Commissioned as part of the National Trauma Transformation Programme (NTTP), the Scottish Government funded four pathfinder projects with a focus on two priority sectors: maternity and substance use services. This report presents a summary of learning from the two maternity pathfinders which were based in Forth Valley and Grampian Maternity Services. The pathfinders took place over a 15-month period from January 2022 to March 2023.
The learning report is intended to support services across Scotland to consider the opportunities and challenges of planning for, developing and implementing sustainable trauma-informed (TI) practice. A key aim of the pathfinders was to enable all staff working in maternity and neonatal services to be TI and appropriately responsive to women, individuals and families who have lived or living experience of trauma (LLET).
The pathfinder areas were provided with dedicated support from a specialist in midwifery and TI Practice, as well as support from a monitoring and evaluation specialist. The maternity pathfinders followed three key phases:
1. Understanding service context and readiness for TI Practice;
2. Improvement planning, informed by phase 1 learning;
3. Implementation of agreed priority areas.
The priority areas of transformational change within both maternity pathfinder areas were identifed as:
- Workforce development;
- Workforce wellbeing;
- Screening and documentation of disclosed trauma.
Identified activities within the pathfinders Theory of Change plan (ToC) 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. This recognised the vast transformation process required within the ToC plan and broke this down into meaningful and realistic activities. In recognition of the limited knowledge and experience in Quality Improvement (QI) within each pathfinder board, the specialist maternity TI lead and evaluation expert facilitated several in-person events to develop pathfinder teams' understanding of QI and the implementation journey, supported with the NHS Education For Scotland (NES) QI resources.
The Scottish Trauma Informed Leaders Training programme (STILT) supported leaders from the Maternity Trauma Informed Steering Group (MTISG) through access to action learning workshops and ongoing, implementation support from the Improvement Service and/or local Transforming Psychologial Trauma Implementation Co-ordinator's (TPTICs) as well as through links with Trauma Champions.
The workforce Training Needs Assessment and NTTP training plan resource guided the 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 Perinatal Mental Health, early pregnancy, public protection or substance use, requiring further assessment on their training needs.
The training programme has been developed from the six 'skilled-level' modules produced by the NTTP. 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. These combine 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 is also included. Evaluation of the programme's impact has seen a clear postive shift in the workers' confidence across all the key components of the learning. Higher positive levels of change were particlarly noted around psychological first aid, understanding the window of tolerance, producing their own wellbeing plans and the impact of trauma on mental health.
Nationally reported NHS workforce pressures, recruitment and retention of staff and their impact on both the organisations' and workforce wellbeing was evident within both maternity pathfinders. This highlighted the need for an initial focus of pathfinder support to be targeted towards the 'Workforce wellbeing' driver. The MTISG produced a driver diagram, logic model and change ideas that aimed to support staff wellbeing. Identified secondary drivers included:
- A 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;
- A formalised process of staff support following a traumatic event, reducing the risk of secondary trauma;
- Coaching process throughout service improvement to become TI;
- Policy/ guidelines that enhance wellbeing through the TI Principles.
Workforce drop-in sessions were established in the pathfinder areas. These provided an effective process to allow the key workers to have a voice on the most appropriate form of support, barriers and to identify new initiatives. This allowed the development and implementation of more accessible and effective interventions. Organisational challenges, culture and leadership have been highlighed as barriers to the workforce feeling able to access appropriate supports when required.
Identification of key staff members with a role to support their 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 settings, the pathfinder learning has suggested a need for a review and redesign of a more efficent, supportive provision which encompasses clinical supervison, reflective practice, coaching and peer support components.
Embedding the current NES wellbeing modules within training plans fosters staff engagement and provides new workforce wellbeing supports and understanding.
Screening and Documentation of Disclosed Trauma
Within the timescale of the pathfinders, the MTISG have reviewed learning from the voices of those with Lived and Living Experience of Trauma (LLET). This included developing their understanding of implementing the TI principles, and the production of a driver diagram, logic model and change ideas. This aimed to ensure:
'All pregnant women residing in their geographical board, who have experienced/ or are experiencing trauma are identified and supported to develop trauma-informed and person-centred maternity plans of care'.
Recognition that midwives have a digital platform with 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 drivers include:
A maternity and neonatal services workforce that has the appropriate knowledge and skills to recognise, respond to and record women's experience of trauma which require:
- Review of the current process on screening and documentation of previous or recurring trauma;
- Workforce trained in NTTP skilled level, maternity and neonatal training and trauma; screening, recording and care plan development;
- Collaboration across departments, professions and specialist roles;
- Consistent approach across the local authority care provision;
- Alignment of trauma screening with GIRFEC and child protection practice.
Families with a history of trauma, attending the maternity and neonatal service help inform screening, documentation and care planning which require:
- Collaboration with families with lived experience of trauma to develop a standardised tool/ process for screening;
- Guidance on how disclosed trauma is recorded;
- An agreed trauma-informed and person-centred plan of care.
The identification of key representatives to develop a focus group to lead on this work included specialist roles supporting families with high incidence of trauma, community midwifery, maternity digital leads, maternity clinical psychologists (MNPI) and 3rd 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 limited timeline of the pathfinder support has not allowed progress of this area of work to-date but this has been recognised as a priority area over the coming year. It is anticipated that this priority area will entail a great deal of commitment, collaboration and resource but is an essential area of transition. Recognition and collaboration across national 'Routine Enquiry' activity is essential in progressing this priority.
Nationally reported NHS workforce pressures, recruitment and retention of staff, and their impact on both the organisation and workforce wellbeing was evident within both maternity pathfinders, directing an initial focus of pathfinder support to be targeted towards the 'workforce wellbeing' driver with associated support activities. This provided a platform that initiated conversation, considered early change ideas embracing TI principles, while developing more accessible and effective workforce wellbeing initiatives.
Development of an implementation steering group, with representation across services and departments recognised to support families across their pregnancy, who will lead project planning, implementation and evaluation, is essential in supporting an enhanced and consistent multi-agency TIP and culture.
Existing NTTP e-learning modules and implementation supporting resources were transferrable to the maternity setting, supporting the pathfinders to develop a Maternity and Neonatal Trauma Skilled Training Programme and helping to inform improvement planning. Embedding reflective practice and coaching sessions provided the opportunity to consider, plan and implement new learning into practice, with evidence of early activity occurring.
Activities that collaborate with LLET are essential in informing implementation planning with feedback loops. pathfinder familiarisation activity identified many existing processes, from services within and who work alongside maternity services, that provide reflection on experience from families accessing the service that required connection to better inform changes required in the wider service.
It is recognised that due to the ongoing development of an NTTP Roadmap that 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. Future focus will include a deeper understanding in relation to; leadership, culture, powersharing with those with LLET and routine enquiry of trauma.
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