National Trauma Transformation Programme - local authority delivery trials: follow-up evaluation - final report

Critical enablers and success factors

This chapter explores the learning generated through the local delivery trials, describing factors that drive and enable progress, and support the development and embedding of trauma-informed practice and trauma-informed services.

An analysis of elements which support implementation and delivery identified four overarching themes, and each is explored in the following sections:

• Delivery personnel and collaboration
• Strategic planning and sustained input
• Training-related enablers
• Staff buy-in and engagement

Delivery personnel and collaboration

A dedicated lead

Participants from all three local authority areas highlighted the importance of a dedicated pilot lead to drive the agenda for the NTTP. They described leads as being vital to building relationships with stakeholders; connecting across different teams; agencies, and boards; following up with staff and keeping “the agenda alive”; helping staff see the relevance to their role; widening training reach; and enabling a strategic focus.

Delivery leads also provided a point of contact to give advice, map training needs across the workforce, organise and deliver training sessions and follow-up workshops, oversee training roll-out, or evaluate training.

“So they were kind of key to, as I said, kind of helping facilitate those sessions, structuring those sessions in a way that we could have got the best out of them.”

Localities without a lead at the outset, for example, due to limited funding, short-term contracts or long recruitment processes, described struggles to build momentum. This restricted the focus of the delivery trial to certain service areas only.

“Without a lead… there was nobody to do that engagement with other directorates to ensure that they were involved from the outset, so… that it was a council-wide embedded ethos.”

“It just felt we were just getting nowhere…Having a dedicated person in post has just catapulted us forward …I do feel for local authorities that have struggled to recruit somebody because I can't see how they could get it off the ground without having somebody quite dedicated to do it.”

Participants emphasised the value of those in the lead role being passionate, having relevant skills and background experience, having protected time, and either being at, or supported by someone with an appropriate level of seniority and influence.

“Somebody who has a background in that world is helpful, not just an interest… trauma is (our lead’s) bag. They understand it, they're trained in it, they deliver it, they're involved in interventions around it... It's helpful in terms of messaging and communication and delivery and training.”

“It sat in my remit, and I wasn't doing much with it because I didn't have the time and I didn't have the skill that (lead) has.”

“Thinking at what level… because some managers are more likely to listen to…a certain grade. It's having that kudos behind you...so that people do pay attention and think, ‘this is something that we should be doing’.”

Shared responsibility and ownership

While a delivery lead is essential, the advantages of shared responsibility and ownership for roll-out, ongoing implementation and embedding change were also highlighted. Some noted the value of having more than one lead to meet workload demand. Others described the effectiveness and benefits of drawing in wider staff, including support from a team of trainers or coordinators to map training needs, colleague involvement to increase the resources available to attend meetings and organise training roll-out, or to devise bespoke training. This wider approach was also reported to bring multi-professional lens perspectives, fostering a strategic focus.

“You need somebody to drive it, but you need the support.”

“(Local authority) managed to secure a bit more funding and recruited senior learning and development officers who are the trainers….their remit is largely about training delivery and the trauma lead coordinator is more leadership training and strategic work around the project.”

“(Our Lead’s) availability to be part of our group has been limited at times. So having some of those new staff coming in who have got a bit of that role about driving forward the training and development side of things… has been really useful.”

Creating trauma champions and/or working groups in the areas of implementation was also valued. These roles were held by staff from different professions, grades and roles, and this was described an effective way to build capacity, create and maintain momentum, promote cultural change within teams or service areas, and operationalise service review and development activity. Where this occurred, it helped create a sense of shared ownership of ambitions and brought a range of perspectives and experiences that informed different aspects of the development work.

“I think it was just using their expertise to try and guide us and I suppose one of the things I was kind of really keen to do was to give a bit of the responsibility to staff to come up with, you know, identify the issues and come up with solutions so that you've got that buy-in from across the board.”

“Trauma leaders for the teams (are) going to assist us to develop the road map for the service…They'll be… the operational group that takes this forward …. the people who help us shape it and test this within the teams.”

