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

1. Phase One: Understanding Service Context and Readiness (See Appendix A -Road Map)

Understanding the organisation or service context and readiness for transformation to become TI is a vitally important step that takes time. Without having an indepth understanding on their current position and their organisational readiness, which is inclusive across the workforce of the Integrated Joint Boards (IJB), implementation plans may become ineffective. A key lesson from the maternity pathfinders familiarisation sessions, was that there were key aspects of the NTTP themes/ drivers that leadership were not always aware of and some disconnect between embedding of new initiatives with workforce engagement or uptake. This summary report follows the pathfinder journey as directed by the maternity services readiness and capacity.

1.1 Leadership: Strategic and Operational

When progressing Trauma Informed Practice (TIP), early connection with key stakeholders across each pathfinder IJB is essential. This requires both a strategic and operational level of leadership which is essential to facilitate a shared understanding of project components and to obtain commitment and ownership from the onset. Engagement should be inclusive of all services/ agencies involved in caring for families throughout pregnancy and the initial postnatal period. Identification of a senior maternity member as the main project contact with responsibilty to feedback progress and learning from the pathfinder activity to senior stakeholders within their board is also vital.

This early communication recognised the vast array of professionals that families meet, services they engage with and connections they make in their pregnancy. This, in turn, allowed identification of key representatives who were invited to their local Introduction to the pathfinder meeting. The meetings were held at both a strategic and operational leadership level and facilitated early collaboration with local area Transforming Psychological Trauma Implementation Co-ordinators (TPTIC) and Trauma Champions. TPTICs and Champions are based in each board area and provide trauma expertise to organisations to support, raise awareness and influence action including training, coaching, implementation and collaborations with people with lived experience of trauma.

1.2 Familiarisation and Multi-Professional Scoping Sessions

Responding to the recognition that familes are supported by a range of professionals across departments and services (both within and working collaboratively with maternity services), it is important that scoping is not restricted to core maternity staff. It is essential to understand current systems, service provision, collaboration with key partners, existing TI knowledge and practice, and how feedback from those with LLET are currently gathered across sectors.

Learning from Multi-Professional Scoping Sessions recognised that maternity care provision often crosses several local authority areas in both rural and urban settings, with varying processes and service provisions, which may impact TIP. Technology and interfaces were found to be complex, with a range of different systems used that did not communicate with one another and increased thepossibilty of those with LLET retelling their story and increasing the risk of re-traumatisation. New specialist service developments were identifed with challenges in sourcing appropriate locations to provide TI care effectively. Construction of a new hospital in one board area is in progress, highlighting the time and efforts needed for planning and transitions of services and how this will impact their capacity to progressing TIP.

All services reported significant workforce challenges with high absence rates, recruitment and retention difficulties and loss of experienced staff impacting skill mix needs in their service provision. As a result, workforce wellbeing was reported to be impacted negatively despite acknowledgement of key support initiatives embedded during the COVID pandemic. In addition, there was inconsistency or absences evident in supervision, reflective practice and supports across different professional groupings/settings (despite many supporting the same families). If these were consistently provided and of high standard they would reduce the impact of vicarious trauma across agencies and roles.

Limited knowledge, or access to NTTP training was evident across agencies. Those within specialist roles, who worked with families with LLET, reported a better understanding of identifiying and supporting families in a TI way. However, key components such as TI principles or drivers to become TI were often unknown. Social work representatives in leadership positions reported involvement and awareness of IJB pre-existing trauma training and joint TI steering groups within their board.

Family Nurse Partnership (FNP) representatives discussed their training and programme of care provided, which embeds and is driven by TI principles and drivers. Their professional supervision structure was identified as being 'Gold Standard' in supporting workforce health and wellbeing and reducing the impact of vicarious trauma on their teams. Health visitors and some community midwives highlighted Child Protection supervision from local Child Protection advisors was effective and supportive when required.

