The Co-Production of the Roots Framework: A Reflective Framework for Mapping the Implementation Journey of Trauma-Informed Care

Abstract

Background
The trauma-informed care programme at the Tees, Esk and Wear Valleys Foundation NHS Trust identified a need to evaluate the ongoing service-wide trauma-informed care implementation effort. An absence of staff, service user and system-related outcomes specific to trauma-informed care presented barriers to monitoring the adoption of trauma-informed approaches and progress over time across the Tees, Esk and Wear Valleys Foundation NHS Trust. This paper describes the co-production of a new self-assessment tool, Roots, a discussion-based framework that facilitates learning and improvement by reflecting on positive or negative examples of trauma-informed services.

Methods
Using secondary data obtained from an affiliated national trauma summit and instruments found in literature, domains and items were co-produced with the help of trauma-informed care leads, NHS staff and service users. The research design consisted of community-based co-production methods such as surveys, focus groups, and expert consultations.

Results
Adopting trauma-informed care requires enthusiasm and commitment from all members of the organisation. Services must adapt to meet the dynamic needs of staff and service users to ensure they remain trauma-informed; this must be done as a community.

Conclusions
Following an extensive co-production process, the Roots framework was published open-access and accompanied by a user manual. Roots can provide both qualitative and quantitative insights on trauma-informed care implementation by provoking the sharing of experience across services.

Full text

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The Co-production of the Roots Framework: A Reflective 1
Framework for Mapping the Implementation Journey of Trauma-2
informed Care 3
4
Steven Anthony Thirklea *, Angela Kennedyb, Petia Sicec and Paras Patelb
5
a Population Health Sciences Institute, Faculty of Medical Sciences, Baddiley Clark 6
Building, Richardson Road, Newcastle University, Newcastle upon Tyne, NE2 4AX, 7
United Kingdom 8
b St. Nicholas Hospital, Jubilee Rd, Cumbria, Northumberland Tyne and Wear NHS 9
Foundation Trust, Newcastle-upon Tyne NE3 3XT, United Kingdom 10
c Department of Computer and Information Sciences, Faculty of Engineering and 11
Environment, Ellison Building, Ellison Place, Northumbria University, Newcastle City 12
Campus, Newcastle-upon-Tyne, NE2 1XE, United Kingdom 13
14
*Corresponding author: Steven Anthony Thirkle, Population Health Sciences 15
Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, 16
NE2 4AX, United Kingdom. ORCID ID - 0000-0002-6115-6637. E-mail: 17
steven.thirkle@newcastle.ac.uk Telephone: 07955593737 18
Abstract 19
Background: The trauma-informed care programme at the Tees, Esk and Wear 20
Valleys Foundation NHS Trust identified a need to evaluate the ongoing service-wide 21
trauma-informed care implementation effort. An absence of staff, service user and 22
system-related outcomes specific to trauma-informed care presented barriers to 23
monitoring the adoption of trauma-informed approaches and progress over time across 24
. CC-BY 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 14, 2022. ; https://doi.org/10.1101/2022.04.13.22273691doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

2
the Tees, Esk and Wear Valleys Foundation NHS Trust. This paper describes the co-25
production of a new self-assessment tool, Roots, a discussion-based framework that 26
facilitates learning and improvement by reflecting on positive or negative examples of 27
trauma-informed services. 28
Methods: Using secondary data obtained from an affiliated national trauma summit 29
and instruments found in literature, domains and items were co-produced with the 30
help of trauma-informed care leads, NHS staff and service users. The research design 31
consisted of community-based co-production methods such as surveys, focus groups, 32
and expert consultations. 33
Results: Adopting trauma-informed care requires enthusiasm and commitment from 34
all members of the organisation. Services must adapt to meet the dynamic needs of 35
staff and service users to ensure they remain trauma-informed; this must be done as a 36
community. 37
Conclusions: Following an extensive co-production process, the Roots framework 38
was published open-access and accompanied by a user manual. Roots can provide 39
both qualitative and quantitative insights on trauma-informed care implementation by 40
provoking the sharing of experience across services. 41
Keywords: Trauma-informed Care; Implementation; Evaluation Framework; Self-42
assessment; Co-production. 43
44
45
46
47
48
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1. Introduction 49
Trauma-informed care has seen various implementation efforts; many have seen local 50
success; others have failed to provide sufficient evidence (1–4). Trauma-informed 51
