care plans. The manager recognised herself as a Trauma-Informed leader, "because we are a small Care Home the decisions come through me. I have autonomy as long as it benefits the ladies and gentlemen that we care for".

Barriers and Enablers Identified

Autonomy was also identified as an enabler of implementation of TIP. The experience of Care Home 2 demonstrates the impact of This factors including ownership status, service size and service model in influencing the ability of staff to implement change within the Care Home.

Home Manager involvement in the promotion of, and implementation of, TIP was considered a critical success factor in this case and likely contributed to the positive buy in from the wider staff group.

3.4.3 Care Home 3 PSL- Large independent Care Home, Highlands

Care Home 3 managed to have a representative at each training and subsequent PSL session (utilising recordings of each). This was a private Care Home, who had already identified Trauma Informed Practice should be a priority and an inhouse psychologist had started to explore implementation, but unfortunately this had not progressed far.

Initial areas for improvement identified were:

1. Gaining support from senior leaders to support the implementation of TIP

2. Establish a TIP stakeholder group

3. Complete an organisational self assessment

Progress Achieved

1. Participants were successful in using materials from the educational component and implementation pack provided during the project to influence senior management colleagues. Development and delivery of an 'elevator pitch' outlining the potential benefits of TIP in their service/organisation led to significant senior management support. This resulted in involvement in company-wide work to improve systems to support implementation of TIP and the development of a training programme for staff working at all levels within the wider organisation. One of the project facilitators also met with the organisational implementation group to promote understanding and implementation of the NTTP and associated training programmes and educational resources.

Participants identified themselves as Trauma Informed leaders within their organisation at the end of the project and their confidence was growing appropriately "Our shoulders get broader and broader as the weeks go on".

2. A stakeholder group was set up to aid implementation, initially focussing on the development of a company-wide training plan based on the NTTP resources, which was further developed by Learning and Development Team. Despite the ongoing need for dissemination of trauma training, informal approaches to raise awareness were noted to have increased recognition of, and discussion about, trauma in relation to resident needs and care planning.

"One thing is we keep saying TIP, we keep saying it, it rolls off our tongue now, you know because when we're talking about situations, because we've had quite a few of them, we stop and we go 'hold on, have we thought about why the person does this and could there be something [some underlying trauma]?'"

This increased discussion, surrounding the impact of trauma, had subsequently resulted in a significant reported attitudinal shift to clients previously considered as 'challenging':

"One young lady, who was very challenging and we had to call the police on, two weeks where the TV was smashed and having to remove other people, ASPs… quite a lot of the staff were ready to walk, all looking for new jobs… But once we talked to the staff and explained that a lot of her behaviours are learned behaviours with what's gone on in the past… she's been through quite a lot of trauma… we quite quickly got back on track and we've been back on track working with her family and the multidisciplinary team. I think just the staff realising about the traumas that went on have changed their attitude towards her."

3. The Trauma Informed Lens Tool (NES) was used and identified a further area of improvement/focus. "Staff wellbeing is central to all of this."

Barriers and Enablers

Organisational support and the backing of senior management colleagues were significant enablers for Care Home 3. The need for those leading TIP to be supported in their role was acknowledged and the project was recognised as a key factor in this (both through the input by facilitators as well as through the other Care Home representatives).

Modelling of good practice by experienced and well respected staff members was considered a key factor in increasing awareness of trauma and changing staff attitudes towards distress behaviour.

3.5 A Summary of Progress Achieved by Non Completers

Two Care Homes engaged well in the project, attending the training sessions and several of the PSL Groups. Despite not attending the last two PSL Groups, participants remained enthusiastic about TIP and had plans to use the NTTP Trauma Skilled Practice e-learning module with staff in their care homes Improved awareness of trauma was being encouraged through staff supervision groups, where the role of communication and relational approaches was discussed, "it was useful to think about what might be happening between staff and patients." These discussions reportedly led to a review of some residents helped Care Plans, focusing more on "how life events affect people's behaviour and the care they need."

One of these Care Homes reported finding the education component of the project was particularly useful in considering the needs of residents living with dementia and that it supported them to, help staff to understand different behaviours, and ways of working with distress

"It is the ones sitting there quietly that we have started to take more notice of and give more time to."

"We did take a lot of learning about different signs and symptoms that someone could have been abused – that's something that has stuck with us and that's something that we've learned."

3.6 Barriers to Engagement

Despite notable progression within each Care Home, many of the representatives experienced significant barriers to attending training, the PSL Groups as well as implementing TIP. These are outlined in further detail below.

3.6.1 Staff Shortages, Time pressure and COVID-19

With the introduction of the highly transmissible Omicron variant, each of the Care Homes experienced significant staffing capacity issues. Consequently, many of the remaining staff were faced with increased workloads maintaining the day-to-day running of the service and prioritising time for the pilot was challenging. This was also reflected in the lack of uptake of the suggested 'drop-in' clinics which where only offered on two occasions and on each time people struggled to make use of the resource due to time pressures.

"We are under pressure, this week I have been on the floor."

"Staff shortages and things… working the floor, trying to do the medication… a lot of other things have had to take priority just now."

"It's just been hectic"

This was, in part, due to the timing of the pilot, however it is also reflective of the ongoing challenge of recruitment and retention in the Care Home Sector as a result of skills shortages, staff burnout and sickness levels and pandemic pressures.

These difficulties were also apparent when implementing some of the agreed priorities in between sessions. On a regular basis, participants would attend the groups understandably not have being able to prioritise time for the agreed action points due to the above challenges. This highlights the importance of being able to allocate some protected time for these activities (even if only 1 hour a week). On these occasions, it was important to create an environment where participants did not feel judged and still felt able to attend the group, despite perceived (or actual lack of progress).

3.6.2 'Bed Blocking'

Representatives reported difficulties in implementing TIP due to an influx of short-term residents awaiting at-home care. With the additional administrative tasks required for these residents, together with staff shortages, staff felt they lacked the time to dedicate to the pilot:

"We've had so many new residents and a lot of them are just, you know, they're in and out, they're there for respite whilst they're waiting for packages of care at home… So that's been my biggest task at the moment, it's just getting everything organised for these people"

"HSC Partnership only care if we have spaces"

3.6.3 Representative Seniority

Another reported barrier was exclusive to a single Care Home, whose representatives felt their non-managerial status within the organisation presented challenges to implementing TIP, whereby strategies could be discussed but not authorised without senior approval. This was contrasting to most of the other Care Homes, whose representatives included managers, suggesting seniority within the organisation played an integral role in the roll-out and progression of TIP.

3.6.4 Online Learning and Support

Delivering both the training and support groups online presented several barriers for the participants. Firstly, as discussed earlier, there were multiple technical difficulties primarily due to difficulties accessing technology other than I pads, or in environments where participants were free from distractions (at home and/or at work). The Microsoft Teams platform was also unsuitable due to limited experience of using the platform, as well as difficulties accessing it generally. These technological challenges will be important to consider in any delivery of subsequent online training or PSL Groups facilitated with Care Home staff. Some participants felt the online forum meant valuable face to face interpersonal connections could not be made, something which was viewed as important for training and groups involving this subject matter and also bearing in mind the difficult context Care Homes have had with the additional scrutiny they have experienced resulting in lack of trust of external agencies.