“So yeah, I think across the board people have been pretty supportive and when we looked to set up a working group within Justice, we had real interest from across all the various teams, specialist teams, localities, various grades and levels of staff as well, all keen to be involved in that. So I think it's been a real positive experience.”

Difficulties in filling trauma champion roles in one local authority area were described; this was linked to concerns about perceived additional workload. One participant valued support from the Improvement Service, which had helped to build awareness of the benefits of the role and encouraged uptake. The importance of protected time to commit to these roles was reiterated, as well as the support of leaders to enable staff to create the capacity to focus on review and improvement activity.

“So it's just recognising that it does take a bit of time and that you're relying on staff who are doing this on top of their day-to-day job as well.”

“People think it's more responsibility….have been nervous to take it on, in case it became bigger than what they can manage.”

“So it really is about you know making it clear that it's important and it's something that has to be prioritised, that time has to be carved out for it.”

Multi-agency working

Relationships and connections were described as key to the success of the work, and some highlighted the value of a multi-agency collaborative approach. This was felt to facilitate knowledge-sharing across services and help embed trauma-informed practice locally and authority-wide.

“That is the biggest change from some of the other work we're doing … it's shared across the agencies…To have that shared understanding and language, knowing that everyone has that level of base knowledge, is really helpful.”

“Rather than it being driven just from one lens… its real strength has been its multi-agency approach and the partners working together.”

Staff in one local authority area explained that while the pilot focussed on health and social care staff, it was important to keep wider partners and stakeholders engaged. They argued this encourages the sharing of learning and practice, and will make it easier to integrate wider partners as delivery expands.

Engagement by people with lived experience of trauma

The value of input from those with lived experience of trauma into the delivery trial was highlighted by some. Pre-established lived experience networks and third-sector partners were described as helping connect staff to experts by experience and facilitating “meaningful collaboration” between them.

“People are coming in with the most horrific experience of trauma right at the front door. We said we really need to involve (people with lived experience of trauma). We think we might be getting it right, but we don't know how (it feels as) a service user to walk in.”

“At the other side of difficult events and circumstances there can be a lot of insight and wisdom.”

Different approaches to involving people with lived experience of trauma were described across the local authorities. These included Experts by Experience groups and people with lived experience of trauma sitting on steering groups or contributing to the delivery of trauma training, workshops, and conferences. People with lived experience of trauma have also provided input and feedback on processes, training packs, strategies, buildings, and environments. This was described as bringing invaluable expertise, encouraging reflection amongst staff, and lending validity to efforts to drive culture change. One person with lived experience of trauma that has been involved in and supported NTTP implementation and delivery activity in a trial site also reflected on the value of their own involvement and how it had benefitted them personally.

“I've been through a lot of difficult things…My drive forward is that I want other people to have more positive, integrated experiences….To be asked to share my opinions of…what's worked for me or what's not worked for me is important to chip into the conversation about how we take things forward…. It's an important part of healing …..because then you're being listened to.”

“It adds validity; it gives them a voice… It makes us stop and think.”

In one local authority, each service area has involved the people with lived experience of trauma in their service review activity to inform what a trauma-informed service would look like, how it would operate, and what needs to change. They have also established an ‘experts by experience group’. This group is working with the local authority to take a wider view and consider what a trauma-informed organisation would need to look like.

“So we set up an Expert by Experience group and we're talking to them about what would you want to see in terms of an organisation being trauma-informed? So what does that look like? We're working with them just now.”

Some, however, raised challenges ensuring non-tokenistic and meaningful involvement of people with lived experience of trauma. They described difficulties in engaging hard to reach and seldom heard groups, staff and resource limitations, and the reluctance of services to “admit they’re wrong about things”. Others called for increased involvement of those with lived experience of trauma in further roll-out. One participant, for instance, felt they should become involved in delivering training in their local authority area. Another advocated for long-term funding of peer support worker posts “to really change that culture”.

