Transformational Simulation for Trauma-Informed Care (TS4TIC) Implementation Toolkit Acknowledgments & Postionality Statement 02 Acknowledgement This Toolkit was supported by a grant from the Health Services Cite this document as: Abbreviations 04 Executive (HSE), the Royal College of Physicians of Ireland (RCPI) and the Health Research Board (HRB), under the Re- McGarry, S., Swords, M., Vallières, F., Ward, M. E., Shields, search Collaborative for Quality and Patient Safety (RCQPS), D., Geary, Ú., Gardner, C., Ní Cheallaigh, C., Lotty, M. (2024). reference number [RCQPS-2021-13-212629.17411]. The Transformational Simulation for Trauma-Informed Care Glossary 04 (TS4TIC) Implementation Toolkit. Published by xxx TS4TIC has been a truly collaborative project. We acknowledge all of the healthcare staff, people with lived experiences, actors For further information contact: mswords@tcd.ie or smcgarry@ and organisations who shared their valuable time, energy and stjames.ie Introduction 06 wisdom with TS4TIC. The team are indebted to the steering committee and the expert advisory group who provided guid- Published Date: TBD ance over the course of TS4TIC and during the design of this toolkit. Chapter 1 Introduction to Key Terms & 09 Concepts Underpinning TS4TIC Thank you to the members of the TS4TIC Steering Committee anc Collaborators whose invaluable feedback contributed to Positionality Statement the overall design and content of the toolkit: Prof. Una Geary, We, the authors of this toolkit, acknowledge our position as a Dr. Sharon Lambert, Ms. Joanne Dowds, Dr. Mustafa Mehmood, team composed of white Irish and Canadian people from profes- Prof. Marie E. Ward, Dr Darragh Shields, Dr. Eileen Sweeney, sional backgrounds. We consciously worked with ethnic minority Chapter 2 TS4TIC: The Planning Stage 21 Ms Sharon Slattery, Mr. Paul Merrigan, Ms. Ann Marie Lawlee, staff and actors from a range of backgrounds over the course of Mr. Alan Buckley, Mr. Paul McLoughlin, Dr. Austin O Carroll, Ms. TS4TIC and have endeavoured to represent their lived experienc- Caroline Gardner, Mr. Rory Halpin, Mr. Dermot King, Dr. Gerry es and perspectives in the content of this toolkit. Nonetheless, McCarthy, Dr. Paul Staunton, Dr. Joseph Browne, Dr. Tara Mc- we wish to acknowledge that our own backgrounds may have Chapter 3 Co-creation & Co-designing Ginty, Mr. Felicien Izaturwanaho, Ms. Aoife Dermody, Ms Nana influenced our write-up of the toolkit. 37 Wiedemann, Dr. Victoria Brazil, Dr. John Connolly, Ms. Aliza the Scenarios Ali, Dr. Meg Ryan, Ms. Muireann Murphy, Ms. Paula Quirke, Dr. Rebecca Murphy, Dr. Karl Kavanagh, Ms. Alison O’Gorman. Authors: Sinéad McGarry, Mr. Mel Swords, Prof. Frédérique Val- lières, Prof. Marie E. Ward, Dr. Darragh Shields, Prof. Úna Geary, Chapter 4 Running Simulations 41 Ms. Caroline Gardner, Prof. Clíona Ní Cheallaigh, Dr. Maria Lotty External Contributors: Dr. Ashwin Sen, Dr. Tara McGinty, Dr. Sha- ron Lambert, Dr. Austin O’ Carroll, Ms. Treasa de Paor, Dr. Austin Bayley, Ms. Caroline Gardner Chapter 5 Reflections & Learning 51 Graphic Design: Sarah Tanishka Nethan Sponsored By: The Health Research Board, the Royal College of Physicians of Ireland & the Health Service Executive Chapter 6 Measurement & Evaluation 63 Version Number: 0.0.3 ISBN: TBD Future Horizons 72 Associated Documents: Protocol paper, systematic literature review, etc Appendices 73 Further Reading 92 © Trinity Centre for Global Health & St. James’ Hospital. This work is openly licensed under CC-BY-NC-SA 4.0. References 93 Abbreviations Their heart rate and breathing slows and their muscles loosen. Thinking slows and emotions feel disconnect- ed. People often experience an almost paralysing sense of threat or dread to the point that they feel frozen or on autopilot.7 This impacts their ability to listen, engage with others, reflect or make rational decisions. Hy- poarousal is a normal biological response to feeling under threat. EAG Expert Advisory Group HSCP Health and Social Care Professional Intersectionality: Intersectionality refers to the idea that a person’s social and political identities intersect to create unique combinations of discrimination and privilege. These identities include factors such as sex, gen- PEARLS Promoting Excellence and Reflective Learning in Simulation der, religion, disability etc., which all come together to form a person’s identity, discriminating or privileging them in different ways.8 TIC Trauma-Informed Care TS Transformational Simulation Organsational Culture: Organisational Culture is the set of values, beliefs, attitudes, systems and rules that outline and influence behaviour and experiences within an organisation. TS4TIC Transformational Simulation for Trauma-Informed Care Patient Representative Group: A group of people with lived experience of using a healthcare service who share their expertise with the organisation. Person-Centred Care: Person-Centred Care aims to treat a patient as an active participant in their own care, Glossary accounting for their own individual context in a holistic way. Prebriefing: Prebriefing is a process in which instructors set out the goals and expectations of the simulation We have provided a list of terms which are commonly used throughout this toolkit: with the learners. This enhances participation and learning, minimises later complaints and disengagement, and reduces potential participant defensiveness and resentment during the simulation and debriefing. The con- Co-Production in Healthcare: Co-Production in Healthcare consists of the direct involvement of service users cept of psychological safety starts in the prebrief phase. to define the problem facing the system; to design & create the solution or intervention; and to evaluate the success of the solution or intervention.1,2,3,4 Principles of Trauma Informed Care: These are the six principles underpinning trauma-informed care approach. They include safety, trustworthiness and transparency, peer support, collaboration and mutuality, voice, choice Debriefings: Debriefings are facilitated conversations among learners and facilitators exploring the relation- and empowerment, cultural and historical and gender issues.9 ships between events, actions, thoughts, feelings and outcomes. Effective debriefings help learners make sense of events. Through reflection, debriefings encourage the transfer of learning from simulated cases to patient Psychological Safety: Psychological safety is a “a feeling (explicit or implicit) within a simulation-based activity care and wider systems. that participants are comfortable participating, speaking up, sharing thoughts, and asking for help as needed without concern for retribution or embarrassment.”10 Facilitation: Facilitation provides the structure and process to guide participants to work cohesively, compre- hend learning objectives and develop a plan to achieve desired outcomes. Psychological Trauma: Psychological trauma, also known as ‘trauma’, occurs when an individual’s ability to psychologically self-regulate is overwhelmed by a single event or series of events. It can have a long-lasting Facilitator: The facilitator is the educator that assumes responsibility and oversight for managing the entire negative impact on a person’s internal well-being, their relationships with other people, and their ability to func- simulation-based experience. tion in society. TS4TIC uses the term psychological trauma as the word ‘trauma’ is primarily associated with acute injuries in a healthcare setting.10, 11 Human-rights Approach: A Human-Rights Approach seeks to ensure that the human rights of people using service are protected, promoted and supported by staff and services.5 Reflective Practice: Reflective Practice is the ability to reflect on one’s actions so as to engage in a process of continuous learning.12 Hyperarousal: Hyperarousal is a stress response. When hyperaroused, a person feels unsafe and moves to flight/fight mode or to their ‘red zone’.6 Their stress response manifests as restlessness, tightening muscles, Quality Improvement: Quality Improvement involves the combined and unceasing efforts of everyone—health- racing thoughts, increased heart and breathing rates, aggressive posture or aggressive behaviour (fight mode) care professionals, patients and their families, researchers, funders, planners and educators to make the chang- or as attempts to leave, often at speed or in anger (flight mode).7 Hyperaroused people often find it difficult to es that will lead to better patient outcomes (health), better system performance (care) and better professional listen, to think calmly or make rational decisions. Hyperarousal is a normal biological response to feeling under development.7 This may involve giving the people closest to issues affecting care or quality the time, permis- threat. sion, skills and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.13,14 Hypoarousal: Hypoarousal is a stress response. When hypoaroused, a person feels unsafe and they move to freeze mode or to their ‘blue zone’.6 Their stress response manifests as appearing withdrawn, and feeling numb. Scenario: A scenario refers to an artificial representation of a real world event whereby a traumatised patient encounters a staff member, or vice versa. Strengths-based Approach: Strengths-based approach is a way of working which focuses on abilities, knowl- edge and capacities rather than deficits or things that are lacking. Transformative Simulation: Transformative simulation is a form of healthcare simulation which aims to directly TRAUMA AWARE improve both patient care and health systems.15 Trauma-Informed Care: Trauma-informed care is ‘a strengths based framework that is grounded in an under- standing of and responsiveness to the impact of trauma that emphasises physical, psychological and emotional safety for both providers and survivors and that creates opportunities for survivors to rebuild a sense of control and empowerment’.9, 11, 16 TRAUMA TRAUMA SENSITIVE INFORMED Introduction TRAUMA Welcome to the Transformative Simulation for Trauma-Informed Care (TS4TIC) Toolkit. This toolkit provides RESPONSIVE guidance on how to use a form of healthcare simulation, transformative simulation (TS), to introduce or explore the principles of trauma informed care (TIC) with healthcare staff. The toolkit supports healthcare organisations to use simulation to improve patient experiences and deliver quality improvements in the wider system. The toolkit is targeted at acute or community healthcare organisations of any size who are interested in using TS as a methodology to explore the principles of TIC. This toolkit will help healthcare staff and organisations to: Adapted with permission from Dr. Sharon Lambert (2024) • Understand the key terms and concepts underpinning TS4TIC such as Trauma Informed care (TIC), Trans- formative Simulation (TS), Psychological Trauma and Quality Improvement and Co-production. This graphic provides one conceptualisation of an organisation’s journey to becoming a trauma-informed or- • Understand the key resources, structures and processes required to plan and implement TS4TIC. ganisation. The National Trauma Transformation Programme17 provides more guidance and additional concep- • Measure and evaluate findings. tualisation of an organisation’s journey to becoming trauma-informed, as does SAMHSA.9 As trauma-informed • Reflect on learning care does not have a single unified definition11, there may be other conceptualisations of the organisational journey that better suit individual organisations. This toolkit provides clear signposting to additional resources relevant to the planning, implementation and evaluation of TS4TIC. Please note, this toolkit is not a roadmap in becoming a fully trauma-informed organisation. There are many conceptualisations of how organisations may become fully trauma informed. This involves entire system trans- formation, with change at every level of an organisation. Further information on this can be found here.17 INTRODUCTION TO KEY TERMS & CONCEPTS UNDERPINNING TS4TIC This chapter provides an overview of the background of TS4TIC and explains the key terms and concepts underpinning the project. It signposts readers to further relevant reading, as required. 10 | Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC | 11 Healthcare simulation replicates or plays out real life Transformative simulation (TS) is a form of health- Transformative simulations may be diagnostic in that The project developed in a large, urban Irish hospital, healthcare situations in a safe environment that aims care simulation which aims to directly improve both simulations may be used to determine what problems which serves people from communities with high to support experiential learning. Experiential learn- patient care and health systems. Where traditional exist or interventional in that simulations are used levels of social exclusion and deprivation. ing is learning through experience20. It creates new forms of simulation educate participants on new to identify potential solutions to problems, or some knowledge through: techniques or topics, transformative simulation aims combination of the two.15, 23 Hospital staff were concerned about the impact of to translate learnings from simulation to practice.15,19 psychological trauma on patients while they were in 1. Having an experience (i.e. participating or ob- hospital. Routine aspects of hospital life (i.e. sharing serving in a scenario in simulation). a ward, examination of the body, waiting for care, assistance with the activities of daily living and 2. Reflecting on that experience (in discussion after Case Example hospital rules) appeared to trigger stress responses scenario). from some patients. At times, staff members also 3. Learning from this (conceptualising learning after An Emergency Department carried out a transformative simulation to understand frontline and sys- felt stressed when interacting with these patients. simulation and discussion). tem responses to victims of domestic violence. The simulation was diagnostic as it emerged during As health care services may be re-traumatising for 4. Trying out what has been learned (applying learn- simulation that participants felt de-skilled and uncertain when they worked with a patient who had some people,11,18 staff understood that psycholog- ing in interactions with patients). experienced domestic violence. Participants also felt such work could prompt trauma responses for ical trauma might be influencing patient and staff A long established practice in healthcare settings, staff who had/were experiencing domestic violence. Simulation was interventional as through sim- experiences. The hospital team reflected on innova- simulation was traditionally used solely as an edu- ulation, potential solutions were identified. Proposed solutions included improved access to private tive ways to introduce or promote the principles of cation tool but it has since evolved to play a role in space, the introduction of a departmental policy, the provision of additional education and further trauma-informed care to improve outcomes for both improving quality and patient safety. simulations. Increased promotion of the employee assistance programme and education on trauma patients and staff. responses were also recommended to support staff. TS4TIC is aware that adult learners have an abun- Transformative simulation15,19 was identified as a po- dance of prior life and work experience that can tentially suitable and novel methodology to promote inspire learning.21 When people have time and space This toolkit provides guidance on preparing, facilitat- psychological trauma does not necessarily convey the principles of TIC. Funding was secured for this to reflect, their ability to develop the way they think ing and learning for and from transformative simula- the broader ecological, socio-economic, cultural, research project. TS4TIC explored whether simulation about things may improve. This allows learners to tion. historical and additional psychosocial factors asso- could improve care for patients with experiences of be more inclusive, reflective, integrate experiences ciated with trauma experiences. Attention was paid psychological trauma and provide feedback to im- and plan actions. This helps in the acquisition of new therefore to highlighting these factors with all stake- prove responses to this patient population at organi- knowledge, skills and competence and self- holders in TS4TIC. sational level. This toolkit is the output of this project confidence.22 and is designed to support other organisations to Trauma can be ‘defined as when an event, or series For the purpose of TS4TIC therefore, Psychological consider how transformative simulation may be used of events, overwhelms an individual’s capacity to Trauma is the lasting harm someone experiences as a within their own systems to introduce or promote the psychologically self-regulate and can negatively af- result of exposure to and experience of, single or mul- principles of TIC. fect the individual’s internal well-being, interpersonal tiple events that overwhelm their capacity to psycho- relationships, and functioning in society’.11 As TIC is logically self-regulate.9, 11, 24 It can be understood as a new and emerging field, there is little consensus ‘the results from an event, series of events, or set of around how to conceptualise and define trauma. A circumstances that is experienced by an individual as number of definitions ranging from more medicalised physically or emotionally harmful or life threatening definitions to broader definitions encompassing the and that has lasting adverse effects on the individ- cultural, historical and psychosocial reality of psy- ual’s functioning and mental, physical, social, emo- chological trauma.11 tional, or spiritual well-being.’9 TS4TIC found that use of the term ‘trauma’ was con- Psychological trauma can arise as a result of expo- fusing in an acute hospital setting, where it is more sure to and experience of: commonly associated with acute clinical injuries. The term ‘psychological trauma’ was subsequently adopt 1. Acute single events: These include house fire, ed in the project to make the term more accessible to mugging, sexual or physical assault, birth or med- Adapted from Kolb20 healthcare staff. TS4TIC recognised that the term ical trauma, car accident, etc. 12 | Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC | 13 2. Complex Trauma: Repeated incidents of the same The Impact of Childhood Adversity trusting or regulated. This increases their risk of now remains activated, long after the threat has traumatic event such as domestic violence, abuse, lasting psychological trauma. Please read more about passed. This leaves the body in a state of hypervig- bullying, homelessness, living in a warzone. This At population level, research shows an association trauma linked to adverse experiences in childhood ilance with an overly heightened sense of danger. is also known as complex trauma.25,26 between exposure to some adverse childhood expe- here. These trauma experiences have shaped the person’s riences and poorer outcomes in physical and mental nervous system, to remain on guard. Developmental trauma is a form of complex trauma wellbeing in adulthood.31, 32 This research is not diag- The Neurobiology of Stress which occurs in childhood.27 Children experience nostic nor is it predictive at individual level. In other Studies show that up to 70% of adults report expe- trauma when they are not adequately protected or words, it does not mean that children who experience Research shows trauma experiences can be passed riences of psychological trauma.36 It is important cared for. The child’s parents/guardian may have their adverse events will necessarily have poorer outcomes on from one generation to next.33,34 Neuroscience has to be aware that any person in a healthcare setting own trauma experiences and their coping skills (i.e. later in life. also demonstrated a link between exposure to trauma may have living or lived experience of psychological use of alcohol or drugs, being physically or emotion- and a negative impact on brain development.35 trauma. This includes patients, visitors and staff. ally unavailable) can cause harm to the child.26, 27 Many children have protective factors which act as a buffer allowing them to overcome traumatic events Exposure to a traumatic event naturally triggers the Childhood experiences that may lead to complex without experiencing lasting harm. Along with other nervous system into ‘fight’, ‘flight’ or ‘freeze’ mode, trauma include physical, emotional, sexual abuse positive childhood experiences, one vital protective an appropriate and healthy survival response in the or neglect, bullying, exposure to violence, untreated factor is a nurturing, supportive, loving relationship face of imminent danger (i.e., during an assault/living addiction, untreated mental health conditions in one’s with a parent or main caregiver, who is responsive to in a war zone)7, 9. People with adequate protective home or community, forced adoption practices, living the child’s needs. Conversely, the absence of protec- factors in their lives often withstand and overcome through a war/conflict, poverty, homelessness, being tive factors, especially the absence of a consistent, exposure to trauma. For others, trauma experiences a refugee and/or experiencing discrimination based responsive, loving adult in the child’s life significantly can profoundly alter the nervous system. The re- on age, race, disability or gender.26, 27 impacts the child’s ability to feel safe, connected, sponse of the person’s nervous system which initially served them well in face of the traumatic event(s), Complex trauma in adulthood can occur when adults experience violence, physical, sexual, emotional, ver- bal and financial abuse or experience events such as civil unrest, war trauma or genocide, refugee and asy- Summary lum seeker trauma, sexual exploitation and trafficking or trauma associated with healthcare experiences.26, There is evidence trauma can be transmitted from one generation to the next. At any 27 Racial trauma28, 29, marginalisation, oppression of stage in the life course, people can develop psychological trauma as a result of expo- human rights, discrimination based on age, gender or sure to and experience of single or repeat traumatic events. Trauma is a unique and disability are all forms of complex trauma which can individual experience. Positive or adverse childhood experiences can contribute to be experienced across the life-course. how someone experiences and recovers from exposure to traumatic events. Traumat- ic experiences can, in certain circumstances, alter or impact brain development and Vicarious Traumatisation refers to the impact of nervous system responses. Patients, staff and visitors in a health care setting may secondary trauma experienced by professionals or have living or lived experience of psychological trauma. volunteers who work with traumatised people.28,30 It is a common phenomenon in healthcare, the criminal justice system, emergency services, child protection and other sectors, resulting from exposure to trau- matic or traumatising material.27 Many people with psychological trauma may have sponse.7 These are illustrated as red zone responses Our understanding of psychological trauma is little awareness of how their experience of trauma (hyperarousal) or blue zone responses (hypoarousal) grounded in the research related to: impacts their present day experiences. Healthcare in the thermometer of regulation6 shown below. staff may have a low level of understanding of the 1. Childhood adversity impact of trauma on patients and in their own lives. 2. Neurobiology of stress Psychological trauma can manifest itself as two stress responses - a hyperarousal or hypoarousal re- 14 | Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC | 15 We all move between our green, blue and red zones. 