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

4. Summary of Learning and Recommendations from the Maternity Pathfinders

Learning from the pathfinders has helped inform the development of an NTTP Roadmap which has been in production during the timeline of the pathfinder. The Roadmap aims to support organisations across Scotland, regardless of sector or purpose, with implementing TI change project. The Roadmap will support organisations to undertake a self-assessment to identify progress, successes and good practice, while identifying areas for improvement in their journey to embedding a TI approach. The nine key themes that the Roadmap explores are vital in creating the culture, environments and ways of working that can resist re-traumatisation and support people's resilience and recovery from trauma. Learning across these themes from the pathfinders is highlighted below.

4.1 Organisational Culture

Recommendations

Consideration should be given to addessing workforce challenges and competing agendas which may impact progression of developing both TI practice and culture through associated change activity.

Key structural challenges that should be considered as part of wider organisational culture include issues such as: protected time and resource for staff training; enhanced workforce wellbeing supports and working conditions that allow uptake of these; capacity to extend time for appointments with vulnerable service users; improving communication and information sharing across departments, agencies and care timelines and, prioritising care versus organisational needs/department activity.

Maternity services should explicitly recognise that families are supported by many professionals across their pregnancy resulting in a need for largescale culture and service change and development across professions and services to fully achieve TIP. Without commitment and representation across professions and services, implementation of change may be impacted, increasing risk of retraumatisation to families supported.The following settings/services and their associated cultures are key to the success of TIP:

• Inpatient setting
• Community Setting
• Midwifery / Obstetric Specialist Support
• Triage / lnterm care
• Neonatal setting
• Perinatal mental health and MNPI
• Health Visitors
• Scan Department

Maternity services regularly support families with a variety of trauma incidents, therefore education and learning needs will vary across these areas/specialisms and will be a part of culutral change.

4.2 Leadership

Recommendations

When progressing TIP, early engagement with key stakeholders across the pathfinder IJB, at both a strategic and operational level of leadership, 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.

Implementation groups should be supported to identify sub-groups of members from maternity workforce development, TPTIC's, specialists with trauma experience and MNPI's, who will lead on the prioritised change ideas. These members will provide feedback to the MTISG.

The following key representitives should be involved throughout all pathfinder meetings:

• Senior midwifery across departments
• Obstetrics, neonatology and anaesthetics
• Allied health professionals
• Health visiting Team Leaders
• Public protection
• Family Nurse Partnerships (FNP)
• Children and families social work services
• Perinatal / community mental health
• Addiction services
• Maternity and neonatal psychological Intervention (MNPI)
• Higher Education Institutions (HEI)
• Key 3^rd sector organisations
• TPTIC's and Trauma Champions.

Early engagement and communications would involve :

• An overview of NTTP and Maternity TI Pathfinder project aims, objectives, core elements and timeline.
• Sharing 'Organisation Window of Tolerance' and links to TI leadership and workforce.
• Establishing MTISG with appropriate representatives, Identifying routes to involve people with LLET.
• Providing a TPTIC update on local NTTP delivery activity.
• Initiating discussions around local/ national policy / strategies and links to TIP.
• Agreeing plans for multi-agency familiarisation sessions to help understand systems, structures and multi-agency working.

4.3 Staff Care Support and Wellbeing

Recommendations

Workforce wellbeing is a priority area to be addressed prior to implementation of new change ideas, embracing a TI culture that nurtures and supports its workforce, embracing the TI Principles.

Identification of key staff members with a role to support staff or colleagues and have the knowledge and experience to provide a range of supervision supports, is fundamental within the development of a sub-group to lead on workforce wellbeing change. Within maternity, various roles from supervisor of midwives, team leaders, MNPI's or Child Protection specialists have been identified.

Workforce drop-in sessions are an effective process to allow the key workers to have a voice on most appropriate form of support, barriers to access and identified new iniatitives. This will allow the development and implementation of more accessible and effective interventions. Survey fatigue and workforce engagement may present a barrier.

Embedding the NES existing workforce wellbeing modules within training plans, supports engagement of staff and provides new workforce wellbeing supports while highlights the importance of self care. Within maternity settings, the learning has suggested a need for a review and redesign of a more efficient supportive provision which encompasses clinical supervison, reflective practice, coaching and peer support components. This should be aligned with national guidance.

Organisational challenges and culture has been highlighed as a barrier to the workforce feeling able to access appropriate supports when required. Systems are required to address these barriers and help promote a nurturing, caring environment with staff who feel able to say 'its ok to not be ok' and receive the support they require.

4.4 Feedback Loops and Continuous Improvement

Recommendations

TI Implementation steering groups ideally require members with a firm understanding and experience of quality improvement (QI) and implementation science. This may be maternity specialist roles such as Maternity and Children's Quality Improvement Collaborative (MCQIC) or from their local board QI Team. Consideration on identifying a Maternity lead for the project who has QI experience or supported to complete training in QI would support and sustain the longevity of transitional change.