“We've moved away from a token person being on a steering group because it doesn't work. In terms of rolling out the Promise, we've got participation workers who are all children with care experience. We've got children's rights workers…. So there's a different way to be doing it with children.”

“Seeing patients as partners. Engaging with them in our designs from the beginning, harnessing feedback opportunities….It’s about giving up that power, isn't it? Saying, ‘Okay, over to you. How would you like it to be?’. That is something we're still struggling with as a culture….That's part of the big shift in changing it all. Otherwise, it's just tokenistic.”

Sustained input and ongoing support

Stakeholders across all trial areas acknowledged the importance of ensuring there is appropriate support in place for all those involved in implementation and delivery activity. This requirement for support spans those leading and co-ordinating at a programme level through to staff teams and individuals who are responsible for service level implementation and activity. The right support is essential to develop realistic plans, remove obstacles and overcome challenges, and sustain momentum.

“And then just, you know, like how we bring the groups together, how we keep the group motivated, you know, if we come to some tricky bits in the pathway, having somebody who is experienced and supportive on this wider team, you actually have a decent discussion of how do I work through this?”

“My line manager is very supportive, and I feel really well supported by her and her line manager who's [name, anonymised], who's the chair. I have been able to highlight and encourage the significance of the work and us working together. It's been received very well and there has been a lot of support there. I think internally, definitely my line management and again the trainers who, some of the trainers who have previously delivered the training have been hugely supportive.”

“Sometimes it can be hugely overwhelming because you just realise how much is going on, how much needs to be done and some of the barriers and challenges that seem to be repeated across the country also then can have its own frustrations, but I think there's definitely a structure in place in terms of support.”

There was recognition that developing a trauma-informed workforce and systems is an ongoing process which requires continued engagement, support, protected time, and resources. This process avoids tokenism and enable teams to develop their approaches effectively and sustainably. Staff from one local authority area which had invested in external trauma training discussed the benefits of having access to regular online drop-in consultation sessions with trainers. This regular contact was highlighted as important for keeping learning fresh and embedding training in practice. Another participant called for trauma training annual refresher courses.

“It keeps what we learned in the training alive, and it's a lovely multi-agency approach… there's a lot of shared learning. It keeps us grounded in the heart of the theory, which is trauma and its impact… it's made a really big difference.”

Follow-up support, scaffolding, and space to consider how to make changes to service processes and environments were also felt to be key enablers. Participants emphasised that trauma-informed practice is wider than how staff interact with people who access services. It involves infrastructure, and cultural change, including the promotion of staff wellbeing, as well as process and policy change.

“It needs in-depth support within services, and you need to sit down with teams and think, ‘What does this mean in terms of how your service operates?’ People go on the training and...intellectually understand it. But making the connections between that and what they go back and do in their service is missing sometimes.”

“It's not just about the training. We’re starting to look at HR policies in terms of how you make a trauma-informed recruitment and retention approach….We've got a psychological service staff helpline to help people cope with trauma and stress… Also looking at standard operating procedures, policies, and practice- all the stuff… for a trauma-informed organisation.”

One participant described the benefits of co-facilitating a development day for their team, focusing on applying learning from level two training. Another highlighted the need for follow-up Scottish Trauma Informed Leaders Training (STILT) sessions to support leaders in identifying key commitments and action plans to guide and drive service development activity. They explained that a national template for post-STILT sessions is being developed, drawing on the learning from the trial, and that it is likely to involve three follow-up workshops that can create a stepped process towards creating an action plan.

“(It was) too much to expect they would get to an action planning stage at the end of (one follow-up session)…. Nationally, we're developing a template for the post-STILT sessions, and it's looking like it might be three workshops….You need a journey post the STILT webinar to get to the action planning stage.”

Participants in two local authority areas, however, highlighted gaps in systems-level activity or ongoing implementation support that they felt had been a barrier to embedding trauma-informed practices within teams or had limited the impact of the training.

“The majority of people said (training) was valuable, it was useful….Less people said that it would lead to direct change in their work…..being there and going into organisations and then really teasing that out would make the difference.”

