It is the Scottish Government and COSLA's ambition to have a trauma-informed and responsive workforce and services across Scotland. This ambition is supported by the National Trauma Transformation Programme (NTTP). The Programme was established in 2018 and provides accessible, evidence-based trauma training resources developed by NHS Education for Scotland (NES). The training and resources are complemented by implementation support to embed trauma informed principles in practice and organisational culture. This includes a Transforming Psychological Trauma Implementation Co-ordinator network aligned to each health board and the Improvement Service, who provide support to local authorities and key community planning partners in embedding a trauma-informed approach.
Overview of Peer Support and Learning Group Pilot in Care Homes
This project exploring Trauma-Informed Practice (TIP) in the Scottish Adult Social Care Sector aimed to determine whether a facilitated Peer Support and Learning (PSL) Group model is an acceptable and effective method of supporting implementation of TIP in residential care settings. It set out to test a PSL model as a means of enabling Care Home workers to come together in navigating common challenges associated with embedding TIP in residential care services with a view to exploring whether this model could be developed and tested in a wider sample of Adult Social Care providers in Scotland.
Six Care Homes providing for older people and people living with dementia participated in the pilot and including representation from both private/independently owned and those run by a local authority. The offer to participating Care Homes included three components:
1. Education about TIP and the implementation of TIP in practice
2. Monthly PSL Groups
3. Weekly 'drop-in' implementation support clinics
The initial component of the project involved the delivery of a three-day training programme designed and delivered by the Project Facilitators. Participants also completed NHS Education for Scotland's 'Trauma Skilled Practice' e-learning module as a pre-requisite requirement for participation in the project. This ensured that the group were commencing the educational component with a minimum level of understanding about psychological trauma and its impact.
PSL Group Component
Following completion of the educational component, monthly facilitated PSL Groups were provided for a period of six months. The purpose of the PSL Groups was to facilitate 'peers' working in the Care Home sector to come together regularly to share experiences of implementing TIP, learn from each other, work together to address common challenges or barriers, and provide peer support.
Building on the initial educational component of the project, each group included an additional focus area for further learning, including:
- Using the educational resources provided by the National Trauma Transformation Programme (NES)
- Identifying barriers and enablers to implementation of TIP using literature and models from Implementation Science
- Utilising implementation tools to support TIP
- Monitoring the implementation of TIP and integration of feedback
Project Evaluation Model
An action learning approach was considered a good fit for evaluation of this project due to its limited duration and the inclusion of action learning as a key component of the PSL Groups. The purpose of action research is to simultaneously investigate and bring about change in relation to a specific issue (Parkin, 2009). In the context of a PSL Group model, it was anticipated that participants and facilitators would contribute knowledge, skills, and experience, supporting a culture of observation and reflection regarding experiences within the group and how they may relate to the wider Adult Social Care Sector.
By the end of the pilot, three of the original six participating Care Homes successfully completed all components, however there was evidence that five of those included the study had progressed on their journey to becoming trauma informed. Examples of progress achieved as a result of involvement in the pilot include:
- Establishing a TIP stakeholder group in the Care Home to aid implementation.
- Using the Trauma-Informed Lens Tool to identify further areas of improvement.
- Conducting a training needs analysis.
- Identifying opportunities for collaboration with organisations such as Rape Crisis and Women's Aid.
- Producing an organisational Statement of Intent, endorsed by senior management.
The training component of the pilot was well received by attendees, who reflected that it was pitched at an appropriate level and met their learning needs. It was also reported that the session specifically focusing on trauma in older people and people living with dementia was valuable. The PSL Group element of the project was also reported to be a success with Care Home representatives sharing positive experiences of this component of the pilot. They reflected that the groups had been helpful in fostering connections with peers, facilitating reflection on their Trauma Informed journeys, and developing a shared learning environment, including the exploration of barriers and enablers to implementation (with people who understood the challenges of implementing TIP in a Care Home setting).
"What seemed miles away has become a reality" – Care Home Manager
Qualitative data provided evidence of progress in the implementation of TIP in all participating services/organisations. Several key findings were identified from this qualitative data that are important to take into consideration in any future training or roll out of the TIP training and PSL Groups model, including:
Following the intense pressure and increased scrutiny experienced by the Care Home sector resulting from the impact of the COVID-19 pandemic crisis, staff wellbeing was identified as a key issue in considering the implementation of TIP. This should be kept in mind when developing future interventions with this sector. Generic supervision was recognised by participants as important and should be offered by suitably trained individuals on a monthly basis.
"Staff wellbeing is central to all of this."