2. A colleague interrupting/talking over another staff member may trigger a stress response for a staff Thermometer of Regulation When a person is hyperaroused, they are in flight or member who was bullied and silenced in school. fight mode, illustrated by moving into the red zone in this diagram. In the “red zone”, people feel physical- 3. Loud noises may trigger a stress response for ly and psychologically unsafe. Their stress response someone who grew up/or lives in a violent house manifests as restlessness, tightening muscles, racing hold. thoughts, increased heart and breathing rates, aggres- sive posture or aggressive behaviour (fight mode) or RED ZONE People with psychological trauma are more easi- 4. Examination of one’s body - for any survivor of as attempts to leave, often at speed or in anger (flight ly triggered from green into blue or red zones and physical or sexual abuse, or neglect, physical mode). People in the “red zone” find it difficult to listen, to think calmly or make rational decisions. Hyperarousal slower to return to the green zone once aroused. examinations can prompt stress responses. or the red zone is a normal biological response to feel- Such triggers may include factors in the physical ing under threat. environment, interactions with other people, smells, 5. An exhausted staff member experiencing vicari sounds or memories. People living with psychological ous trauma may experience a stress response trauma, therefore, often have a very limited sense of when an anxious patient continues to call for embodied safety - the experience of feeling at ease assistance with what the staff member perceives and physically safe in your own body. to be non-urgent issues. People function best in the green zone, a state of normal arousal, where they feel physically safe, calm, connect- Operating regularly from the blue or red zones im- 6. A Black woman, aware that Black women often ed and focused.6, 7 In the green zone, people have the pacts our ability to regulate, or balance, our emotions receive less pain relief post labour37 may experi- GREEN ZONE capacity to regulate their emotions and behaviours, can and behaviours and limiting our ability to use our ence a stress response when she feels her pain use their higher brain functions to make rational deci- higher functions of our brains to think clearly and in a levels are being ignored or minimised by staff. sions, feel able to listen, to reflect, to engage with others calm way, to develop positive relationships with oth- and make sense of their experiences. Some people with ers or to consider the perspective of others and cope Trauma is a unique and individual experience. People psychological trauma may have limited capacity to op- with the situations in which we find ourselves. may be exposed to the same traumatic event and erate from the green zone compared to people who have may have different reactions, this may be explained not experienced trauma. This means they feel threat- The hospital environment can be unintentionally trig- through epigenetics, early or later childhood experi- ened more easily and enter their red (hyperarousal) or gering for patients, staff or visitors: ences. Both exposure to and the experience following blue zones (hypoarousal) much more rapidly.6, 7, 9 a traumatic event may shape the short and long term 1. Waiting and uncertainty are often part of patients’ stress responses of the person. experience - i.e. waiting for team, waiting for test results etc. may trigger a stress response for someone who was neglected as a child & lived When a person’s response is hypoaroused, they may with high levels of uncertainty, i.e. uncertain as to BLUE ZONE appear to be in freeze mode, illustrated as moving into when they would be fed, clothed, washed, brought the blue zone in this diagram. In the blue zone, people to school etc. also feel unsafe. Their stress response manifests as appearing withdrawn and feeling numb. Their heart rate and breathing slows and muscles loosen as the body Case Example moves into shutdown. Thinking slows and emotions feel disconnected. People may experience an almost Amir and Ben are seven year old boys. Their parents are close friends. The boys’ mothers are killed paralysing sense of threat or dread to the point that they in a road traffic accident while driving together to collect the boys from school. Both boys are deep- Materials from the CPD Certificate in feel frozen or on autopilot. This impacts their ability ly traumatised. Amir has a strong supportive family. He is supported to share his feelings in an age Trauma-informed Care: Practice and Theory, to listen, engage with others, reflect or make rational appropriate way. Amir has a strong attachment with his father and other family members and while University College Cork (Copyright © 2022 Dr decisions. Hypoarousal or being the blue zone is also a he continues to grieve, over time, he adjusts to life without his mother and continues to feel safe and Maria Lotty) normal biological response to feeling under threat. loved. Ben lives alone with his father who finds it very difficult to speak about the loss of his wife. (Adapted with permission from Maria There is silence in the house around her death. Ben’s father drinks heavily and is often absent from Lotty6) 16 | Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC | 17 Trauma Informed Care Approach is underpinned by six key principles: the family home. Ben is often left to fend for himself. He struggles to understand the finality of his mother’s death, the loss of her love and routine. Ben often feels unsafe, unloved and overwhelmed 1. Safety with responsibility. As he copes, Ben often feels angry with his father and others. He is unsure why Quality improvement involves the combined efforts this is the case. of everyone—healthcare professionals, patients and 2. Trustworthiness and Transparency their families, researchers, payers, planners and ed- Who might be more likely to struggle to remain in the green zone as a result of their traumatic expe- ucators—to make the changes that will lead to better 3. Peer Support rience? Amir or Ben? patient outcomes, better system performance (care) and better professional development.7 It is about giv- 4. Collaboration and Mutuality ing the people closest to issues affecting care quality the time, permission, skills and resources they need 5. Voice, Choice and Empowerment Participation in simulation helps staff recognise when psychological trauma. It also improves staff skills to solve them. It involves a systematic and coordi- patients are in the red or blue zone. In simulation, the and collaboration, decreases the use of restraint and nated approach to solving a problem using specific 6. Cultural, Historical and Gender issues facilitator prompts staff to reflect on best responses seclusion and reduces prevalence of drug and alcohol methods and tools with the aim of bringing about a to support a patient who is presenting as in the red use among people with psychological trauma.38, 39 zone or in the blue zone. Interactions involve both patients and staff. Simulation supports staff to reflect on which zone of the emotional thermometer they are operating from themselves. Staff consider how this may impact their responses and experiences and how it may impact the response and experience of the patient. Trauma-informed care (TIC) is a new and emerging field. It is an approach that has been influenced by 1) growing understanding of the impact of psychologi- cal trauma on brain development and stress respons- es, 2) an increased awareness of the harmful impli- cations of psychological trauma across the lifespan, and 3) a recognition of the need for organisations to respond in effective ways. TS4TIC defines TIC as ‘a strengths based framework that is grounded in an understanding of and respon- siveness to the impact of trauma that emphasises physical, psychological and emotional safety for both providers and survivors and that creates op- portunities for survivors to rebuild a sense of control and empowerment’9. It is important to note that TIC is an emerging field and there is not a single unified definition of what trauma-informed care entails11. In healthcare, research shows that organisational inter- ventions to promote the delivery of trauma-informed healthcare can support wellbeing among people with 18 | Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC Chapter 1: Introduction to Key Terms & Concepts Underpinning TS4TIC | 19 measurable improvement.’13, 14 Collating the findings from PDSA cycles throughout the project identified areas of learning and ensured Focusing on supporting safe, effective, caring, re- that this learning informed further project develop- sponsive, person centred care in well governed, sus- ment within the pilot site. tainable and equitable systems, Quality improvement places equal emphasis on partnership approaches with people and communities. Simulation offers an innovative way to improve the quality of care de- livered to individual patients and provide feedback which may improve the quality of system responses Co-production refers to consulting, including and to this patient population. For further information, involving people who use and work in services from please see further resources here. the start to the end of any project that affects them.1, 2, 3, 4 It places all people affected by a project at the Using Plan, Do, Study, Act centre of the process and ensures their inclusion in (PDSA) Cycles: all aspects of it. Co-production lies at the heart of TS4TIC. Collabo- ration is a principle underpinning TIC and the TS4TIC team worked collaboratively with people who use TS4TIC used the Institute for Healthcare Improve- and deliver services throughout the project. This ment’s Model for Improvement40 as part of our quality included collaborating with staff and patients around improvement methodology. The use of Plan, Do, co-designing scenarios, implementing and adapting Study, Act cycles. The Plan-Do-Study-Act (PDSA) simulations, measuring and evaluating progress, Worksheet is a helpful quality improvement tool for feeding back into the system and planning future documenting a test of change. PDSA cycles test progress. Co-production was an integral component change by developing a plan to test the change of the project and a vital ingredient in the success of (Plan), carrying out the test (Do), observing and TS4TIC. learning from the consequences (Study), and deter- mining what modifications should be made to the test For further guidance on using co-production, please Adapted with permission from NHS England41 under the Open Government License (Act). See the sample PDSA cycle below. use this resource. Table 1. Sample PDSA Cycle Cycle Objective Plan Do Study Act Summary 1 To engage a We sought We offered We attracted In order to run cost-ef- broad range of to maximise spontaneous interest from a fective simulations, we This chapter provides an overview of the key terms and concepts underpinning TS4TIC. At the end of staff on a busy opportunities for in-situ simula- wide variety of switched to using pro- this chapter organisations will be familiar with some information related to: ward in simula- as broad a range tions to ward staff groups but tected teaching time tion of ward staff as staff during their lack of protected to increase participant • The role transformative simulation plays in healthcare possible working day time to attend numbers. While this simulation pre- increased participa- • Key concepts, the origins and stress responses associated with psychological trauma vented partici- tion, we lost the ability pation for many. to recruit as broad a • Key concepts and principles of trauma informed care range of staff as we had during sponta- • Key concepts associated with Quality Improvement and PDSA cycles relevant to TS4TIC neous simulation. We considered alternative • The importance of co-production in TS4TIC means of recruitment for these groups. TS4TIC: THE PLANNING STAGE Key Individuals: Key Activities: Project Lead • Identification of Project Lead Expert Advisory • Creation of EAG Group • Recruitment of Facilitator, Actor(s), Trainers Trainers, and Champions Please keep an eye out for icons signifying various actors across different stages of the programme. 22 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 23 existing simulation programmes, TIC expertise, or Table 2. Key Milestones of TS4TIC’s Implementation organisational characteristics (i.e. culture) which enable the rapid delivery of TS4TIC across their entire Before Simulation (Key Mile- During Simulation (Key Milestones) After Simulation (Key Milestones) This chapter outlines the steps required to introduce service. Other organisations may have far less re- stones) and develop TS4TIC in a health care setting. It high- sources, or barriers within their organisational culture • Consider costing • Promote simulation with all • Use agreed measurement and lights the resources, knowledge, culture, leadership and may decide to ‘start small’ in an individual de- relevant stakeholders in the evaluation tools. engagement, preparatory and planning work which partment. It is important to note that the implemen- • Appoint Key Roles organisation. are required to support the implementation and eval- tation and evaluation and time it takes to implement • Use learning and reflection to uation of TS4TIC. TS4TIC will vary from site to site. This chapter will • Identify and invest in training • Run SImulations, use measure- improve simulation (i.e. refine support organisations to estimate a timeline for their as required ment and evaluation tools if scenario, seek mentorship This chapter sets out the structures and supports service. The timeline for TS4TIC is shared in Appen- relevant. around challenging aspects of required to support the implementation and delivery dix A, with key milestones in Table 2. • Establish EAG facilitation. of TS4TIC. Some organisations may already have • Seek feedback from participants • Agree any Measurement & around • Use agreed pathways to dis- Evaluation tools which will be seminate quality improvement used • effectiveness of scenario and re- recommendations from sim to ‘Starting Small’ Case Example flections on what worked about key stakeholders in a timely • Select area to pilot simula- sim experience and what might way. A GP/Physician introduces simulation in the reception area of the service, focusing on responding to tions improve it. patients with hyperaroused or red zone responses. The team plan two simulations. This results in im- • Use co-production with all rel- proved patient care delivered by reception staff and leads to system change (e.g., changing signage, • Prioritise co-production • Record and reflect on learning evant stakeholders to develop providing more comfortable seating, in waiting room, etc). from simulation any quality recommendations • Agree pathway for dissem- raised in simulation. ination of information from • Address any red flag concerns, simulation back to relevant i.e., breach of psychological TS4TIC Milestone Timeline stakeholders safety • Co-design scenarios • Plan Logistics for simulation • Build relationships to pro- mote TS4TIC across service An Expert Advisory Group with at least 1-2 members with experience of TS4TIC to sup- port the implementation and sustainability Successful implementation of TS4TIC requires dedi- of the project (i.e., the ‘Expert Advisory cated resources and structures. Organisations inter- Group’). ested in implementing TS4TIC should resource: A trained simulation facilitator who will be A named Project Lead with dedicated time responsible for leading the simulations (i.e., to develop, implement and sustain TS4TIC the ‘Facilitator’) (i.e., the ‘Project Lead’) Individuals who are willing to play the role of patients with psychological trauma (i.e., the ‘Actors’) 24 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 25 Individuals who have an interest in TS or Dedicated staff time to participate in sented in co-design, including frontline staff and • Record and reflect on iterative learning while TIC and who are willing to act as advocates simulation workshops. and people who use healthcare services. running simulations. for this approach within the organisation (i.e., the ‘Champions’) An individual may carry out more than one role, i.e. in • Work with the EAG to ensure that simulation sce- When Learning from Simulations, the Project Lead TS4TIC, the Project Lead also served as Facilitator. narios are realistic and representative of learning should: In-house trainers (i.e., the ‘Trainers’) during the preparation phase. • Work with the Expert Advisory Group to ensure Access to appropriate education and train- • Record and reflect on iterative learning during the successful implementation and development of ing as required by the Project Lead, Facili- co-design stage. TS4TIC. tators, Actors, and Project Champions. When Running Simulations, the Project Lead should: • Keep records of observations and suggestions arising out of simulation to ensure feedback is • Support facilitator/actor development and perfor- looped back into the system. mance (remember the Project Lead may also be the facilitator). • Carry out relevant evaluation/research. • Promote the project across departments to en- • Reflect on collated iterative learning and share The Project Lead manages the development and implementation of TS4TIC. Ideally the Proj- courage participation. with relevant stakeholders. ect Lead will be familiar with organisational culture and structures, with a good understanding of TIC and TS. As both TIC and TS are new and emerging fields, time may be required at the • Attend to any issues arising from simulation (i.e. Other General Responsibilities: outset for a Project Lead to develop skills, knowledge, and access further training. At all stag- strengthening psychological safety, environmen- es of the project the Project Lead must promote the importance of co-creation and co-pro- tal factors, etc). • Organising logistics to support the project. duction between all relevant stakeholders. This practice lies at the heart of TS4TIC. When Preparing for Simulation, the Project Lead • Record and reflect on iterative learning during the should: preparation stage. • Develop their skill and knowledge set in TS and • Identify and agree key indicators to measure The Expert Advisory Group (EAG) is designed to provide guidance to support the develop- TIC. TS4TIC’s success - see the Compendium of Indi- ment and implementation of TS4TIC within the organisation. Remember an EAG is simply a cators in Appendix F for a list of potential indica- gathering of people with the right expertise to steer and guide TS4TIC in an organisation. In • Learn of any current use/knowledge of simulation tors for measurement & evaluation. smaller organisations, one or two members may be sufficient to develop the project, once and trauma -informed care within the organisa- members are aware of when to seek additional expertise if required, even on an ad-hoc tion. • Ensure that clear ‘feedback loops’ to the wider basis. system are agreed to ensure learning and quality • Promote the concept and benefits of TS4TIC as a improvement recommendations from simulations quality improvement project to the organisation. are fed back to all relevant stakeholders in the organisation. • Use or adapt tools (such as SAMHSA’s guidance Sample EAG creation in a small healthcare organisation: for implementing a trauma-informed approach)3 During Co-Design stage, the Project lead should: to map existing strengths in the organisation As a dentist, Ada is concerned that patients who have been sexually abused may experience trauma reactions which align with TIC. Develop and maintain relationships with leaders and during dental treatment. Ada is a trained Facilitator and plans to introduce TS4TIC to improve responses to champions of similar programmes within or outside patients with psychological trauma. She organises a small EAG from within her practice, composed of two • Build relationships across the organisation, rang- of their organisation which align with the principles of dentists, one dental nurse and a receptionist. Ada speaks to a TIC expert in a local university who provides ing from management to frontline workers, in or- TIC. advice on TIC skill development. This expert agrees to act as a remote ad-hoc advisory member of EAG and act der to secure support and ‘buy in’ for the project. as Co-Facilitator on the day of simulation. A colleague in another practice with Quality Improvement expertise • Ensure that all relevant stakeholders are repre- agrees to join EAG. 26 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 27 In larger organisations, the EAG should where possi- • Provision of a physical environment for reflection ble, consist of representatives from executive man- and feedback with and to the Project Lead. agement, medical, nursing and health and social care professional (HSCP) education, along with experts • Recommending any additional measures, re- in transformative or healthcare simulation, quality sources, expertise, etc required to successfully improvement, organisational change, TIC, frontline implement the project. practice, project champions and people with lived The facilitator assumes responsibility and oversight for managing the entire simula- experience of using the services. Attention should • Ensuring that feedback and learning from TS4TIC tion-based experience, including leading the prebrief, simulation and guided discussion in be paid to maximise opportunities for diversity in is effectively directed to and shared at relevant the debriefing stage. Psychological safety underpins successful simulations and the facilita- EAG membership. It should, ideally, include external levels to inform system change. tor plays a vital role in supporting the safety of participants. expertise. Just as smaller organisations may use external experts to access all relevant skills, larger • Linking the project with similar efforts in other Facilitation requires a distinct skillset. Facilitators ‘must have the education, skills and ability organisations should proactively seek external rep- sites within and outside of the organisation, and to guide, support and seek out ways to assist participants in achieving outcomes.’42, 43 resentation on EAG. External expertise brings a ‘fresh at a national level to key stakeholders (e.g. in a lens’ and increases the likelihood that organisational primary care service, links with national primary Training courses and conceptual models exist to support approaches to facilitation and de- blind spots are identified and addressed. care networks) to share learning. briefing. It is crucial that facilitators have specific training and access to mentorship. While there are a variety of facilitation methods available, for the purpose of consistency, TS4TIC At any stage, the EAG may seek additional expertise used the PEARLS (Promoting Excellence and Reflective Learning in Simulation) framework to support their work. model of facilitation (See Appendix B).44 Access to a content expert in TIC should also be available along with additional TIC training for facilitators, if required. The TS4TIC team Key Responsibilities of the EAG include: accessed both onsite and remote TIC expertise. • Provision of expertise which supports the or- Depending on experience, facilitators may have novice, competent or proficient facilitation ganisation to effectively implement and sustain skills and will require appropriate support and mentorship relevant to their level of exper- TS4TIC. tise.43 All facilitators should engage in continuous professional development, reflection and assessment of their facilitation skills. • Governance of TS4TIC and ensuring TS4TIC’s alignment with the strategic objectives of the When selecting staff members for facilitation training, consider staff with relevant content organisation. knowledge and an understanding of reflective practice. Ensure mentorship support is in place.43, 45 Mentorship can be provided by skilled facilitators in or outside of the organisation. EAG Composition The facilitator must have strong interpersonal and communication skills. At the outset of TS4TIC, the role of facilitator was initially designed for a nurse. Ultimately a medical social worker was recruited as facilitator and reflective social work skills proved valuable. It is useful for organisations to broadly consider the transferable skills and experiences from a variety of professions which may prove useful in the facilitation role. The facilitator should be afforded the opportunity to observe any simulations available in the organisation. The facilitator may choose to run the simulation with a co-facilitator. Care should be taken to ensure each facilitator is aware of best practice in co-facilitation.46 28 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 29 Responsibilities of the Facilitator: • Manages all logistics associated with simulation. • Sets the conditions for and supports participants’ in playing the role of actor. It is preferable to use staff actors in an area or department outside psychological safety and provides a safe space of their usual place of employment in order to enhance the realism of simulation. This may be for participants to speak freely throughout simu- more challenging in a smaller service - consider, over time, developing a staff actor network lation. with other organisations. Actors require a support structure if any aspects of simulation prove distressing - usually provided through the facilitator, with access to all relevant supports in an • Facilitates introduction (prebrief), facilitates sim- organisation. ulation, and provides debrief (guided discussion after facilitation). TS4TIC used professional actors with lived experience of trauma which proved very powerful in simulation. This could be replicated in other locations, i.e. by working with a trauma-informed • In debrief, the facilitator supports participants to organisation to develop a pool of actors with lived experience. critically reflect on the events of simulation and in TS4TIC simulations and supports participants to consider how simulation can both improve their delivery of patient care and inform system Responsibilities of the Actor: change. • To work with the facilitator to select and prepare • Collates and reflects on practitioner and system for an appropriate role to play in simulation. learning and uses agreed feedback loops to feed relevant information back to the system. • To engage in debrief, providing the trauma history of the patient character and to reflect on actor experience as required. In simulation, actors play the role of patients with experiences of psychological trauma. Depending on the resources of an organisation, paid professional actors may be used, or Many organisations may have champions of simulation or TIC among their staff. These champi- staff members may be trained to play the patient role. See Appendix C for guidance on sup- ons are staff who may/may not hold a key decision-making role, but may influence the successful porting staff members to play actors. implementation of TS4TIC. Typically, such champions are staff members who are skilled in the delivery of person centred care, who value human-rights approaches, and are well regarded with- All actors, whether professional or staff, must complete some training in TIC prior to simula- in their teams. tion. All actors must have knowledge of: 1. Psychological trauma - what it is, how it arises. 