Another important area highlighted by stakeholders was supporting staff to implement practice change, and to work safely and effectively in a trauma-informed way. Stakeholders emphasised that staff training alone was not enough to implement learning, and highlighted the need for appropriate support and opportunities for reflection and supervision to be in place to protect and maintain the wellbeing of staff.

“So my hope would be that it [supervision] can carry on as long as people are finding it valuable because I do think when you're working in a stressed environment and you've got a stressed workforce it's very hard to be trauma-informed. So you need to keep some of these things in there that can hold the staff, that can slow them down, help them think a bit about the practice because otherwise we all go slightly into trauma mode and become reactive in our practice.”

“(It’s) not just ‘I've been trained, tick, that's it done’. We need to think about how services are putting networks of support in place.”

“Everyone within the team completed their trauma training. We've now moved on to workshops where people can help co-design new reflective spaces. We're looking at their recording systems and toolkits and trying to share that practice with other teams. We're trying to build all of that in so that it feels like we've gone the whole way through a journey with them.”

Finally, the involvement of those with lived experience of trauma is recognised to be a valuable and essential aspect of developing trauma-informed services. However, the need to carefully consider, and ensure, that the appropriate support is in place for those with lived experience of trauma who are participating in involvement activity is also essential. People with lived experience of trauma can find their involvement in this activity to be emotionally draining and potentially re-traumatising if appropriate measures and support are not in place.

“Sometimes afterwards I feel very drained or exhausted ….(It would help to) create a bit of time and space...to have a bit of reflection on how a task or a session went for me and did I get everything out that I wanted to say? Were there bits that I feel that I'd want to retract… am I coping okay with this? Little check-ins. That type of acknowledgement is then feeling inclusive….and nurturing our relationships that we have with each other. So, we're sort of moving from the same place.”

Sharing learning and good practice and celebrating successes

Some participants discussed the value of events or opportunities for staff across services to come together to share learning and celebrate successes. This was felt to help avoid duplication of work, maintain momentum, and facilitate buy-in. However, time and capacity constraints, and having someone who can facilitate and coordinate this activity can be a barrier.

“We've got a network of trauma coordinators…so that we can share best practice, look at challenges... look at as a broader organisation…how to develop a trauma-informed approach…. The Scottish Government bringing the champions together..(to facilitate) learning networks might (also) be a good thing.”

“Really celebrating our achievements…we had a conference when (local authority) received funding to be a pilot site, and that got loads of buy-in…. Having some kind of event and really shining a light on it really does get the appetite for training.”

“You want to be able to share learning so that you know if I hear that homelessness are doing something I could then link in with them and you're not reinventing the wheel. Similarly if they're hearing about what we're doing it might be of interest then you're sharing that across the board. I do think that's something we need to think about, what are the opportunities for sharing some of the learning across the different care groups.”

Strategic planning

The delivery trials also highlighted the value of longer-term planning underpinned by a wider strategy that can support implementation and sustainability. Roadmaps and strategic, improvement, or action plans, as well as planning tools - such as the trauma lens tool^[2] - were described as helpful to encourage, validate, and structure the introduction of trauma-informed changes.

“At a policy level, the expectation is there that we will have that understanding from all staff…Having that recognised as such an important aspect is a key thing”.

“We started to develop a plan using the trauma lens tool. Really took our time to think about someone's journey from first contact all the way through our services and what that looks like in terms of access, environment, all those kinds of things. And from there we created a draft action plan. (The tool helped) structure our thinking and make the plan tangible…so that you've not got this scattergun approach.”

Participants from two local authorities felt a lack of early-stage strategic planning or the prioritisation of training staff over strategic focus had limited the impact of the delivery trial.

“I'm quite eager and excited for the change nationally towards being more a ‘transformational program’ rather than ‘training program’ because I think that title didn't help in (local authority) - it became very much on training.”

