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

Challenges and barriers

This chapter explores the learning relating to the different factors and circumstances that have created challenges or hindered progress and implementation activity. Five overarching themes were identified, which are discussed in the following sections:

• Resource constraints, capacity and staff burnout
• Challenges reaching staff and services
• Siloed service and unintegrated workstreams
• The impact of COVID-19
• The transition from pilot to ongoing and expanded delivery

Resource constraints, capacity and staff burnout

Challenges linked to high workload, understaffing, time, funding, logistical, or resource constraints within services were frequently raised. There was recognition that some staff and teams are under immense pressure. These limit capacity to release staff to attend training and ongoing supervision, or to engage in implementation and service level change activity.

“In a time of real budget constraints, highest levels of sickness leave seen since records began….across the UK, people are just stretched…Asking them to do anything feels like an additional ask, even if it's just trying to do things a bit differently.”

“Trying to find time in everybody's diary was a real challenge, given the seniority of the group and how much they have on.”

“Before we started delivering the training, we went back to people who'd had it in the past (for feedback)….the overwhelming barrier to using it was capacity, being too busy, caseloads being too high.”

Participants expressed concerns about staff burnout and high staff turnover, and these were highlighted as barriers to reflection and trauma-informed practice. The participant below also highlighted the recruitment and retention challenges for services in remote and rural areas.

“Staff are really burnt out…. We're working with having to do more and more with less and less. If you don't have well teams, you're not going to have teams that…are going to carve out the time to do a walkthrough of their service or whatnot.”

“The islands and the further away places… the small rural schools, it is a challenge to recruit there. All that change isn't good for the children either, and that adds to their trauma because they've got different people coming in and out.”

The importance of non-tokenistic and accessible support for staff wellbeing was emphasised. One participant reflected that employing a wellbeing coordinator within their local authority had helped with this. Staff from one local authority also felt it was essential for managers to complete trauma training equivalent to the staff they supervise, arguing this would enable them to support staff wellbeing adequately, and help them to implement new skills and changes to practice. Some training content at enhanced level was therefore adapted for staff in management and supervisory roles.

“Staff wellbeing has to be a huge priority. (But) well-being often gets buzzed around as “Oh, here's some mindfulness” or…“Take a walk at lunchtime”… is seen as a very individualised responsibility…. Whereas a lot of the time, it's actually about people having the tools they need to do their jobs better.”

“In (local authority), we have lots of wellbeing initiatives…, but I don't know that staff on the ground always feel that.”

“We adapted some of our content to make it much more in a management supervisory role.…taking note of potential for things like vicarious trauma, burnout, compassion fatigue, for the well-being of the workforce.”

Protecting staff time for reflective practice, follow-up implementation support, and engaging with service-level development activity was felt to be vital. It was argued these steps would prevent staff burnout as well as promote engagement with the trauma-informed agenda and facilitate meaningful change in practice and systems.

“Difficult dynamics with service users…can upset and burn staff out. (Reflective) groups are about helping us overcome that and deliver a better service for service users. But a by-product of that is that it can reduce staff burnout.”

“If you don't build in time for people to have supportive conversations, debrief, (attend) supervision or access training, it doesn't happen.”

There were calls for a reduction in other responsibilities to free up staff to attend to this agenda, or significant changes to current ways of working for some staff groups.

“We need to stop doing something to make space for these other things…..we seem to be just adding on and adding on to our jobs.”

“(Protected supervision time should) be a mandatory part of (education staffs’) working life. I don't know how I would do the job of our teaching and support staff if I didn't have dedicated time to offload. It needs to be a national priority for education staff.”

Delivery leads were also described as being “spread extremely thinly”. Their high workload and part-time or short-term contracts were highlighted as barriers affecting the training roll-out, implementation support, and the sustainability of progress. There were calls to increase resourcing for these posts and to fund these in the long term.

“It was a huge piece of work for them…Because they (have) their own jobs as well.”

One local authority has recently invested in a team of dedicated additional staff to help support and coordinate further training and service review and redesign. This was viewed as helpful in meeting demand, focusing teams, facilitating staff engagement, driving the agenda forward, and engendering faith that reaching more of the workforce is achievable.

“I'm hopeful that the momentum that (leads) were able to build up has created traction that will enable (the new) team to come in and really focus and provide that dedicated support that we weren't really able to give it that it needed and deserved.”

Some participants outlined challenges linked to the availability of trainers or delivery at more enhanced levels alongside the ongoing supervision and coaching these require. This is often done by psychologists, but competing clinical caseload demands mean they may have limited capacity to deliver beyond health staff. There were calls for: a greater mix of professional backgrounds among trainers; the creation of local trainer posts for each service; and increased resourcing of supervisors to enable a greater range of staff groups to access enhanced level training.

