A data-driven, implementation-focused

European Journal for Person Centered Healthcare 2018 Vol 6 Issue 1 pp 62-68

ARTICLE

A data-driven, implementation-focused, organizational change approach to addressing secondary traumatic stress Ginny Sprang PhDa, Leslie Anne Ross PsyDb and Brian Miller PhDc a Professor of Psychiatry & Executive Director, University of Kentucky College of Medicine, UK Center on Trauma and Children, Lexington, KY, USA b Senior Consultant, Core Curriculum on Child Trauma, UCLA-Duke University National Center for Child Traumatic Stress, Los Angeles, CA, USA c Director, Children’s Behavioral Health, Primary Children’s Hospital, Salt Lake City, Utah, USA

Abstract The literature is replete with examples of the heavy toll that Secondary Traumatic Stress (STS) exacts among the workers who assist trauma survivors. The subsequent impact of STS on the workforce manifests in low morale, turnover, loss of productivity, job dissatisfaction and presenteeism. As organizations strive to become more trauma-informed, addressing the impact of traumatic stress on providers and first-responders becomes a critical component of best practice in a traumainformed workplace. The implementation framework detailed in this paper serves to facilitate the development of organizational supports for workers in trauma-serving settings. The process begins with a data-based decision support measure (the STSI-OA) and is facilitated by the use of the STSI-OA Organizational Change Toolkit that includes a range of activities to address STS in the workplace and evaluates progress toward becoming STS-informed. Integration of the STSIOA and the NIRN implementation framework into an evidence-informed toolkit provides a model for creating success in the implementation of STS prevention and intervention practices. Keywords Adversity, coping, coping strategies, implementation, leadership, low morale, organizational change, person-centered healthcare, productivity loss, psychometric analysis, resilience, secondary traumatic stress, STSI-OA Correspondence address Dr. Ginny Sprang, University of Kentucky College of Medicine, UK Center on Trauma and Children, 3470 Blazer Parkway, Suite 100, Lexington, KY 40509, USA. E-mail: [email protected] Accepted for publication: 13 August 2017

Introduction

- is at the root of many mental health and wellness issues facing patients served in the public sector [11]. Similarly, there is ample evidence of the heavy toll that indirect trauma or Secondary Traumatic Stress (STS), which is created through sharing of this trauma information in a helping relationship, exacts among the workers who work to assist trauma survivors [12,13]. As a result, one of the most important front-lines of defense in Society against untreated mental illness, those individuals who help and support our most vulnerable populations, is itself threatened. To assist organizations in addressing this threat to the workplace, the Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) tool [14,15], was developed to operationalize an organization’s role in addressing secondary traumatic stress by outlining a series of policy, practice and training activities that would enable a unit to address STS in the workplace based on its unique characteristics and needs. Based on the current literature relevant to STS risk and protection, principles of organizational learning and development [16,17] and

The cumulative cost of staff burnout and stress on the workforce is well-documented and rising [1-3]. Some economists estimate that occupational stress costs businesses in the United States over $40 billion a year [4] and leads to worker absence from the workforce at a rate that is four times higher than for all other occupational illnesses or injuries [5]. Several decades of research documents the significant, pervasive and negative effects of chronic stress, burnout and indirect trauma on workers and organizations, including but not limited to, increased conflict at work [6], higher turnover intentions, reduced quality of work and presenteeism (employees who are present but whose work is compromised) [7-9]. Fortunately, there is evidence to suggest that a significant return on investment can be realized at a rate of $2 to $5 for every dollar spent on stress control efforts [10]. There is growing and widespread recognition that primary trauma - which arises from sources that can range from child abuse and domestic violence, to military service 62