The multi-professional scoping sessions were grouped into the following:

Inpatient Core Maternity

• Antenatal
• Postnatal
• Triage
• Daybed Unit
• Labour ward/AMH
• Scan Dept
• Obstetric clinics
• Community Hospitals

Specialist Midwifery Roles

• EPAS
• Bereavement and loss
• Substance Use
• Adult and Child Protection
• Perinatal Mental Health
• Digital
• Workforce Dev

Community Midwifery

Community Midwives across Pathfinder board areas

Student midwives

Maternity Community Hospitals

Neonatal Services

• Senior Nurse
• Nurses
• Midwives
• ANNP
• Paediatrician
• AHP

Mental Health Services

• PMHT
• MNPI
• CMHT
• Clinical Psycholgist
• Consultant MH Nurses

Other Health Services

• Health Visitors
• FNP
• GBV Specialists
• CP Leads

Social work and Addiction

• Children and Families SW
• Addiction Teams
• Addiction Psychology
• Alcohol and Drug Partnership
• 3rd Sector Organisations
• Maternity Partnership Voice (MPV)

Multi-agency sessions considered the following key components:

Checklist

• Role, responsibilities and length service
• Service team and skill mix
• Service base, provision and target audience
• Multi-agency working and processes
• Screening and documentation of trauma
• Understanding of NTTP and Providing TIC
• Trauma training accessed or accessibility
• Workforce health and wellbeing policy and iniatives
• Identified TIP, enablers and barriers
• Processes to hear voice of LLET
• Management support
• Policies, guidelines, processes and service priority drivers

1.3 Maternity Trauma Informed Implementation Steering Group (MTISG)

Within larger organistions, such as maternity services, establishment of a multi-agency implementation steering group is essential from the onset. Membership should include those recognised as key professionals who will lead on developing and implementation of service change with partners in the transition to become a TI maternity service. The MTISG should embrace learning from the pathfinder familiarisation and scoping activities to inform their local ToC model. Within smaller services, development of actions plans may be sufficient.

Early project planning, leadership introductions and familiarisation sessions across the pathfinder board, helped identify key stakeholders involved in providing care to families across their pregnancy journey. In establishing the MTISG representation was sought from; midwives (across departments and roles), obstetricians, neonatal nurses/advanced neonatal nurse practictioners (ANNP), paediatricians, allied health professionals (AHP) (sonographers, occupational therapists), anaesthetist, perinatal and infant mental health (PIMH), Maternity and Neonatal Psychological Interventions (MNPI), social services, addiction services, health visiting / family nurse and third sector organisations. In addition, engagement and involvement of local TPTICs and trauma champions was crucial in guiding local joint implementation board direction and learning.

The MTISG developed locally agreed 'Terms of Reference' and aimed to convene monthly meetings through a combination of Microsoft Teams and in-person sessions. Members have been encouraged to access STILT training and embrace support from their local TPTIC. Implementation resources, developed and adapted as part of the pathfinder specific to maternity and neonatal services, have supported the members to evaluate their position in delivery of TIP and guide development of key change ideas.

There were difficulties in securing attendance across representatives due to existing workforce challenges and competing agendas. This has impacted the continuity of representation, the progress of the agreed group activities and difficulties in forward planning in the absence of key individuals.

1.4 Trauma Informed Lens Event

The NTTP have developed a resource^[6] for services to use to support them to consider their own organisation service provision using the key trauma principles of safety, choice, collaboration, empowerment and trust. This resource provides step by step guidance, directing participants to apply the TI Lens tool to their setting to support identification of:

• Areas of good practice – Keep and do more of;
• Identified risk of retraumatising – Stop or change;
• Recognised opportunities – add into their service.

A journey for families, from confirmation of pregnancy until transfer of care in the post natal period, consists of attendance at a variety of appointments within different departments and services. Reflection on these journeys highlighted the range of professionals involved, processes and interventions of a sensitive nature encountered, and the impact this may have on those with LLET.

The Trauma Lens Tool, 'Workshop Guidance Notes'⁶, programme was extended to a full day, to allow the development of department / team specific maps of care and collaboration with families with LLET, who had recently received maternity care. Participants from the core workforce were identified through the MTISG and attendees were split into sub groups to review their service journey. Specific sub group settings were: Inpatient setting

• Community Setting
• Midwifery / Obstetric Specialist Support
• Triage / lnterm care
• Neonatal setting
• PMH and MNPI
• Health Visitors
• Scan Department

The participants considered the prevalance of trauma, recognising the impact and how they respond to those they are supporting within their service via facilitated discussions in their groups. They recognised common trauma events they support included: birth related trauma, bereavement/ loss and recurrent miscarriages, gender based violence, ACE's, sexual trauma, physical assault or a significant trauma incident such as road traffic accident or episodes of significant ill health. They identified that the definition and impact of a traumatic event can vary person to person.