“We probably would have liked more people to do the train the trainers.... It's always tricky when you're training very busy professionals….their main priority is practice delivery. They're key posts, so they didn't always have capacity to contribute.”

“To look at working with people in an enhanced way, we need psychologist support, which we don’t have. Clinical supervision is absent at the moment…. Our psychology colleagues are very clear- you need that in place to do that safely.”

Finally, the scale and complexity of the task of rolling out trauma-informed training and helping an entire workforce to become trauma-informed was also raised as a challenge. Aligned to this, while the funding for local authorities from Scottish Government is an enabler to implementation and delivery, the annual nature of the funding was reported to create challenges. The lack of clarity or certaintainty about funding beyond the current funding period, was perceived to be creating a barrier to longer-term planning, achieving system change and ensuring sustainability.

“I completely understand the complexities of having a trauma-informed workforce and actually how complicated that is to reach out to everybody within a workforce.”

“There's a degree of frustration about the pace of all of this. But it's nobody's fault. It's one of those ones that it's trying to turn a tanker, trying to find, get the building, the resource to start to get a hand on who all needs to be trained. I feel unkind saying that I'm frustrated, but we would have hoped that we would have had a series of training dates that we could have just got staff through in a clearer direction about what level we would be training people on.”

Challenges in reaching staff and services

Senior-level engagement

Some senior leaders' lack of, or a superficial, engagement with the trauma-informed practice agenda was highlighted as a challenge in two local authority areas. This was felt to have limited the reach of implementation activity to certain service areas, or discouraged the uptake of training amongst teams and frontline staff.

“We did the STILT training…. people cognitively seem to understand it, but …we want things to be different. This isn't a tick-box exercise. This is an active thing with meaningful change that you can see…. I just felt that was very much not there.”

“We need to widen this out to (other) services…not just focusing on one area…..I think it shows a lack of senior leadership over all services in (local authority area) that they weren't present in discussions.”

Suggested reasons for lack of engagement by leadership included: competing demands and time and capacity constraints; scepticism amongst managers who felt they already worked in a trauma-informed way or that training was too basic for their teams; insufficient focus on the development of trauma-informed leadership as part of the delivery trial; or a lack of recognition of the ongoing process involved in cultural change work.

“I would hazard a guess they just simply couldn't even afford the time to think about going on those trainings."

“Sometimes we think as part of this change work you go to a meeting, or you go on a piece of training, or something's presented to you, and that's it.”

“It has been about what training is available, how do we put our staff through this training, rather than what does trauma-informed leadership look like .... rather than how we make our workplaces and our services and our organisations more trauma-informed…which includes our senior leaders.”

“Some of the managers…who went to (level one training) came out of it thinking ‘Oh, this is really basic, our staff should all know this stuff’…. there's a scepticism there.”

Successful attempts to reach leaders, and suggested ways to increase their engagement included:

• attending pre-established senior-level meetings;
• raising awareness about the benefits and relevance of training;
• sustained engagement and review opportunities to keep the agenda alive and support ongoing implementation;
• more targeted support and bespoke training packages for managers and teams so that training aligns with pre-existing knowledge levels;
• being clearer on intended outcomes for leadership teams;
• executive-level directives about following through on implementation activity and improved governance and accountability.
• “(Delivery lead has) chipped away at team leads to get them on board, and that's been much more successful…... Having continued conversations, going back to people and saying, 'Remember I emailed you about that?' Just that…gentle reminder has really worked.”

“It's about how we get the content for the leadership group (training) to really help us think about trauma-informed leadership of services…. Engagement wasn't as good as it was hoped…But I think there's huge buy-in. It's thinking about what outcomes we'd like to achieve as leadership teams and what the process is to get there.”

Reaching frontline staff and services

All three local authority areas reported challenges in engaging some frontline staff and services, with varied uptake of the trauma-informed practice agenda described. Some expressed frustration about the slow pace of roll-out, noting staff groups or service areas that did not participate; or stressed the importance of widening out activity, so that changes in practice move beyond one service area.

“We don't have all the staff trained….there's a general frustration around about the pace of the rollout of the training… it's a massive task.”

“It needs to be understood as relevant, not just within those traditional services that we see as working with trauma…It needs to be housing, customer services, corporate. Otherwise… it's always going to be disjointed. And then you might do a lot of work, and it’ll just be completely undone by another interaction.”

“One of the gaps for us in terms of training is our admin workers.”