Embedding data measurement plans and feedback loops from the onset, which are regularly reviewed and adapted, would support the services to assess the impact of their change ideas and adapt as required.

Inclusion of the voice of those with LLET is essential when developing their ToC and change plans and their input should be encouraged/reflected on throughout the project transition journey. A TI approach that supports existing work around local priorities, with feedback loops and power sharing processes to inform what's working/ not working in our service.

Within larger organisations, ToCs can highlight the longer term transition to become TI, however recognition of the scale of change within these plans and the services ability to progress these must be addressed. Production of more 'bite size', realistic and achievable driver diagrams, individual project logic models and measurement plans support the implementation team to progress priority areas. Smaller services or departments may find action or improvement plans to be more suitable to their needs.

Development of project planning resources is more effective through in-person sessions as the process is reliant of visual tools and group working. These processes require commitment across all departments and roles to be effective. Collaboration with local area TPTIC and champions can support this work.

4.5 Power sharing with People with Lived Experience of Trauma

Recommendations

Services should aim to always provide TIP whether there is known trauma for the individual or not. It should be recognised that disclosure is not always easy for women/individuals attending maternity services.

Services require early recognition of possible high incidents of specific traumas relevant to their area of work and families using their service. Early scoping recognised that the maternity workforce can have a focused understanding of trauma linked exclusively to pregnancy or birth, such as miscarriage, loss or traumatic births. However, awareness of the psychological impact of wider single incident or complex trauma, such as ACEs or gender based violence was lacking. Workforce development to increase knowledge and understanding of these wider issues will help identify families where collaboration and feedback loops exist and can subsequently be embedded.

Multi-agency scoping sessions also highlight, that despite many partner services working alongside the maternity workforce who had embedded processes that heard the voice of those LLET, there was a disconnect to maternity services in terms of informing service change. Engagement with all key agencies is pertinent to scope existing feedback mechanisms that can be built on.

Power sharing with families with LLET is essential from the onset. Those with LLET and agencies who support them should be encouraged to work in collaboration with maternity service redesign related to their care.

4.6 Staff Knowledge, Skills, and Confidence

Recommendations

Services are encouraged to recognise key leaders within their organisation with a responsibilty to support the transition to become TI, who will attend trauma informed leaders training and supported coaching sessions in collaboration with their local TPTICs and Trauma Champions. It is recommended that key representatives are selected across the organistions departments and professions to access STILT.

A workforce TNA is required to assess accurate workforce knowledge, practice, and service provision in line with TI principles to inform appropriate training plan specific to their service. This combined with NTTP knowledge and skills framework and associated Training Plan, will guide role specific level of trauma training required. Senior members across the workforce are required to encourage the participation of all their staff in a TNA, to provide a more accurate assessment. The TNA is also a good platform for the key workforce to provide their perception on their organisations readiness to become TI by identifying enablers, barriers, leadership support structures and existing workforce health and wellbeing initiatives.

The development of a service-specific sub-group to champion and drive all workforce development activities would support more effective implementation of training requirements. This is encouraged to align with the NTTP resources and local area TPTIC. Within maternity, the pathfinders have identified a workforce development role with the newly developed Clinical Psychologist MNPI's and will be invaluable within the sub-group. Members with coaching training and experience in reflective practice facilitation would support connection to training provision, learning and impact on implementation of TIP.

When designing a training programme it is advised to be mindful of the current workforce challenges and realistic capacity for training commitments. Consider commencing training with NES wellbeing and Psychological First Aid modules, aligned with the TI principles, as this would support engagement with the service transition while providing the workforce with iniatives that will support their wellbeing.

The programme of training needs to be realistic and achievable for the organisation, particularly through the current challenging times. It is also recommended that the content is applicable to the learning needs of the service, particpants and roles. Embedding reflective practice and coaching structures that are setting specific, are vital to support transition of learning into practice that are meaningful and 'owned' by the core workforce.

Early identification of a team of trainers to facilitate the ongoing programme of training delivery is essential for sustainability. This will also allow identification of any additional training requirements they may require such as coaching. Consideration of development of a 'train the trainer' programme to develop a national cohort of champions to deliver the maternity programme nationally would support the drive and consistency across Scotland Maternity services.

Recognition that some practioners will require additional training due to their speciality and role supporting families with higher incidence of LLET is important and planning to meet their needs is essential both for the practioner and the family.

4.7 Policies and Processes

Recommendations

Consideration is required in how to effectively review policies, guidelines and processes during challenging times where organisational capacity is limited. Identifying a small team of leaders to focus and drive the process forward over a realistic and obtainable timeline would be recommended.

A focused session with the Implementation Steering group, which has representation across departments and roles, would be effective to identify key policies, guidelines and processes to be reviewed. Learning from the 'Trauma Informed Lens' event and the 'workforce drop in session' will provide further areas to be reviewed. It is essential to scope policy outwith the maternity service that can impact them such as Human Resources.

