Psychological peer support for staff: implementing the Trauma Risk Management model in a hospital setting
Intended for healthcare professionals
Evidence and practice    

Psychological peer support for staff: implementing the Trauma Risk Management model in a hospital setting

Moya Flaherty Supporting Our Staff lead, Northampton General Hospital NHS Trust, Northampton, England
Victoria Elizabeth O’Neil Head of academic programmes, Northampton General Hospital NHS Trust, Northampton, England

Why you should read this article:
  • To increase your understanding of the Trauma Risk Management model of psychological peer support

  • To appreciate the potential benefits of peer support for staff exposed to challenging events or times

  • To read about one trust’s response to increased staff support needs during the COVID-19 pandemic

One of the many consequences of the coronavirus disease 2019 (COVID-19) pandemic is that the psychological well-being of nurses and other healthcare staff has received greater attention. The Supporting Our Staff (SOS) service, set up in 2017 at Northampton General Hospital NHS Trust, provides psychological peer support to staff using the Trauma Risk Management (TRiM) model. TRiM is a psychological risk assessment and peer support model designed to mitigate the risks associated with exposure to traumatic events. It was initially developed and used in the UK armed forces but has started to be used in healthcare organisations.

This article describes the development and expansion of the SOS service, the implementation of the TRiM model by the SOS team, and the significant part the service has played in the trust’s response to the increased psychological support needs of its staff during the COVID-19 pandemic.

Nursing Management. doi: 10.7748/nm.2021.e1977

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@moyaflaherty

Correspondence

moshopsacc@gmail.com

Conflict of interest

None declared

Flaherty M, O’Neil VE (2021) Psychological peer support for staff: implementing the Trauma Risk Management model in a hospital setting. Nursing Management. doi: 10.7748/nm.2021.e1977

Published online: 19 October 2021

The coronavirus disease 2019 (COVID-19) pandemic has been the dominant narrative in healthcare in the UK since it began in early 2020 and has affected nurses in many ways, personally and professionally. Nurses have had to deliver care in extremely challenging circumstances, while lockdowns and social distancing have made it difficult for them to participate in activities that would have enabled them to take their mind off work, such as going to the gym.

One of the many consequences of the COVID-19 pandemic is that the psychological well-being of staff has received greater attention. In March 2020 the British Psychological Society (2020) released guidance on the psychological needs of healthcare staff as a result of the pandemic. The guidance contains recommendations on how nurse managers can support staff well-being. They include providing visible leadership, normalising psychological reactions commonly experienced by staff exposed to challenging or traumatic circumstances, and establishing clear peer support structures. The NHS has put in place a range of mechanisms designed to support the well-being of staff, including a confidential phone line, a text messaging service, well-being apps and bite-sized guides or courses (NHS Leadership Academy 2021).

At Northampton General Hospital NHS Trust, a service called Supporting Our Staff (SOS) had been developed before the COVID-19 pandemic to provide psychological peer support to staff. The authors of this article are both involved in the SOS service and the article describes how the service has expanded since its launch in 2017, how the Trauma Risk Management (TRiM) model (Greenberg et al 2008) was adopted by the SOS team in 2019, and how the SOS service was reinforced to play a significant part in the trust’s response to COVID-19. This article may be of interest to other healthcare organisations that wish to develop their peer support structures and implement the TRiM model.

Key points

  • British Psychological Society guidance on how nurse managers can support staff well-being include providing visible leadership, normalising common psychological reactions to traumatic or challenging circumstances, and establishing clear peer support structures

  • Trauma Risk Management (TRiM) is a psychological peer support model designed to mitigate the risks associated with exposure to traumatic events

  • TRiM, which originated in the UK armed forces, has started to be used in healthcare organisations

  • The TRiM response to potentially traumatic incidents includes planning meetings, trauma incident briefings and staff assessments

  • The TRiM model has been adopted at Northampton General Hospital NHS Trust by a staff support service that provides psychological peer support to any staff facing challenging events or times

Developing a psychological peer support service

Setting up the service

The SOS service was set up in 2017 by Northampton General Hospital’s resuscitation team to offer psychological peer support to staff following a potentially traumatic incident, mostly in the form of ‘hot’ or ‘cold’ debriefs. A hot debrief is conducted in the immediate aftermath of an incident (Gilmartin et al 2020) while a cold debrief occurs days or weeks after an incident (Wolfe et al 2020).