It was suggested that implementation of TIP in Care Homes requires involvement from those in management and leadership positions with the authority to make changes at a service or organisational level. Team leaders were considered to hold a central role in training and implementation due to the nature of their role in bridging the gap between workforce and senior management. For example, Team Leaders are often involved in decision making to support sustainable change, as well as a role in supporting the practice of the frontline workforce. This also linked with feedback regarding the importance of prioritising protected time to attend training, which may be influenced at Team Leader level.
The mode of training delivery was recognised as a potential barrier or enabler of change as remote delivery training be challenging with this sector. Access to IT equipment, creating an appropriate learning environment, and IT literacy were all acknowledged as factors to consider. This was more problematic during the pandemic crisis as staff were often attending educational sessions from home where issues relating to connectivity, caring responsibilities, and lack of control over the home environment could be problematic and likely affected levels of engagement.
Facilitators of the PSL Groups need to be knowledgeable and experienced in trauma, TIP, implementation science, and National Trauma Transformation Programme resources. The ability to hold the PSL Group space in a compassionate, non-judgemental manner is also thought to be important. Participants reported that an initial face to face meeting with facilitators would improve their experience and stressed the importance of facilitators having previous experience working with the Care Home sector.
Other factors considered important in qualitative feedback included the delivery platform for PSL groups, with Zoom appearing to be easier to access in comparison to Microsoft Teams in this pilot. It was reported that protected time for follow up implementation groups was equally as important as for training delivery and that tasks should be pre-agreed with staff in management and leadership roles. Staff from those organisations who struggled to support this within the pilot project reported feelings of frustration regarding lack of support and progress, and it was reflected that regular engagement with senior management should be prioritised for representatives in more junior roles within the organisation
Implementation packs were provided to all participants to support them in undertaking a range of tasks to support implementation of TIP. Participants reported that these packs added value and reflected that an organisational assessment proforma was particularly useful in supporting the identification and prioritisation of tasks. It was reported that hard copies of packs were preferred for ease of access and because this was felt to support tailoring of information to each individual service/ organisation.
Identifying organisations to support trauma survivors
Where relevant, early collaborative work to identify partners who can support older adults who have experienced trauma should be a priority. This worked well in one Care Home, who identified that supporting older people was a strategic priority of a third sector partner organisation (Rape Crisis). It was also felt that building relationships with partners and stakeholders was also essential in supporting signposting, for clients as well as their families, and carers.
Evaluating the implementation of TIP
Whilst the limited pilot timescales did not result in extensive implementation plans, Care Homes raised interesting change ideas relating to identification of trauma, recording of trauma within care plans within current systems, and methods of exploring monitoring and evaluation of implementation of TIP at a local level. For example, counting the number of times routine enquiry is used, how this is documented, and frequency of TIP discussion in relation to client care delivery.
"Trauma as a word is being used so much more."
Challenges and Opportunities
Support from Leadership
Management support was found to be influential in creating a sense of commitment to the implementation of TIP and creating service/organisational culture to support change. Care Home Manager involvement in the promotion and implementation of TIP was considered a critical success factor and likely contributed to the positive engagement from the wider staff group. Additionally, support for those leading TIP is recognised as crucial, and this project was identified as a key factor in providing support for colleagues taking part.
"The chief executive, she's been in touch and we're looking at the statement of intent and she's really on board and really wants to be involved and to help move this forward … It's been so important in starting the journey to have them involved and on board, it makes it clear to everyone else we've got that senior management buy in by signing the statement of intent."
Autonomy was also identified as an enabler of implementation of TIP. Learning from this pilot highlights the importance of factors such as ownership status, service size, and service delivery model are likely to influence the implementation of change within Care Homes. Additionally, modelling of good practice by experienced and well-respected staff members was considered a key factor in increasing awareness of trauma and changing staff attitudes towards distressing behaviour. However, ongoing capacity pressures and a lack of managerial involvement in the project were often cited as barriers to autonomous decision making.
Improving Knowledge of Trauma to Support Identification
Staffing capacity pressures and restrictions on education and training budgets were identified as a barrier to implementing trauma training and education within the Care Homes. Participants noted the challenge of releasing staff to attend the educational component of this project, citing unpredictable capacity due to recruitment and retention issues and sickness absence. Gaining informed consent in relation to information gathering and sharing was identified as a barrier to improved identification of trauma in Care Home residents. The combination of these two challenges makes it difficult for Care Home staff to improve their knowledge generally, as well as in relation to their specific residents.
"…once we talked to the staff and explained that a lot of her behaviours are learned behaviours with what's gone on in the past… she's been through quite a lot of trauma… we quite quickly got back on track and we've been back on track working with her family and the multidisciplinary team. I think just the staff realising about the traumas that went on have changed their attitude towards her."
"One thing is we keep saying TIP, we keep saying it, it rolls off our tongue now, you know because when we're talking about situations, because we've had quite a few of them, we stop and we go 'hold on, have we thought about why the person does this and could there be something [some underlying trauma]?'"
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