4.8 How we Design and Deliver Services

Recommendations

A TI Roadmap has been in development during the timeline of the pathfinders and will support services during their self assessment and improvement planning. As the Roadmap is being developed to be applicable across all organisations and services, it is recommended that the maternity specific resourses are used in addition within this setting.

It is important to recognise that organisational self assessment and improvement planning requires a detailed 'Phase 1' familiarisation and scoping exercise to inform their planning and attempting the implementation phase independent of these may not be as effective.

The NTTP TI Lens Event resource is a great tool for services to consider their position in providing TIP and facilitates department/ service specific change ideas meaningful to the workforce who will implement the change. These findings will aid development of their Theory of Change Model. It is recommended that the event is facilitated over a day to allow meaningful and important discussions to occur and appropriate time to develop their plans and change ideas. Given the varied pathways and timeline for families supported through their maternity journey it is essential to expand the event across professions, departments and teams. Inclusion of families with LLET, who are/ been supported by the maternity service, is paramount to help inform transition to become TI across the varied trauma experiences identified is essential.

The use of Improvement planning tools such as stakeholder analysis and communication plans, combined with early leadership communication, will support identification of key personnel to be included. Without commitment and representation across professions and services, implementation of change may be impacted, increasing risk of retraumatisation to families supported.

Consideration should be given to workforce challenges and competing agendas which may impact progression of change ideas and associated activity. Development of subject specific sub-groups should be considered to progress activities such as, workforce wellbeing and workforce development. These focused groups would drive forward the change ideas and feed back to the MTISG. Identification of senior representives across services and departments, who will feed back progress to their wider service is of benefit. Services may consider an identified role to lead on this work locally with support from a national lead expert for TIP in maternity.

Collaboration with the local TPTICs and trauma champions is recommended to learn from IJB process and support multi-agency local service development.

The review of current practice on screening and documentation of disclosed trauma is pertinent to understanding change requirements when planning practice change. Identification across the varied trauma screening questions and documentation suggests capacity is required to understand any limitations to the existing recording process eg. Badgernet, the digital platform used within maternity and neonatal services.

Development of an identified lead sub-group across departments with enhanced knowledge on the needs of families with LLET will support facilitation of the change ideas and engagement of/ collaboration with families known to the service. Within the maternity setting, it is vital that changes within documentation, multi-agency information sharing and agreed care planning align with GIRFEC and Child Protection, keeping the child at the centre.

4.9 Maternity Pathfinder Outstanding Drivers

It is recognised that due to the ongoing development of NTTP Roadmap there will be a need to update learning and align it with updated/additional drivers. The maternity pathfinders will be encouraged to assess their progress against the Roadmap when launched. Further focus will include a deeper understanding in relation to; leadership, culture, budgets and powersharing with those with LLET.

4.10 Maternity Pathfinder Key Learning Summary

Maternity Key Learning

• Phase one familiarisation activities provide a platform to evidence existing TIP, areas to be developed and aids organisational assessment and planning.
• Inclusion of all professionals, recognised to support families across their pregnancy, supports enhancement and consistency of multi-agency TIP /culture.
• An implementation steering group, with representation across services/ departments, to lead project planning implementation and evaluation is essential.
• The STILT learning programme and collaboration with local TPTIC / Champions enables service leaders to drive forward implementation of TIP.
• TNA is a good platform for the key workforce to provide their perception on their organisations readiness to become TI whilst scoping existing knowledge.
• Development of a Theory of change model to set out TIP activities with short/interim/ long term service outcomes, facilitates implementation planning.
• The Trauma Informed Lens event supports the core workforce to reflect on care provision and build meaningful plans to enhance TIP within their area of work.
• Newly developed MNPI and PMH services embrace TIP and recognised as an essential addition within maternity and neonatal services.
• The maternity 'Best Start Policy' centres 'continuity of carer' in developing maternity care and supports embedment of TIP.
• Maternity holistic booking assessment process, using GIRFEC principles, provides a good platform to build disclosure of previous or recurring trauma.
• An initial focus on development of a Workforce wellbeing driver diagram with change ideas, not only support planning and evaluation but was found to be a key catalyst to engagement towards implementation of TIP.
• Workforce wellbeing sessions were effective, allowing them to have a voice on the most appropriate form of support, identify barriers and suggest new initiatives.
• Embedding wellbeing learning/ resources within the training programme, facilitate engagement while also embedding new wellbeing initiatives for the workforce.
• Scoping allowed recognition of existing processes to hear the voice of those LLET across agencies such as FNP, 3rd Sector organisations, some specialist roles.
• Anonymised 1:1 session for families with LLET to share their experience, supports identifications of existing TIP whilst identifying areas requiring developed.
• Collaboration with families with LLET is a priority area to review existing screening of trauma, documentation and developing plans of care that are TI.
• 'Maternity and Neonatal Trauma skilled Training programme' developed from existing NTTP module is, provides knowledge across a range of topics in addition to TIP.
• Implementation science supports transition of learning into practice, with reflective learning sessions and post training monthly coaching sessions evidencing the reflection and change of practice identified.