care is an evolving organic system model (5,6). It requires a paradigm shift in thinking 52
for service providers to deliver care that is rooted in the understanding of the 53
widespread prevalence and effects of trauma on people (7). An informed 54
conceptualisation of trauma is threefold: the trauma event, acknowledging that 55
traumatisation can occur when psychological/social integrity is threatened; how the 56
event is experienced; and the effects of the event (7). This shift in thinking and 57
conceptualisation of trauma constitutes trauma-informed care. All members of the 58
organisation must embrace the constituents of trauma-informed care for the system 59
model to be of significant benefit; it must not be imposed upon individuals but rather 60
emerge from individuals who experience the organisation (8,9). For systemic 61
adoption, many organisations require concrete evidence of the benefits that trauma-62
informed care provides (10,11). These benefits are numerous; however, they are often 63
not quantifiable. This does not serve the implementation of trauma-informed care 64
well, as service providers are requesting effective techniques for implementing the 65
necessary changes and specific examples of what it means in practice (10). 66
Establishing the need to develop metrics that can be used in qualitative and 67
quantitative ways to demonstrate the effective implementation of trauma-informed 68
care and realise the benefits that this systemic and individualistic change can provide 69
(11). Calling for a development process bespoke to the organisation, as trauma-70
informed care is an emergent paradigm (3,8). 71
Organisational culture change demands individuals to follow suit and to sometimes 72
abandon personal principles (12–14). A frictionless change requires the consideration 73
of affect, sub-groups, personal and existing organisational values, and the quantity and 74
quality of support from leadership (8,9). Factoring in complexity concepts such as 75
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emergence, self-organisation, and the sensitivity to initial conditions can assist in the 76
understanding of human systems and utilising previous developments can save time 77
and help co-construct a bigger picture of what it means to be trauma-informed (15,16). 78
This article provides basic information on the Roots framework so that future work 79
can benefit; it uses a similar reporting structure provided by Jung et al. (2009); as a 80
result, readers are given a topographical view of the framework (9). 81
2. Background 82
At the Tees, Esk and Wear Valleys (TEWV) Foundation NHS Trust, Dr Angela 83
Kennedy, with the help of other key figures, established the trauma-informed care 84
programme to implement trauma-informed care into services. Large-scale training and 85
service-change efforts were proving successful. However, an efficient implementation 86
and evaluation method was seen to be missing. Research and development efforts 87
were identified as being necessary to investigate potential solutions. The project that 88
emerged had one aim: To co-produce an integrative framework for data collection, 89
analysis, and interpretation. The objectives to reach this aim were threefold. The first 90
was to identify a relevant body of knowledge and investigate similar approaches that 91
have sought to evaluate trauma-informed care. The second was to co-produce an 92
evaluation framework that is bespoke to the United Kingdom. The third was to 93
produce documentation for practical use. Three fields from the literature helped 94
construct the narrative. These were organisational culture change, complexity theory, 95
and trauma-informed care. The organisational culture change literature is highly 96
applicable to trauma-informed care (8,9). Trauma-informed care can be viewed as a 97
culture and the change required is a cultural one. Complexity theory can offer an 98
informative view of culture - recognising that culture is a complex phenomenon that 99
emerges in the interactions between actors is conducive to successful change 100
(15,16,18). Within the trauma-informed care literature, previous frameworks were 101
identified; these were systematically evaluated (1–3,19). The Roots tool emerged from 102
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a co-production approach to development with staff and service-users being consulted 103
at each stage. 104
2.1. The Implementation of Trauma-Informed Care 105
Trauma-informed care is socially constructed in the environment (9). It is manifested 106
and brought to life by the inhabitants of the service. Significant system change is 107
required for the implementation of trauma-informed care. This change marks a shift in 108
thinking from what is wrong with you to what happened to you. This is an essential 109
step to begin the narrative of care (7). All facets of the organisation must engage in 110