Initially the SOS service was used mainly by staff involved in cases of traumatic cardiac arrest. The service was staffed by a team of resuscitation officers, emergency department workers and others with an interest in, and experience of, providing psychological support to colleagues. The SOS team members had previous experience of acting as facilitators, gained from being involved in simulation training and/or from working in an environment where hot debriefs were routinely held after incidents.

Staff volunteered to join the SOS team and performed their role in the SOS service alongside their main role at the hospital. The amount of time they dedicated to the SOS service depended on the flexibility of their main role. They were encouraged to work for the SOS service within their normal working hours, but if they were unable to do so they could potentially be paid as bank staff.

The SOS team initially comprised 12 members with various professional roles including nurses, operating department practitioners and doctors. This diversity was important in encouraging different staff groups to engage with the service. Evidence shows that being able to understand and identify with another person’s lived experience is an important factor in providing effective peer support (Balogun-Mwangi et al 2019). This was more likely to be the case with several staff groups represented in the team.

Expanding the service

Anecdotal feedback on the initial SOS service had been positive, but the SOS team felt the service was not being used to its full potential and wanted to widen its scope to support staff facing any challenging event or time. In 2019 the service was relaunched to provide support not only to staff involved in potentially traumatic incidents but also to those accumulating workplace stress or facing personal issues – for example relationship breakdowns or recurrence of previous mental health conditions.

To facilitate access to the SOS service, a web page with an embedded referral form was added to the intranet and a dedicated mailbox was set up to manage online referrals. The principle was that all referrals were welcome, given that cases which could be managed more appropriately by other services such as human resources would be redirected to those services.

To advertise the relaunch, the SOS team, with support from the hospital’s communications team, designed new written materials explaining the widened scope of the service and how staff could refer themselves to it. Information about the expanded service was disseminated to staff via email, computer screensavers and the hospital’s closed social media groups.

Sourcing a suitable model of support

Hot and cold debriefs were central to the initial SOS service. However, in its guideline on post-traumatic stress disorder (PTSD), the National Institute for Health and Care Excellence (NICE) advises against using psychological debriefing to prevent or treat PTSD, since there is little evidence of any benefits and some evidence that psychological debriefing can potentially produce worse outcomes than no intervention (NICE 2018). The expanded SOS service needed another model of psychological peer support, ideally backed up by evidence.

A search of the literature was conducted to identify a more structured and evidence-based model of psychological peer support, and three potential solutions were identified:

Psychological first aid has emerged as one of the interventions used to assist people in the aftermath of a disaster or traumatic event to manage the psychological consequences of what they have experienced. Psychological first aid does not have to be delivered by mental health professionals but can be delivered by lay people, for example from humanitarian aid workers (Dieltjens et al 2014).

Mental health first aid has emerged as a way of training members of the public to improve their understanding of mental ill health and change their attitude towards it, enabling people to identify those at risk of mental ill health or experiencing a mental health crisis. Interest has been growing about the use of mental health first aid in the workplace to provide early interventions to staff experiencing mental ill health at work or as a consequence of work (Bell et al 2018).

TRiM is a psychological risk assessment and peer support model designed to mitigate the risks associated with exposure to traumatic events. The TRiM model is designed to identify members of staff who are at increased risk of developing mental health issues following a potentially traumatic event and ensure they have access to appropriate support (Greenberg et al 2008, Whybrow et al 2015). TRiM was initially developed in the Royal Navy and has been used predominantly in the UK armed forces, but its use has been extended to other organisations where staff are at risk of being exposed to potentially traumatic events, such as police forces (Greenberg et al 2008, Whybrow et al 2015). TRiM has started to be used in healthcare organisations – see for example Bedor (2018).

Implementing the Trauma Risk Management model

The effectiveness of psychological first aid and mental health first aid in the healthcare setting has not yet been sufficiently researched or demonstrated, so TRiM was deemed to represent the most suitable alternative to psychological debriefing and it was decided to adopt it as the model of support to be used by the SOS team. SOS team members underwent training to become TRiM practitioners and the TRiM model was implemented and adapted to the local setting and requirements.