2. Common stress responses of people with psychological trauma. 3. What helps and hinders someone in the red/blue zone to return to the green zone. Responsibilities of the Champions: • To positively influence engagement in simulation and organisational feedback loops. Actors also require ongoing support around how to tailor a performance to maximise the ob- • To promote and support the work of TS4TIC. jective of each individual simulation. If staff actors are used, ideally they should have experi- • To champion trauma-informed principles after ence and skills working with patients with psychological trauma, and a genuine interest • To form part of a TS4TIC Champion community in simulation in frontline practice and at systems the service. level. 30 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 31 • To support their colleagues’ psychological safety 1. Role of organisational culture and their own by encouraging other participants 2. Importance of ‘feedback loops’ to speak up, to share their thoughts and to ask for 3. Working with Leaders help with simulation in a non-judgemental way. Developing internal expertise to deliver regular training will make implementing TS4TIC more sustainable in the long term. While organisations may initially use external expertise, it is rec- Where to Start? ommended to invest in in-house trainers. Trainers should ideally represent different profession- al groups, ranging from administrative and security staff to healthcare assistants and clinical From the outset, it is important to consider where staff. TS4TIC ‘fits’ within an organisation. For some or- ganisations, TS4TIC may represent the first time that Trainers must have education in and knowledge of TIC approaches and TIC practice. If they are transformative simulation has been used for or that Organisational Culture plays a pivotal role in the involved in simulation facilitation, they should have specific facilitation training and access the principles of TIC are introduced. For others, it may success of TS4TIC. Organisations are often unaware to mentorship. Investment in high quality, accredited training is always the optimum choice. be one of many existing tools used to raise aware- of barriers within their own culture which may inhibit Accredited remote training was provided through this programme to the facilitator in the pilot ness and promote knowledge, as part of a broader and limit the efficacy of trauma-informed projects TS4TIC project. Additional information on training standards can be found here. strategy related to the delivery of innovative educa- like TS4TIC. Similarly organisations may be unaware tion methods or TIC. of their existing strengths and practices that already align with the principles of TIC. The introduction of Along with dedicated resources and roles already TS4TIC affords organisations a rare opportunity to pause and reflect. TS4TIC considers how existing Responsibilities of the Trainers: • To share expertise with relevant persons, i.e., outlined, there are key ingredients in the preparation culture can hinder or support their work with patients EAG, project lead, facilitator, actors, etc. stage for the successful implementation of TS4TIC in • To provide education in TIC approaches and TIC every organisation. These ingredients include under- who have experiences of psychological trauma. practice and support TIC projects (as content • To support and promote TIC research in organisa- standing of the: expert) in the hospital. tion. • To provide guidance and support around scenario design, simulation planning, simulation activity. Trauma Organised Culture Trauma Informed Culture Some organisations may become aware that TIC projects like TS4TIC thrive in trauma-in- they are trauma organised systems. Trau- formed organisational cultures. Trauma-in- ma-organised systems are crisis-driven - they formed organisations are reflective, transparent are reactive, rather than reflective. They are and collaborative. In such organisations, the characterised by having fragmented and siloed six principles of TIC; (explored in simulation in Simulation participants should reflect staff groups working in organisations. All members of services, authoritarian leadership, low lev- TS4TIC) safety, trustworthiness and transpar- organisations, regardless of role/grade should be invited to participate. The Project Lead should els of psychological safety and high levels of ency, peer support, empowerment, collabora- be clear at outset that a staff mix is essential to support successful simulation. Learning and interpersonal conflict, and their staff are often tion and cultural sensitivity are also embedded reflection is significantly enhanced by a mix of staff grades, roles and experiences. The original overwhelmed and numbed to their work. Such in organisational culture. These principles are TS4TIC simulations had participants from administration, catering, nursing, medicine, health care organisations often ignore or are uncomfortable clearly evident in the governance and leader- assistants, security, health and social care professionals, healthcare managers and other groups. addressing racial and other disparities. Trauma ship, policies, and physical environment of the organised systems are in a state of organisa- organisation. They are visible in the service’s tional hyperarousal and are challenging places engagement and involvement with people with to manage, to work in and to receive care in. lived experience of trauma, cross sector collab- Responsibilities of the Participants: simulation, and to provide feedback on how real- Such organisations struggle to support patients oration, screening, assessment and treatment of istic simulations are. and staff with experiences of psychological patients or service users, training and workforce • To participate in co-design. trauma and without culture change are less development, progress, monitoring and quality • To engage in simulations and in the debrief dis- likely to implement TS4TIC successfully.41 assurance, financing and evaluation structures • To show up on time to simulations. cussion. within the organisation.9, 16, 47 • To try to suspend disbelief about the realism of 32 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 33 Organisations which are most responsive to people focuses on abilities, knowledge and capacities rather informed, they cannot consider or act on learning with experiences of trauma embrace the four ‘Rs’ of than deficits or things that are lacking. from simulations. TIC. Trauma-informed organisations realise the wide- spread impact of trauma and understand potential The principles of TS4TIC may align with the prin- Feedback loops ensure that all information is shared In TS4TIC, feedback loops can help strengthen or paths for recovery; recognise the signs and symp- ciples of many other projects in healthcare organi- between all relevant stakeholders. In TS4TIC, it is reform system responses, improve communication toms of trauma in clients, families, staff, and others sations e.g., programmes related to person centred important that the learnings and quality improvement between groups across the system, provide new rec- involved with the system; respond by fully integrating care, shared decision making, quality improvement recommendations from simulation are shared with ommendations, provide collateral for existing policies knowledge about trauma into policies, procedures, programmes, end of life care, human rights based all key stakeholders across the system. It is equally and promote co-production. Sharing recommenda- and practices, and seek to actively resist re-trauma- approaches to care. The principles also align with important that the system is encouraged to respond, tions and practice wisdom from simulation partici- tisation.9 the codes of ethics and behaviour individual health to plan and communicate a response back to other pants is a powerful way. professions are tasked to uphold. stakeholders. Using a strengths based approach sup- ports successful communication between groups. The introduction of TS4TIC supports the identifica- tion of aligning practices and trauma creating re- Feedback loops by their nature are circular and cru- sponses in organisations. Identifying existing helpful cial to the success of TS4TIC. Simulation participants practices and values can build organisational confi- may feel simulations are pointless if they identify dence that TS4TIC aligns with its overall mission of learning and do not receive feedback from the sys- providing quality healthcare. In so doing, TS4TIC may tem. Similarly, if relevant stakeholders are not kept prompt culture change which is of benefit, not only to From the outset, use a strengths-based approach. A patients but to staff and the wider organisation itself. strengths based approach is a way of working which Case Example In a substance misuse support service, simulation participants were frontline workers. In debriefing, they advised that the service had a ‘challenging behaviour’ policy which focused on the behaviour Case Example of people using the service. Participants felt this policy was trauma creating, reactive and punitive and did not correlate with the principles of TIC (i.e. building safety, trust, voice, empowerment with The Project Lead explored examples of trauma-informed practice with a patient representative group service users). Following simulation, the Project Lead shared this perspective with management and in TS4TIC. One representative Keyshia shared her experience of living with a long term illness which shared recommendations from staff for additional training and policy reform. Management were required her to attend five different hospital teams. She was overwhelmed and felt unsafe with so interested in hearing of the helpful practices identified by staff in simulation (which aligned with TIC) many healthcare professionals in her life. Keyshia explored this with her hospital team and it was and agreed to work with staff to develop and pilot a trauma informed policy in the service. agreed Keyshia could attend one primary consultant. Keyshia talked of the importance of feeling em- powered, having choice and voice, feeling safe and building trust - all principles of TIC. The Project This in turn was shared with frontline staff. A working group with representatives from across the Lead was able to highlight this as a practice which aligned with TIC practices within the hospital. service, including people who used the service was established to co-produce a response. Equally, the patient representative group highlighted facilitators and barriers to implementation of Leaders for the purpose of TS4TIC included executive examples of experiences which did not reflect TIC. TS4TIC. (senior) and middle management, frontline managers They shared insights into some of the organisational at operational level and other managers in strategic barriers within the healthcare service such as poor • Carry out organisational self-assessment to es- Engaging Essential Leaders roles which may influence TS4TIC implementation signposting and poor quality buildings and highlight- tablish where current practices overlap/align with (i.e., policy, recruitment, human resources, education ed the importance of effective communication and TIC & share with management. For the purpose of TS4TIC, all key decision-makers and training, participation of participants in simu- providing compassionate care. across the organisation are leaders. This reflects con- lation, etc). It also included project champions and cepts of distributed leadership, which is not some- members of the patient representative group. Responsibilities for Project Lead: thing ‘done’ by one individual leader to others, rather it is ‘a group activity that works through and within • Consider and learn about organisational culture, relationships, rather than individual action.’48, 49 34 | Chapter 2: TS4TIC: The Planning Stage Chapter 2: TS4TIC: The Planning Stage | 35 uation measures are agreed at outset. • Build relationships with executive, middle and frontline managers to seek input and simulation Genuine support and ‘buy in’ of executive, middle participation from all grades and staff roles. Work and frontline leaders and managers is critical for the with clinical areas to find times and dates that success and sustainability of TS4TIC. Leaders should best work for them. be keenly aware of the influence they have on organi- sational culture. • Seek areas with genuine interest/experience in working with patients with psychological trauma TS4TIC requires dedicated resources and support. to co-design scenarios and pilot simulations. It is It is essential that leaders show their understanding important to create and build on success/word- of this and invest appropriately. They must demon- of-mouth about simulation. strate knowledge of the nature, purpose, benefits and limitations of TS4TIC and clearly communicate this • Support the design and trialling of scenarios to across the organisation. ensure they are contextually valid and authentic. Key Steps for the Project Lead of TS4TIC by highlighting things the organisation already does well, and could develop further. Leaders may be able to support the work of the Proj- • In advance of simulation, support a planning day With Support of Expert Advisory Group, Project Lead ect Lead in a variety of ways. For examples, leaders with all relevant stakeholders to rehearse prebrief, should: • Emphasise co-production aspects of the project can: simulation and debrief in the physical environ- and present TS4TIC as something which names ment which will be used for simulation. • Identify key leaders in the organisation. Brief and builds on existing good practice and aligns • Gain and use knowledge of both TS and TIC in executive, middle and frontline management, with the stated values of the organisation. Project their role, including in their communication • Support facilitator access to mentoring. patient representative groups and other identi- Lead could draw on mission/value statements across the organisation. fied leaders on project, explain purpose, goals and strategy documents should evidence this. • Promote psychological safety. and potential outcomes. Highlight the benefits • Recognise that TS4TIC is a tool which can inform of TS4TIC for staff and people who use services. • Seek resourcing and management support for the organisational change. • Communicate that simulation is a safe space to Contextualise TS4TIC in relation to a fully trau- introduction, implementation, spread and sus- practise dealing with some of the challenges staff ma-informed system. tainability of TS4TIC. • Consider TS4TIC as part of a broader roadmap to face every day and that expertise or knowledge is deliver TIC services. not expected. • Seek to understand barriers and opportunities for • Ensure suggestions for quality improvement from organisational buy-in and staff participation from TS4TIC participants are fed back to management, • Meaningfully support co-production with people leaders. along with key findings from simulation debrief- with lived experience of psychological trauma. ings. • Signpost key leaders to further training in TIC and TS. • Ensure that once leaders are engaged, ongoing work is carried out to sustain the project, with Summary • Identify TS4TIC champions – people with some regular feedback and leadership engagement on understanding and/or interest in progressing TIC progress made/planned. The planning stage of TS4TIC is critical for its successful implementation and sustainability. through TS methodology. Focus on relationship building with leaders of projects with principles • Build and maintain a community of leaders and a Resource requirements for TS4TIC include a Project Lead, Expert Advisory Group, trained facilitators which already align with TS4TIC (i.e. person cen- community of practice to exchange knowledge, and actors, trainers, participants and champions, all of whom have access to accredited training as tred care/end of life projects) or in areas where reflect, share experiences and learning, consider required. TS4TIC may be particularly welcome/helpful (i.e. innovative opportunities etc. areas where staff routinely work with patients Organisational culture, feedback loops, engaging and planning with leaders are equally important exhibiting symptoms of psychological trauma). factors to consider in the design, implementation and evaluation of TS4TIC. Consider implementation of TS4TIC in these Promoting TS4TIC with Leaders areas first. Effective planning ensures that TS4TIC is clearly understood across the organisation. It means simula- • Map existing knowledge in the organisation of tions are adequately supported, learning is captured TS/TIC – share with management. This provides and used to inform frontline practice and organisa- an important opportunity to ‘take the mystery out’ tional change. It ensures any measurement and eval- CO-CREATION & CO-DESIGNING THE SCENARIOS This chapter will outline how to co-design and refine scenarios for use in simulation. It will explore how to identify key stakeholders with whom Project Leads should collaborate to ensure scenarios reflect their views. Key Individuals: Key Activities: Project Lead • Co-creation of scenarios for simu- lation Expert Advisory Group • Identification of suitable location and staff participants for simula- Facilitator tion Actor(s) 38 | Chapter 3: Co-creation & Co-designing the Scenarios Chapter 3: Co-creation & Co-designing the Scenarios | 39 • Reflect on who would be helpful to speak with • Listen for examples of good practice which aligns their interpersonal skills to resolve it as best as they and when to do so. with TIC principles and also less helpful practices can. The scenario also raises awareness of any stress which may be trauma inducing. responses they may experience themselves. Co-design refers to designing with people and incor- • Consider how to involve staff grades of all types, porating their ideas into the final approach. Co-de- visitors, patients, and patient representative The Project Lead should speak directly to patients or At end of initial co-design stage, the Project Lead sign is the philosophy of co-production in action. groups in co-design. Reflect on the variety of people who visit the service about their experiences. should: Co-design recognises the importance of consulting, methods needed to contact them. These may The Project Lead may be able to speak with patients including and involving all relevant stakeholders who include seeking approval and agreeing pathways who serve as patient representatives (in the organi- • Ensure scenarios are brief and representative of use, work or visit a service from the start of a project to speak with visitors and patients, contacting sation, or in other similar organisations). The Project common experiences in the healthcare setting. through to completion. It places people impacted by patient representative groups, considering access Lead may also speak with peer and self-advocacy a process at the heart of the process to ensure their to day and night staff etc. groups for people who are likely to use healthcare • Ensure scenarios are designed in a way which wisdom and expertise is reflected in it. services (i.e., older persons, disability, refugee, ensures that a clinical or practical solution will In Co-Design Workshops the Project Lead should: LGBTQI, etc) or with professional advocacy groups. not resolve issue, (i.e., more pain medication) Co-design in TS4TIC allows organisations to work Consider any communication support which may be but rather that interpersonal skills are required to with different groups to produce scenarios that reflect • Clearly explain the purpose and role of co-design. required to support a patient representative to partic- support patient to return to green zone (i.e., en- common situations involving patients with trauma ipate in co-design, i.e., accessible spaces, communi- suring patient feels safe, has choice, experiences responses in their service. • Pay attention to the psychological safety of par- cation support, interpreter, etc. collaboration, cultural sensitivity, etc). Sample ticipants. scenarios can be found in Appendix D. It provides an opportunity to liaise with all relevant stakeholders and ensure that scenarios reflect a di- • Consider the entire patient, visitor and staff jour- verse range of expertise. This supports the realism of ney when designing scenarios. scenarios brought to simulation, which has a signif- icant impact on the success of a simulation and the • Explain hypoarousal and hyperarousal stress A scenario consists of a person with a history of psychological trauma who encounters something in ‘buy in’ from participants and wider organisation.2, 3, responses (using the thermometer of regulation 50, 51 to do so proved very helpful in TS4TIC). Ask