“I would have liked more realistic thought and consideration within the strategy. Rather than just thinking ‘we've got this money, we'll train people’… to have fitted that into a longer five-year, ten-year plan …. With more thought and consideration, it could have been more effective.”

The changes in staffing, and those involved in progressing the trauma agenda in two of the trial sites meant it was difficult to get an in-depth understanding of the governance structures, and their effectiveness, during the trial period. In the other local authority, a robust governance and monitoring structure was described, with a steering group which included the heads of service responsible for each service area involved in the trial as well as wider partners and stakeholders, which reported to the chief executive of the local authority. An implementation group sat beneath the steering group and included managers from each of the service areas involved and with responsibility for operationalising the delivery plans and reporting into the steering group. This structure was described as effective, helping to create and maintain momentum. The seniority of membership of the steering group was also perceived to send a message, and set the tone, about the importance of the trial and what it was trying to achieve.

However, those leading and involved in taking the work forward since the trial period ended recognise the value and importance of effective governance structures. In all areas, work has been undertaken to reinvigorate, re-establish or reconfigure governance structures to ensure they are fit for purpose and can support ongoing progress and expansion of delivery.

“The chief exec ran a whole morning around trauma, and we're all STILT trained. But where's the governance around how your service is different now that you have an understanding of trauma?.... (It needs) a governance structure in place so that there is accountability attached to it. Otherwise, you'll get drift.”

“I suppose it's making sure you've got that governance in place. I can only obviously speak for Justice but as I touched on we've got an action plan that's in place and once that's signed off, there'll then be an expectation that we can report on progress within that plan, so that every few months I would be asked to go back to the head of service and say, 'Right, okay, from the trauma-informed working group, here's where we're at in terms of actions one, two and three, and maybe where are the barriers, what are the delays, what's causing that?”

“I now chair the city-wide steering group. So we've reinvigorated it and made it a much bigger affair. And you get a buy-in from all the other services. So like Police Scotland, the ambulance service, the fire service…. What we do is we take things back to the corporate management team, which is chaired by the chief, about where we are in terms of the plan, and also the plan in terms of organisational readiness to become a trauma-informed organisation.”

Others highlighted the long-term nature of systemic change work or suggested the need for realistic goals and timeframe expectations - due to the preparation involved in meaningful strategic planning and activity and competing demands on staff.

“It's taken longer than anticipated…The plan becomes quite lengthy, and it's just trying to break that down into manageable chunks. What are quick wins …and what's longer-term ambitions …If you're going to take a methodical approach and really think about your service as a whole, you need to take your time to do that prep work and identify the key issues before you jump into creating a plan.”

“This is transformational change that's going to take your service ten years easily to fully embed this. Don't get lost and try to run away with it.”

Some participants raised benefits of the overlap with, or importance of aligning, the trauma-informed agenda with other strategic frameworks or workstreams- such as the Nurture approach in schools, the Mental Health and Wellbeing Strategy, Getting it right for every child (GIRFEC), closing the attainment gap, the psychological therapies and interventions specification, maximising independence, Child Protection, and the Medication Assisted Treatments (MAT) Standards. Examples were given of delivery leads working closely with teams and other strategy leads to bring together the different strategic priorities to enable a coherent approach and avoid duplication of workload.

“There's lots of things that we've done as a service, but maybe not framed it around the trauma agenda….It's time to bring things together in a much more cohesive way.”

“The Scottish government's launch of the psychological therapies strategy for all health services and mental health services is very aligned to the trauma strategy….They're all saying the same things in slightly different terms….They're all aligned… so we've got a clear vision of where the trauma work fits in.”

Training related enablers

The content and delivery of training

Participants identified strengths related to frontline and leadership training content and delivery. Some gave or referenced positive feedback about the sessions. Others were positive about the training framework and materials-including supports to signpost attendees to if needed. One participant wished national training resources had been developed before delivery leads take up their post, to facilitate faster rollout.

Valued aspects of the different training and leadership sessions included reflective elements, the trauma lens tool, follow-up workshops, and the fact that the training was delivered by skilled and experienced trainers and attended by staff from different professional backgrounds.