There were mixed views about whether pre-existing familiarity with the concept of trauma-informed practice facilitated staff engagement. While some felt there was greater buy-in by staff directly involved in working with people who have experienced trauma, others were concerned that the training replicates existing knowledge. Limitations attributed to a broad-brush approach to training were also highlighted, and the importance of pitching the training at an appropriate level was emphasised.

“For the general public and those new to trauma-informed practice - training is fine. But for those who work with trauma day to day - more tailored in-depth training is needed. But we only have access to level one and two.”

“Learning assistants may have gone through so many different trainings and offers. It's about getting the professional learning respectful to what they're bringing to the table… With the small amount of time we've got for that type of activity, we've got to get it right, or we can create more barriers and tension.”

“For level one training because you're doing a broad-brush approach where a variety of people could turn up online, …people would think ‘Oh, I do this already’ or ‘this isn't relevant for my job’.”

“Some …departments (think) it's not really our business.”

Staff workload pressures were also raised as a potential barrier to engagement, with the need to be thoughtful about this and pace change appropriately. Other barriers to reach and engagement included: insufficient support and encouragement from managers to attend training or implement learning from this; the COVID-19 pandemic; lack of promotion of the agenda due to gaps in delivery lead provision; and the necessarily restricted focus of pilot activity.

“I don't know if there's been ….great sign up to a lot of the training. And that's about people feeling that they've got the time and space…If you don't have leaders saying, “This is relevant and important, and you need to carve out time to do it”, people aren't going to go on it.”

“There's absolutely the appetite for it, and people are asking (in service areas that have not been reached). You can't do everything all at the one time… we've had to do a planned and staged response to the training.”

Examples of factors which facilitated engagement in training and embedded trauma-informed practice within teams included: delivery leads being present within teams and providing sustained implementation support; providing support to managers to support their teams; defining clear outcomes and establishing what level staff should be trained to; promoting awareness of the benefits of training; highlighting the culture change aspect of the trauma-informed practice agenda; and identifying training needs and the best ways of meeting these.

“(Leads) coming into the offices, meeting with the team leaders, meeting with staff…that would probably have helped.”

“There's huge buy-in for trauma-informed practice. It's the buy-in to the roll-out of the training, I guess. We need to understand what training needs people have and how we are going to meet them. Is it by doing this course? Or is it more reflective spaces? Or is it just having space to think about the learning you've already done.”

“Emphasise that it's not just about practice, this is about looking at the system, and that's the difference in this instance. We are asking senior management now to really think about the decisions they're making about your buildings, your environment, capital spend, what impact that'll have on your practice and what that'll mean for you and interacting with patients, clients, service users.”

Some participants felt there were advantages to aiming for small, targeted, or steady changes.

“The trauma programme…on local levels and on national levels can be massively overwhelming as a piece of work…(It helps to) plan small pieces of work that help support teams to do things in a different way but are really thoughtful.”

“Pick a small area to start with and be thorough. And that will then go out…as long as you pick…SMART goals, something that's realistic”.

“One of our strengths is that we've started small in our pilot…and now we're starting to broaden out to (other) services. That's given us a focus and a smaller pool of people to prioritise. We've been able to see what that roll-out looks like and learn from things and then we know how we would then map that on to (other) services. Sectioning it out or compartmentalising it in that way has been really, really helpful.”

A targeted approach, to model what can be achieved with one group, was viewed as beneficial to scaffold, provide practical tools, and promote a snowball effect of interest in the trauma-informed agenda.

“It’s important to model that you could do things differently… We've just started a pilot around that reflective space, peer support spaces …… to develop a template or guidance to cascade throughout the council…That's what people need. They need somebody to show them that it's possible and then to give them that scaffolding and support to be able to do it themselves.”

“Focus on the areas that have a good appetite and use that as an example…..If (for example) they see that a reception area is really improved in terms of aesthetics, that is a visual thing for other people (to think) "Oh, actually, that'd be really good."

Siloed services and unintegrated workstreams

The lack of integration of service delivery and joined-up working was highlighted as a barrier to: consistent embedding of trauma-informed practice across the whole workforce, more ambitious preventative practice, or cohesive work across teams.

“As much as we talk about joined-up working and not being in silos - the reality is….there isn't always that connection. With our library services, if we could provide community spaces...where people could come for support on an informal basis, we are preventing somebody relying on emergency out of hours. We don't do that necessarily very well.”

‘My team share a building with NHS teams. We work in different ways. We have different ideas about how to manage risk. Things like…that can be quite conflicting... It's not necessarily always very cohesive.”

“In the area that I'm in, it's not just mental health, there's older people, there's learning disability and it wasn't getting implemented in those areas. It was a bit more patchy…I think because we're a bit fragmented.”