the hospital environment which triggers a stress re- participants to give examples of times when they sponse for them, and requires a response from staff. In TS4TIC, co-design was found to be integral to the observe these responses from other people in success of scenario development. Multiple iterations their service (or if they feel safe to do so, when While TS4TIC focused primarily on patients with psy- they observe these reactions in themselves). chological trauma, other stakeholders may have trau- of co-design were used to design the finalised sce- ma responses. The person with psychological trauma, narios, found in Appendix D. • Ask if there are common flashpoints which may could be a patient (i.e., stressed about an aspect of be useful to examine. Staff and patient advocates their healthcare experience), a visitor (i.e., stressed may identify particular areas, times of day or days about care of patient) or a colleague (i.e., a staff of the week that see an increase in patient-staff member experiencing vicarious or racial trauma). The tension, e.g., reception, the early morning, or the person with psychological trauma will interact with staff. The scenario is designed to require staff to use The Project Lead is responsible for planning and weekend. Management and staff may also identi- leading co-design workshops. These are spaces to fy particular existing policies that lead to tension allow relevant stakeholders to reflect on common and may warrant examination through simulation, experiences involving patients with psychological i.e., discharge policies, behaviour management Summary trauma in the healthcare setting. policies etc. This chapter provided an overview of the co-production and co-design process for simulation sce- In advance of Co-Design Workshop, the Project Lead • Consider using de-identified or anonymised ad- narios. At the end of this chapter, organisations should be familiar with: should: verse incident reports, patient feedback forms or similar reports within the organisation. They may • The reasons for co-designing simulation scenarios. • Ensure that dedicated time and space are made inform scenario design, as they often provide • How to run a co-design workshop. available to ensure participation from as wide a valuable information directly from patients and • What a TS4TIC simulation scenario looks like. stakeholder group as is possible, in co-design. visitors. RUNNING SIMULATIONS This chapter highlights important aspects to consider when facilitating simulations including: • Planning for a simulation workshop. • Delivering a pre brief. • Supporting simulation. • Facilitating debrief. This Chapter references roles for Project Lead and Facilitator. In TS4TIC both roles were carried out by a single staff member. This may vary from one organisation to the next. Key Individuals: Background Support: Project Lead Trainers / EAG / Hospital Management Facilitator Participant 42 | Chapter 4: Running Simulations Chapter 4: Running Simulations | 43 Once the date and time is confirmed, advertise simu- simulation. It is important to ensure that they are lation among potential participants. Use visual post- comfortable with sharing their experiences with a ers, email, internet and all other staff communication group of strangers. Actors must be aware that they Preparation and planning are key ingredients for channels to promote simulation. Invite organisational do not have to share their experiences if they feel successful simulations. Many of the common pit- leaders and frontline managers along with project uncomfortable. falls in simulation (such as poor attendance, lack of champions to proactively support the promotion of realism, and interruptions) can be avoided through simulation among staff. The project also used professional actors without careful preparation. There are a number of factors lived experiences of trauma. All professional actors which should be considered to support successful Prepare materials: - Print out any information re- should be paid appropriately. Staff actors may also be simulation. Table 4.1 below provides an overview of quired for simulation in advance, i.e. ‘Simulation in used in the project. See Appendix C for information the minimum resources needed to run TS4TIC simu- Process’ room signs, simulation information leaflets, on how to select and support staff actors. lations: and employee assistance/counselling programmes. While the TS4TIC facilitator did not provide materials Using a diverse range of actors is a key to represent- Table 4.1 Minimum Resources Required for TS4TIC in advance, film and reading material could be shared ing a diverse patient population. in advance with participants. Individual/Resource Minimum Number of Resource Needed Boundaries need to be explicit around the actor sup- Facilitator 1 Facilitator Be aware that introducing TIC may be distressing or porting a participant’s sense of safety, i.e., no touch- Actor 1 Actor, professional or staff retraumatizing for participants, depending on their ing of participants by the actor (unless agreed, i.e. own trauma experiences. Ensure that resources ad- simulating a trauma-informed removal of a patient Participants Depends on Organisation; the pilot project ran simulations of 8+ participants, but vertising TS4TIC clearly notes participation is volun- who poses a risk to others). smaller organisations may not be able to field that many participants. tary and signposts people to all employee assistance Location 1 Location and wellbeing programmes. 4. Facilitator Readiness: The facilitator should have a good understanding of the area in which simulation is 2. Consider Participation: Reflect on who to include 3. Actor Readiness: Select an actor for simulation taking place, i.e., the work demands of staff, the pa- and how to do so. Consider which participants (role (refer to Chapter 2 for actor role and preparation). The tient cohort, staffing resources, department culture, and staff grade) would usually be involved in a real facilitator and actor should work together in advance pre-existing experiences of simulation and TIC. This The Project Lead, with facilitator, should: life scenario, i.e. reception staff, catering staff, nurs- of simulation. Both should rehearse through the helps the facilitator to engage with participants and ing staff, medics, visitors, security etc. In order to scenario until the facilitator is satisfied that the per- plan realistic simulations run at times which maxi- 1. Consider Location: Where possible, use locations recreate as realistic a simulation as possible, en- formance is sufficiently realistic and representative mise participation. (i.e. clinical spaces) which allow actors and partici- deavour to ensure that those who are usually present of trauma experience. This is vital to engage partici- pants to create as realistic a simulation as is possible are represented in simulation. Staff involved in the pants. Actors are a vital part of TS4TIC, whether they If the facilitator is researching any aspect of simula- (in situ simulation, i.e. simulations involving a triage simulation play their authentic role. The only excep- are paid or staff actors. Their psychological safety tion, preparation should be made to ensure all as- patient should ideally take place in a triage space, tion to this is if a staff actor is used to play the role of during the scenario is paramount, and they should pects of the research plan are adhered to i.e., distrib- dental patient in dental surgery, a distressed visitor patient. be supported by the facilitator in the simulation. The uting participant information leaflets, consent forms, at a ward desk etc. Given the busy nature of many scenarios developed for use in simulation may touch baseline surveys, etc in advance. healthcare environments, it is not always possible to In most organisations, simulations work best where on potentially traumatic material for the actor, and source free clinical spaces or replicate environments staff have dedicated and protected time to partic- if any actor is uncomfortable portraying elements of Additionally, the facilitator should ensure all practical for simulation. In such cases, training rooms or edu- ipate. Seek the support of frontline managers and a role in a planned scenario, that should always be and logistical issues are attended to in advance of a cation spaces adjacent to the clinical workspace may relevant staff to coordinate simulation times and accepted. simulation to reduce their own cognitive load on the be used. dates which facilitate maximum attendance. Manag- day. This will allow the facilitator to focus on welcom- ers may be able to facilitate roster changes, protected All actors used in the pilot TS4TIC project had an ing participants and facilitating prebrief, simulation Additionally, consider in advance the likely number of time or cross-cover of roles to allow staff participa- introductory level of trauma-informed training. The and debrief. participants, the room space available, any technolo- tion. They may also arrange to include simulation in pilot project used actors with lived experience of gy required (i.e. visual/audio, assistive technology for existing dedicated teaching time or may find other trauma which proved very powerful in simulation. The facilitator, along with the Project Lead should participants with disability). Arrange circular seating solutions to ensure staff participation. Be aware of Decisions around sharing trauma experiences were request tasks of relevant stakeholders in advance for participants. It is important that the selected loca- less successful times to run simulation in an organi- made between the facilitator and actor and attention of simulation. This includes requesting executive tion remains free from interruption for the duration of sation such as particularly busy time periods, and key was explicitly paid to the actor’s psychological safety. managers communicate support for project and set the entire prebrief, simulation and debrief. holiday periods. Additional support should be made available to actors expectations that frontline staff will be facilitated to who reveal their own lived experiences as part of the attend, request frontline managers and peer cham- 44 | Chapter 4: Running Simulations Chapter 4: Running Simulations | 45 ions promote simulations in advance, support staff Minimise elements of surprise - Clarifying sult in an evaluation of individual staff mem- engagement and ensure a good mix of staff and Simulation Support Requests Objectives, Environment, Roles, Confidential- ber skills. Instead it serves as an opportunity grades attend etc. This will ensure that the greatest from Stakeholders ity and Expectations to promote team discussion and consensus on number of potential participants are aware of simula- approaches which align with trauma-informed tions and will be able to attend them. Participants are more likely to engage when they principles. Encourage staff volunteers to engage have a sense of control and clearly understand what with the patient in any manner they choose – is expected of them and others in simulation. If (i.e., as if they themselves are having a “good learners are clear about expectations in simulation day” or a “bad day” at work, then to act as they and debriefing they are also more likely to meet those normally would). This again removes the focus on expectations. individual skills. Day of Simulation: Consider the following on the day of simulation: From the outset, the TS4TIC facilitator should ensure • Build trust by clarifying confidentiality. Ensure that they arrive early and well-prepared as this com- that participants are aware that talking and • The room should be appropriately set up. Sign- municates respect for participants and will enhance thinking about trauma can be uncomfortable and posting should indicate when a simulation work- their own experiences of the work. The facilitator anyone can leave at any time. Participants direct- shop is taking place to prevent interruptions. should be aware of participants’ self-care needs ly involved in simulation should be reminded that prior to commencing a simulation session. This may they can use a ‘pause button’ to stop simulation • If the simulation is occurring adjacent to patient include, for example, ensuring they are not rushed, or or seek help if needed. clinical areas, it is important to advise patients hungry. Participants should be offered a few mo- that a simulation activity is taking place. ments to self-regulate before starting simulation. • Agree on a fiction contract. The fiction contract allows the facilitator to acknowledge that the • The actor should arrive in advance of participants In TS4TIC, the aim is to deliver a prebrief which In the pre brief, the TS4TIC facilitator should: realism of the simulation has limitations. It calls to allow for any final preparations. maximises the opportunity to establish psychological on participants to accept this and give full com- safety. The prebrief also sets out the objectives and • Clarify simulation objectives, roles, confidenti- mitment to maximise learning opportunities. • The facilitator may have to remind the clinical area manager to release staff or prompt atten- goals of simulation, explains the process and creates ality and expectations - never assume these are understood. • Simulation is likely to be just one part of the par- dance. Participants should be welcomed to the a positive learning space. ticipants’ busy work day. In pre brief, the facilita- room and directed to any paperwork the facilita- • Set a relaxed tone. Explain that TS is an oppor- tor should: tor may wish them to complete in advance (i.e., tunity to identify and build on existing quality sign in sheets, consent forms, pre-simulation practice when working with patients with psycho- 1. Clarify length of time of simulation and survey). logical trauma. debrief (45 minutes – 1 hour may be appro- priate). • Cancellation of agreed simulation activity should be minimised as much as possible. Flexibility is Psychological safety is present when there is ‘a • Use inclusive language - be aware of the lan- 2. Request phones/pagers are silenced if feeling (explicit or implicit) within a simulation-based guage ability of all present in the room. possible. important and it may be necessary to shorten the length of the simulation activity to allow it to activity that participants are comfortable participat- 3. Remind participants that their participation ing, speaking up, sharing thoughts, and asking for • Clearly explain roles of all present (i.e., actor, is valued. proceed as planned. help as needed without concern for retribution or facilitator, participants, co-facilitator if present) 4. Reference refreshments/opportunity to embarrassment.’10 gather at end of debrief if available. • Simulation workshops are composed of three • Clearly explain relevant terms. Participants may equally important parts, the prebrief, the simula- People are more likely to feel it is acceptable to take not have any understanding of psychological Conveying respect for participants and taking a tion and the debrief. It is important to ensure psy- trauma or TIC approaches. Provide a brief over- genuine interest in their perspective is a hallmark of chological safety throughout the entire process. risks, work at the “close to the margins” of their com- fort zones, try new things, learn, make mistakes and view. Depending on time available, visual aids and a skilled facilitator. Participants learn best when they reflect honestly when they feel psychologically safe. brief education videos could be used. A poster of sense there is unconditional positive regard for their Psychological safety is akin to being in the green the thermometer of regulation proved very helpful sense making in simulation. This essentially assumes zone of the emotional thermometer of regulation, to explain trauma responses in TS4TIC. that people are doing the best in a scenario with the when people are focused, feel safe and are engaged. skills, knowledge and perspectives they have. In pre- The prebrief is the discussion which takes place prior In order to set the conditions for psychological safety, • Clearly explain the role of debriefing afterward. brief and throughout entire simulation, the facilitator to simulation and it sets the tone for all that follows. the TS4TIC facilitator must: should: • Clarify that performance in simulation will not re- 46 | Chapter 4: Running Simulations Chapter 4: Running Simulations | 47 • Communicate a genuine interest in the way Using the PEARLS debriefing tool44 allows the facil- participants approach the scenario, how they itator to explore reactions of participants to explore make sense of what happens and how they then reactions, describe the simulation, analyse the simu- act. As discussed in Chapter 2, facilitators require core lation, summarise the learning and identify take home debriefing skills. There are training programmes and messages. • Ensure that participants feel a genuine sense of practice models which support effectively debriefing. respect for their own perspectives. This section provides information on the general role In debrief, the facilitator should focus on aspects of and function of debriefing and provides some best the simulation which aligned or did not align with the The prebrief can be adapted according to the cir- practice tips. It also assumes that all facilitators will core principles of TIC.9 These include safety, trust, cumstances. If simulation is taking place regularly have baseline knowledge in debriefing post simula- peer support, collaboration, empowerment, cultural, and participants are familiar with the facilitator and tion. historical and gender issues. Participants should be content, the prebrief can be concise, a quick ‘revisit’ invited to consider how events in the simulation (or of core components. A simulation with participants Debriefings are facilitated discussions which promote similar events in their work environment) support or unfamiliar with the facilitator or content may require reflection and help participants understand the even undermine these principles. The facilitator should much more time and discussion. The presence of line ts of simulation. Conversations between the partic- ask participants to reflect upon the patient’s stress managers among participants should be acknowl- ipants and facilitator(s) explore the relationship be- responses. It is equally important that participants edged. There may be power dynamics and hierarchies tween the events, actions, thoughts, feelings and out- reflect upon their own stress responses, if any, during which may make participants, including managers comes. Debriefing involves active participation from simulation. Participants should consider how this feel vulnerable. Clarifying that simulation is a reflec- the learners. It focuses on learning and improvement. may have impacted upon their interaction with pa- tive and learning space for all participants may prove It often identifies potential for learning and reflection. tients. helpful (See sample pre brief in Appendix E). Effective debriefings in transformative simulations support participants transfer learning from simula- tion to patient care. Debriefings provide information Responding to Challenges within Debriefing to inform system change. Using the skills outlined in A facilitator may encounter challenging situations the PEARLS model44 of debriefing can ensure that the within debriefing, including but not limited to: partic- A well designed scenario should support staff to facilitator is focusing on participants’ experiences in ipants who may be uncomfortable speaking within focus on their verbal and non -verbal communication simulation. It allows opportunities for new mindsets, the group, disengaged participants, participants who skills, rather than resolving the practical issues. If the member has left their own ‘green zone’ or may reflections and learning rather than merely educating dominate, react emotionally, or defensively. There are simulation ends quickly, or anything arises to inhibit warrant further exploration to understand the staff participants on TIC. a number of strategies a facilitator can use including realism (unexpected noise, actor doesn’t sufficiently member’s perspective during debrief discussions. naming the dynamic, validating, normalising, general demonstrate a trauma response), feel free to pause, As in prebrief and simulation, maintaining a sense of ising, paraphrasing, broadening and previewing.53 reset and restart. The participant or actor can also Additionally, the facilitator should observe the actor’s psychological safety is vital during debrief. A debrief stop the simulation at any stage if required by raising response to the staff member. Observe for increased is only effective if participants feel psychologically their hand and saying ‘I am hitting the pause button’. signs of trauma responses and for signs the actor is safe, when they feel comfortable to work at the edge regulating and returning to the green zone. of their comfort zone. Participants feel confident The facilitator should carefully observe staff inter- enough to risk making mistakes in the service of action with the patient and among colleagues for The facilitator, or a co-facilitator ideally, may wish to learning, without fear of shame or humiliation. elements that align with the key principles of TIC. take brief notes to support the debrief. Note-taking These may include efforts to establish safety, trust, must not adversely impact their observation and There are implicit strategies the facilitator may use to collaboration, empowerment and cultural consider- situational awareness of how the scenario is unfold- support psychological safety during simulation such ation in the interactions. Other less helpful forms of ing. When the facilitator is satisfied there is adequate as use of empathy, active listening, showing positive the interaction should also be noted for the purposes content to support debrief and learning, the simula regard through non-verbal and verbal communication of learning during debrief, i.e. a raised voice, closed tion should end and participants should be invited and culturally appropriate use of eye contact. The body language, standing over patient, missed oppor- into a circle to commence debrief. facilitator must work from a space of curiosity, and tunities to demonstrate empathy, a focus on explain- authenticity, with a genuine interest in understand- ing rules rather than using active listening skills with ing the perspective of participants. Validating partici the patient, etc. These may be signs that the staff pant perspectives, normalising reactions and sharing member has left their own ‘green zone’ or may war- experiences of vulnerability can all support psycho- rant further exploration to understand the staff logical safety and learning.52 48 | Chapter 4: Running Simulations Chapter 4: Running Simulations | 49 Case Example Summary At times, participants may express disbelief in the relevance or applicability of trauma-informed This chapter provides an overview of running simulations for TS4TIC. By the end of this chapter, principles in practice. It is important that the facilitator remains aware of their own stress responses, organisations will have a better understanding of: stays in a green zone and is connected to the participants. In our experience, participants in the wid- er group generally offered alternative perspectives when usefulness of trauma-informed principles • The necessary components for running a simulation scenario. were challenged. • The steps the Project Lead & Facilitator should take before running a simulation. • The necessary parts of a simulation pre-brief. Jim: We don’t have time to sit around for ages making someone feel safe and listened to. • The psychological safety required to run simulations. • The necessary parts of a simulation debrief. Facilitator: I can understand someone feeling that way when under time pressure. Does anyone else have thoughts on what Jim has just said (broadening…) Aliza interjects: I can see where you are coming from but often just taking those few minutes to con- nect with someone prevents everything escalating which always takes a lot longer to resolve. Michael: This place is a zoo. How can we possibly offer choice to someone? Facilitator: Yes, it can feel like a hard thing to do, can you think of a time you have ever been able to help a patient have some sense of choice here? Can anyone else? What happened?’ It is important that facilitators are aware that partici- ion. pants may be raising a concern which needs to be fed back into the system so that staff can be adequately • Ask participants to experiment with learning supported to use trauma-informed principles. Asking points. ‘Can anyone imagine what would need to happen for you to be able to offer a choice in this scenario?’ can • Remind them that services similar to their own provide valuable learning for the wider system. have found these techniques to be useful from patient care and staff wellbeing perspective. It is also important that the facilitator avoids lectur- ing when trauma-informed principles are questioned • Seek to revisit again in follow up simulation or and instead maintains a curious perspective to through follow up conversations. understand resistance from participants. trauma-in- formed principles require a shift in mindset and this As happens with other healthcare interventions, use takes time. All issues do not have to be and are rarely of trauma-informed principles in patient care will not dealt with in a single simulation. always guarantee a patient will return to the green zone. The facilitator should remind participants that When encountering resistance, the facilitator can it affords the best pathway to support best outcomes also: for both staff and patients. It also gives staff new frameworks to reflect on why interactions did not go • Broaden the discussion to include all views, well and how they might be improved in the future. • Highlight where practice aligning with TIC princi- ples is already successfully used in the organisat- REFLECTIONS & LEARNING This chapter shares key reflections and learning arising from the ex- perience of planning and implementing TS4TIC. As TS4TIC is designed for use in any healthcare setting, many of these reflections will have relevance for other organisations. It is hoped that individual organisa- tions can adopt, adapt and further develop TS4TIC to meet their own needs. 52 | Chapter 5: Reflections & Learning Chapter 5: Reflections & Learning | 53 remote access to additional experts, the aims were refined to focus on using simulation to explore the use of the principles of a TIC approach in practice. TS4TIC found that transformative simulation The Project Lead also used reflective practice tools54 emerged as a helpful methodology to identify or learn to understand learning and the perspectives of the Consider how Healthcare staff Use simple plain terms to explain TS4TIC. Use a strengths-based about practices to identify or learn about practices many stakeholders involved in TS4TIC. Organisations to explain often have limited approach that frames TS4TIC as building on existing ability, knowledge, which align with the principles of TIC. Some of the may choose to adopt PDSA cycles or other tools to TS4TIC time to absorb new and capacities in an organisation; rather than focusing on gaps or key learning points that emerged during the pilot support them in capturing learnings in their settings. information. Com- deficits. project are listed below. The use of PDSA cycles as plex explanations outlined in Chapter 1 allowed the TS4TIC team to of TS4TIC may be Sample Descriptive Text: collate and act on these learnings during the project. unhelpful. ‘TS4TIC recognises that psychological trauma may impact patient and staff experiences in health care settings. This project is interested in Table 5.1 Learning Points from Planning Stage improving staff and patient experiences. It also improves the ability of Learning Point Risk Solution staff to reflect on their own experiences and interactions, along with those of patients. This project builds on our existing strengths and Consider Defi- Trauma-informed Organisations should select the definition most suitable for their things we already do well. It also shares new learning and practice nitions care- care is a new and service. Ensure that the broader ecological, socio-economic, cultural, wisdom from our staff in simulation with the wider system, providing fully emerging field historical, and other psychosocial factors associated with trauma are opportunities for quality improvement. and there is little fully embedded in the approach used. consensus on key It is worth highlighting that TS4TIC places value on skills, culture, and definitions related Case Example: helpful responses which we know are helpful to patient populations. It to trauma. Some also helps staff name less helpful practices that should be avoided. definitions provide TS4TIC initially used the word ‘trauma’ when promoting the project, a narrow, biomedi- as it is widely used throughout the TIC field. This caused considerable TS4TIC helps build safety, offer voice and choice, support empow- cal view of trauma. confusion as healthcare staff associate the word ‘trauma’ with acute erment and collaboration, show cultural sensitivity, and offer peer medical injuries. The team then decided to use the term ‘psychological support. These are interventions that we know are highly valued by trauma.’ The team recognised that this does not adequately capture patients and when working this way, staff themselves may have better the broader ecological, socio-economic, cultural, historical, and other outcomes. psychosocial factors associated with trauma. Significant attention was paid to these factors in all contact with all stakeholders in the project. Consider tools Healthcare staff While there are a variety of tools available to explain trauma responses, Ensure aims Healthcare or- Organisations must be prepared to reflect upon and if required, to to explain often have limited TS4TIC found the thermometer of regulation6 to be the most effective. are deliverable ganisations may revise the aims and objectives of TS4TIC as knowledge of TS, Quality Trauma Con- time to absorb new It provides a visual guide that is accessible to staff with varying levels and expec- initially have/lack Improvement, and/or TIC grows. Relevant expertise must be accessi- cepts information. Com- of language proficiency/fluency. tations are proficiency in one ble to ensure that aims are deliverable and expectations are realistic. plex conceptuali- realistic. or more compo- This expertise may be available internally or may need to be sought sations of trauma Asking staff to recall a time when their stress response seemed dispro- nents of TS4TIC. externally on a planned or ad hoc basis. Remote access improves may be unhelpful. portionate to the trigger (i.e., public speaking/being late) is also help- accessibility to expertise. Organisations may need to access addition- ful. It allows staff to physically relate to nervous system responses and al support around quality improvement, TS, or TIC, depending on the helps them understand the thermometer of regulation. expertise levels available with a service to ensure deliverable aims and realistic expectations are produced. It is useful to identify helpful practices in debriefing and place trau- ma-informed language on them (i.e., building safety/choice/empower- Case Example from TS4TIC: ing, etc). Promoting In a busy health- When promoting TS4TIC with executive management: Highlight where The aims of TS4TIC were redefined in this project. While the hospital TS4TIC care environment, TS4TIC aligns with existing organisational values, mission statements, team had transformative and quality improvement expertise, additional where stakehold- and strategic plans. expertise in TIC was required. Project partners with trauma-informed ers manage com- expertise highlighted that the originally stated aim of using simulation peting priorities, Share examples of where TS4TIC can deliver outcomes that align with to introduce a full trauma-informed approach was unrealistic. Using 54 | Chapter 5: Reflections & Learning Chapter 5: Reflections & Learning | 55 inefficient com- existing organisational values, mission statements, and strategic plans. Simulations featuring hypoarousal responses were carried out in a munication could Share examples of where TS4TIC can deliver outcomes that align ward setting where staff had time, space, and privacy to work with reduce engage- with the stated aims of the management team, i.e. in a hospital where someone. Co-design and simulation both highlighted that additional ment. patients are often asked to leave if drug or alcohol use is suspected, systemic resources are required to support staff to use the principles explain how a simulation may support staff to use trauma-informed of TIC (i.e., establish a sense of safety through grounded exercises). principles to support a patient to stay in hospital. This aligns with per- Organisations may need to pay specific attention to how best to design son-centered healthcare/ reducing unplanned discharges. hypoarousal or hyperarousal responses, depending on the setting. It is useful to highlight to executive management that the principles of TIC should be applied universally to benefit all patients, not only those who have experienced psychological trauma. Table 5.2 Learning From Co-design The evidence base for TIC is growing rapidly,11 and evidence relevant Learning Point Risk Solution to each organisation should be shared with relevant stakeholders to Consider how Despite the co-de- Despite the co-design process, staff may on occasion find scenarios inform the implementation & evaluation of TS4TIC. to achieve sign process, staff in simulation too easy, too difficult, or lacking in realism. If this occurs, realism in sce- may perceive the facilitator should again inquire about the common hypoarousal When promoting TS4TIC with frontline management and staff, use narios. scenarios to be (blue) responses, vs hyperarousal (red) responses, that staff encoun- existing knowledge of the area of work to give examples of how TS4TIC unrealistic. ters and refine scenarios accordingly. This can take place in simulation. could assist staff. For example, highlight how withdrawn patients who asking the actor to increase or decrease stress responses or quickly may be hypo aroused/in the blue zone may be considered ‘difficult adapt some other aspect of the scenario. to engage’ or ‘unmotivated to make progress’ and provide examples of how simulation may help staff reframe this behaviour as a trauma Be aware that a scenario that works in one area may not translate into response. They can then reflect on how best to support the patient to another. In the TS4TIC pilot project, Emergency Dept staff were ac- regulate and connect. customed to more severe red zone responses than would have been considered routine or common in ward areas. This does not necessarily When promoting with Patient Representative Groups, focus on how translate into a better staff skill set for responding to signs of psycho- TS4TIC seeks to address many of the concerns often raised by patients logical trauma, but scenario design should allow for a wide range of within the system, i.e., lack of safety, trust, voice, choice and empow- stress responses experienced by staff. erment, cultural sensitivity, collaboration and peer support, and active listening proved helpful to engage patient representative groups. The ultimate litmus test for the realism of a scenario is the response of the participants themselves. Scenarios are a success if participants Word of Mouth Builds Momentum: Starting simulations in areas well themselves feel it replicates a real-life situation they have or could known to the facilitator, with existing good relationships with staff and imagine encountering in their roles. strong project champions, helped promote TS4TIC via ‘word of mouth’ and build momentum/interest across the organisation. An area where Staff may identify additional issues with their ability to work in a TS4TIC is most likely to succeed within an organisation is a helpful trauma-informed way that the co-design team did not account for in place to start simulations and promote the project. scenario design. This feedback should inform the next run of co-design and scenario development as a form of quality improvement. Ensure that It may be tempting Simulations in the TS4TIC pilot project focused on hyperarousal stress scenarios to focus on a par- responses far more than hypoarousal responses. This reflected an ini- Consider bias Bias and Stereo- Seeking diverse perspectives gives the best possible chance to be reflect a range ticular stress re- tial concern that the time and environment required to support some- and stereotyp- typing can appear mindful of stereotyping and bias during scenario design. of trauma sponse in scenario one with hypoarousal/in the blue zone, was simply not available. This ing in scenario in the scenario responses. design, depending was due to staff working in busy, overcrowded, stimulating, acute, and co-design. design process. The Project Lead should reach out to advocates/ groups who represent on the setting. understaffed areas. or work with people whose identity includes one or more of the aspects listed below. This helps identify any unconscious biases present. While In reality, it highlighted that hypo-aroused patients often go unnoticed. at first, it may be easier to focus on one aspect, combining two or more The TS4TIC team initially found it more challenging to design realistic aspects of identity may lead to a richer understanding of the people scenarios for this group and required additional skills/reflection to do using a healthcare service daily: so. 56 | Chapter 5: Reflections & Learning Chapter 5: Reflections & Learning | 57 • Disability, including intellectual disabilities, physical disabilities Consider loca- Location can im- Staff commented on the value of in situ simulations (simulations that • Gender, including transgender and non-binary people tions available pact staff engage- took place in actual clinical environments staff would usually work in) • Sexuality ment in simulation. when this was possible to facilitate. • Ethnicity, including minority ethnic groups such as Irish Travellers, Roma, and First Nations peoples in the Americas Avoid using spaces usually used for staff breaks/rest for simulation. • Age, particularly older people Consider re- Reflective practice Promoting staff reflection: In TS4TIC, simulations and debriefs focused • Religious minorities flective space may be a new and on the patient and staff experience. Staff were asked to reflect on their • Immigrants, refugees, and asylum seekers at times, unsettling stress responses during the simulation, as well as that of the patient. experience for This provided a deeper understanding of their own experience, how Case Example: staff this impacted their interactions, and increased their understanding of the patient experience. Be aware that this may be a new experience for In TS4TIC, a scenario was designed that asked a Nigerian actor to many healthcare staff, many of whom may have little opportunity to avoid eye contact with staff. This was one of the indicators displaying learn or use reflective skills. Ensure that time and space is provided for hypoarousal. The Nigerian actor had not been part of the co-design. this. When presented with the scenario she advised that direct eye contact is considered a sign of disrespect in some contexts in Nigeria. She Routinely provide access to employee support or counselling services advised that avoiding eye contact in this scenario was culturally appro- in simulation. priate. Consider how Debriefing can Conversations may develop in simulation about wider departmental This highlighted a failure to adequately co-produce the scenario with simulation open sensitive and and organisational culture. Staff may share examples of where TIC all relevant stakeholders. The scenario was subsequently revised. can prompt uncomfortable practice was and was not valued and the subsequent impact on patient reflection on discussions, which care. There may be aspects of an organisations’ patient or staff identity that organisational if poorly facilitated, have not been referenced in this toolkit, and they should be considered culture could impact upon Facilitators should, when possible, encourage learners to lead the dis- in the co-design of simulation scenarios as well. staff. cussion in debriefing, paying due regard to the psychological safety of all participants. Some staff may question the usefulness of the trau- ma-informed principles in practice. In the TS4TIC pilot, other partici- Table 5.3 Learning From Running Simulations pants often successfully addressed this without facilitator intervention. Additional tools are available to assist the facilitator. Learning Point Risk Solution Consider the Inaccessible ma- Ensure any materials provided, including information leaflets, consent Silent Trauma: Simulations may also identify silent trauma in the accessibility of terials can deter or evaluation forms (if relevant) are written in simple, accessible lan- workplace environment. Simulation can identify areas where staff, materials used. participation. guage. their teams or an organisation as a whole require further support and/ or education. This can be particularly the case in terms of the inter- It was clear in TS4TIC that the use of complex language or jargon can sectionality of identity and issues that arise as a result of a patient or undermine the psychological safety of participants before the simula- professional’s gender, race, sex, disability, class, religion, ethnicity, etc. tion begins. This is a sensitive discussion that needs to be skilfully facilitated. It is important to be aware that staff language and literacy skills may Case Example: vary and plan accordingly. During scenario design, some ethnic minority staff referenced racial Consider the Poor use of staff Simulations were run with staff with and without protected time in abuse from patients as a source of trauma. Simulations recreated some best use of time can deter TS4TIC. Simulations were significantly more efficient and effective of the common scenarios involving racist abuse perpetrated by pa- staff time. participation. when staff had protected time away from ward/departmental respon- tients. A hyper aroused ‘patient’ in the simulation was racially abusive. sibilities. This allowed them to participate and engage in simulations. This was then explored in debriefing. It was clear that in the simulation, Staff were visibly more relaxed and engaged. there was uncertainty and silence about how to respond to the patient. In debriefing, ethnic minority staff shared their racial trauma, in light In general, simulations lasted up to 45 minutes. of the abuse and the silence of the healthcare system in the face of abuse. White staff members discussed their sense of helplessness, 58 | Chapter 5: Reflections & Learning Chapter 5: Reflections & Learning | 59 shame, and lack of skills in responding to racial abuse targeting a Table 5.4 Learning after Simulations colleague. This was a very powerful simulation. Many staff members had worked within the hospital for decades and advised that simulation Learning Point Risk Solution provided the first opportunity to discuss racial trauma in the workplace Importance Dissemination of the findings and recommendations to key stake- and to consider recommendations for system change. of promoting holders in the system takes place after simulation. It is important to co-production emphasise the importance of ongoing co-production to ensure that the It is important to routinely provide contact details for employee sup- system re- participants who proposed a recommendation or raised concerns are port/counselling services in every simulation. The facilitator should sponses part of the solution-finding process. Participants are likely to be dis- acknowledge the sensitive nature of discussions and normalise this heartened if they share learning in simulation and do not receive further may be unsettling for staff. communication from the wider system on these issues. Follow-up with If an organisation carries out follow-up interviews/surveys, the impact It is important that following the identification of silent trauma, the participants is of TS4TIC may be captured. In the absence of this, informal follow-up system responds in a way that places co-production and healing at invaluable. can provide powerful testimony of the direct impact of TS4TIC. This the heart of their response. In the case example above, the hospital often helps key leaders in the organisation to recognise the benefit of responded by arranging listening exercises to better understand staff TS4TIC. concerns and is co-producing an anti-racism policy with staff. Pay attention Breaches in Psy- Psychological Safety: Psychological safety was enhanced by the condi- Case Example: to Psychologi- chological Safety tions set out in Chapter 4. This was fostered by reminding participants cal Safety undermine simula- that healthcare staff typically have very little opportunity to reflect or The TS4TIC were asked to design a scenario focused on staff respons- tion experience learn about interactions with patients. The expectation that everyone es when patients used drugs or alcohol in an acute medical ward. In may learn something, regardless of their role or grade helped to flat- co-production, staff and managers reported that such incidents were ten hierarchies or address power dynamics in the room. This helped stressful for patients and staff. TS4TIC ran a simulation in which staff the simulation feel like a safe space. Be aware that some participants worked with a hypo-aroused patient who had used drugs on the ward. may wish to withdraw from the simulation. It is important to ensure all Staff reflected on their own experience and that of the patient in de- participants, including any who may withdraw are provided with access briefing. Practices aligning with the principles of TIC were discussed. to contact details for employee support and counselling services. One week later, the Project Lead contacted the ward manager. She Equally acknowledging and exploring breaches of psychological safety advised that since simulation, staff intentionally and successfully used is vital. the principles of TIC to work with a patient who was struggling to man- age addiction on the ward. Create reflec- Failure to reflect A novice facilitator worked in TS4TIC. The facilitator’s performance tive space may limit the noticeably improved with facilitation experience and with accredited Ensure clear Weak dissemina- Dissemination provides an opportunity to promote and share findings for facilitator development of training in TIC. It is advisable to invest in quality and accredited trau- pathways for tion may under- from TS4TIC. Adequate planning ensures all relevant stakeholders sup- learning facilitation skills. ma-informed training to develop internal content expertise. dissemination mine the effective- port the dissemination of the project in and outside of the organisation. are established ness of TS4TIC. Additionally, facilitators should use reflective practice tools to support at the outset of Dissemination usually leads to additional interest in the project and critical thinking about their skillset. Recording and listening back to the project. requests for simulations from new areas. This is in itself, a valuable op- sessions, and asking for a more experienced facilitator to observe sim- portunity to identify project champions, in staff members spearheading ulations may also prove helpful. TS4TIC in their departments. Relationship building is a key ingredient to the success of TS4TIC. Dissemination supports maintaining and Facilitators may encounter stereotypes and misconceptions in their de- developing relationships across the organisation. briefing sessions. Discussions of how, gender, ethnicity, class, disabili- ty, religion, and/or sexuality may arise in simulations. Facilitators need In-person and online events offer valuable opportunities to disseminate to explore stereotypes surrounding these topics in a way that respects and share experiences internally and externally. Dissemination can take participants’ psychological safety while also addressing any bias they place: may have. • At the local level in healthcare service 60 | Chapter 5: Reflections & Learning Chapter 5: Reflections & Learning | 61 • At the regional level in the healthcare sector • At national level with health service senior management or national stakeholders • At the research level with academic partners. Simulation places language and value on existing practices that align with the principles of TIC. Staff often feel empowered when practices that build safety, trust, empowerment, collaboration, cultural sensitiv- ities, and peer support in patients are named as valuable skills. It may also open up discussions that may be uncomfortable. Summary Mapping learning from outset through to completion of simulation is essential in TS4TIC. Use of PDSA cycles supports iterative learning which in turn, promotes quality and development of simula- tions. Organisations should promote a reflective practice approach throughout TS4TIC to ensure that adequate space is given to critically think about the learning underway. MEASUREMENT & EVALUATION 64 | Chapter 6: Meaurement & Evaluation Chapter 6: Meaurement & Evaluation | 65 surement & evaluation can allow organisations to Practices and gain a multi-faceted understanding of the impact of To identify current processes and practices that are considered consistent or inconsistent Processes TS4TIC. with the principles of TIC. Policies and To develop new policies and procedures for implementing TS4TIC and to improve existing Individual organisations may choose to adapt or Procedures policies and procedures e.g., ensure that policies for the development of patient-facing develop measurement and evaluation tools in their information advise that all information is communicated in a trauma-informed way Measurement and evaluation are key to ensure that setting. Environment To ensure that all patients accessing care feel they are entering a safe environment the development and implementation of TS4TIC is of benefit to an organisation, staff, and service users. Measurement and monitoring of TS4TIC can help In designing objectives, organisations should aim to uncover for whom and in what context TS4TIC works create objectives that are specific in their description, When monitoring progress, the first step is to de- (or does not work). The continuous use of evidence to realistic in their achievability given the context, and fine the goal an organisation hopes to achieve by determine whether, and if so how, simulation ap- observable in a way that allows for clear and measur- implementing the TS4TIC approach. In other words, proaches should be used to promote the use of more able assessment. ‘what is it we are trying to achieve?’