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CompassResearch to policy and practiceIssue 02 May 2017Women’s Input into a Trauma-informed systemsmodel of care in Health settings (the WITH Study):Key findings and future directionsPrepared byProfessor Kelsey Hegarty, The University of MelbourneDr Laura Tarzia, Research Fellow, The University of MelbourneMs Alyssha Fooks, Project Manager, The Royal Women’s HospitalAssociate Professor Susan Rees, The University of New South WalesWomen’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)
ANROWS Compass (Research to policy and practice papers) are concise papers that summarise key findings of research onviolence against women and their children, including research produced under ANROWS’s research program, and provideadvice on the implications for policy and practice.This report addresses work covered in ANROWS research project 1.9 “Women’s Input into a Trauma-informed systems modelof care in Health settings (the WITH Study)”. Please consult the ANROWS website for more information on this project. Inaddition to this paper, ANROWS Landscapes and ANROWS Horizons papers are available as part of this project.ANROWS acknowledgementThis material was produced with funding from the Australian Government and the Australian state and territory governments.Australia’s National Research Organisation for Women’s Safety (ANROWS) gratefully acknowledges the financial and othersupport it has received from these governments, without which this work would not have been possible. The findings andviews reported in this paper are those of the authors and cannot be attributed to the Australian Government, or any Australianstate or territory government.Acknowledgement of CountryANROWS acknowledges the traditional owners of the land across Australia on which we work and live. We pay our respectsto Aboriginal and Torres Strait Islander elders past, present, and future; and we value Aboriginal and Torres Strait Islanderhistory, culture, and knowledge. ANROWS 2017Published byAustralia’s National Research Organisation for Women’s Safety Limited (ANROWS)PO Box Q389, Queen Victoria Building, NSW, 1230 www.anrows.org.au Phone 61 2 8374 4000ABN 67 162 349 171Women’s Input into a Trauma-informed systems model of care in Health settings: Key findings and future directions /Kelsey Hegarty et al.Sydney : ANROWS, c2017.Pages ; 30 cm. (ANROWS Compass, Issue 02/2017)I. Sexual assault services – Australia. II. Rape victims – Services for – Australia. III. Domestic violence – Psychological aspects.IV. Mental health services – Australia.I. Hegarty, Kelsey. II. Tarzia, Laura. III. Fooks, Alyssha. IV. Rees, Susan.ISSN: 2204-9622 (print) 2204-9630 (online)Creative Commons LicenceAttribution-Non CommercialCC BY-NCThis licence lets others distribute, remix, and build upon the work, but only if it is for non-commercial purposes and they creditthe original creator/s (and any other nominated parties). They do not have to license their Derivative Works on the same terms.Version 3.0 (CC Australia ported licence): View CC BY-NC Australia Licence Deed View CC BY-NC 3.0 Australia Legal CodeVersion 4.0 (international licence): View CC BY-NC 4.0 Licence Deed View CC BY-NC 4.0 Legal Code
ANROWS Compass May 2017IntroductionTrauma-informed care seeks to create safety for patientsby understanding the effects of trauma (including pastand present violence), and its close links to healthand behaviour (Quadara, 2015). However, there is nocurrent model outlining how services can optimallyundertake trauma-informed care when both mentalhealth problems and a history of sexual violence arepresent. There is a strong relationship between womenexperiencing sexual violence and poor mental health.The relationship can be understood as extremelycomplex, requiring collaboration between multiplesectors to provide effective care. Mental health andsexual violence services often see the same women;however, commonly there is a lack of communicationand cross-referral between services (Quadara, 2015).This report presents a summary of key findings of theWomen’s Input into a Trauma-informed systems model ofcare in Health settings (the WITH Study), commissionedby Australia’s National Research Organisation for Women’sSafety (ANROWS), and the implications for policy andpractice. The WITH Study, based in Victoria and NewSouth Wales, aimed to understand how to promote andembed a trauma-informed organisational model of care,responsive to women and practitioners, into the complexsystem of mental health and sexual violence services.Our research included:Part A (see Figure 1) an ANROWS state of knowledge report (Quadara, 2015); qualitative work (interviews, multimedia digital storytelling)with 67 women; andPart B qualitative work (case study approach using discussiongroups and interviews) with 72 staff at a major publichospital, a clinical mental health service, and three sexualviolence services.The final part of the study will involve a knowledge translationexhibition. This will form a separate linked ANROWSreport, and we will develop journal papers and fact sheetsfor practitioners explaining our findings. The WITH Studywas based on participatory action research and feministprinciples (Burgess-Proctor, 2015); therefore we intentionallyfocused on the voices and lived experience of women, withtwo survivors working as research assistants to co-facilitatestaff workshops.Women’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)1
