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

3. Phase Three: Implementation of Priority Areas

3.1 Workforce Development

Trauma Informed Leaders

TI organisations require leadership that understand, drive, and inspire TI change, embody the key principles, and build accountability for long-term improvement. This requires leaders who; understand the prevalence and extent of the impact of trauma on people and services, create and actively sustain accountability, infrastructure and implementation support and model a culture of choice, empowerment, collaboration, trust and safety through their own behaviour and attitudes. The Scottish Trauma Informed Leaders Training (STILT), is a crucial resource to equip key leaders to support and lead transitional change.

The STILT learning programme supported leaders from the maternity pathfinder MTISG through access to action learning workshops and ongoing implementation support from the Improvement Service and local TPTICs. STILT provides links with their local champions to support a joint commitment to TI practice across their IJB and wider Scottish workforce in partnership with Scottish Government and COSLA. Workforce challenges impacted the ability for many group members to access the training, however notification of future sessions are shared regularly with the hope other members can access it over time.

Workforce Development Implementation Planning (Appendix C Workforce Development Driver Diagram

All staff require the knowledge, skills, confidence, and capacity to recognise, and respond to people affected by trauma. Leaders who understand workforce training and implementation needs directed through the NES Psychological Trauma Knowledge and Skills Framework and training plan resource is paramount. Access for all staff to training relevant to their role, supporting transition of learning into practice.

Review across both pathfinders TNAs highlights the need for development of a 'trauma-skilled' level training programme for the core maternity and neonatal workforce. The programme would encompass all four NES 'Developing your trauma-skilled practice' and wellbeing resources with embedded reflective practice and coaching sessions to support learning into practice.

The implementation group were supported to develop a 'Workforce development' driver diagram and logic model, to plan additional activities required to facilitate learning across the workforce. These identified key secondary drivers required to facilitate change activities:

• Understanding of staff awareness, knowledge and training accessed on Trauma Informed Practice.
• NTTP Knowledge and Skills Level of training requirements across workforce roles
• A Maternity and Neonatal Workforce Trauma 'Skilled' Training Programme
• Trauma Informed Training Trainers and Workforce Development Sub-Group
• Reflective Practice and Coaching process throughout training and service improvement
• Higher Education Institutes that embed trauma education in their curricula.

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The Implementation groups were supported to identify a sub-group of members from maternity workforce development, TPTIC's, specialists with trauma experience and MNPI's, who will lead on the workforce development change ideas and agreed training programme. These members will provide feedback to the MTISG.

Development of a Maternity and Neonatal Tailored 'Skilled level' Trauma Training Programme

The level of TI training required across the maternity workforce is determined by their unique roles and responsibilities and should be guided through the NES Knowledge and Skills Framework, previously discussed. It is essential that individuals have the level of training required. The NTTP aspiration is that all workers across all service sectors will develop a TI level of understanding and skill. 'Workers who have regular contact with children or adults who may be affected by trauma (even if this is not known about) would develop a trauma-skilled level of understanding and skill'.

Using the Trauma Knowledge and Skills Framework

Step 1 Identifying the worker's relevant practice level.

Step 2 Determining recovery stages relevant to the worker's role.

Step 3 Defining knowedge & Skills relevant to the workers role.

Step 4 Specifying the worker's trauma training needs.

Step 5 Identifying relevant training to meet these training needs

Step 6 Considering organisational readiness to support the use of trauma training in practice.

The maternity TI expert at NES used the NTTP training plan resource to guide level of training required across the maternity and neonatal core workforce, identifying a requirement for all staff to have training at a 'skilled level'. Some practioners were noted to have more enhanced contact with families with LLET within their area of speciality such as PMH, early pregnancy, public protection or substance use, requiring further assessment of their training needs in addition.

The training programme was developed from the six 'skilled-level' E-learning modules produced by the NES NTTP, consisting of four e-learning modules that support the understanding of the impact of trauma and how to develop a trauma-informed approach, and two e-learning modules focusing on promoting worker well-being and psychological first aid. Thus combining learning activities that develop understanding on requirements to become TI as well as building the important conditions through developing their own wellbeing and principles of implementation science. In recognition of maternity interventions increasing the potential risk of re-traumatisation, the recently updated 'One out of four' E-module was also included.