. The answer to TIC approaches and/or improve the quality and safety this question will help an organisation to outline the of existing care is important. Table 6.2 Examples of objective design specific goals or objectives for TS4TIC. This is the first step in the measurement and evaluation pro- Objectives It is important to note at the outset that measurement should be: Definition Example cess. For example, a common goal for organisations and evaluation in the field of trauma informed care conducting TS4TIC might be ‘to improve care team Specific The objective is clearly defined Instead of “to reduce the negative interpersonal interac- in healthcare is challenging. Trauma experiences of confidence in applying trauma-informed principles’. and precise in what it is trying to tions between care team and patients accessing care” staff and patients are individual and changes in ex- achieve. a more specific objective would be “to improve inter- periences may be difficult to quantify. It may initially Thinking Collaboratively personal interactions between care team and patients appear to be challenging to demonstrate a direct re- turn to management, which is why a range of metrics As different stakeholders might prioritise different accessing care in X department by half within the next year.” should be selected and analysed together. objectives, it is worth agreeing multiple goals or objectives together. As a first step to help co-design Realistic The objective is achievable and If resources are limited, setting a realistic objective might Qualitative feedback, i.e., analysing debrief tran- a measurement and evaluation approach, an organ- feasible within the given con- be ’to reduce the negative interpersonal interactions scripts, facilitator notes, performing follow-up inter- isation should consider what they hope to achieve text, resources, and time frame. between care team and patients accessing care by a third views with participants, should form a central part across different aspects of the health system (e.g., Objectives are challenging, but within the next two years‘, rather than an overly ambi- of a measurement & evaluation plan. Qualitative among patients, care teams, within service delivery, attainable. tious goal that may not be achievable. data can provide a richness and depth to the effects practices and processes, policies and existing proce- Observable The ability to measure and An observable indicator for a large urban hospital could of TS4TIC on staff’s practice or on the system that dures). assess progress using clear and be “increase staff knowledge of psychological trauma quantitative measurement cannot always access. It measurable indicators (see Step and its effects on patients”, as this can be more readily can be difficult to gather data in healthcare settings. Table 6.1 provides some additional examples of dif- 2 - Identifying Indicators). measured through simulation exit questionnaires. As such, relying on a wide variety of types of mea- ferent types of objectives: Table 6.1 Example objectives for TS4TIC What are we hoping to achieve? Area of the Health System Objective Once an organisation knows what it wants to achieve, Patient objectives can be set out. Organisations must de- To improve the quality of interpersonal interactions between healthcare providers and people cide ‘how’ they will know if what has been set out to accessing care from a TIC perspective. be achieved has been accomplished. Indicators are Care Team To improve the care team’s confidence in applying trauma-informed principles. those changes that organisations expect to see or what will be observable once objective(s) is/are met. To regularly use simulation approaches for TIC as part of ongoing learning for the care team. Here, organisations ask, ‘what sort of changes might we observe in the case where we have successfully To improve the care team’s knowledge of the effects and manifestations of trauma. achieved our objective(s)?’. 66 | Chapter 6: Meaurement & Evaluation Chapter 6: Meaurement & Evaluation | 67 Thinking of the answers to these questions, and able account as to whether that objective has been simulations (process measure). continuing the previous example, organisations might achieved. • Care teams actively seek to have simulations take place in their ask, ‘what do we expect to see that would indicate work area (balancing measure). that care teams are more confident in applying trau- These indicators may cover the process of imple- ma-informed principles?’. When designing indicators menting TS4TIC (e.g., how many care team members Care Team To improve the An increase in the: organisations will also want to consider: took part in simulations??); the outcome of imple- care team’s knowl- • Percentage of total relevant hospital staff who when asked cor- menting TS4TIC (e.g., did TS4TIC lead to a reduction edge of the effects rectly identify the widespread nature of trauma within the general • Among whom a change might be observed? (e.g., in negative interpersonal interactions between care and manifestations population (outcome measure) patients, care team) teams and patients accessing care?) and any knock- of trauma. • Percentage of total relevant hospital staff who when asked correct- on effects or consequences of implementing TS4TIC. ly list four common trauma responses (outcome measure) • Whether it is realistic for this change to be ob- The latter are called balancing indicators (e.g., does Practices and To identify current • Identification of examples of current work practices and processes served and, if so, investing time and resources in TS4TIC in one de- processes practices that are identified as a source of potential harm to patients or staff (process partment result in unintended negative consequences considered incon- measure) • How might this change be observed? (e.g., an elsewhere?). sistent with the • Suggested changes to current practices and processes in order to increase or decrease in numbers, percentage, principles of TIC. make them more trauma-informed (process measure) average, number of, etc.; listing of examples) See expanded Table 6.3 as an example, below: Policies and To ensure that all • Patient-facing documents, hospital signs, videos, and forms re- Procedures patient-facing vised to include more trauma-informed language (process/balanc- It is recommended to use several indicators that, information is ing measure) when considered together, will offer a more reli- communicated in • Number of changes to policies or procedures to make them more a trauma-informed trauma-informed (outcome measure) Table 6.3 Example of Indicators of Success for TS4TIC way What are we hoping to Environment To ensure that all Identification of aspects of the physical environment (e.g., excessive achieve? How will we know when this has been achieved? patients accessing noise, confined spaces) that are considered inconsistent with the prin- care feel they are ciples of TIC (outcome measure) Area of the Health System Sample Objective Sample Indicators entering a safe environment. Patient To reduce the negative Care teams can cite examples of positive interactions with pa- interpersonal inter- tients as a result of applying the skills they acquired through actions between care the simulation in post-simulation interviews (outcome mea- Developed as part of TS4TIC, Appendix F: Compendi- ation, an example of which is generated here as a teams and patients sure). um of Indicators lays out several indicators organisa- result of following the steps provided (See Table 6.4). accessing care. tions may want to consider, along with some exam- ples of tools that can be used to assess how each of Care Team To improve care teams’ Increase in the percentage of care teams members who, after these indicators could be measured. confidence in apply- taking part in the simulations, report they can “somewhat” or ing trauma-informed “very” confidently: principles • Adjust their ways of working to make all types of patients feel safe, regardless of their actions (outcome measure). • Build trust with all types of patients, regardless of their actions (outcome measure). • Be fully transparent with patients (e.g. about wait times) (outcome measure) Next, make sure to consider ‘when’, ‘where’, and ‘how’ • Collaborate and encourage patients to participate in their organisations will obtain the information needed to own care (outcome measure) measure indicators. This is otherwise known as the Care Team To regularly use simu- • Total number of unique care team members who actively Means of Verification. Organisations may also want lation approaches for participate in the design of the scenarios (process mea- to indicate ‘who’ (e.g., facilitator, researcher) will be TIC as part of ongoing sure). responsible for each of these indicators throughout learning for hospital • Total number of unique care team members who regularly the implementation of the simulations. Together, this staff. attend simulations (process measure). information can assist organisations to put together a • Total number of departments with staff represented within Measurement and Evaluating Table for implement- 68 | Chapter 6: Meaurement & Evaluation Chapter 6: Meaurement & Evaluation | 69 Table 6.4 Use of the Means of Verification in TS4TIC Care Team To improve the An increase in the: Pre- and post-training surveys care team’s • Percentage of total relevant hos- using measures of confidence What are we hop- How will we know when this has How, where, and when will I knowledge of pital staff who correctly identify adapted for the principles of trau- ing to achieve? been achieved? source this information? the effects and the prevalence of trauma within ma-informed care. Area of the Sample Objective Sample Indicators Means of Verification manifestations of the general population (outcome Health System trauma. measure) Pre-training surveys completed Patient To reduce the Decrease in the % of patients exiting Exit Surveys with patients con- • Percentage of total relevant online or in in-person within a negative interper- the service that report a negative ducted within the hospital at time hospital staff who correctly list week prior to their participation in sonal interactions interaction(s) with care teams (out- of discharge four common trauma responses the first simulation. between care come measure). (outcome measure) teams and pa- Follow-up interviews with care Post-training completed online tients accessing Care teams can cite examples of teams who have participated in or in in-person within a week care. positive interactions with patients one (or more) simulations (see after their participation in the first as a result of applying the skills they Compendium of Interview Guide). simulation, and again six-months acquired through the simulation afterwards. (outcome measure). Practices and To identify current • Examples of current work prac- List or accounts of the different Care Team To improve hospi- Increase in the % of care teams who, Pre- and post-training surveys processes practices that are tices and processes identified as examples of current practices tal staff’s confi- after taking part in the simulations, using measures of confidence considered incon- a source of potential harm to pa- identified by simulation partici- dence in applying report they can “somewhat” or adapted for the principles of trau- sistent with the tients or staff (process measure) pants during debriefing as poten- the trauma-in- “very” confidently: ma-informed care. principles of TIC. • Suggested changes to current tially stressful to patients and/or formed principles • Adjust their ways of working to practices and processes in order staff. make all types of patients feel Pre-training surveys completed to make them more trauma-in- safe, regardless of their actions online or in in-person within a formed (process measure) List or accounts of the different (outcome measure). week prior to their participation in economic, political, and social • Build trust with all types of the first simulation. barriers to implementing sim- patients, regardless of their ulation for TIC, as identified by actions. (outcome measure). Post-training completed online simulation participants during • Be fully transparent with pa- or in in-person within a week debriefing or during follow-up in- tients (e.g. about wait times). after their participation in the first terviews with staff who took part (outcome measure) simulation, and again six-months in the simulation. • Collaborate and encourage pa- afterwards. tients to participate in their own List of suggested changes to care. (outcome measure) current practices identified by Care Team To regularly use • Total number of unique care Scenario design workshop and simulation participants during simulation ap- team members who actively simulation attendance records. debriefing and during follow-up proaches for TIC participate in the design of the interviews with staff who took as part of ongoing scenarios (process measure). Attendance records should reflect part in the simulation. learning for hospi- • Total number of unique care which department(s) participants Policies and To ensure that all • Patient-facing documents, List of documents, hospital signs, tal staff. team members who regularly belong to. Procedures patient-facing hospital signs, videos, and forms videos, and forms revised to attend simulations (process information is revised to include more trau- include more trauma-informed measure). Number of requests received for communicated ma-informed language (pro- language. • Total number of departments simulation to take place (by work in a trauma-in- cess/balancing measure) represented within simulations area). formed way • Number of changes to policy or (process measure). procedures (outcome measure) • Care teams actively seek to have simulations take place in their work area (balancing measure). 70 | Chapter 6: Meaurement & Evaluation Chapter 6: Meaurement & Evaluation | 71 Environment To ensure that all Identification of aspects of the Improvements to physical areas Related to “Compare Across Cases”, above, data Organisations need to establish governance arrange- patients access- physical environment (e.g., exces- made as a result of introducing disaggregation refers to breaking down data into ments for supporting TS4TIC implementation and the ing care feel they sive noise, confined spaces) that TS4TIC different categories (i.e., males and females, disabili- EAG can assist with this. It is important to present are entering a are considered inconsistent with the ty group, age group) and analysing different patterns results and information in a way that is meaningful safe environment. principles of TIC (outcome measure) between them. This process is considered essential to different groups of people - e.g. frontline staff; for understanding how different sub-groups respond Board members; patients and their families/carers. to the introduction of the simulations. It’s also im- There are different approaches and formats that are portant for identifying and understanding how differ- more suited to each group. Patient and staff stories For qualitative data, organisations may wish to: ent categories of individuals are differentially affected can be a very powerful way to convey the benefits by existing processes and practices. of an approach like TS4TIC. There is a rule of thumb 1. Conduct a Content Analysis: Conduct a content Organisations must come up with a systematic plan, in improvement work however that we merge these analysis to explore the frequency and prominence or approach, to analyse the data collected through a stories with good data plotted over time - ‘No Stories of specific words, phrases, or concepts within the means of verification (e.g., via surveys, observations, Without Data, No Data Without Stories.’ qualitative descriptions. This can provide insights follow-up interviews). Known as an analytical strate- into key themes. gy, organisations might need to consider different ap- proaches depending on whether the indicators centre 2. Conduct a Thematic Analysis: Identify and around numbers (e.g., total or average numbers, per- analyse recurring themes within the qualitative centages - quantitative data) or around descriptions Keeping track of the data over time is essential to descriptions by assigning labels or categories to (e.g., examples, accounts - qualitative data). show that changes organisations make with TS4TIC common themes or concepts present in the qual- have been an improvement to the service. There are itative data. Group similar descriptions together For quantitative data, organisations may wish to: many excellent guides available on measurement and to uncover patterns or trends to present results monitoring for improvement to help plot data over back in a more understandable way (see Step 5: 1. Identify Trends and Patterns: Examine the nu- time to show any trends in how implementing TS4TIC Presenting and Communicating Results) merical data to identify trends and patterns over is affecting a service. Quarterly reporting on these time. Use tools like run charts and graphs to visu- trends over time to the EAG would be recommended. 3. Triangulation with Quantitative Data: Combine alise trends in total or average numbers, percent- The EAG can help make sense of these trends and qualitative findings with quantitative data to ages, or other quantitative measures (see Step 5: best advise on where and how in the system any enrich the analysis. Triangulation involves com- Presenting and Communicating Results). further steps need to be taken to ensure that TS4TIC paring and contrasting results from different data interventions sustain. sources to enhance the validity and reliability of 2. Compare Against Benchmarks: Compare the the overall analysis. numerical indicators against the organisation’s predefined policies, benchmarks, strategic objec- 4. Contextual Understanding: Interpret the quali- tives, or standards. Assess whether the observed tative descriptions within their specific context. numbers align with expectations or if there are Consider the perspectives, experiences, and voic- important discrepancies that require attention. es represented in the qualitative data to inform a more nuanced analysis. 3. Conduct Statistical Analysis: Statistical meth- ods can include calculating averages, standard 5. Compare Across Cases: If applicable, compare Summary deviations, correlations, or conducting inferential qualitative descriptions across different cases or statistics (e.g., Chi-Square analysis to compare groups. Identify similarities and differences in the This chapter describes how an organisation can identify a number of indicators of success for its changes in percentages or mean testing (e.g., narratives to gain a deeper understanding of the evaluation of TS4TIC. By the end of this chapter, an organisation will have a better understanding of: t-Tests, ANOVAs to compare mean knowledge or context. confidence scores pre-post training) in order to • Why the measurement & evaluation of TS4TIC is a necessary part of the process. identify significant relationships or differences. • How to set measurement & evaluation goals. • Identifying indicators of TS4TIC’s success that fit the organisation. • How to analyse the data gathered. 