The participant below felt that in their local authority, the prioritisation of training roll-out neglected a synchronised approach to implementation activity by services, hampering more widespread cultural change. A few said geography limits joined-up working and makes coordination between services more difficult. One participant was hopeful that the move to integrated services and the employment of more delivery leads would improve co-ordination in the future.

“The focus has been on training rather than… how do we make sure the council and health and education are in the same place?... There hasn't been a space holding everyone together….There have been some lovely isolated projects, but they haven't felt like they were part of a wider movement across agencies.”

“What I really wanted them to do is make sure it's coordinated because the size of (local authority area) is so big……You get a huge variance of practice; you're constantly up against a lack of standardisation and consistency. So, we're making sure that things are equitable and equal, and practice is the same.”

“It is so disparate; you'll have different social work teams, for instance, working in (one town) than you will in (another)… I wonder if the geography gets in the way?”

The national programme landscape was also described as confusing by a small number of participants due to the wide range of different workstreams, training interventions, and projects that fit under that banner and the array of different services involved.

“People don't understand what the National Trauma Training Programme is … There have been so many different components. ..I didn't realise that we were part of a delivery trial... There are different pots of funding and multiple different organisations. There's government, NES, different parts of the council… We've had third-sector and private training providers - that confused people as well because we got training from a private provider…They were saying they were level three aligned… but it wasn't actually the National Trauma Training Programme.”

Although the overlap of trauma-informed practice with other national strategies was felt to be helpful by some, it was also described as confusing for staff, adding to a sense of yet more workload, or leading to work duplication. An overlap between strategies and a crowded trauma-informed practice landscape were also identified as barriers to evaluating the NTTP and teasing out impactful factors.

“We're already down the line with our own support programmes, and schools are really tight on time. To then want them to do another layer of training with something that's got such a massive overlap with what they've already done...We need to step back and get that strategic view of which bit is covered where.”

“It's difficult to measure because there's so many strands of work that feed into this… it's harder to measure exactly what's making the difference.”

Participants called for better integration between strategies, workstreams, and training programmes or highlighted efforts to align these. Suggestions included a more robust monitoring system or professional learning across different strategies to avoid duplication and enable targeted training offers. One participant said the Improvement Service had helped them stay informed about how the different strands of NTTP activity tie together. Another felt that the programme website, currently under construction, will help people understand the different components of NTTP.

“We have been trying to help them see where they could take a lens to their existing work so that it didn't feel like it was another task or something that sat separately.”

“(We use) an accredited course… for all our residential services…learning disability services, daycare services and to home care. It's… our behaviour management approach. We're trying to look at that through a trauma lens so that they join up…. rather than people going away and developing programmes that are quite different.”

A small number emphasised that trauma-informed practice should be the foundation which underpins everything that staff and services do, rather than seen as additional to, or separate from, current practice.

“We need to stop this from being seen as something additional and begin to see it as how we do things around here. It's how we work, it's how we provide a service, it should just be a part of everything that we do day to day.”

“It's almost like you've done your trauma-informed training, tick, next…how it almost sits on top of your practice instead of underpinning it.”

“Having that message that this isn't something that you do, this is who you are. It shouldn't be a strategy. I don't like the fact there's a trauma strategy group. It's more of a strategic trauma group- so that things move on from being something that you have to do, (to) just a way of being.”

The impact of COVID-19

The COVID-19 pandemic had a disruptive impact in the early days of the trials. It affected training roll-out plans; drew attention away from trauma-informed practice; limited the support available to delivery leads; reduced opportunities to bring service leaders and managers together for STILT sessions and follow-up workshops; restricted the availability of systemic implementation support; and negatively impacted pilot reach and progress.

“During COVID, it was firefighting. There was no ability to plan forward or to think about doing anything other than core business.”

“People were so diverted thinking about…how to respond to the pandemic. I was on my own just getting on with it.”

A small number described unforeseen positive consequences of adaptions to delivery approaches, necessitated by the pandemic. These included:

• an increase in the number of people reached by the training due to online delivery;
• in one local authority area, the pause in pilot activity brought an opportunity to reflect on the emerging evidence base for best practice, leading to a shift in focus to leadership training and systems-level change.

“We probably delivered more sessions than we would have done face-to-face…It was convenient, very accessible when they were working from home.”

One participant also felt that there had been, and was further scope for, useful learning about the impact of collective trauma to inform further roll-out.

“There was work being done about (trauma-informed practice) during a time where people were all experiencing elements of collective trauma…I wonder… if there might have been even more insights they may have learned to take forward.”