this transformation for trauma-informed care to recognise success. Adaptations to the 111
physical environment, raising awareness, and training staff are relatively minor steps 112
in comparison to the tidal-wave requirements of change on systems and care processes 113
(20). 114
2.2. Roots – A Discussion-Based Framework That Facilitates Learning and 115
Improvement by Reflecting on Positive or Negative Examples of Trauma-116
informed Services. 117
Roots is a developmental framework that uses insights from organisational culture 118
change, human behaviour, complexity theory, and trauma-informed care evaluation. 119
Roots was developed in the United Kingdom and was released in April 2021. There 120
are currently two versions available. One for staff and another for service users. Both 121
versions are identical with only changes made to terminology for accessibility 122
purposes. The definition or conceptual model of Roots is as follows: for an 123
organisation to be trauma-informed, it needs to apply trauma-informed principles and 124
culture in practice. Adopting a systems-wide value model requires enthusiasm and 125
commitment from all members of the organisation. As organisations and individuals 126
within the organisation change, the service must adapt to meet the dynamic needs of 127
staff and service users to ensure they remain trauma-informed (9). Communication 128
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and clarification of these values, across teams, departments, buildings, or trusts will 129
assist in providing individuals with the self-knowledge that is often missing, i.e., how 130
are we adhering to the principles of trauma-informed care that we, as a group, have 131
selected as being relevant right now? and how are we able to improve in the areas 132
that we are not doing so well in? The intended purpose of Roots is to map the 133
implementation journey of trauma-informed care. The tool is for staff, service users, 134
and teams to think about what might make up trauma-informed care in their areas. It 135
takes the form of a word document that is completed by the facilitator on the 136
discussion of each item. Roots is comprised of 54 items answered quantitatively using 137
a RAG (red, amber, and green) rating, and qualitatively by prompting for reasons of 138
applicability and examples in practice. These items are shared among seven domains: 139
Safety (11 items), Language (8 items), Social (7 items), Trauma-specific Interventions 140
(7 items), Empowerment (7 items), Whole System (6 items), and Compassionate 141
Leadership (8 items). The set of practice points for reflection by the group challenges 142
thinking and enables discussion. The applicable to service column is asking for the 143
reason why this item needs to be applied in service to facilitate trauma-informed care. 144
However, each item is indicative and may not be applicable in every setting. The 145
implementation column is the RAG rating which asks the user how trauma-informed 146
they believe their service is with regards to the item in question. The example column 147
asks for examples as to why the service may or may not be delivering trauma-148
informed care. Reflecting on each practice point can stimulate positive or negative 149
examples and provide meaningful information. The act of assigning a colour can 150
allow the individual or service to reflect on their current standing with trauma-151
informed service delivery. This can also prompt and motivate individuals and services 152
to improve delivery. Providing examples can be useful for clarity and comparison. 153
The level of measurement used in Roots is ordinal. 154
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Items were generated by using a combination of surveys, focus groups, expert 155
meetings, and secondary data. The domains within Roots were obtained from the 156
National Trauma-informed Care Community of Action’s implementation report titled: 157
Creating a Narrative for Trauma-Informed Service Transformation which emerged 158
from a summit of clinicians, managers, leaders, people with lived experience, 159
researchers, and other interested parties on Thursday 28th March 2019 (21). An 160
investigation into the literature uncovered previous approaches. These instruments and 161
frameworks were studied, and domains were taken from four prominent frameworks 162
which were then compared at a trauma leads meeting with the domains that emerged 163
from the national trauma-informed care summit. At the same meeting, trauma leads 164
were provided with definitions on the summit domains and asked to provide a set of 165
standardised questions (items). These items were then shared with psychologists to 166
translate for staff accessibility purposes. Further translation was required for the 167
service-user version and so the staff version was shared with an expert by experience 168
group. Both staff and service-user versions of the framework were then issued to 169