“It was quite reflective. I could think back to when I was … dealing with people who were really traumatised and trying my best to meet their needs. This all of a sudden gave me a framework that I could have worked with… I thought I ‘wish I knew that now’- because I would approach that differently.”

“I got a lot from (the trauma lens tool), just thinking about small modifications that you can make to be more trauma aware, things that you maybe don't even think of."

“It was giving us the opportunity to.. network with a variety of other people from areas of the council that we wouldn't normally work with…it's quite nice to gain their perspective on things.”

Those whose local authority also invested in specialist external trauma-informed training and follow-up consultations found this greatly beneficial and relevant to their roles. The opportunities for peer learning and ongoing support this provided were also highly valued. However, a small number raised difficulties with other externally commissioned training materials, including the fact that these were not at an advanced enough level or aligned with the NES training programme.

There were mixed views about the relative benefits of online or in-person training. Face-to-face delivery was felt to be more impactful and provide more opportunities for questions, informal discussion, and follow-up with attendees; this was described as important given the sensitive nature of the topic. IT equipment issues and staff completing training from their usual working environments also limited privacy and caused disruption. However, online training was seen as more accessible and cost-effective and enabled wider reach. This was particularly relevant during COVID-19 restrictions and for those working in remote and rural locations.

“(Online delivery) allows training to happen. Facilitators (are) in totally separate places and delivering training to people spread all over the place….Feedback from the online group was that people far prefer it to be in person… but I don't think we could ever say we can only do it in person because the geography would mean so many places didn't get any support… there's a place for both in person and online.”

“Because of (local authority’s) geography..(face-to-face training) becomes expensive. You'd be having to provide accommodation and things like that as well.”

Managers accommodating travel time for in-person training was seen to help enable this. Factors identified as mitigating some of the limitations of online training included: NES training materials; the skill, preparation, and flexibility of delivery leads and trainers to adapt materials and establish a safe context for training; ensuring attendees have appropriate IT equipment and a private space to log into the training; giving staff protected time- away from their usual environments- to complete online modules; and building in additional time to call or email attendees to check in on their wellbeing following sessions.

“It probably takes a bit more preparation and skill on the part of the facilitators, making sure you have enough time to set the context to ensure safety and to be available at the breaks…You have to do a bit more than if you were there in person.”

In one local authority area, sessions to pilot online delivery helped identify some of the challenges to overcome to ensure all staff could access and engage in the training. It also identified areas for the development of training content, including an assessment and reflective practice element.

Mapping training needs and bespoke content

Some participants highlighted the importance of mapping training needs across the workforce or using a needs analysis to devise more bespoke content - to ensure people access training appropriate to their level and needs, and that of the people accessing the service.

“Use the NES resources, assess your staff, do a survey, work out your needs, train the people to that appropriate level”.

“Everyone's at such a different point of their understanding and knowledge that to make (STILT training) really useful… it needs to be more bespoke to different groups….For social work and education, it's perhaps more bread-and-butter stuff. Spend time on sharing the basic understanding of trauma-informed practice with leaders from other departments for whom trauma-informed practice would be a newer concept.”

Participants from one local authority area described the benefits of undertaking a training needs analysis to understand services’ level of contact with those accessing the service and identify the most appropriate training level for them. This enabled them to target relevant training to those most in need, resulting in a more targeted rollout of training.

Challenges identifying training needs were, however, raised. These include low response rates to mapping surveys, difficulties interpreting responses to these, and barriers to monitoring training uptake, such as disparate e-learning systems. Staff from one local authority area explained that work to integrate the NES TURAS system with their local e-learning system had improved the ability to monitor and report on uptake and progress. Administration support was also seen as vital to achieving this.

“It took a lot to tease apart what had been done…They had these surveys (which said) 90 something per cent of staff have been trauma-informed (but) we need to understand what that means, what level of training are we thinking of?”