The programme structure is based on Implementation science with embedded reflective practice and coaching sessions. Running over a 10-week period, it has been designed to be facilitated virtually with protected time to access the range of Skilled level training modules through practioners' TURAS accounts. These include:

• Four Microsoft Team sessions to introduce new concepts, consolidate learning from E-Learning Modules, and for participants to share learning, key insights and start to consider transition of learning into practice;
• Three periods of protected time to access self-directed learning, including E-Modules, videos, online resources and supporting documents;
• Monthly coaching forum on completion, to support workplace-based application of the principles of TIP;
• An online community which will provide a secure space where information and resources can be posted and shared, and an opportunity for discussions and networking between participants within their service.

The training programme commenced by addressing workforce wellbeing supports inclusive of 'Staff Wellbeing: 'Taking care of yourself' e-learning and developing own wellbeing planning tool and the 'Psychological First Aid' (PFA) module. This facilitated engagement, through challenging times, while embedding early wellbeing initiatives.

Within one board area, members of MTISG accessed the planned modules from the training programme to assess priority learning that would be feasible to include due to ongoing workforce challenges and service capacity. This led to a shortened version of training that excluded 'Developing your trauma skilled practice' modules 2 – 4. These modules focus on more specific aspects of trauma such as trauma in children and young people, the mental health impact of trauma and understanding substance use as a coping strategy. However, the final Team session shared key messages from these modules and encouraged participants to access modules to enhance their learning.

It was agreed that the Maternity TI Project lead would facilitate the training with initial cohorts of 15 participants, identified by their service, to evaluate the training efficiency and compare any implications of the shortened programme. Pre and post course confidence surveys were completed by particpants to assess impact of each of the modules with Team sessions activities supporting the overall programme evaluation.

Ongoing workforce pressures impacted some participants' ability to attend all sessions. However, sessions were recorded with permission and shared within their cohort/Teams community. Allocation of participants differed with one board allocating staff linked to a central work rota and the other allocating staff voicing an interest. Evaluation of the programme's impact saw a clear postive shift on the workers' confidence across all the key components of the learning. There were higher positive levels of change particularly around psychological first aid, understanding the window of tolerance, producing their own wellbeing plans and understanding the impact of trauma on mental health.

The maternity service accessing the full 10 week programme have trained two cohorts and had two post training coaching sessions with learners embracing new change ideas that they are keen to implement. The shortened maternity service pathfinder have trained four cohorts, with a higher drop-out rate, and no attendance at planned coaching session to-date, reflecting competing workforce challenges.

3.2 Workforce Health and Wellbeing (Appendix D Workforce Wellbeing Driver Diagram)

Wellbeing is critical for a TI workforce, across departments and roles. Creating a healthy workplace culture is vital, where staff feel safe, supported and well when they are supporting others. Workforce care, support and wellbeing is particularly important for workers directly supporting people affected by trauma, and/ or who work in roles where they may be exposed to traumatic experiences, or face an increased risk of experiencing vicarious trauma, moral injury and compassion fatigue. Without the necessary proactive measures (e.g. supervision, reflective practice) and reactive (e.g. action plan for responding to critical events) in place, the challenges in supporting people affected by trauma can often leave us feeling disconnected from our values as practitioners and can impact our safety and wellbeing. The workforce needs to be well to be able to support others.

Nationally reported NHS workforce pressures, recruitment and retention of staff can impact on both the organisations' and workforce wellbeing as was evident within both maternity pathfinders. This highlighted the importance of the initial focus of pathfinder support to be targeted towards the 'workforce wellbeing' TI driver. Findings across all the Phase one activities to help understand the services' readiness to implement TIP, highlighted the importance of enhancing wellbeing initiatives that are effective, accessible and are informed by the workforce.