72 | Future Horizons Appendices | 73 Future Horizons Appendices TS4TIC offers healthcare organisations a valuable op- portunity to use transformative simulation method- Appendix A - Sample TS4TIC Timeline and Roadmap ology to identify and place value on practices aligned with trauma-informed care in their setting. It also af- fords an opportunity to provide quality improvement recommendations from frontline staff about common hospital experiences, to the wider system. TS4TIC is one tool of many tools which may be used to introduce or explore the principles of trauma-in- formed care in healthcare settings. While simulations were used in TS4TIC to explore interactions between staff and patients, organisations could use simula- tion to explore other relationships. The use of trau- ma-informed principles in recruitment, induction, in interactions between patients, staff, visitors, between colleagues, team meetings etc. could all potentially be explored in simulation. TS4TIC is a collaborative project, emphasising co-production and co-creation at every step. It is vital that organisations embed this philosophy in their Appendix B: PEARLS Tool/Facilitation Guidance approach to TS4TIC. PEARLS HEALTHCARE DEBRIEFING TOOL: As mentioned at the outset this toolkit is not a roadmap to becoming a fully trauma informed organ- Scenario: Jack is a patient who attended an Emergency Department with chronic back pain and is for discharge isation. That process requires entire system change with follow up referral to his primary physician. and investment which was beyond the scope of this project. Interested organisations should consider Trauma History: As an Irish Traveller, Jack is a member of an ethnic minority who has experienced marginalisa- how best to progress TS4TIC within their setting. This tion and social exclusion throughout his life. Jack grew up in foster care and felt very little control and choice toolkit strongly recommends using accredited train- in his life. He experienced developmental trauma as he experienced emotional neglect and physical abuse and ing programmes and developing in-house expertise was often abandoned by his primary caregivers. Jack often felt unseen, ignored, excluded and unsafe. to progress any aspect of TS4TIC. Trigger in Hospital Environment: Jack was told upon arrival to hospital that the Emergency Dept couldn’t help TS4TIC does deliver an innovative cost effective way him. Jack feels helpless and unsafe and becomes hyper aroused, in red zone and fight mode. to explore the principles of TIC (which align with ex- isting good practice in many organisations), in a way Background: During the simulation, the facilitator observes skills related to the principles of trust, choice and which can transform staff and patient experiences safety in this simulation. and deliver recommendations for quality improve- ment. Stage Tasks Sample Phrases Facilitator Skills It is our hope it provides a pathway to transform care Reaction Explore initial feelings/ Any initial reactions or Validate discomfort when and experiences in your organisation. emotions. Identify thoughts? working at the edge of ex- and acknowledge the pertise/comfort zone. learner agenda. Sum- How are you feeling now the marise key themes. simulation is over? ‘We don’t often get the op- portunity to reflect on some 74 | Appendices Appendices | 75 What are your first thoughts on of the common experiences he wanted to discuss this at the what you just saw/participated in our job and it can be a nurse station or move to private in? little uncomfortable when office. She also asked if there was we do.’ anyone he would like to call and have someone on speakerphone to Show genuine interest in support him (ask the actor to share the experience and per- experience if needed). spective of participants. Check in on whether sim- The facilitator can share observa- ulation was realistic from tions ‘I noticed the patient relaxed participants perspective when you used open body lan- - how close to reality was guage and a calm tone.’ that, if you had to score from 1 -10? Facilitator can share point of view ‘Watching Patient X become so If not realistic, acknowledge frustrated when the office was this, welcome feedback and repeatedly interrupted, got me explore the reasons why. thinking about how our physical Description Revisits the agreed Can one of you share one or Facilitator may describe environment can impact our ability purpose of simulation two sentences just summaris- what they saw. ‘Okay, so to connect with people’ to ensure everyone ing what the staff member was just a reminder, the team shares the same un- asked to do? were asked to work with a Facilitator can inquire: How did you derstanding. patient with psychological see it? What was going through trauma who feels under your mind when he began to shout threat and is in the red zone and Staff A stepped back? or fight/flight or blue zone or freeze mode (refer to Facilitator can clarify the rationale visual aid if available). of the participant ‘From what I am Analysis Select a focus for At this point, I would like to What worked well and why? hearing, when the patient became learning – select per- switch gears and discuss critical of your colleague, you felt formance domain/gap. whether Jack felt safe, under- What aspects would you defensive. What was going on stood, empowered or a sense of change and why? for you? What zone were you in? control in what was happening. Where was he? Can I just bring us back to the It is always preferable to start when Jack started to share encourage participants to So you decided to raise your voice his concerns about discharge share reflections and lead to warn him that you would not spoke, what did the group notice discussion themselves. tolerate any more of his behaviour. about Staff Member A’s re- You did this as you felt it would sponse? What worked well and If required, the facilitator stop him. Is that right? Did that why? What aspect might you can provide specific feed- help? No… so let’s explore why… change and why? back on use of TIC skills/ less helpful skills: I noticed The facilitator can close perfor- What type of body language Staff A introduced herself mance gaps: asking next time what best supports building trust and and used very open body might a staff member in a similar a sense of safety with patients language and conveyed a situation do differently next time? when they are in the red zone or genuine interest in what fight/flight mode? Jack was saying her, she Can I ask the group for potential offered choice and asked if suggestions to this problem? 76 | Appendices Appendices | 77 Actor Reveal Actor reveals a trauma Actor X -Can you share with us Facilitator can explore the ing choice (or acknowledg- experience which led what has happened in the life of exposure to trauma (mul- ing that we wish we could to the patient’s trauma (name character) to cause him tiple/repeat) and the likely offer choice) are all helpful response in simulation. to react that way? impact on Jack. practices. By contrast, when we use defensive or At this stage, the actor reveals closed body language, use Jack’s trauma history. The our power in a very authori- TS4TIC pilot used an actor who tative, almost parental way, was also an Irish traveller who i.e., ‘Don’t curse at me, I had experienced social exclu- won’t tolerate/accept’, the sion and revealed this. The group feel those are less reveal provided by an actor with helpful practices. lived experience of trauma was Final Tasks Facilitators should end very powerful. simulation by directing Ask about Take Facilitator summarises Can you share whether what you Summarise feedback from participants to further Home Messages messages to take from experienced today will influence group - I hear that you feel resources, signpost simulation to 1) patient patient care and how? this will help you see the to further training in care and 2) inform patient’s behaviour in a new organisation or pro- system change Imagine you worked in a per- way, and that your focus vide information on fect hospital on a perfect day may be on helping them feel additional resources, and you were able to work with safer, rather than reacting including TIC com- patients in this way all of the to their behaviour.’ munity champions in time, what would have changed organisation, etc. to help you do that? ‘I hear you feel more educa- tion, time and safer staffing The facilitator should levels would help.’ provide information on Summarise Facilitator sums up key Can someone share a summary Learner led: Where the employee counselling learning of learning today? participants summarise key supports if available learning and encourage staff to In my opinion, the key take use as needed. home messages from this simu- Facilitator led: So what I lation are. am hearing is that when we If available, refresh- show respect and a will- ments or a few mo- ingness to listen through ments to connect our verbal and non verbal should be provided to language, when we try and participants at the end offer choice, or at least ac- of debrief. knowledge we would like to offer choice but are limited Appendix C: Actor Guidance in the space that we have, when we stay in a calm STAFF ACTOR RESOURCE: space ourselves and avoid raising our voice, when we Introduction: are genuinely interested in what a patient has to say, This resource is intended to support healthcare staff who participate in the TS4TIC simulation as staff actors. patients feel safer in our ex- Staff actors portray patients with psychological trauma who experience a trauma reaction in the healthcare perience. So building trust, setting. This resource will explain the role of actors in TS4TIC simulations, as well as provide guidance on how a sense of safety and offer- actors can prepare and provide believable portrayals of patients. 78 | Appendices Appendices | 79 An actor will be required: In TS4TIC Simulation: • To complete introductory training to TIC. Depending on the setting, this may be internal, external or online Before any TS4TIC simulation, each actor will be given a patient case study to rehearse and prepare. This case training. study will contain the following background information about your character: • ●To work with the facilitator on scenario design in advance of simulation. • A brief description of the patient and their reason(s) for visiting the hospital. • To act as a patient with psychological trauma in simulation. The patient is experiencing hyper arousal • A description of the patient’s trauma trigger and how the character will behave or respond if they leave their (fight/flight) or hypo arousal (freeze) in response to something in the healthcare setting. green zone. • ●To offer reflections from a patient’s perspective on their experience and/or their reaction or response to the • ●The patient’s behaviour and the intended outcome to simulation if a participant offers a trauma-informed approach or communication style used by participants in the TS4TIC simulation exercise. response or a non-trauma-informed response when engaging with the patient. • ●To participate as an actor in debriefing/reflection exercises, led by the facilitator, to improve the simulation Once the actor has reviewed this case study, they should take an opportunity to discuss any questions or exercise or experience for participants in the future. concerns about the patient or portrayal of this character with the Facilitator. An example of a patient case study from the TS4TIC simulation exercise is attached as an appendix to this resource. Skills and Experience: Rehearsal and practicing the simulation: • Acting Skills and Experience: Acting abilities or experienced public speaker with the capacity to realistically embody characters (i.e., patients), including the portrayal of trauma responses, symptoms, and emotional An ideal way to prepare for the TS4TIC simulation is to observe another simulation with an actor, especially if triggers. this is your first time. Another way to prepare is rehearse and gather feedback from peers about the believabil- ity of the performance. Some actors may wish to invent some background details (i.e., why they have come to • Empathy: The ability to convey a sense of realism and empathy in portraying patient experiences, contribut- the hospital, a past traumatic experience, etc.) to help make this portrayal more believable or convincing, or to ing to a more immersive learning environment. These portrayals are meant to be realistic, and not meant to elaborate on the information that actors have been given. exaggerate or misrepresent people who have past traumatic experiences. Some useful tips to help when an actor is preparing are to: • Communication Skills: Effective and confident communicator comfortable speaking and working with healthcare staff and practitioners in a manner consistent with the character. • Speak comfortably and clearly • ●Emotional Range: Portray a broad spectrum of emotions, from calm and cooperative to distressed or agitat- • ●Explore your emotional range by practicing the trauma reaction in different ways ed, and prepared to challenge participants or appear confrontational when simulating patient encounters. • ●When rehearsing, film yourself or record your voice to get an impression of the performance • Adaptability: To work with the facilitator to be flexible and adaptive to changes in scenarios, instructions, or improvisational elements to ensure the simulation aligns with the learning objectives for participants. Discuss characters that each actor is comfortable and suitable to play: • ●Feedback: Provide constructive feedback to participants, emphasizing the interpersonal aspects of their Not everyone can realistically play all characters. Be open to having a discussion with the facilitator about performance during debrief / reflection exercise. Also, it is expected that actors will share feedback or com- which staff actors would feel more comfortable or be suitable to play certain patients or incorporating specif- ments from the perspective of their character, and not necessarily as a professional working in a hospital ic trauma responses into their performance. Some other considerations might include, the staff actor’s age, setting. appearance, experience, or familiarity working with certain patient groups, and whether people feel personally comfortable with playing specific patient and/or patient issues. • ●Confidentiality: Maintain the confidentiality of simulation scenarios and discussions, respecting the sensi- tivity of simulations and the feedback shared by participants. It is important for staff actors to be mindful of their comfort level when portraying patients or their past trauma experiences. Staff actors must pay close attention to their mental wellbeing and any feelings of distress, which • ●Team Collaboration: Work with the team of facilitator, participants, and/or other actors to ensure seamless they could experience vicariously, and to raise any concerns about your self-care immediately with the Facilita- coordination and delivery of simulation exercises. tor. • ●Excellent Self Care: Actors need to be practiced in self-care and have a good toolkit for managing emotion- Costuming and Props: ally challenging stories and situations at work. Costumes and props can play an important role in helping actors get into character and making their perfor- 80 | Appendices Appendices | 81 mance more believable for the audience. Take time to consider your character’s outfit and appearance, so that it facilitate this discussion with participants. is authentic to the patient being portrayed. Having time to bring a prop, changing your hairstyle, or adding some makeup to a character can be helpful. Time and resources should be allocated for these steps when preparing This debriefing exercise is an integral part of the simulation, which invites reflection and discussion from the for simulation. group about the simulation they just watched. It is important to remember the simulation is not over, and there will be opportunity for an actor to receive feedback about their performance or its believability, after the partici- Getting into character pants have left. Before the start of the simulation, the staff actor should take some time or a private moment to focus and get During this debriefing exercise, you may be called upon by the Facilitator to: into character. This can range from actor to actor, and it might involve rehearsing lines, some physical activity to help keep your energy up, or watching a brief video or audio clip to help stay in character. • ●Explain what the trauma trigger, which led the patient to leave their window of tolerance. Simulating and Portraying a Patient • ●Offer perspective about why the patient may have reacted in certain ways, such as reacting to whether the participant used a trauma-informed response or a non-trauma-informed response. The staff actor’s goal is to make their performance authentic and believable for participants. Not everyone will feel this expectation was met after the simulation has ended, especially if this is your first time. With practice • Share some background details about the patient’s past trauma or the reasons they are attending the hospi- and time, staff actors will feel more comfortable in delivering their performance, as well as will receive feedback tal to give some background on the patient’s state of mind. from the Facilitator that will help actors to understand how their performance can be improved or what were some of the key strengths of their portrayal, when working with participants. When sharing information or details with participants, remember the staff actor’s role in the simulation is to support the participant. An actor should avoid sharing any professional insights or contribute to the discus- Improvisation and Being Flexible sion as a participant. Ultimately, an actor should be prepared to share information only when they have been prompted by the Facilitator. Each staff actor has different comfort levels with improvisation. When performing, an actor should be prepared to react in different ways, especially depending on whether a participant offers a trauma-informed response or a non-trauma-informed response in the simulation. With rehearsal and more experience participating in sim- AFTER A SIMULATION: ulations, an actor’s confidence in improvisation and comfort with displaying a range of emotional reactions or responses will develop over time. Feedback for Staff Actors on Performance and Authenticity Also, it is important to remember the simulation is not scripted, so staff actors should be prepared for partici- Save any questions or feedback for the Facilitator until the simulation has ended and the participants have left pants to react to the performance in unexpected and novel ways (i.e., offering reassurance to a patient, being the room. At this point, the staff actor will have a chance to talk about their experience. The actor will receive forceful, empathizing with a patient’s feelings, or asserting that certain rules or policies must be followed, etc). feedback from the Facilitator about ways they might improve their performance or the believability / authentici- ty of their patient performance. See Appendix 2. Managing challenges of colleagues who know actors in professional roles Leaving your Role in the Room TS4TIC avoided using staff actors in simulations in their own departments. A staff actor may still encounter participants who they have worked with or will be on good terms with if involved in simulation elsewhere in the After the simulation has ended, the actor’s role has ended. Some useful exercises to help with leaving the role hospital. This can be difficult for an actor who is portraying a patient who appears aggressive, oppositional, are: verbally abusive or behaves in a challenging way. It is important to remember this is a simulation, where both the actor and the participant are encouraged to react in ways that are believable and authentic. • Going for a walk or doing some light physical activity At the start of the simulation, the Facilitator will introduce the exercise and outline how the simulation will run • Doing some mindfulness or breathing exercises for participants and the role of the actor. If it is appropriate, ask the Facilitator if it is okay to acknowledge the actor’s familiarity with the participants or whether this can be mentioned in the introduction, so that it is ac- • Speaking with a friend or close colleague cepted by the group. • ●Avoiding any stressful situations immediately after the simulation Offering perspective and feedback as the patient If a staff actor experiences any distress or discomfort from participating in the simulation, it is important you When the scene between an actor and participants has run its course, the Facilitator will invite both the actor raise this with the Facilitator, who will signpost them to appropriate support. and participant to take their seats. This will be followed by a debriefing which involves group discussion, ques- tions, and feedback. This exercise will be led by the Facilitator. It is not the actor’s responsibility to manage or 82 | Appendices Appendices | 83 Checking-In with Yourself Feedback Questions for Staff Actors: At the end of the simulation and after all participants have left, In the days following the simulation, it is a good idea to routinely check-in with yourself and whether it has the Facilitator may hold a brief round of feedback with the staff actor(s) about their experience and brought up any uncomfortable or distressing feelings. Some people might have trouble with putting the simula- the performance simulating a patient who experienced a trauma reaction. tion behind them, or it may have brought up difficult or troubling thoughts. These feelings may linger, and some people may notice they do not appear until days after the simulation has ended. If an actor notices any unusual 1. How did you feel interacting with participants? If you have any concerns, please explain. signs or symptoms, this should raise this with the Facilitator. 2. Did you feel confident interacting with participants and simulating a patient experiencing a trau- If a staff actor is no longer interested in participating in the simulations, bring this to the attention of the Facili- ma reaction? tator, so a new actor can be recruited in time for the next simulation. The psychological safety of all individuals involved in the simulation is a top priority. 3. What aspects of the simulation did staff actors find were most useful or engaging for partici- pants? Example of a Patient Case Study 4. What aspects of the simulation did staff actors find were most difficult or challenging for partici- pants? Wayne 5. In terms of performance, what would make this simulation more believable and authentic? Character Description: Wayne is a 50-year-old male who has spent much of his adult life in and out 6. What further training, experience or information would enhance your ability to simulate your role of prison. `The sterile smell of an Emergency Department and authority figures remind him of being in simulations? in prison. He has come to the Emergency Department complaining of abdominal pains. Wayne does not like the environment. Wayne wants to bring in a member of his family. 