2the complex system of mental health and sexual violence services?What are the extrinsic and intrinsiccontextual factors between mentalhealth problems and sexual violence?Interviews, 30 women,(Susan Rees, University of NSW)EvaluationInterviews, 18 health practitioners(Kelsey Hegarty, The University of Melbourne)ImplementationSystems change work in liberative dialogue workshopsworkshops withwith practitionerspractitionersWhat factors influence the implementation of elements of atrauma-informed system model of care for women experiencingmental health problems and sexual violence?Part B : Health servicesHow have existing models beenimplemented and evaluated incomplex service systems?Literature review and synthesis(Antonia Quadara, AIFS)What are the pathways to safetyand care for women who haveexperienced mental healthproblems and sexual violence?Interviews, 32 women(Laura Tarzia, The Universityof Melbourne)How can we engage with the community throughexhibitions to effectively impart personal narratives oftrauma and recovery and messages about care?Temporary knowledge transfer exhibition:10-15 women and practitioners(Jo Besley, University of Queensland)Part C : Knowledge translationHow does process of digital storytelling affectwomen’s mental health and wellbeing?Digital storytelling workshop, 5 women(Delanie Woodlock, DVRCV)Part A : Women’s voicesHow can we promote and embed a trauma-informed systems model of care, responsive to women and practitioners intoFigure 1 Overview of WITH StudyANROWS Compass May 2017Advisory groupWomen’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)
ANROWS Compass May 2017Key findingsComplex interrelationship of mental healthand sexual violence experiencesFrom timeline interview analyses conducted by the University ofNew South Wales research team, several patterns (models) wereevident over women’s lifetimes. The following were importantfactors leading from sexual violence to mental health problems:Disclosure issues: disclosure of sexual abuse being ignored or blamed onthe child or young woman by a family member, absenceof a trusted other to disclose sexual violence, disclosureof sexual violence being minimised or ignored by others;Isolation issues: early childhood sexual abuse or parental neglect heightensrisk of future experiences of sexual violence and then, withanxiety symptoms, alcohol and drug use in later life; and isolation from significant others during their lifetimeincreasing the risk of being “targeted” by potentiallyabusive men.Women were also able to articulate a recovery model, which isintegrated below into the findings from the Victorian interviewsRecovery and pathways to careIntegrating data from the studies in Part A suggests that, fromwomen’s perspectives, to recover from sexual violence andmental health problems: supportive counselling was essential, including feelingas if experiences of sexual violence were being genuinelyheard, believed, and validated by the practitioner; healing was enhanced by, or dependent on, holistic servicesthat understand their individual experiences and respondaccordingly to empower women; women were connected to services and services wereconnected with each other; there was a need to support both “surviving” and“thriving”, including practical help that facilitates a positiverecovery process; digital storytelling was a process that could assist womenin this transformation to thriving, although it requiredsupporting women if they became distressed as theyremembered their experiences; women needed to understand the concept of male powerand how it is associated with violence and to realise thatmany other women experience sexual violence; there was a benefit in moving away from a reliance onalcohol and drugs, and proactively avoiding people whoare violent; women were able to use medication, if needed, to alleviatedepressive and anxiety symptoms and engage in therapeuticsocial activities.Some women felt that a holistic service model was lacking,particularly when dealing with the complex needs of thosewho experience life at the intersection of sexual violence andstructural forms of oppression and marginalisation. In particular,participants identified challenges for services supporting womenwith multiple compounding factors, such as family violence,alcohol and drug problems, and being from Aboriginal andTorres Strait Islander or culturally and linguistically diversebackgrounds. Women emphasised the importance of being ableto easily access appropriate ongoing trauma-informed servicesthat