Developing and embedding a bespoke Trauma Informed Care clinical model

Please describe a relationship, service intervention, program implementation, policy, or other that you initiated or know about that would be considered trauma-informed:

As with most forensic services our care delivery was largely informed by the medical model and related infra-structure such as the Mental Health Act and Ministry of Justice. There was increasing frustration that this model failed to match the complexity of our service users and the knowledge staff held around the lifelong impact of trauma.

From this awareness and the service struggling as a whole we embarked on an 18month systems change process to develop and start the process of creating a service vision, clinical model and changing practice. Alongside, this work the forensic service as whole embarked on a piece of work with organisational development support to embed collective leadership.

In terms of the clinical model work, a cross section of staff met for three key sessions to surface the current clinical model, highlight the strengths and challenges of this model, create and test a new clinical model, with wider staff group and service users and plan for implementation.

 

What was the outcome?  

The diagram below is the summary emblem of our clinical model and the outcome of our work.

                        

At its heart is our service tag line “nurturing safer futures”. This is deliberately mindful not just of the safer futures for our service users but also for staff and the public. The model explicitly adopts the principles of trauma informed care at its heart, but the framing around the sides provides explicit acknowledgement of some of the tensions of applying TIC within the constraints of a forensic service. For example, working collaboratively whilst establishing safety, particularly at times of acuity, requires careful thought and can pull staff and services in different directions.

This model is not just an emblem. We are keen to put the “principles in practice” of TIC. The process of embedding the model has been key to its success and fundamentally different to how we have approached change before.

There has deliberately been no launch date, no mass training or no change of paperwork. Instead the focus has been on connecting and ensuring the model runs through the heart of everything the service does. The emphasis has been on experiential learning through existing structures and reflective spaces rather than classroom based didactic learning.

For example, our case formulations, reflective practice and supervision are all conducted through a trauma lens. All our training now has explicit connections to the impact of trauma including our risk assessment training and our induction. When all our policies are reviewed we ensure this is through a trauma lens. For example, when we reviewed our search policy, rather than agree to the initial proposal of more invasive search procedures we agreed to increase the emphasis on the relational element of searching.

Using the 10 ingredients of TIC we are developing other initiatives to strengthen the change and culture.  For example, our recruitment process has embedded the principles and  we have co-developed via our recovery college a service leaflet explaining to new service users and staff the principle of TIC and what it looks like in our service.

As a service we recognise that this is a long term journey requiring constant attention and adaption. Our next steps are to develop a trauma pathway though-out the service and with links to community provision. We are focused on developing a second level of training for our trauma champions and embedding “clinical model: making it real” groups to share good practice and challenges of implementation across the service.  We are currently analysing the results of our Proquol staff survey to develop interventions to best support staff.

Although many parts of the journey have involved co-creation, we are aware we need to increase the inclusion of service users’ perspectives and peers involvement.

 

What supported the positive outcome? (systemic supports? Organizational supports? Interpersonal supports?):

 We have achieved our change without any additional resource. It has been about using resources differently. However numerous factors have contributed to the positive outcome

• In the first instance we had external facilitation to support the group that were working on behalf of the forensic service to surface and create a clinical model. This was essential at the time given the fragility of the service.
• Focussing on engagement and process, rather than an end product.
• Managerial and leadership support.
• A group of interested and committed multi-professional staff who led the work (not owned by one discipline alone)
• Aligning the model to values and behaviours – so there was consistency throughout the service
• A passionate workforce
• Creating a model that is  flexible enough to be applied in different ways across the service without losing its core values
• Being pragmatic and acknowledging where the service is at, and working from that starting point. (the difference that makes a difference). We have not set it up as a challenge to the dominant medical model but a compliment. This is being realistic of the constraints of a forensic setting.
• Using evidence. We have assessed and collated the level of trauma in our current group of service users and related this to the theory.
• Explicitly acknowledging and including the power differentials inherent in a forensic service.

 

In what way has your example changed you, your practice or your goals?

It has further increased my knowledge, understanding and passion towards TIC.

It has demonstrated the importance of working at systems change level, rather than imposing change.

It has demonstrated what a group of passionate people can achieve.

It has demonstrated that even within a forensic service, significant change can occur.

 

Tell us more about what motivated you to bring this example to discuss:

We started from a really challenging position and have turned services around without additional resources. We want to share the process and outcome with others as good practice.

We are really proud of the work we have achieved and continue to achieve. We can see real change in our care delivery, our staff team, and we are starting to see the effects of this for our service users. For example, we have previously held a low threshold to recalling some of our community patients when they are exhibiting signs of mental distress. The intent has been to act early to minimise risks of further deterioration, but equally to reduce risks of further offending, and whilst we acknowledged and tried to minimise the distress of bringing someone into hospital against their will, this was something that was seen as inevitable, the damage to be repaired later. In recent months we have approached the situation slightly differently. Through the use of the trauma informed formulation, we have been able to respond to the early warning signs in the same timely manner, but have been able to have a different kind of conversation with some service users about their distress. In doing so, we have enhanced the relational risk management and reduced the need for admission for some of our service users. Safety has been maintained without further traumatisation. Where admission has been unavoidable, we have been able to plan and execute this differently. Whilst we have yet to formally evaluate this we have seen admissions occur for ‘high risk’ service users without the need for police involvement / restraint.

 

Whose needs are met in the example that you outline:

Different needs are met at multiple levels but are aligned throughout the system. Largely by aligning values and translating the values into shared practices and behaviours and language.

Service users are receiving more holistic care, driven by individual formulation and holistic understanding of their needs and recoveries. We are reducing the trauma caused by admission to secure environments and restrictive interventions.

Staff have a clearer and more consistent framework, knowledge base and support structures. Anecdotally they are reporting greater satisfaction and wellbeing at work (we are capturing this more formally)

MDT’s have an explicit model to refer to as an anchor to help resolve tensions and conflicts. They have a shared language and direction.

Service level – the service has a clear vision, has shared values and direction. Key targets for commissioning purposes have improved dramatically and are sustained. A trauma pathway to link care across the elements of the service is evolving.

Trust wide – the service has gone from a failing service to one consistently held up as a positive example. This is not all down to the clinical model work but alongside other service improvement work this work has been a tangible process and project to unite behind and work on.

Regional services our journey and story is gathering interest from other services who are adopting similar process.

Commissioners we are continuing to meet our commissioned and statutory requirements in regard to public protection.

 

Was there any one person or factor that was central to the success of your example and why:

The process we adopted and continue to adopt has been the main factor behind its success  coupled with a key group of passionate and committed people who have held the process over a sustained period.

 

What can you or others do to spread this good practice to colleagues and services:

We have written a paper.

We are speaking at numerous local forums.

The change in the service is being used across the trust as an example of positive change.

We are receiving many informal enquiries which we are responding too.

We are very happy to contribute to the summit!

I was reading the edited book “secure recovery” which was all about embedding the recovery model in secure settings and the tensions this creates and the adaptions required.

I was really inspired and wondered if one outcome from the summit was a set of providers coming together to create a similar edited book. If there were enough secure care providers it could have a narrow focus, however a broad focus of adapting TIC principles to different settings would be equally exciting!