Since 2018, the Scottish Government (SG) has committed over £1.5 million to design and deliver a National Trauma Training Programme (NTTP), led by NHS Education for Scotland (NES), which aims to develop and support a consistent, highly skilled, trauma-informed workforce across all frontline services.
Three local Delivery Trials Sites were established in Argyll and Bute, Glasgow and Midlothian during summer 2019, to test a range of approaches to implementing the delivery of high quality and sustainable trauma training in differing contexts. These trials are one of many elements of the NTTP.
This interim report presents learning from a process evaluation of the Delivery Trials Sites which aimed to explore contextual issues that contributed to successful implementation and to inform the roll out of the NTTP. The evaluation used a Theories of Change approach.
Delivery Trial Site Outputs
Each site built on previous trauma related work such as Adverse Childhood Experiences. Substantial work was undertaken across the sites to: establish multi-agency steering groups; conduct needs assessments; tailor training content; raise awareness; establish skilled internal trainers or commission training providers; agree plans to embed and sustain training; identify opportunities for participation from people with lived experience and agree monitoring and evaluation processes.
A number of barriers delayed full implementation of both the trials and the evaluation, including limited time-frames and local staffing and workload challenges. The COVID-19 pandemic prevented the delivery of all frontline workforce training and the subsequent monitoring and analysis of the impact of that training within and across sites.
Scottish Trauma Informed Leadership Training (STILT) was delivered in two sites and local roadshow sessions in three sites. These short face to face sessions were aimed at local leaders to raise awareness and achieve a shared understanding of Trauma Improved Practice (TIP) and its impact. STILT sessions aimed to highlight the benefits of culture change to embed TIP principles and secure support for frontline staff training. STILT training was positively received. Catering for varying knowledge levels from different services was challenging as was identifying the appropriate levels of leaders to target in different sites. The most senior partnership and political leaders were targeted in the second waves of training where that had not been achieved in the first wave.
Differences in approach influenced by context
Contextual issues such as geography, quality of existing partnerships and prior involvement in TIP influenced the different approaches progressed. The main variations in approaches were in relation to whether sites targeted all agencies within their Health and Social Care Partnerships (HSCPs)/Local Authority or focused on specific sectors or geographical localities. One site intended to saturate frontline services across their partnership, one targeted change in CYP’s Services and one throughout services in a specific locality within a much larger partnership.
Partnerships and third sector engagement
All areas established multi-agency implementation groups to lead the work. Faster progress was made in areas with consistent project lead officers, stable multi-agency groups and where project managers had dedicated time allocated to their role.
Third sector agencies were involved in the implementation groups in two sites. In one site some third sector partnership staff participated in the train the trainer programme and were part of an ‘in house’ training team. One site ‘commissioned’ the tailoring of content and delivery of their level 2 and 3 training from a consortium of national third sector agencies that were experienced providers of services for looked after CYP. An unanticipated issue that arose in this process was the need for consideration of, and negotiated solutions to, ownership and management of intellectual property with regard to training content, tools and approaches within the public and third sector consortium.
Leadership and culture change
Emphasising that staff value training and benefit in terms of their own experiences and responses to trauma encouraged commitment from leadership. Delivery of STILT and awareness raising led to interest and demand for input and training from other services within partnerships and/or an increased interest from, and opportunities to engage with, strategic leaders (e.g. CEOs and Elected members) to scale and spread training and TIP. Early work also raised awareness of the wider NTTP and associated tools.
Published TIP literature suggests that culture change requires additional focus beyond training and must include staff health and wellbeing actions that ensure appropriate staff support, supervision and self-care as well as policy and practice alignment. The initial prioritisation of training in the three sites meant these other elements were not as yet developed beyond what was existing practice in the trial localities.
One site suggested that services with more rigid service user rules (e.g. housing, finance, police) struggled more with aspects of culture change associated with TIP. However, these services were also ‘coming on board’ even within the short time frame of the trials.
Engagement of people with lived experience of trauma
Whilst all sites had intended that people with lived experience would be involved at a strategic level within their implementation groups the reality of achieving this was challenging. Such strategic involvement may not be the most attractive role for people with lived experience. Roles such as co-production of training content and delivery and/or supporting peer evaluation may prove more attractive and fulfilling.
One site planned to co-produce bespoke training for and with foster/kinship carers and adoptive parents. Once complete the resulting content and process should be informative for the NTTP roll out. In the other sites the most fulfilling roles for people with lived experience were still being identified and participants engaged.
Participation as a Delivery Trial Site brought additional work to partnerships and services that were already experiencing substantial work pressures. The progress achieved took substantial time and effort. Evidence suggests that achieving such organisational change takes upwards of 2 years. Embedding TIP across multiple organisations with varying purposes (e.g. health, care, education, leisure, etc.) as was the case in all three sites may take even longer.
The support via the NTTP from NES was viewed positively and STILT and e-learning resources and tools valued. Timing of the release of new content and tools when local agreements on these had already been made and ensuring that e-learning did not reduce attendance at face to face training were two areas for potential improvement.
Partnership contexts result in the need for tailored rather than overly centralised approaches.
Changes in practice and services that may have resulted post training could not be monitored given the postponement of frontline training. Relevant literature however suggests that evaluation should be integrated at the planning stage and be pragmatic and proportionate to the scale of programmes and resources. There are many existing tools and scales that can be used to enhance planning and evaluation locally and nationally. Where resources allow, further validation of these scales is needed to inform more consistent use across interventions and allow more robust analysis. This, in turn, will help inform issues such as optimum length of training course and necessary packages of interventions to maximise positive impacts on individuals, teams, partnerships, systems and people with lived experience.
The early learning from the process evaluation reinforces the conclusion from a recent systematic realist informed review which stated that:
“Five factors were instrumental in implementing trauma informed care across a spectrum of initiatives: senior leadership commitment, sufficient staff support, amplifying the voices of patients and families [people with lived experience], aligning policy and programming with trauma informed principles, and using data to help motivate change”.