7. Do you have any feedback or suggestions? Note for Actor on Trauma Trigger: Wayne is at-risk of leaving his window of tolerance and going into a hyper aroused state when he feels that his actions or feelings are being controlled, a loss of per- sonal autonomy and/or choice, or if he feels unsafe. Appendix C: Sample Scenarios Wayne is uncomfortable around figures of authority. He hates being in hospital and is fearful he will As TS4TIC was developed in an acute urban hospital, scenarios were written for this setting, reflecting common be admitted. Wayne feels overwhelmed and does not fully understand what has been explained to experiences of patients and staff. Individual organisations must co-design their own scenarios. Each scenario him around his condition or plan for treatment. He does not trust doctors or nurses and wants his features background information known only to the actor. Information is provided to simulation participants family present to ask questions with him. When he finds it hard to verbalise his frustration, he can by the facilitator before simulation begins. In debriefing, after the group discussion, the facilitator invites the become loud and demanding. actor to share the background for the patient. This ‘reveal’ often allows participants to better understand the behaviours they witnessed. His way of dealing with difficult situations is to try and control outcomes, this can include becoming loud and domineering. SCENARIO 1: EMERGENCY DEPARTMENT - JOSEPH In the simulation, please remain in your window of tolerance in response to trauma sensitive cues Staff volunteers in this scenario may be a nurse, doctor, health and social care professional, health care assis- from staff members (i.e., you should build rapport, share information) and move outside your window tant etc. Staff volunteers may call on another colleague during simulation to assist, just as they would do in of tolerance in response to non-trauma sensitive cues from staff members, (i.e. choose hyper re- actual practice. sponses, such as raising your voice, showing anger or verbal aggression). Background for Actor: Joseph is an Irish Traveller who was removed from his family following allegations of Simulation Outcomes: neglect. He grew up in foster and residential care and had very little control in his life. Joseph has little trust in authority figures. He experiences discrimination due to his ethnicity and is regularly socially excluded. He pre- • If Staff provide mainly trauma sensitive response(s): Build relationship and stay sented to the Emergency Department with back pain and is being discharged. He is still in pain, feels he is being excluded as he is an Irish Traveller and he is in the red zone. • If Staff provide mainly non trauma sensitive response(s): Tell staff, you are going to a different hospital where you will be treated with respect (Irish Travellers are a recognised minority ethnic group in Ireland who were traditionally nomadic. Irish Travel- lers are subject to discrimination across many levels of Irish society, including education, housing and health- care. At time of publication, the life expectancy of Travellers was 65.9 years compared to 79.3 years in the 84 | Appendices Appendices | 85 general Irish population).55 Information provided to Staff: You have just received a handover. Joseph is a patient who presented with back explore how some of the ways we work with these patients may align with the principles of psycho- pain to the Emergency Dept. He has been discharged back to the care of his general practitioner and is shouting logical TIC and give us an opportunity to discuss the benefits or indeed the limitations of this ap- that he is not going to go. Please intervene. proach in our care setting. SCENARIO 2: SURGICAL WARD: MICHELLE I need to explain a few concepts. When I talk about Psychological Trauma, I am talking about the lasting harm which arises as a result of exposure to a single traumatic event such as a mugging/ This scenario can be used with doctors, nurses, physiotherapists, social workers, occupational therapists, assault/house-fire or from exposure to multiple traumatic events such as abuse or neglect in child- health care assistants etc. It could also be adapted for use with catering staff, hospital volunteers etc. hood, exposure to domestic violence, bereavement, homelessness, discrimination based on your race, age, gender or disability, fleeing war…the list is long so it isn’t surprising to hear that in some Background Information for Actor: Michelle is a 79 year old patient recovering from spinal surgery she sus- studies, 70% of the adult population have reported experiences of psychological trauma. tained in a cycling accident. Decades previously, Michelle grew up in a violent and chaotic home with little sense of safety. Michelle has had counselling throughout her life. She is retired from her successful busi- That means it is highly likely we encounter patients with psychological trauma every day. It is also nesswoman and enjoys being a grandmother. Michelle is overwhelmed by how she feels in the hospital. Being very likely we ourselves or our colleagues have experiences of psychological trauma which may dependent on others to meet her needs, in a loud and busy ward surrounded by strangers has overwhelmed her. impact how we relate to other people in certain situations. She dreads requiring any physical assistance, the thoughts of strangers touching her pushes her into the blue zone. For many people, they may have enough protective factors (i.e. a supportive adult in childhood, a support network during bereavement) in their lives to enable them to deal with their exposure to psy- Information provided to Staff: Michelle is not cooperative with any assistance required to mobilise or transfer chological trauma. For many others, they lack those protective factors and their exposure to psycho- her. She continuously tells staff that she does not need any assistance or is very withdrawn. Some of your col- logical trauma results in lasting harm, which changes the way they relate to the world, including the leagues have said she is unmotivated to help herself. Please intervene. ways they react to other people in certain situations. There are clear messages from neuroscience which shows that psychological trauma changes brain development and alters the way our nervous SCENARIO 3: MATERNITY WARD: LISA system reacts to events we perceive as stressful. People living with the lasting harm of psychological trauma may feel under threat on a very regular basis and more so than others, in certain situations. This scenario can be used with any healthcare worker in any role. What happens when we feel under threat? (It is helpful to introduce a visual aid such as thermometer of regulation here) We leave our green zone, which is a space where we feel safe, choice, calm and The actor is primed to avoid focusing on the clinical symptoms but rather indicate a lack of trust in the entire able to make good decisions. As stress develops, we may go into the red zone where our breath- system. Scenarios are designed to avoid focusing on clinical presentations but to encourage staff to engage ing and heart rate increases, where our muscles tighten and prepare for battle, where our thinking with the patient’s traumatic response to triggers in their environment. becomes rapid. This is fight or flight mode. We may go into the blue zone or freeze mode where our thinking and breathing and body slows and where we may feel an intense sense of dread and Background Information for Actor: Lisa is a pregnant Black woman admitted with high blood pressure. Her own shutdown/withdrawal. Sometimes in healthcare settings, behaviour from a patient reacting from a mother died in childbirth and she is keenly aware of higher rates of mortality and pregnancy complications genuine place of fear due to psychological trauma is reframed as challenging or difficult behaviour. experienced by Black women. Lisa has experienced discrimination and racism at various stages in her life and trauma-informed responses allow us to ‘tilt the lens’ on this and view behaviour in a different way. feels very unsafe in hospital care. She does not trust hospital staff to respond to her symptoms and fears for her unborn child. She is in the red zone. TIC is a skilled way of responding to people with experiences of psychological trauma. Many of the principles of TIC align with or overlap with existing good practice in healthcare and simulation pro- Information for Staff: You have just come on duty and have been advised that Lisa has been asking a lot of vides an opportunity for us to explore and consider how we might use these principles when working questions about her care overnight. Staff advised that Lisa appears to be easily irritated and doesn’t seem to be with patients with psychological trauma. listening despite the same answers being provided. She wants to speak to someone this morning. You need to see her this morning, please intervene. Our aim is to focus on recognising stress responses and responding to them using trauma-informed principles. Appendix E: Sample Prebrief Does anyone have any questions so far? ‘I am X and I am the facilitator here, thank you for making the time and effort to join this workshop. Some important housekeeping issues. We are using simulation today to explore how we work with patients who have experienced psycho- logical trauma. We will run a quick simulation and then I will facilitate a debrief. The debrief will I expect the simulation to last less than five minutes with a 20-30 minute debrief. Tailor the debrief 86 | Appendices Appendices | 87 time to match the available time). Afterwards we will have some refreshments/small break before member (as they would in a real-life situation) to approach with whom to share concerns in simula- returning to work. tion. Please silence phones/pagers/bleeps if possible. This is our actor X who will be playing our patient ‘Jack’ today. Jack will be playing a patient with Appendix F: Compendium of Indicators psychological trauma who is feeling threatened when he is asked to leave hospital and he is in ‘fight’ mode. There is no right or wrong way to engage with Jack and there is no guarantee you will be able STAFF OUTCOMES to resolve his concerns for him, so please just act as you would normally on a busy day in your area. Staff knowledge - Attitudes - Skillset Perhaps you are feeling full of energy at the start of your shift, perhaps you are distracted or feeling a little burned out today, just act as you normally would in those circumstances. Tool: ARTIC (Attitudes Related to Trauma-Informed Care) I see we have some managers in the room, it is important to remember that regardless of our roles Link to Tool: Licensed that most of us have never received any form of training in TIC (facilitator could ask for a hands up) and very little mentorship. Nobody here is an expert in this and we are all here to listen and learn Overview/Description: A validated tool used by organisations and service systems to measure staff attitudes from each other. This isn’t about our role within the organisation, it is about thinking about how we toward trauma-informed care. The ARCTIC Scale measures professional and paraprofessional attitudes to- connect with a fellow human who feels under threat and is in distress. It is also perfectly normal for ward TIC and has become a go-to measure for TIC program evaluation in a variety of settings, including: us to feel outside of our comfort zone stepping up to do this, so remember we are all here to back each other up. • Early childhood education/Head Start • Traditional K-12 school systems We have tried to make this space and scenario as realistic as possible. We all know this can’t repli- • ●Therapeutic schools cate reality on the wards, but I am asking everyone to suspend disbelief and bring as much energy • ●Child welfare systems and realism as you can to this simulation so that we can maximise learning to bring back out to our • ●Behavioural health systems patients and system. • ●Hospitals and health care systems • ●Juvenile justice systems I am recording this session today solely so that I can capture key learning. I am the only person who will have access to the recording. In debriefing, I will ask about what you all feel works well and what Peer Review Articles: Baker, C.N., Brown, S.M., Wilcox, P.D. et al. Development and Psychometric Evaluation of doesn’t work well in scenarios like the one we will play out here today. I will also ask what our organ- the Attitudes Related to Trauma-Informed Care (ARTIC) Scale. School Mental Health 8, 61–76 (2016). https:// isation needs to do to support you to work with patients who are in the red or blue zone. It is import- doi.org/10.1007/s12310-015-9161-0. https://link.springer.com/article/10.1007/s12310-015-9161-0 ant that we all trust one another to create a safe learning space and ensure that what happens in this room is confidential and stays in this room. Description: ARTIC-45, which includes 45 items and seven subscales (five core and two supplementary sub- Any questions?’ scales). Subscales are (a) underlying causes of problem behaviour and symptoms, (b) responses to problem behaviour and symptoms, (c) on-the-job behaviour, (d) self-efficacy at work, (e) reactions to the work, (f) Can I have a volunteer? Remember at any stage in the simulation you can call on another colleague personal support of TIC, and (g) system-wide support for TIC. Each of the five core subscales has seven to assist you if you run out of ideas or need help. You can also press the pause button and step out of items; each of the two supplementary subscales has five items. In line with our analytic plan, a 35-item form simulation at any stage. excluding the supplementary subscales and a 10-item short form including content from the core subscales were also created, respectively, called the ARCTIC-35 and the ARCTIC-10. All items are written at a sixth If nobody volunteers, reassure the room again that it is normal to feel slightly anxious and at the grade reading level as indicated by the Flesch-Kincaid Grade Level test. edge of their comfort zone and encourage people to consider participation. You can also point to the blue zone of the thermometer of regulation and remind staff that if they feel a sense of dread or Recommendations for use: We found the ARTIC-10 difficult to use with healthcare staff as a result of its lay- fear(as though participation in simulation is a threat), they themselves are feeling ‘freeze’ or if they out. Staff of all literacy and education levels found the layout confusing, and so we recommend adapting the Appewnadnitx t Eo :l eSaavem ‘pflilgeh Pt.r’ eTbhrisie isf an opportunity for staff to reflect on the fact that our body can react to ARTIC or choosing another scale to measure staff’s attitudes towards TIC. an event as though it is a real threat - something patients with psychological trauma may experience frequently. ‘I am X and I am the facilitator here, thank you for making the time and effort to join this workshop. Participant Target: Staff WIf eth aerree ucsoinntgi nsuimesu tlaot bioen a t ohdeasyit aton ceyx,p aldovreis heo twhe w pea wrtoicrikp awnitths tphaattie tnhtes awchtoor h caavne seexlpf-esreielenccte ad sptsayfcf ho- logical trauma. We will run a quick simulation and then I will facilitate a debrief. The debrief will Available languages: 8 languages (currently Spanish, French, Japanese, Farsi, and Dutch - with Turkish, Greek, and German in process) 88 | Appendices Appendices | 89 STAFF OUTCOMES Examples of use: Staff knowledge - Attitudes - Skillset Stokes, Y., Jacob, J. D., Squires, J., & Vandyk, A. (2020). Using the ARCTIC-35 to Measure Nurses’ Attitudes Related to Trauma-Informed Care. Journal of Nursing Measurement, 28(1), 185-199. Tool: Foundational Measure of TIC Knowledge Niimura, J., Nakanishi, M., Okumura, Y., Kawano, M., & Nishida, A. (2019). Effectiveness of 1●day trauma●in- formed care training programme on attitudes in psychiatric hospitals: A pre–post study. International journal Link to Tool (May require journal access) of mental health nursing, 28(4), 980-988. https://doi.org/10.1111/inm.12603 Overview/Description: The Foundational Measure of TIC Knowledge is a 30-item scale that measures staff’s knowledge of TIC. It measures staff’s knowledge across six topics: TIC implementation and principles; the STAFF OUTCOMES neurobiology of stress and trauma; Adverse Childhood Experiences (ACE) research; work-related stress and Staff knowledge - Attitudes - Skills trauma; systemic oppression and issues of power; and historical trauma including intergenerational transmis- sion Tool: TICOMETER Recommendations for use: The Foundational Measure of TIC Knowledge should be used to determine the lev- el of knowledge of TIC and trauma in your organisation before you begin, and can also be used as a method of Link to Tool: Licensed determining the success of TS4TIC and your staff’s learning about TIC through TS4TIC. Overview/Description: A brief assessment tool that can measure trauma-informed care (TIC) in health and Suitable for participants: Suitable for all staff human service organisations at a single point in time or repeatedly as well as determine training needs. Available languages: English The TICOMETER© measures the degree to which an organisation is engaged in trauma-informed practices. It evaluates needs and progress in implementing trauma-informed care and ensuring its sustainability. It is the first psychometrically validated instrument that measures the levels of trauma-informed care in health and STAFF WELLBEING human service organisations Tool: TISC-R Consisting of 35 items across five domains, the TICOMETER© assessment takes approximately 15 minutes for staff members to complete online and scores are available to the organisation immediately. The five do- Link to Tool (May require article purchase) mains include: Overview/Description: The TISC-R is a 10-item scale that measures the trauma-informed self-care practic- es used by healthcare workers. Each of the items are rated on a 5-point Likert scale from “Not at all” to “To • Building trauma-informed knowledge and skills a very great extent”. Sample items include “I seek continuing education on the effects of trauma on helping • ●Establishing trusting relationships professionals.”, “I utilise peer support.”, and “I have developed a written plan for myself that is focused on • ●Respecting service users work-life balance.” • ●Fostering trauma-informed service delivery • Promoting trauma-informed policies and procedures Recommendations for use: The TISC-R should be used alongside other measures to determine the level of need for self-care practices among staff. Using the TICOMETER© in less than 15 minutes, you can assess your organisation’s Suitable for participants: Suitable for all staff • Level of trauma-informed care • Staff training needs Available languages: English • ●Implementation priorities Examples of use: Used with child welfare workers (Salloum et al., 2018) Bassuk, E. L., Unick, G. J., Paquette, K., & Richard, M. K. (2017). Developing an instrument to measure organ- isational trauma-informed care in human services: The TICOMETER. Psychology of Violence, 7(1), 150–157. https://doi.org/10.1037/vio0000030 Unick GJ, Bassuk EL, Richard MK, Paquette K. Organisational trauma-informed care: Associations with indi- vidual and agency factors. Psychol Serv. 2019 Feb;16(1):134-142. doi: 10.1037/ser0000299. 90 | Appendices Appendices | 91 PATIENT OUTCOME ORGANISATIONAL OUTCOMES Tool: TIPS Link to Tool TS4TIC Interview Guide Overview/Description: The Trauma-Informed Practices Scale (TIPS) is a 20-item scale that measures how Link to Tool: Found in Appendix service users perceive the extent to which DV services are trauma-informed. It measures their perception across four themes: (a) environment of agency and mutual respect, (b) access to information on trauma, (c) Overview/Description: The TS4TIC Interview guide was developed by the TS4TIC team to gather participant’s opportunities for connections, and (d) emphasis on strengths. A supplemental 13-item scale also measures experiences and recommendations for improving the simulations. It is an 8-question interview guide that (e) cultural responsiveness and inclusivity and (f) parenting support. Sample items include: “Staff respect the asks participants to discuss their experience of taking part in a simulation, what themes emerged during the choices that I make.”, “Staff treat me with dignity.”, and “I am learning more about how to handle unexpected simulation they attended, whether anything changed in their practice or their perception of themselves as reminders of the abuse and difficulties I have endured.” healthcare workers. It also asks how the simulations could be improved to contribute to learning or how they could be improved in general. Recommendations for use: TIPS may require adjustment for use in non-DV services. Questions dealing with patients’ strengths, mutual respect, and cultural responsiveness may be more relevant to non-DV services. Recommendations for use: The TS4TIC Interview Guide should be used after running simulations in order to gather data on how effective they have been in introducing TIC to your organisation. It can also serve as a Suitable for participants: Suitable for all participants measure of how realistic the simulations are, and can be used to refine the simulations for your needs. Available languages: English, Spanish Suitable for participants: The interview guide is suitable for all participants. Available languages: The interview guide is available in English as a part of the Toolkit. Tool: CPC (Consumer Perceptions of Care) Link to Tool Scottish Trauma Transformational Programme Self-Assessment Overview/Description: The Consumer Perceptions of Care scale was developed to measure consumers’ perceptions of their care, and their satisfaction with behavioural health services. It is a 26-item scale that Link to Tool measures (a) service integration, (b) choice in services, (c) cultural sensitivity and (d) trauma-informed as- sessment. Each of the items are rated on a 4-point scale from “strongly agree” to “strongly disagree”. Sample Overview/Description: The Scottish Trauma Transformational Programme (STTP) Self-Assessment allows an items include: “I was able to get all of the services I thought I needed”, “My service providers were sensitive to organisation to assess their readiness to begin implementing trauma-informed care, and suggests a range of my cultural/ethnic background”, “I felt safe and comfortable when I met with my service providers”, and “My activities for organisations to undertake to support the implementation of trauma-informed care. service providers know how to share information and communicate clearly with me”. Recommendations for use: The STTP Self-Assessment should be used as part of wider efforts to create a Recommendations for use: May need adaptation as it was developed for use with women who have suffered trauma-informed organisational roadmap. It can shape the initial designs of TS4TIC’s simulations and may abuse, and therefore some items may not be relevant for use in your organisation. help to identify areas where TIC is needed most. Suitable for participants: The CPC is suitable for use with all patients. Suitable for participants: The self-assessment is suitable for all participants. Available languages: English Available languages: The STTP self-assessment is available in English. Examples of use: Clark, C., & Young, M. S. (2009). OUtcomes of mandated treatment for women with histories of abuse and co-occurring disorders. Journal of Substance Abuse Treatment, 37(4), 346-352. https://doi. org/10.1016/j.jsat.2009.03.011 92 | Further Reading References | 93 Further Reading References This is a list of additional accessible resources that you may find helpful in expanding your understanding of 1. Fotta M, Gay y Blasco P. Innovation, Collaboration and Engagement: Proposals for Gypsy, Roma and Travel- trauma-informed care, the implementation of trauma-informed care and psychological trauma as a whole. ler-related Research. In: Fotta M, Gay y Blasco P, editors. Ethnographic Methods in Gypsy, Roma and Travel- While the material discussed in these resources is also discussed in our bibliography, these resources are more ler Research. Lessons from a Time of Crisis. 1 ed: Bristol University Press; 2024. p. 15-37. widely available and accessible. 2. Marsilio M, Fusco F, Gheduzzi E, Guglielmetti C. Co-Production Performance Evaluation in Healthcare. A Chapter 1 Systematic Review of Methods, Tools and Metrics. International Journal of Environmental Research and Public Health [Internet]. 2021; 18(7). • ●NHS Education for Scotland’s Roadmap for Creating Trauma-Informed and Responsive Change • ●Beacon House’s resources on Developmental Trauma 3. Palumbo R. Contextualizing co-production of health care: a systematic literature review. International Jour- • ●Quality Improvement Made Simple, by The Health Foundation nal of Public Sector Management. 2016;29(1):72-90. • The Institute for Healthcare Improvement’s Model for Improvement • ●NHS England’s Co-Production Resource Toolkit 4. Maren B, Paul B, Peter M, Michael S, Gail A, Lisa O-A, et al. Coproduction of healthcare service. BMJ Quality & Safety. 2016;25(7):509. Chapter 2 5. Office of the United Nations Commissioner for Human Rights, World Health Organisation. The Right to • Examples of accredited trauma-informed training: Health. Geneva: Office of the United Nations High Commissioner for Human Rights; 2008, June. 45 p. Re- 1. ●University College Cork’s Certificate in Continuing Development in Trauma-informed Care port No.: GE.08-41061–June 2008–13,600 2. ●Dublin City University’s Professional Development Course in Trauma Informed Practice in Health and Social Care 6. Lotty M. The thermometer of regulation. Reproduced with permission from the CPD Certificate in Trau- • ●International Trauma Training Guidelines ma-Informed Care: Practice and Theory. Cork: University College Cork; 2022. Chapter 3 7. Corrigan FM, Fisher JJ, Nutt DJ. Autonomic dysregulation and the Window of Tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology. 2011;25(1):17-25. • International Coproduction Health Network in Jönköping University • Middlesex University’s Coproduction Practice Hub 8. Cooper B. Intersectionality. 2016 [cited 3/26/2024]. In: The Oxford Handbook of Feminist Theory [In- ternet]. Oxford University Press, [cited 3/26/2024]; [0]. Available from: https://doi.org/10.1093/oxford hb/9780199328581.013.20. 9. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Substance Abuse and Mental Health Services Administra- tion; 2014. 20 p. 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