share information, provide referrals, and support womenin accessing help for their complex issues, not only duringcrises. It was important that the whole organisation, fromthe environment to the reception staff, be trauma-informed.Factors influencing implementation of atrauma-informed health systems modelof careThere are many barriers to change in health systems. Forinstance, with limited time available, there often tends to bea focus on direct service to clients over talking with otherservices. The main facilitating factors emerging from theworkshops with staff and consultation with stakeholdersacross the service settings were as follows: the need for relationship building between teams; a greater shared understanding of roles and language; improved integrated care and coordination of referrals; further training of staff; more workforce support; strong leadership and governance; and improved information systems for monitoring and evaluation.Women’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)3
ANROWS Compass May 2017From interviews with practitioners, similar themes aroseabout the importance of space and places, the need to worktogether internally and externally, the challenge of balancingcompeting needs or legal requirements, the need to tailortraining to individual workers, the need to support workers,and the importance of the delivery of sensitive practice beingguided from the ground up.Implications for women, practitioners, andhealth systemsThe importance of trauma-informed care and empowermentapproaches was clearly articulated by women who hadexperienced mental health problems and sexual violence andby staff and practitioners. In particular the importance ofresponding to the needs of diverse women and women withmultiple associated issues (family violence, child abuse, alcohol,and drug issues) was highlighted. There are many terms usedfor this type of care and approach, but we feel that adoption ofa trauma and violence-informed framework encompasses therequirement for a holistic response to women experiencingmental health problems and sexual violence (see Box 1).Figure 2 outlines how this trauma and violence-informedframework underpins a woman centred care approach(empowerment and a holistic response) (Garcia-Moreno etal., 2015) and a practitioner or staff-centred service (focusedon supporting practitioner needs and providing education andresources). These approaches are required for women and staffto feel they are entering a safe and supportive health setting.There are several health systems models for violence againstwomen in operation globally (Garcia-Moreno et al., 2015).When applying the lens and context of mental health andsexual violence services from the WITH Study, we haveintegrated our findings and the literature to focus on fourmain building blocks to enact change or implement featuresof the above women and practitioner-centred approaches.Figure 2 Health Systems Implementation ModelHow does thework get doneacross services?Relationship building(Talk, time, trust, and shared language)Integrated coordinated care(Clear roles, referrals, policies, and champions)Practitioner-centred serviceurceresoandSupportateucEdspronwedpohoEmlis tic a llyTrauma and violenceinformed frameworkReWomen-centred careReflective system(Women’s and practitioners’ voices, audits)4Why does thework happenthat way?Environment and workplace scan(Space, time, culture, and data systems)Women’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)
ANROWS Compass May 2017Box 1Trauma and violence-informed care (TVIC)expands the concept of trauma-informedcare to account for the intersecting impactsof systemic and interpersonal violence andstructural inequities on a person’s life. This bringsinto focus historical and ongoing violence andtheir traumatic impacts so that problems arenot seen as residing only in a psychologicalstate, but also in social circumstances.(Varcoe, Wathen, Ford-Gilboe, Smye,& Browne, 2016)How does the work get done across services?(collective action) Relationship building was a very strong theme across thestudies, involving women and staff participants to enableimprovement within the health system to happen. Theysaid that teams within services and different services needto be connected through opportunities to talk togetherand develop trust over time and a shared understandingof their different frameworks and roles (Wathen, Sibbald,Jack, & MacMillan, 2011). Integrated co-ordinated care was seen to be a requirementfor enactment of a trauma-informed framework and care.This involves very clear roles described for staff and referralpathways mapped internally and externally. In addition,policies supporting the trauma-informed work and staff“champions” within the service to drive the work are needed.Why does the work happen that way?