wider audiences at the NHS trust using surveys to further articulate the forms. Trauma 170
leads meetings were used to discuss the results and changes were decided on. Focus 171
groups were then arranged to pilot test the framework. These were conducted with 172
staff; trauma leads and their staff members in their respective services, and a small 173
group of service-users. Prior to the focus groups, the service-user framework was 174
modified to reflect a third-person perspective rather than what was seen to be a 175
confusing first-person one; this was the only significant modification made to the 176
framework since the initial translation. Items were not reduced or modified further as 177
they were voted as being essential to remain in the framework. Due to resource 178
restrictions, it was not possible to conduct a follow-up assessment on the 179
psychometric properties of an instrument (reliability and validity). However, focus 180
group data would suggest strong face validity, acceptability, and feasibility. The 181
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framework does have the potential to be susceptible to bias if the facilitator is part of 182
the team or has an agenda. This can be mitigated by using external facilitators. There 183
are no norms attached to the Roots tool. However, these can be created locally if 184
group comparisons are desired. Roots has no formal method of calibration. Informal 185
methods can be set by users of the tool to ascertain accuracy. There is currently no 186
data recorded for further tests of reliability such as internal consistency or 187
reproducibility (test-retest and inter-observer). The content, criterion, predictive, 188
convergent, discriminant, cross-cultural, and dimensional validity of Roots remains 189
untested. Roots is designed to be sensitive and open to change, the tool must reflect 190
the needs of the individuals it serves. 191
The Roots tool was co-developed, and pilot tested in mental health care settings. 192
These services included the community, prison services, adult wards, and CAMHS 193
(Child and Adolescent Mental Health Services). However, Roots has the potential to 194
be deployed in any setting, with changes made to the language and the exercise. 195
3. Statement of the Problem 196
The Tees, Esk and Wear Valleys NHS Foundation Trust has been implementing 197
trauma-informed care for many years. Early implementation efforts took the form of 198
care pathways. In 2009, the trauma-informed pathway was designated as the first 199
clinical link pathway. This pathway differed from clinical routes in that it was relevant 200
regardless of the diagnosis of trauma. Instead of encouraging talents that the 201
workforce cannot supply, the trauma-informed pathway encourages staff to use their 202
skills in trauma-informed ways. This empowered staff when they realised that this 203
meant they could offer something critical to service users. A business case was 204
developed by the trauma-informed care lead, Dr Angela Kennedy, for a formally 205
funded project to embed trauma-informed care into services. A goal of the project was 206
to integrate trauma-informed care into policies, programmes, and local systems and 207
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contribute to the evidence-base for trauma-informed care. The trauma-informed care 208
programme at the Tees, Esk, and Wear Valleys NHS Foundation Trust realised the 209
need for an evaluation and implementation framework to make progress with this 210
trauma-informed system change. Checklists have been created and measurements 211
have been conducted previously regarding trauma-informed change, but never in the 212
United Kingdom. The NHS is a unique system in that it represents a large number of 213
individuals spread out over many localities. The TEWV NHS Foundation Trust is one 214
of the largest specialist mental health and learning disabilities trusts in the country, 215
with an annual income of £380 million and a workforce of over 6700 staff operating 216
from around 100 sites in Durham, Teeside, North Yorkshire, and York and Selby. 217
TEWV NHS provide a range of inpatient and community services to 2 million people 218
living in County Durham, the Tees Valley, Scarborough, Whitby, Ryedale, Harrogate, 219
Hambleton and Richmondshire. TEWV NHS services are spread out over a wide 220
geographical area of around 3600 square miles, inclusive of coastal, rural, and 221
industrial areas (22). The geographical nature of the TEWV NHS Foundation Trust is 222
conducive to complexity. All NHS trusts are subject to stringent ethical procedures 223
and research involving staff and service-users undergo strict ethical clearance 224
procedures. An implementation and evaluation framework unique to these particular 225
circumstances that was able to navigate strict ethical boundaries was essential. 226
4. Methods Used During the Development of the Roots Framework 227
The collaborative development of the Roots framework was a five-step process. 228
