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

2. Phase Two: Improvement Planning

Following completion of a comprehensive familiarisation process, discussed in phase one of the project, leaders are required to consider how they can take the key learning to build their local improvement plans in their journey to become TI. The process the pathfinders followed in developing their long term service improvement plans is detailed below.

2.1 Organisational Self-Assessment and Improvement Planning

Many people with LLET highlighted the importance of the care setting feeling welcoming, safe and accessible, offering choice on their care and care provider, developing care plans in collaboration, helping them feel respected and, building a trusting relationship. By considering a person's journey through their pregnancy, considering all their interactions, relationships, environments and resources, and taking this learning into their service design, services can actively resist re-traumatisation and support recovery.

When planning TIP change ideas it is important to embed feedback loops to create an ongoing dialogue between the organisation and people who work in, alongside or come into contact with the service. Pro-actively and routinely encouraging feedback from these groups helps the service understand how they can continue to reduce barriers to accessing support.

Within the maternity pathfinders, the MTISG were supported to review their current service provision using two maternity specific implementation resourses, designed during the project. These were, 'Creating trauma informed change in maternity services: Implementation guidance and planning resource'^[7] and 'Implementation guidance for trauma informed care in Scotland: A tailored self assessment resource for maternity services'^[8]. These tools helped the leads to consider the key drivers for organisations and to deliberate on their current status against these when developing their improvement plans. The resources supported the steering group to consider how to align their implementation plan in line with findings from phase one: Understanding service context and readiness, change ideas from the 'Trauma Informed Lens Event' and learning from those with LLET.

Workforce challenges significantly impacted the pathfinders ability to progress both their self assessment and planning with the trauma-informed specialist and evaluation expert faciliating and supporting the steering group through the guidance and processes.

2.2 Developing Theory of Change (ToC) Model (See Appendix B - Theory of Change Model)

It is important for services to take time to consider how they can effectively and efficiently start to implement their identified change projects /plans to become TI. Developing a ToC supports the improvement aims by agreeing the desired outcomes and providing an agreed programme theory about what needs to change to achieve these. The visual diagram is a useful tool to help teams develop and communicate their change theory over a longer-term timeline. It articulates what parts of the system should change, in which way, and includes evidence-based activites to make this happen. It is used to help plan improvement project activities and ensure team engagement, while providing a framework to inform future evidencing of progress. Within smaller services, the development of action plans may be sufficient.

Learning from the pathfinder's familiarisation activities, in particular the 'Trauma Informed Lens Event' and organisational self assessment, provided many change ideas/ activities which aligned with the TI drivers. These all contributed to the following overarching outcomes:

• Trauma informed practice is sustainably embedded across all maternity systems and services with effective cross-sector collaboration;
• Health and wellbeing of those affected by trauma (who use, work in or with maternity services) is improved;
• Reduced inequalities and improved life chances for those affected by trauma (who use, work in or with maternity services).

The pathfinders MTISG were supported by both the specialist in Maternity TIP and Monitoring and Evaluation, to develop their five year + ToC model through several in-person activities, with representation across the departments as previously discussed.

Both maternity pathfinder IJBs had very similar ToC plans, activities and change ideas, reflective of maternity services nationally. These models considered the core TI drivers being suggested within the NTTP which can be aligned with the developing Roadmap. Roadmap drivers include: Culture, Leadership, Workforce care, support and wellbeing, feedback loops and continuous improvement, Powersharing with those with LLET, Workforce knowledge skills and confidence, budgets, policies and processes, and services design and delivery.

Having an understanding and experience in Quality Improvement (QI) and implementation science is helpful for services to develop their ToC and associated change ideas that embed measurement plans and reporting structures. Capacity and experience within the pathfinder boards impacted the steering groups ability to progress this work in the absence of the specialist leads. The newly developed Roadmap provides a national ToC that services can use and adapt in combination with a action plan templete.

2.3 Implementation of Trauma-informed Practice Priorities

It is important when implementing change ideas and actvities that the QI process is central to the progression. It involves a systematic and coordinated approach to implementing change using specific methods and tools with the aim of bringing about a measurable improvement.

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Following activities and learning from Phase one: 'Understanding service context and readiness' and development of their local ToC model, the priority areas of transformational change within both pathfinder areas were identifed as:

• Workforce development;
• Workforce wellbeing;
• Screening and documentation of disclosed trauma.

Identified activities within their ToC plan required further detailed planning to support implementation through development of, topic specific driver diagrams, logic models and measurement plans for each of the three areas above. This recognises the vast transformation process required within the overall pathfinder ToC and breaks this down into meaningful and realistic actvity plans.

To support this process, in recognition of the limited knowledge and experience in QI, the specialist TI experts facilitated several in-person events that developed their understanding of QI and the Implementation journey, supported through the use of NES QI resources accessible through TURAS.

2.4 Enhancing Documentation, Policies and Processes

Policies and processes provide clear guidelines to staff and people coming into contact with services about how the organisation operates and its values and culture. Evidence highlights that successful implementation of TI knowledge and skills into practice needs to be reinforced by policies and processes that "hard wire" the values and principles of a TI approach into the way the organisation works, not solely relying on training workshops or a well- intentioned leader.

If the workforce are constrained by protocols or policies that do not recognise the impact of trauma, they may be unable to minimise the risk of re-traumatisation that their training has taught them to recognise. This can risk moral injury for staff, as well as potentially feeling disconnected from their work and a sense of helplessness. It is also important for organisations to consider where there might be tension between a trauma-informed approach and existing organisational policies by exploring where flexibility, choice and collaboration with staff and people affected by trauma could be built into policies and processes.

Early familiarisation within the pathfinders sourced their services leading documents inclusive of: Best Start: A Five Year Forward Plan for maternity and neonatal care in Scotland, The Promise, GIRFEC and National guidance for child protection in Scotland. Policies that focused on employee wellbeing or that included TI principles within, were unknown to many of the staff engaged, identifiying a need for a focus group to review local policies from across both their organisation and department. The maternity implementation resources provide guidance for leaders to consider how they approach their review of their policies, guidelines and processes.

Unfortunately, the workforce challenges and capacity of senior midwives to participate in this activity impacted any progression within this theme/driver. Discussions with the pathfinders to identify senior midwives to participate in processing this activity was encouraged and will be a focus over the next year.