Immediate support is provided to staff at the time of an incident by a senior manager of the team or service where the incident has occurred. This is followed by a planning meeting to establish what further response is required. That response usually takes the form of a trauma incident briefing, often followed by an individual or group assessment. A follow-up assessment takes place one month later and in some cases a referral is made for professional support.

Planning meetings and trauma incident briefings

After the immediate response to an incident, a senior manager of the team or service where the incident has occurred and a TRiM practitioner hold a planning meeting. Each incident is different so a planning meeting is needed every time, since the response will vary. The response is usually a trauma incident briefing led jointly by the senior manager and the TRiM practitioner.

All staff involved in the incident are invited to attend the trauma incident briefing. Before the TRiM model was implemented, debriefs in response to incidents focused on a small number of clinical staff directly involved in the incident. TRiM encourages a wider approach whereby all staff directly or indirectly involved in, or affected by, the incident, including support staff, are invited to take part.

The trauma incident briefing has two parts: first the senior manager provides an account of the facts, then the TRiM practitioner explains psychological reactions commonly seen among staff exposed to similar incidents, normalises the emotions (or lack of emotions) staff may feel, and signposts them to sources of support such as their line manager, a member of the SOS team or the trust’s employee assistance programme 24-hour helpline. TRiM practitioners are usually available to speak with staff afterwards and distribute written materials with further information – for example, information on how colleagues, friends and family members can support affected staff and details on how to access the SOS team for a one-to-one session.

Initial and follow-up assessments

In some cases a trauma incident briefing may be all that is required in response to an incident. However, trauma incident briefings are often followed by an assessment conducted by a TRiM practitioner, who will assess the risk of psychological distress to staff. TRiM practitioners are trained to hold structured well-being conversations with staff, using a checklist to spot potential signs and symptoms of acute stress and psychological distress.

The TRiM assessment may be conducted with individual members of staff in one-to-one sessions or with all staff in a group session, depending on the outcome of the planning meeting. If all affected staff have a shared experience, the assessment may be best conducted in a group session. Alternatively, if one individual has a particular need to speak alone, perhaps because they are in a leadership role or because they have had a different experience from others, then a one-to-one session may be more appropriate.

One month after the initial TRiM assessment, a follow-up assessment takes place to review each person’s progress and assess whether anyone needs professional support, in which case they will be referred to another service.

Referrals

Most people recover from a traumatic incident or stressful time at work without professional support – in fact, there is evidence that many people in these circumstances experience post-traumatic growth (Greenberg 2020). However, in some people, symptoms of psychological distress do not settle. This can be an early indication that they are at risk of developing PTSD, so it is important that they are referred to an appropriate trauma service that can offer assessment and treatment by mental health professionals. If a referral is required, the SOS team has several options including the in-house staff psychology team and the Improving Access to Psychological Therapies (IAPT) service offered by the local community and mental health trust, Northamptonshire Healthcare NHS Foundation Trust.

Supporting the team

A crucial aspect of the SOS service is that TRiM practitioners are adequately supported. Studies show that people who undertake trauma work can experience vicarious trauma (Cohen and Collens 2013), which is a risk the TRiM practitioners on the SOS team are potentially exposed to. Since the service was relaunched in 2019 the team has received support from a lead health psychologist, who provides regular supervision and training to team members and takes referrals from those who feel they need additional support. A culture has been promoted in which TRiM practitioners can decline to work on a particular incident and can take a break from the service.

Running the service during the pandemic

Supporting the well-being of staff

When the COVID-19 pandemic started to affect hospitals in the UK in early 2020, the health and well-being of staff was identified as a priority in the trust’s response to the pandemic and the expanded SOS service came into its own. An increasing number of staff who had been involved not in a single potentially traumatic incident, but in a series of potentially traumatic events or circumstances sought support from the SOS team. The TRiM model was adapted so that, where appropriate, the trauma incident briefing stage was left out and the SOS team went straight to the assessment stage. The checklist used by TRiM practitioners to assess staff was adapted to omit risk factors that only relate to a specific incident.

Between April 2020 and February 2021 the SOS service provided:

  • 300 one-to-one TRiM assessments.

  • 75 group TRiM assessments.

  • 90 referrals for professional support, including to occupational health, the in-house staff psychology team and GPs.

