National Trauma Transformation Programme: Trauma-Informed Maternity Services Pathfinders - Learning Report

Summary Report

Background

Commissioned as part of the National Trauma Transformation Programme (NTTP), the Scottish Government funded four pathfinder projects with a focus on two priority sectors: maternity services and substance use services. This summary report presents learning from the two maternity pathfinders which were based in Forth Valley and Grampian Maternity Services. The pathfinders took place over a 15-month period from January 2022 to March 2023.

This learning report is intended to support services across Scotland to consider the opportunities and challenges of planning for, developing and implementing sustainable trauma-informed (TI) practice. A key aim of the pathfinders was to enable all staff working in maternity and neonatal services to be TI and appropriately responsive to women, individuals and families who have lived or living experience of trauma (LLET). The learning from the pathfinders has also informed the development of a forthcoming NTTP Roadmap for Trauma-Informed organisations, systems and workforces.

Context

The Scottish Government's ambition, shared with COSLA, is for a trauma-Informed and responsive workforce and services across Scotland. This ambition is supported by the National Trauma Transformation Programme^[1] founded on Transforming Psychological Trauma: A knowledge and Skills Framework^[2] (2017), developed by NHS Education for Scotland (NES).

Being 'trauma-informed' means being able to recognise when someone may be affected by trauma, collaboratively adjusting ways of working to take this into account and responding in a way that supports recovery, does no harm and recognises and supports people's resilience. Being TI involves:

• Realising how common experiences of trauma, adversity and ACEs are
• Recognising the different ways that trauma can affect people
• Responding to support recovery
• Resisting re-traumatisation
• Recognising the central importance of Relationships
• Respect Resilience

Trauma-informed approaches will benefit all people who come into contact with members of the workforce, including people with experiences of trauma and Adverse Childhood Experiences (ACEs) and/or people impacted by socio-economic disadvantage and discrimination, as well as all others.

Five key principles underlie trauma-informed practice: safety, trust, choice, collaboration, and empowerment. The development of trauma-informed practice requires systems, services and organisations to be aligned with these five principles. Therefore, implementation of trauma-informed practice is often described as an 'ongoing process of change' or a 'continuum of implementation'.

Being 'trauma-informed' is not about providing interventions for trauma-related difficulties, although that can be part of it in certain contexts. It is about enabling members of the workforce to address the barriers that people affected by trauma can experience when accessing the care, support and treatment they require. It also involes preventing trauma related distress that can be triggered by any contact with staff in services (i.e. re-traumatising).

The importance of involving people with LLET and adversity is essential in developing trauma-informed approaches. It is also acknowledged that members of the workforce will likely be affected by trauma, through their own personal experience and, in many cases, 'vicariously' in the course of their work. It is particularly challenging for staff to support people affected by trauma when their own wellbeing is at risk. Workforce wellbeing is therefore fundamental to a trauma-informed approach.

Learning highlights that workforce training is a key component of any organisation's journey to becoming trauma informed. Equally important are the culture, environments, and supportive ways of working in an organisation that can enable sustainable change that makes a difference to all of us who are affected by trauma. No matter how trauma-informed a practitioner may be, if we are constrained by protocols or policies that do not recognise the impact of trauma, we may be unable to minimise the risk of re-traumatisation that our training has taught us to recognise. This can risk disempowering staff and creating a sense of helplessness, leading to potential disengagement from empathy for people we are supporting.

Transforming Psychological Trauma in Maternity Services: Nursing, Midwifery and Allied Health Professionals (NMAHP)^[3] Project Report

As part of background scoping, NES comissioned research exploring the views of maternity care staff in Scotland. This focussed on the workforce knowledge, skills and identified barriers and enablers to develop trauma-iInformed maternity services. Common themes were found across all professional groups highlighting clear knowledge and confidence gaps and a desire to learn and respond more effectively to the psychological trauma experiences of women, birthing people and their families.

There was further recognition that all staff working within or alongside maternity and neonatal services have a key role in ensuring women, individuals and their families feel safe and secure during their pregnancy journey and that the transition into parenthood is important. The project identified the necessity for substantial scoping of workforce development needs relating to trauma- informed care provision for maternity and neonatal services.

The report concluded with recommendations based on three overarching themes to help facilitate the next steps in leading Scotland's maternity services towards becoming truly trauma responsive. If actioned these recommendations will ensure that women/individuals have a positive experience in their pregnancy and parenting journey, while diminishing the longer term negative impact of past adverse or traumatic experiences. The recommended three themes from NMHAP Project report are:

• Workforce Education
• Service Delivery
• Implementation

A key recommendation was to identify two maternity pathfinder project boards to explore what tangible steps are required to design, deliver, and sustain Trauma Informed maternity services. This was supported by the Scottish Government NTTP Steering Group and led to the Maternity Pathfinder Project.

Approach to Pathfinders

The pathfinder areas were each provided with dedicated support from a specialist in Midwifery and Trauma-Informed Practice (TIP), as well as support from a Monitoring and Evaluation specialist. The pathfinders followed three key phases:

1) Understanding service context and readiness for TI Practice.

2) Improvement planning, informed by phase 1 learning.

3) Implementation of agreed priority areas.

4)

Pathfinder Methods and Timeline

Phase 1: Understanding service context and readiness for Trauma-Informed Practice (January 2022 – June 2022)

Familiarisation with the current service provision and relationship building through:

• Supporting key stakeholders to develop a shared understanding of the aims and objectives of the pathfinder project and gaining leadership commitment from the onset;
• Establishing a Maternity Trauma Informed Implementation Steering Group (MTISG);
• Familiarisation and multi-agency scoping sessions to understand; the current systems and services, the key workforce/partners involved, existing TI knowledge and practice, and how feedback from experts by experience are currently gathered;
• Trauma Informed Lens Event in collaboration with those with LLET;
• One to one sessions to hear the voice of those with LLET;
• Workforce training needs analysis (TNA);
• Collaboration with local Trauma Champions and Transforming Psychological Trauma Implementation Co-ordinators (TPTIC).

Phase 2: Improvement Planning Informed by Phase 1 Learning (June 2022 – March 23)

Based on the learning outcomes from Phase 1, Phase 2 included:

• Organisational self-assessment and improvement planning using NTTP resources and draft Maternity Service Improvement planning tools- 'Creating trauma- informed change in maternity services: Implementation guidance and planning resource'^[4] and 'Implementation guidance for trauma- informed care in Scotland: A tailored organisational self-assessment resource for maternity services')^[5];
• Developing a Theory of Change (ToC) model agreeing priority areas, associated activities with embedded monitoring and evaluation structures.

Phase 3: Implementation of Agreed Priority Areas (Nov 2022 – March 2023)

• Access to Scottish Trauma Informed Leaders Training (STILT).
• Review findings from the Training Needs Analysis to inform workforce development planning.
• Development and delivery of a Maternity Tailored Skilled level Trauma Training Programme that embeds reflective practice and coaching structures, to support implementation of new learning.
• Support forworkforce health and wellbeing initiatives implementation planning.
• Screening, documentation and care plan implementation planning.