Firstly, a literature review was undertaken to investigate similar approaches. These 229
other approaches were evaluated using an existing culture instrument review 230
framework (17), and were then compared with the domains that emerged from the 231
national trauma summit at a trauma leads meeting. Items were generated at the same 232
meeting and were taken to surveys with staff and service users to confirm articulation. 233
Focus groups were held with one service user group and five different staff services. 234
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These were used to further articulate and pilot test the framework in practice. The 235
process can be seen in Figure 1. 236
237
Fig.1 – Methods used during the co-production process of Roots 238
The design of the Roots framework stemmed from the ongoing work of the trauma-239
informed care programme. This meant that the research design evolved alongside 240
programme implementation. Monthly meetings with trauma leads contributed 241
significantly to the research design. The trauma leads are select individuals who 242
represent trauma-informed care in their respective services. They were instrumental in 243
the facilitation of various developmental facets, including access to various staff and 244
service user groups. Approximately twelve trauma leads would usually be present at 245
each meeting. The first phase of this study was an evaluation of other similar 246
instruments and frameworks (9). The literature contributed to expectations and other 247
considerations for trauma-informed service evaluation; including the use of principles 248
or domains for which both implementation and evaluation can revolve. Meanwhile, 249
the trauma-informed programme was a joint-organiser of a national trauma summit 250
titled: Creating a Narrative for Trauma-informed Service Transformation (21). The 251
goal of this summit was to respond to calls from people with lived experience of 252
trauma in services and the challenge of trauma being included in the new NHS 10-253
year plan. It was arranged as a forum to share ideas for good practice and an 254
opportunity to network with others who are motivated towards similar goals. This was 255
held on Thursday 28th March and brought together clinicians, managers, leaders, 256
people with lived experience, researchers, and many others. Attendees were asked to 257
think of a specific positive example that they have experienced, witnessed, or been 258
involved in. The aim of this was to tap into individual wisdom and creativity and to 259
explore the multiple dimensions of what it means to be trauma-informed and share 260
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concrete examples that can be replicated by others. A report was drafted titled: 261
Developing Real-World System Capability in Trauma-informed Care: Learning from 262
Good Practice (21). In this report, seven domains were observed as having emerged 263
from the summit, these were: 1) Safety, 2) Human Experience Language, 3) 264
Empowerment, 4) Healing Interventions, 5) Responsive System Design, 6) 265
Compassionate and Transformational Leadership, and 7) Relational Reparation (21). 266
These domains were significant to the Roots framework as they had been developed 267
with individuals that have experienced UK health systems. The domains were used 268
but their wording was amended to better reflect local services. The revised domains 269
were: 1) Safety, 2) Language, 3) Social, 4) Trauma-specific Interventions, 5) 270
Empowerment, 6) Whole System, and 7) Compassionate Leadership. 271
5. The Co-Production of Domains and Items 272
At a trauma leads meeting, the seven domains were judged against the domains taken 273
from the literature. Four instruments were selected for this process, the Attitudes 274
Related to Trauma-Informed Care (ARTIC) (1), the Creating Cultures of Trauma-275
informed Care (CCTIC) (4), the TICOMETER (2), and the Trauma-informed Practice 276
(TIP) Scales (19). These were identified as being relevant and empirically tested. 277
During the meeting, the trauma leads worked through a slideshow that presented the 278
domains from the literature alongside the domains from the summit and were asked to 279
determine encapsulation. Encapsulation was confirmed if one or more of the summit 280
domains captured the meaning used in the language of the domains from the literature. 281
Table 1 presents the ARTIC comparison, Table 2 presents the CCTIC comparison, 282
Table 3 presents the TICOMETER comparison, and Table 4 presents the TIP Scales 283
comparison. The left column represents the domains from the instruments found in the 284
literature, and the right column represents which domain from the summit that trauma 285
leads felt captured the meaning of the corresponding domain from the literature. This 286
process was held to determine if the summit domains were appropriate for use. The 287