Wellbeing initiatives were noted to be championed and enhanced within both pathfinders during the recent COVID pandemic. However, there appeared to be a disconnect with the key workforce accessing these. The MTISG produced a driver diagram, logic model and associated change ideas that aimed to support staff wellbeing. Identified secondary drivers concluded the need for:

• Process to monitor and evaluate staff psychological wellbeing across the workforce.
• Supervision provision that enhances staff support and wellbeing
• Effective and easily accessible workforce wellbeing Initiatives
• Formalised process for staff support following a traumatic event to reduce risk of secondary trauma.
• Coaching process throughout service improvement to become Trauma Informed
• Policy/ guidelines that enhance wellbeing through the Trauma Informed Principles

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Activities commenced from the driver diagrams within the pathfinder timeline have included:

• Facilitation of workforce wellbeing drop-in sessions, allowing an anonymised platform for the workforce to feedback on their experience in accessing or receiving local area supports. Identifying most effective supervision processes, barriers and enablers to accessing support iniatitives, suggested new activities they would find helpful and an opportunity to provide new ideas.
• Embedding of their own wellbeing planning tool and Psychological First Aid, within the Maternity and Neonatal Skilled level training Programme. With reflective practice and coaching sessions to support transition of learning into practice.
• Findings from the drop-in sessions have been shared with both areas 'Supervisor of midwives', maternity senior leads and their organisational wellbeing groups to assist the development of a more efficient and effective supervision programme for their workforce.
• Development of a Peer Support Wellbeing Sub-group.

During the lifespan of the pathfinders, it had been an aim to trial the use of the 'Professional Quality of Life' (PROQOL)^[9] questionaire which assesses the impact of work-related stress on compassion satisfaction and compassion fatigue. The 5 minute validated tool, provides the participants a personal report on their risk assessed score's for compassion satisfaction, burnout and secondary traumatic stress with immediate associated self-help appendices to support the individual. This tool is thought to provide a platform for clinical leaders to obtain insight staff wellbeing and further develop appropriate support mechanisms to prevent, compassion fatigue, secondary traumatic stress, and staff burnout.

Support from NES Clinical Governance and Information sharing team have been working in collaboration with both IJB clinical governance leads on developing an agreed Data Protection Impact Assessment prior to use within the services. The PROQOL has been replicated at NES, and both boards are in agreement to trial use going forward. An internal report on learning from this process has been provided to the commissioners.

3.3 Screening, Documentation and Care Plan Implementation (Appendix E Screening Driver Diagram)

Support that helps individual recovery often comes from engagement with peers, family, communities and services. Where care providers share power and collaborate with people with LLET in developing their unique care plans, the evidence supports that this can help people's recovery through developing trusting relationships and knowing that their expertise about their life is valued. Providing a platform where individuals feel safe to share their trauma experience and are supported to develop plans that will reduce risks of re-traumatisation is beneficial. Organisations that embed TI principles throughout their care will also improve the experience for people who may not feel able to share their trauma event.

Within the timescale of the pathfinders, the MTISG have reviewed learning from the voice of those with LLET and their development of their understanding of implementation of the TI principles, to produce a driver diagram, logic model and change ideas with an aim that 'All pregnant women residing in their geographical Board, who have experienced/ or are experiencing trauma are identified and supported to develop person-centred maternity plans of care'. With recognition that midwives have embedded practice that aligns with 'Getting It Right for Every Child' (GIRFEC) and 'Child Protection' processes that involve screening for some previous traumas, the primary driver aim was for the 'Maternity and Neonatal Services workforce to have appropriate knowledge and skills to Recognise, Respond and Record women's experience of Trauma'. The identified drivers to achieve this included:

• Review of current process on screening and documentation of previous or recurring trauma
• Workforce training in NTTP skilled level Maternity Prog and Trauma screening, recording and care plan development
• Collaboration across departments, professions and specialist roles.
• Consistent approach across IJB local authority care provision.
• Alignment of trauma screening with GIRFEC an Child Protection practice.
• Collaboration with families with LLET to develop a standardised tool for screening and recording disclosed trauma and agreed person-centred plan of care

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The identification of key representatives to develop a sub-group or focus group to lead on this work included specialist roles supporting families with high incidence of trauma, public protection, community midwifery, maternity digital leads, MNPI and 3^rd sector supports such as Maternity Partnership Voice. These representatives are identifed as key roles that can identify and connect families they are supporting to participate in the development of guidance on screening, documentation and care plan development.

The timeline of the pathfinder support has not allowed progress of this area of work to date but has been recognised as a priority area over the coming year. It is anticipated that this driver will entail a great deal of commitment and resource but is an essential area of transition.