Each group used the TI principles to consider every contact or experience women with LLET may have within their department. The groups were able to use their findings to develop 'Plans for Trauma Informed Change' specific to their area of work, which supported their local implementation team to develop their ToC model and guided activities. Common themes across services included:

Keep and Do More Off

• Continuity carer or Team
• Holistic assessment
• GIRFEC Screening
• Person centred care plans
• Informed choice
• Multi-agency communication/ working
• Collaborative Birth Plans
• Risk assessment and planning
• Embedded pathways
• Orientations for staff and families
• Specialist Support Teams
• Initial 'Debrief' for staff

Add into service or practice

• TI Training for staff
• Protected time and resource
• Extend time for appointments
• Client Informed 'Trauma Section' in Badgernet
• 'Safe Space' for staff and families
• Revisit risk assessment and plans in collaboration
• Embed process for meaningful client feedback
• Multi-agency accessible info
• Prioritise care vs department activity
• Accessible Information for families
• Enhance wellbeing supports
• Improve communication across dept, agencies and care timeline

Stop or Change

• Use of negative language
• Reduce amount of care providers women see
• Multiple appointments for families with complex needs – consider 'One Stop Shop'
• Inconsistent systems, digital platforms and equipment
• Ineffective handover of care
• Staff support following adverse events – enhance
• Cultural attitudes – presumption and impact on care

A pdf of this image is available separately on request if a larger font size is needed.

The sessions concluded with smaller facilitated discussions with women who were recognised to have experienced a traumatic event, to reflect on their unique, care journey, highlighting:

• areas they felt to be good practice and supportive;
• areas of difficulties/ challenges they faced;
• areas recognised to be a risk of re-traumatising;
• suggested areas of improvement to better the care for families attending maternity services.

1.5 Voice of Those with Lived and Living Experience of Trauma (LLET)

We cannot expect to develop TI maternity services and systems if we do not listen to and learn from people who have experienced trauma to understand what changes need to be made within the services we provide. Leaders, experts by profession and experts by experience all bring different knowledge and expertise about what works and what doesn't when supporting people to recover from trauma. Power sharing collaboratively, developing processes so that people affected by trauma are safely and meaningfully involved in decision making leads to developing services that are more likely to be designed around people's needs. This can help reduce barriers for people to access support, ensure those services and systems are seen as supportive resources for people affected by trauma, and ultimately contribute to improved outcomes for people and communities. No service or system can be trauma-informed if it is not informed by people with lived experience of trauma.

Families were identified who had recently received care from the pathfinder service, had a history of trauma and were comfortable to share their experience through one-to-one interviews with the Project Leads. The families were identified through maternity and neonatal staff with a specialist role (Public Protection, Substance use, FNP, MNPI, Bereavement, PMHT) and local 3^rd sector organisations. These organisations provided emotional support for the women to share their experience within a confidential and psychologically safe environment. All details shared remained anonymous and were collated to present to the pathfinder MTISG and Senior Midwives. Early scoping and workforce recognition of traumas from the 'Trauma Informed Lens Event' identified traumas commonly seen within maternity services included women who experienced:

• Sexual Abuse
• Bereavement and Loss
• Assault or traumatic event
• Family Trauma eg. loss or separation
• Adverse Childhood Experiences
• Trafficking /Refugees
• Critically ill Newborn
• Gender Based Violence
• Birth Related Trauma

Feedback was informed by women's unique experiences and varied depending on the event(s) which led to their trauma. Learning relating to service provision and care, which impacted on trauma, was fed back to the local service leads. Key learning from across LLET interviews highlighted common themes around communication, care environments, timeline and continuity of care/ carer and trusting relationships. Reflection also allowed recognition of the impact of not receiving care underpinned by TI principles and the risk of re-traumatising during their maternity care experience. In addition, it is known that these challenges can also create barriers to families receiving appropriate support or disclosing their trauma experience to allow the development of their own individualised, care plan. It should also be noted that families may fear disclosing issues such as domestic violence or mental ill health, if it is perceived that the disclosure may impact on child protection decisions around parental capacity to provide appropriate, safe care.