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trauma leads all agreed through consensus that all domains from the four instruments 288
were captured by one or more of the domains from the summit. However, trauma 289
leads felt as though staff wellbeing should represent the eighth domain. 290
Table 1 – ARTIC Comparison 291
ARTIC
SUMMIT
Underlying Causes of Problem
Behaviour and Symptoms
Social Context, Language
Responses To Problem Behaviour and
Symptoms
Safety, Social Context, Trauma
-
Specific
Interventions
On
-
The
-
Job Behaviour
All
Self
-
Efficacy at Work
Safety, Whole System,
Compassionate
Leadership, Empowerment
Reactions to the Work
Trauma
-
Specific Interventions
Personal Support of TIC
Safety, Whole System
System
-
Wide Support for TIC
Whole System, Compassionate
Leadership, Safety, Social Context
Table 2 – CCTIC Comparison 292
CCTIC
SUMMIT
Safety
All
Trustworthiness
Safety, Language, Empowerment, Whole
System, Social Context
Choice
Empowerment, Safety, Social Context
Collaboration
Empowerment, Whole System, Social
Context, Safety
Empowerment
Empowerment,
Language, Whole System
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Trauma Screening Process
Safety, Language, Empowerment,
Trauma-Specific Interventions, Whole
System
293
Table 3 – TICOMETER Comparison 294
TICOMETER
SUMMIT
Building Trauma
-
Informed Knowledge
and Skills
All
Establishing Trusting
Relationships
All
Respecting Service Users
Whole System, Safety, Language
Fostering Trauma
-
Informed Service
Delivery
All
Promoting Trauma
-
Informed Policies and
Procedures
Whole System, Language
295
Table 4 – TIP Scales Comparison 296
TIP SCALES
SUMMIT
The
Environment of Agency & Mutual
Respect
Social Context, Safety, Empowerment,
Language
Access to Information to Trauma
Trauma
-
Specific Interventions, Safety,
Empowerment, Language
Opportunities for Connection
Empowerment, Trauma
-
Specific
Interventions, Social Context
Emphasis on Strengths
Social Context, Trauma
-
Specific
Interventions, Language, Safety
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Cultural Responsiveness & Inclusivity
All
Support for Parenting
Trauma
-
Specific Interventions, Social
Context, Safety
297
At the same meeting, trauma leads were asked to develop up to 10 items per domain. 298
Trauma leads worked through a slideshow that presented definitions of each domain. 299
Four items were generated for the domain safety. Six items were generated for the 300
domain language. Four items were generated for the domain social. Six items were 301
generated for the domain Trauma-specific Interventions. Eleven items were generated 302
for the domain empowerment. Seven items were generated for the domain Whole 303
System. Eight items were generated for the domain compassionate leadership. Four 304
items were generated for the domain staff wellbeing. 305
The results of this meeting were shared with the trauma-informed care programme 306
team. The items underwent translation to accommodate common language used by 307
staff for purposes of familiarity and accessibility. This discussion contributed to the 308
removal of some items and the addition of others. The requested domain, staff 309
wellbeing, was removed as it was voted unnecessary in respect of it being represented 310
across the other domains. As two forms were needed, one for staff and another for 311
service users, the translated items were then sent to an experts by experience group 312
working from the Recovery College in Durham, United Kingdom. The experts by 313
experience group worked through the items and translated them for service user 314
accessibility. 315
Both forms, existing only as items, were then placed into two separate SurveyMonkey 316
surveys. Convenience, criterion, and snowball sampling methods were used for the 317
recruitment of participants. Staff and service-user samples were recruited through 318
trauma leads who distributed information on the study. When participants registered 319
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interest, the trauma leads then distributed further information through a participant 320
information sheet and a web link to the survey. The surveys asked participants to 321
prioritise the items and leave feedback on articulation. The addition of a RAG rating 322
added a quantifiable indicator to the survey. The staff form was distributed to staff 323
members, and the service-user form was distributed to service users. The inclusion 324
criteria were as follows: staff are identified as being available, engaged in the TEWV 325
NHS trust, and chosen or recommended by those aware of the study. Service users are 326
identified as being available, involved in the NHS trust, and selected by staff. The 327
exclusion criteria were as follows: no affiliation with the NHS TEWV Foundation 328
Trust, under the age of 18 or over the age of 65, or at imminent risk of harming 329
themselves or others. Recruitment was difficult as national restrictions were imposed 330