“Our admin person has created a system of data collection.. around all training activities…(They’ll) be a clearer reporting mechanism back up to the steering group …. Having an admin person has really enabled that to happen because it's a massive bit of work.”

Staff buy-in and engagement

Importance of senior buy-in

Participants across all three local authority areas felt that securing buy-in, commitment, and support at a senior level is a critical enabler to sustainable service development and change while also giving a clear sign of the importance of the work and its priority.

Senior buy-in was described as key to: demonstrating the priority placed on the work, engaging frontline staff; enabling managers to be able to deliver trauma-informed supervision and support to staff; and providing necessary strategic oversight and direction to facilitate system-level change. Where there were gaps in senior leadership buy-in, this was felt to have limited the impact of the delivery trials.

“I think we made a conscious effort, first of all, that we had to start from the leadership and go down, because they were the people that will make it happen for the staff, and they were the people that will help and enable policies to be changed, practice to be changed, all the stuff that needs to be changed, as well as allowing staff to be trained and given them, and they need to give them the organisation's agreement that they can deliver and they can practice in a trauma-informed way.”

“You need managers knowing what this is about so that as their staff teams come on board with the training (managers can) have meaningful conversations with them …But equally, the senior management bit is about… working out how we're going to roll this out…It needs that strategic oversight and influencing buy-in.”

Support for the trial from one local authority chief executive, for instance, helped ensure the delivery lead’s access to senior management. This resulted in strong engagement and proactive support from some heads of service and service managers, which enabled good engagement from staff in those service areas.

In another local authority, the change in approach from a bottom-up training delivery to one where STILT training and support for managers was prioritised is perceived to have been critical to the success of the trial and the ongoing work. It helped to ensure a shared understanding of goals across service leadership and why it was essential to support the development of effective services. It also enabled leaders to model trauma-informed practice within their own leadership approach.

“We held an executive leadership STILT ….We replicated it at three stages of management … The STILT framework was hugely helpful in that process….. What we were trying to emphasize was that it's not just about practice. This is about looking at the system.”

“We talk about trauma-informed care for our patients, but we need to be trauma-informed with our staff. To be able to do that, you need to have been on the training and understand what this means for your services, but also for your own leadership.”

Senior buy-in was evidenced by:

• financial investment in the trauma-informed agenda;
• the time commitment afforded to staff to focus on implementation;
• consideration of staff’s wellbeing as part of trauma-informed practice;
• the organisation of trauma-informed practice leadership forums or high numbers of managers attending STILT training and follow-up sessions;
• the visibility of leaders in working groups and their trauma-informed knowledge;
• Governance and reporting structures that involved senior leader representation.

“If I was to jump back eight years….I'm not sure I saw the head of service, the assistant chief.…. (Now) our management teams are really informed in relation to the bigger picture. Our assistant chief could have as good a discussion with a frontline worker as their senior…The knowledge and detail in relation to the challenges... it's not tokenistic; they understand that.”

The national-level trauma-informed practice agenda, the allocation of funds to support this by the Scottish Government, and the STILT training offer were identified as helpful in securing senior buy-in.

“The expectation that leaders will have done STILT training… that's actually been helpful because that's got buy-in from the services. When there's…operational managers with huge competing demands, that certainly helped focus our services' attentions.”

Staff buy-in

Buy-in from frontline staff and their commitment to, and enthusiasm for, the trauma-informed practice agenda was also seen as a key strength across all delivery trials.

“There's a huge appetite for learning across the local authority. I've had conversations with staff from third sector, NHS, local authority. Everybody is keen for trauma training.”

“The staff's commitment to sign up to it….you can’t underestimate that. Despite all the pressures they're under, we've still got a bunch of people saying, "Yeah, I want to improve this.”

The benefits of giving staff agency and the need for a bottom-up agenda, alongside a top-down approach to encourage staff engagement, were highlighted.

“I was keen to give a bit of the responsibility to staff to identify the issues and come up with solutions so you've got that buy-in from across the board. So it's not about someone coming in and saying you're doing this the wrong way.”