1.6 Workforce Training Needs Analysis

A workforce that is able to recognise where an individual may be affected by trauma and work in a way that minimises distress and maximises trust can do two things:

1. Support the recovery of people affected by trauma by providing them with a different experience of relationships. People with LLET identify that the most important part of their recovery was developing a safe and trusting relationship with a worker thus making them more likely to seek further support.

2. Minimise the barriers to receiving care, support and interventions that those affected by trauma can experience when memories of trauma are triggered by aspects of the service or interactions with staff. Thus contributing to people finding it easier to navigate and engage with the services/ systems that they require, support and strengthen their resilience and improve outcomes.

A workforce training needs analysis (TNA) survey, to measure local self-assessed levels of understanding, knowledge, skills, and confidence about TIP within the Pathfinder Maternity Services, was distributed to all the workforce across maternity and neonatal services. The survey explored the following key themes:

• Background information: place of work, role, and length of experience within maternity settings.
• Understanding, experience, and confidence in providing TI care in their practice.
• Trauma Informed Practice as an organisation.
• Workforce wellbeing policy, supports and initiatives.
• Identified barriers to adopt TIP.
• Identified supports required for the service to become TI.
• Knowledge and access of the NTTP and associated training participated.
• Examples of existing TIP for families.
• What individuals/ service are hoping to gain from the pathfinder project.

The survey aimed to inform organisational readiness to become TI and help inform the development of an appropriate Maternity and Neonatal training programme across the workforce. It sought to provide a baseline against which changes in staff understanding, knowledge, skills, and confidence in providing TIP could be assessed in future.

Despite senior maternity staff representatives encouraging workforce participation on numerous occasions over a 3-month period, uptake of the survey was challenging across both pathfinder boards. Final response rates were 33% of maternity staff in Board 1 and 11.4% of Board 2. Therefore, findings cannot be seen as representative but provide some insight into training needs which align with findings from the NMAHP and pathfinder initial scoping exercises. Key TNA findings suggest:

• Less than a third of respondents in either board (22-30%) were previously aware of the NTTP. With only three participants in one board and fifteen within other having completed any of the training courses or accessed materials related to the NTTP.
• Between 23-57% of respondents expressed a lack of confidence in understanding and applying principles of TIP
• Between 20-38% of respondents thought TIP values were evident in their service and 13-17% felt that leaders championed TIP. Given the current context within the NHS, leaders' focus has been on ensuring safe levels of staffing to deliver core services.
• That only a third or less of respondents in either Board felt encouraged to undertake TIP training, likely reflects the current context within the NHS in terms of workload, demand to cover for staff absences and loss of staff within the service. Within the scoping element of the pathfinders, it was evident that fulfilling mandatory training was a huge challenge for the Board areas. Securing protected time for training and coaching is therefore a substantial challenge for anyone wanting to roll out TI practice and one all organisations are required to address.
• Few respondents (9-13%) were aware of activities to engage those with LLET in their services design and delivery. This element of the NTTP also requires substantial support and expansion, if NTTP ambitions are to be achieved.
• Whilst around half of respondents thought staff wellbeing was supported, the remaining staff were either ambivalent or disagreed that this was the case. Given the current context (absences, understaffing and retainment challenges) within the NHS and the learning from the scoping and wellbeing drop-in phases of the pathfinders which reinforce these themes, staff health will require to be prioritised as a key element of the NTTP roll out.
• Coaching was reported by 10 -13%, with supervision provision varied across teams. Frequency of supervision was reported to be reduced due to workforce challenges and the impact of the recent pandemic.

Many examples of existing good TIP were provided from respondents and evident during the pathfinder projects despite the challenging circumstance that services and staff were facing. For future progress of TIP, it seems likely that many of the current structural barriers such as workload, demand, staffing levels and environment challenges, which have impacted on staff training, wellbeing and the capacity of leaders and staff, will need to be addressed. Recognised good trauma-informed practice included:

"Having a talking therapy service out with psychological therapies, where people may need to discuss previous traumas. Also, the inclusion of dads and families as we sometimes tend to forget them, but not meaning to."

"We offer family centred care, parents are not visitors they are essential care givers"

"Fully explain the process of and reasons for any procedures. Always offer chaperone for intimate examinations"