as a result of the Covid-19 pandemic. The results were analysed using Microsoft Excel 331
to determine priority. A trauma leads meeting was held to discuss these results and it 332
was voted that all items should remain in the final framework, mainly due to high 333
applicability. Although the survey results contradicted this for a few items, the 334
presentation of the survey was questioned for confusion. 335
A quality assurance process took place and involved confirming meaning across items 336
in both staff and service user forms with the research team. The framework was 337
drafted as a table, in which there are four columns: practice point for consideration 338
(item), applicable to service (reason), implementation status (RAG rating), and 339
example (justification). The set of practice points for reflection by the group 340
challenges thinking and enables discussion. The applicable to service column asks 341
why this item needs to be applied in service to facilitate trauma-informed care. 342
However, it is recognised that each item is indicative and may not be applicable in 343
every setting. The implementation column is the RAG rating and questions the user on 344
how trauma-informed they believe their service is with regards to the item in question. 345
The example column asks for examples as to why the service may or may not be 346
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delivering trauma-informed care. Reflecting on each practice point can stimulate 347
positive or negative examples and provide meaningful information. The act of 348
assigning a colour can allow the individual or service to reflect on their current 349
standing with trauma-informed service delivery. This can also prompt and motivate 350
individuals and services to improve delivery. Providing examples can be useful for 351
clarity and comparison. 352
Pilot tests were held with both forms with staff and service user sample groups. Five 353
full-length evaluation exercises were held with staff, and one rudimentary exercise 354
was held with service users. Staff focus groups were evaluating the framework and the 355
exercise, whilst the service user group was evaluating the framework. Service users 356
felt empowered when discussing the items of the framework and agreed that the 357
majority of items were essential. Staff found the exercise helpful, and all services 358
requested the completed framework to begin actioning items. 359
A user manual was created to facilitate instructions and to contain the Roots 360
framework. This is now published open access on the Future NHS community 361
platform for practitioners and researchers as long as they have an NHS or public 362
health England email address. 363
6. The Roots Framework Learning Model 364
The Roots framework uses insights from complexity theory. This is recognising that 365
human change is complex because there is rarely one right way of doing something. 366
The service will need to adapt to meet each individual’s needs and remain responsive 367
over time. These complexity principles guide the use of Roots towards change and 368
evaluation: change in individuals or organisations is rarely linear. A reflexive 369
approach that evolves is of benefit. There is not a one size fits all interpretation of 370
trauma-informed implementation. Different settings need to define what is needed for 371
them through methods of co-production. Different teams within an organisation, 372
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different individuals within teams, and different service users may all display or 373
perceive different strengths concerning the implementation of trauma-informed care. 374
Roots allows for the bringing together of different narratives towards a wider picture. 375
The items emerged from previous examples and are created to be both generic and 376
specific but not exhaustive. New ones can be created as long as they are tangible and 377
observable. Roots needs to be embedded within a learning organisation framework 378
accompanied by an attitude of respect to ensure that progress can be made. 379
7. Study Limitations 380
In the UK, there are many restrictions placed upon social and healthcare research. 381
Research studies must navigate strict ethical standards. In many cases, these standards 382
can form boundaries for what is possible in research. As trauma-informed care is a 383
relatively new concept in the UK, pioneering research must first take the first steps. 384
These initial studies must take place so that more elaborate studies can follow. As 385
Roots is the first trauma-informed evaluation framework to emerge out of the UK, 386
many aspects of the study were impeded. The Tees, Esk and Wear Valleys NHS 387
Foundation Trust has a workforce of over 6700 staff operating from around 100 sites 388
in Durham, Teesside, North Yorkshire and York and Shelby (22). This study is unable 389
to claim to be fully representative as the samples used were often limited to 390