(reflexive monitoring) A reflective system was highlighted by staff participants asneeded to enact improvement in the delivery of traumainformed care. This included hearing more from womenabout what they would like changed in the system as wellas to provide feedback to practitioners. Staff input andfeedback to management into changes in strategy, policies,and resources was also essential. Audits of how womenflow through the system on their pathway to safety andwellbeing, as well as what practitioners are enacting, wouldallow quality improvement to be monitored. Environment and workplace scans on a regular basiswould allow improvements in areas that practitionersand women described as requiring attention. These areasincluded better spaces to have private and confidentialdiscussions, and review of workflow patterns to allowsufficient time to engage with women on these sensitivetopics. Assessment of culture, values, and beliefs withina workplace can impact any change process. Monitoringand evaluation also requires better data systems to bedeveloped.These building blocks are based on Normalisation ProcessTheory (May et al., 2009), which aims to clarify the processesby which interventions, new behaviours, or ways of doingthings become embedded into everyday practice. Key tohealth systems change is asking two questions from thistheory: How does the work get done across services? and Whydoes the work happen that way?The above implementation model is proposed to becomplementary to existing health systems models in thearea of violence against women to assist workplaces toimplement changes. The building blocks are areas of focusfor an organisation to pay attention to.Women’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)5
ANROWS Compass May 2017Strengths and limitations of theWITH StudyImplications for health servicepractitioners and managersThe WITH Study integrated the voices of women and stafffrom a hospital, three sexual assault centres, and a clinicalmental health service. The strength of the WITH Study is inthe inclusion of innovative methods and analyses of women’svoices, as there has been limited research in the area of mentalhealth problems and sexual violence that involved womenwith lived experience. However, the inclusion of only Englishspeaking women limits our findings, as does the inclusionof participants from a small range of services. In addition,there was limited consultation across the services and thestaff and practitioner voice is not necessarily representativeof the settings. However, integration of all themes across thestudies, combined with the use of theory and evidence, providesstronger support for the Health Systems ImplementationModel than if it had been based on an individual project.Women during their lifetime often experience sexual violenceand mental health problems and they present to multipleservices seeking holistic women-centred care. They wish to belistened to and connected across services in an integrated way.Women have multiple complex needs that require a systemresponse (sufficient time, confidential space, strong leadership)that supports practitioners to deliver trauma-informed care.Implementing such a response is to be facilitated by managersand practitioners working on how to build relationships acrossteams and services and how to structure systems to integrateand coordinate care. Further, there is a need to reflect moreon what women say they want in health settings and whatpractitioners say will assist them to optimally deliver care.Implications for health servicepolicy-makersTesting and further validation of the Health SystemsImplementation Trauma and Violence-Informed Model isneeded in health settings. This would entail addressing thebuilding blocks in any implementation of violence againstwomen or trauma-informed interventions and evaluating theprocess and outcomes. If this model does assist organisationsto develop further their delivery of trauma-informed care,then adoption into Victorian government policies on gendersensitivity and safety and recovery from mental health maybe warranted.There is a need for more research to inform policy-makers thatincorporates women’s voices about the care they receive whenthey experience mental health problems and sexual violence.Similarly, more work needs to be undertaken in greater detailabout what practitioners understand the enablers are whendelivering trauma-informed care.6Women’s Input into a Trauma-informed systems model of care in Health settings (the WITH Study)
ANROWS Compass May 2017DefinitionsDeliberative dialogueSystems model of careDeliberative dialogue is a style of facilitated workshop.Through deliberative dialogue, participants explore areas ofcommon ground from which alternatives can develop andaction can form. It is a way for people to be able to worktheir way through diffe
3 NS Compass ay 2017 Womens Inpt into a Trama-inorme systems moel o care in Healt settings (te IH Sty) Key findings. Complex interrelationship of mental health . and sexual violence experiences. From timeline interview analyses conducted by the University of New South Wales research team
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