Box 1 features some qualitative feedback received from staff who used the SOS service between April 2020 and February 2021. Box 2 provides an example of how the TRiM model was used by the SOS service during the COVID-19 pandemic to support a team after the death of a staff member.

Box 1.

Qualitative feedback received from users of the Support Our Staff (SOS) service

  • ‘My SOS practitioner has great credibility because she has walked the walk and really understands the circumstances and pressures. I was sent away with a leaflet for my partner, so he had some tips on how to support me through a difficult experience. This was unbelievably useful.’

  • ‘The meeting was very helpful and I felt better knowing that I was not the only member of staff feeling the way I was.’

  • ‘Was made to feel normal when talking to the team and warm at a time when I felt nothing. Great service, thank you.’

  • ‘Seemed a lot about following the “learned script” rather than a natural flowing conversation. But appreciated the safe non-judgemental place to talk.’

  • ‘I found it very useful, and good to speak to someone who understands the pressure and what you face, and didn’t feel like just another number. Really took the time to get to know what was going on with me.’

  • ‘Very helpful and involved practitioner. Made me feel listened to and cared for. The session was supportive and non-judgemental and helped me to think about myself as a person and not just as a professional.’

  • ‘This service has been invaluable to me as someone who struggles with anxiety at the best of times. It has definitely stopped me from going off sick with stress, and with the support of the SOS team I managed to only take two days off sick during the whole pandemic. This has made me feel so much stronger in myself and resilient, and dare I say a bit proud? I have also referred my team where I have felt they needed extra support.’

Box 2.

Using the Trauma Risk Management (TRiM) model to support a team after the death of a staff member

Planning the trauma incident briefing

  • The SOS service, senior team leaders and hospital directors held a planning meeting to discuss how to break the news of the death of a staff member to staff about to come on duty

  • TRiM principles and psychological reactions to expect from staff in this situation were explained to the senior team leaders

  • The SOS service members gained knowledge of what information the family had consented to share with the wider team

  • The roles of the SOS service and senior team leaders in the trauma incident briefing were agreed

  • Plans were made to determine how many trauma incident briefings would be required to speak with all staff given the varying shift patterns

  • A discussion took place regarding whether to offer one-to-one assessments to staff members who had a closer relationship with their deceased colleague and/or to any staff members who may have been more vulnerable than others because of their past experiences

Conducting the trauma incident briefing

  • The director of the division broke the news to staff and communicated the information that the family had consented to share

  • A TRiM practitioner explained to staff what psychological reactions people commonly experience in these circumstances and provided advice on how staff could look after their own mental well-being and ask for support

  • TRiM practitioners were available afterwards to speak with staff if required and written materials, including details of how to access the SOS service for a one-to-one assessment, were distributed to staff

Expanding the team’s resources

Because of the effects of the pandemic on staff’s professional and personal lives, TRiM practitioners were undertaking more assessments than ever before. As well as their involvement with the SOS service, most team members worked in clinical areas of the hospital where a sharp increase in activity was expected.

In April 2020 the trust’s human resources director secured funding to train an additional 20 TRiM practitioners. The director of nursing and the medical director nominated candidates for the SOS team, while team members themselves actively recruited new members. The SOS team was expanded to include midwives, healthcare assistants, porters, physiotherapists, pharmacists, chaplaincy staff, and administrative and clerical staff. With these new recruits, the SOS team reached 47 members.

In June 2020, in recognition of the positive effects of the SOS service on staff and the increase in its activity, the head of professional development at the trust was seconded to take up a full-time role as SOS lead. This has enabled the service to continue to proactively support staff and supervise TRiM practitioners.

Another consequence of the pandemic was that a much higher proportion of staff required referral following TRiM assessments. The staff psychology team ensured that their service was available to all who needed it. Twice-weekly case discussions between the staff psychology team and the SOS team were instituted, which enabled the SOS team to discuss, with staff’s consent, any cases they thought might require the input of a psychologist. In some instances the staff psychology team were able to recommend other local services deemed more appropriate for a particular staff member.

Joined-up approach

The trust has a variety of staff support services – beyond the SOS service there is occupational health, the staff psychology team and the health and well-being team. It is important that clear and consistent information is provided on how and when staff can access each service. Clear pathways have been established so that if staff contact one service when another would be more appropriate, signposting or referral is straightforward.