convenience, and the actual number of participants was low. To achieve a confidence 391
level of 99% for a population size of 6700 with a 5% margin of error, 604 staff 392
members must have been involved in the study. For service users, an ideal sample size 393
with the same parameters would be inclusive of 663 participants. In combination, a 394
repeated study would need to consult at least 1200 participants to be statistically 395
significant. The use of qualitative data helps mitigate this through practicality and 396
transparency. The research team had ultimate control over the end-product, meaning 397
that key stakeholders at both staff and service user levels should have been involved in 398
signing off the product. The service user focus group is a good example of this, there 399
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were questions raised over some items, but this was not regarded in the finished 400
version. The development of Roots also took place during the Covid-19 pandemic and 401
data collection began when the UK was put under lockdown – this caused delays to 402
the study as all non-covid related research received suspensions from the NHS. There 403
is also a distinct lack of any form of psychometric testing – delays to research and 404
resource expiration made it impossible to continue working on Roots. 405
Further Work 406
Roots is the United Kingdom’s first foray into the evaluation of trauma-informed 407
services. Much of the precursory work is already done in the United States of America 408
(USA). However, UK healthcare services are delivered very differently than they are 409
in the USA. The development of Roots provides perfect foundations for future work, 410
either using or building on Roots. One of the fundamentals of UK-based development 411
is the practicalities of set-up. Establishing long-term commitment and navigating strict 412
ethical standards are two of the arrangements that must be considered. Acquiring 413
health research authority approval through a completed Integrated Research 414
Application System (IRAS) should be completed early, and applications should be 415
thorough to ensure acceptance. Before use, a thorough psychometric assessment of the 416
tool should be prioritised to ensure reliability and validity. Self-assessment 417
maintenance should be carried out with exceptional regard to the language used. A 418
dynamic self-assessment should be co-produced; the contents of which change with 419
time to ensure consistent reliability with the people they serve. 420
Conclusions 421
The co-production of the Roots framework involved staff and service-users from the 422
Tees, Esk and Wear Valleys Foundation NHS Trust and also utilised secondary data 423
from a national trauma summit titled: Creating a Narrative for Trauma-informed 424
Service Transformation. Relevant secondary data, trauma-informed care programme 425
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lead meetings, surveys, focus groups, and consultations with staff and service users 426
constituted the research design. The development of Roots was an experimental 427
process and the research evolved alongside the progression of the trauma-informed 428
care programme at the Tees, Esk and Wear Valleys Foundation NHS Trust. Roots is 429
published open-access and is supported by a user manual. 430
431
432
433
DECLARATIONS: 434
• Ethics approval and consent to participate – The United Kingdom's Research 435
Ethics Committee of the National Health Service's Health Research 436
Authority gave ethical approval for this work. Informed consent was obtained 437
from all individuals included in the study where necessary. 438
• Consent for publication – The authors affirm that human research 439
participants provided informed consent where necessary for publication of 440
data collected. 441
• Availability of data and material – Not Applicable 442
• Competing interests – All authors certify that they have no affiliations with 443
or involvement in any organization or entity with any financial interest or 444
non-financial interest in the subject matter or materials discussed in this 445
manuscript. 446
• Funding – This work was made possible by support from the Tees, Esk and 447
Wear Valleys Foundation NHS Trust and Northumbria University. Funding 448
bodies had no influence on the study. 449
• Authors’ Contributions 450
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o CONCEPTION: ST, PS and AK 451
o METHODOLOGY: ST, PS, AK and PP 452
o DATA COLLECTION: ST 453
o INTERPRETATION OR ANALYSIS OF DATA: ST 454
o PREPARATION OF THE MANUSCRIPT: ST 455
o REVISION FOR IMPORTANT INTELLECTUAL CONTENT: ST, 456
PS, AK, and PP 457
o SUPERVISION: PS, AK, and PP 458
• Acknowledgements: This work was made possible by support from the 459
Tees, Esk and Wear Valleys Foundation NHS Trust and Northumbria 460
University.. 461
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References 471
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