During the pandemic, pathways between staff support services within the trust have been reinforced through the development of a steering group and central hub. This has enabled the trust to coordinate approaches between services, share evidence and best practice guidance, and provide cross-organisational support. In addition, Northamptonshire Healthcare NHS Foundation Trust, the local community and mental health trust, was asked to supplement existing staff support services by offering targeted team support, whereby a qualified clinical or counselling psychologist is paired with a specific service or team.

Conclusion

The SOS service at Northampton General Hospital NHS Trust was set up in 2017 to undertake hot and cold debriefs with staff involved in cases of traumatic cardiac arrest. In 2019 the service was expanded to provide psychological peer support to all staff facing not only potentially traumatic incidents but also challenging events or times, and the SOS team adopted TRiM, a psychological risk assessment and peer support model that originates in the UK armed forces.

The SOS team members were trained to become TRiM practitioners, which enabled them to facilitate trauma incident debriefings and undertake assessments to identify staff at risk of psychological distress and PTSD. During the COVID-19 pandemic the SOS service played a significant part in the trust’s response to the increased psychological support needs of its staff.

It has established itself as an important component of the trust’s staff support services and works in conjunction with other services, such as occupational health and staff psychology, to ensure staff well-being is maintained.

References

  1. Balogun-Mwangi O, Rogers ES, Maru M et al (2019) Vocational peer support: results of a qualitative study. Journal of Behavioral Health Services and Research. 46, 3, 450-463. doi: 10.1007/s11414-017-9583-6
  2. Bedor C (2018) Trauma support for staff in an acute hospital. Healthcare Counselling and Psychotherapy Journal. 18, 4.
  3. Bell N, Evans G, Beswick A et al (2018) Summary of the Evidence on the Effectiveness of Mental Health First Aid (MHFA) Training in the Workplace. http://www.hse.gov.uk/research/rrpdf/rr1135.pdf (Last accessed: 23 August 2021.)
  4. British Psychological Society (2020) The Psychological Needs of Healthcare Staff as a Result of the Coronavirus Pandemic. http://www.bps.org.uk/sites/www.bps.org.uk/files/News/News%20-%20Files/Psychological%20needs%20of%20healthcare%20staff.pdf (Last accessed: 23 August 2021.)
  5. Cohen K, Collens P (2013) The impact of trauma work on trauma workers: a metasynthesis on vicarious trauma and vicarious posttraumatic growth. Psychological Trauma: Research, Practice, and Policy. 5, 6, 570-580. doi: 10.1037/a0030388
  6. Dieltjens T, Moonens I, Van Praet K et al (2014) A systematic literature search on psychological first aid: lack of evidence to develop guidelines. PLoS One. 9, 12, e114714. doi: 10.1371/journal.pone.0114714
  7. Gilmartin S, Martin L, Kenny S et al (2020) Promoting hot debriefing in an emergency department. BMJ Open Quality. 9, 3, e000913. doi: 10.1136/bmjoq-2020-000913
  8. Greenberg N, Langston V, Jones N (2008) Trauma risk management (TRiM) in the UK armed forces. Journal of the Royal Army Medical Corps. 154, 2, 124-127. doi: 10.1136/jramc-154-02-11
  9. Greenberg N (2020) ‘Going for Growth’: An Outline NHS Staff Recovery Plan Post-COVID19. http://www.rcpsych.ac.uk/docs/default-source/about-us/covid-19/going-for-growth-version-3-05-05-20.pdf?sfvrsn=7cf71c97_4 (Last accessed: 23 August 2021.)
  10. National Institute for Health and Care Excellence (2018) Post-Traumatic Stress Disorder. NICE guideline No. 116. NICE, London.
  11. NHS Leadership Academy (2021) Supporting Our People. http://people.nhs.uk (Last accessed: 23 August 2021.)
  12. Wolfe HA, Wenger J, Sutton R et al (2020) Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative. Pediatric Quality and Safety. 5, 4, e319. doi: 10.1097/pq9.0000000000000319
  13. Whybrow D, Jones N, Greenberg N (2015) Promoting organizational well-being: a comprehensive review of Trauma Risk Management. Occupational Medicine. 65, 331-336. doi: 10.1093/occmed/kqv024

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