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implementation science [18], the tool describes what an STS informed organization would look like if all the activities described in the item set were enacted fully. Furthermore, the tool can be used by organizational representatives at any level to evaluate the degree to which their organization is STS-informed and able to respond to the impact of secondary traumatic stress in the workplace. This article describes how the STSI-OA can be used to create organizational change in the context of an implementation process framework described by the National Implementation Research Network (NIRN). This organizational change process begins with a data-based decision support tool (the STSI-OA) and is facilitated by the use of the STSI-OA Organizational Change Toolkit [14]. This toolkit provides information on how the tool can be used within an implementation change process, includes a range of activities to achieve the goals identified in the STSI-OA and examples of individual and organizational outcomes that can be used to track progress over time. Several decades of research point to the centrality of personal efficacy, through active coping, to human agency [19,20]. Several meta-analytic studies on coping selfefficacy provide compelling evidence that belief in one’s ability to produced desired outcomes through active coping behaviors can improve psychosocial functioning and enhance resiliency [20-22]. This principle holds true in high stress environments and following exposure to trauma. Benight & Bandura [23] note that “Self-appraisal of coping capabilities, determines, in large part, the subjective perilousness of environments”. Resilience to adversity is enhanced when individuals play a proactive role in their adaptation to stressors (such as indirect trauma exposure) rather than passively absorbing organizational and environmental assaults [23]. When organizations remove obstacles to effective problem solving by workers and feed personal self-efficacy, resilience is enhanced. This converging evidence regarding the importance of active coping and self-efficacy in trauma recovery is instructive in identifying strategies to address STS in the workplace and the types of activities that should be included in the STSI-OA.

responsibility with the organization as a whole for sustained workplace wellness. For the purposes of this organizational assessment, STS was defined for respondents as the trauma symptoms caused by indirect exposure to traumatic material, transmitted during the process of helping or wanting to help a traumatized person. Resilience was defined as an individual's ability to adapt to stress and adversity in a healthy manner. Organization, as used in this context, refers to the workplace setting that was the target of the STSI-OA assessment. Items on the STSI-OA are organized into domains of activity related to organizational promotion of resilience building activities (7 items); the degree to which an organization promotes physical and psychological safety (7 items); the degree to which the organization has STS relevant policies (6 items); how STS has informed leadership practices (9 items) and routine organizational practices (11 items). Employees respond to each item based on the degree to which they perceive their organization is addressing the specified practice or protocol. These response categories include 1 = “Not at All, 2 = ”Rarely", 3 = “Somewhat,” 4 = “Mostly” and 5 = “Completely. A “Not Applicable” response is provided and is not coded. Scoring involves using these values to sum all items in a domain for a subscale score and all 40 items for a total score. Items corresponding to each domain are listed as a footnote to Table 1. Total scores range from 0-200, with higher scores indicating a higher level of competency in each area of activity. See Table 1 below for mean, standard deviation and quartile cutoffs. Table 1 General description of the scores by final domain and total on the STSI-OA, with quartile cutoffs for a national sample of respondents (N =629)

Overview of the STSI-OA The STSI-OA is a 40-item measure that assesses an organization’s approach to STS prevention and intervention. A STS-informed organization incorporates not only the capacity of the individual to effect personal change, but creates a culture of wellness by addressing the impact of trauma at every level of the organization. The overlay of implementation science principles in this process allows organizations to assess their level of STSinformed practice, create a strategy for change consistent with their current capacity and need and choose what areas need to be targeted for improvement. They can monitor change overtime and create an inclusive partnership with staff and stakeholders in the process which shifts the focus from individual responses to self-care to shared

Domain

Number of Items

Mean(Standard Deviation)

Median(Lower quantile, Upper quantile)

Resiliency Building Activities

7

17.04 (10.7)

16 (12,20)

Promoting Safety

7

16.28 (10.9)

14 (9,20)

STS informed Policies

6

10.65 (8.1)

9 (6,14)

STS informed Leadership Practices

9

19.78 (15.3)

17 (10,26)

STS informed Routine Practices

11

23.19 (22.88)

17 (8,30)

Total

40

86.97 (59.78)

73(50,107)

Resilience Building = STSI-OA Items 1 a–g, Safety = STSI-OA Items 2 a–g, STS Policies = STSI-OA Items 3 a-g, Leadership Practices = STSI-OA Items 4 a–I, Routine Practices = STSI-OA Items 5 a–g and 6 a-d

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STSI-OA Toolkit

Organizational

Secondary traumatic stress and PCH

Change

The NIRN implementation drivers are ultimately designed to be used collectively to ensure high-fidelity and sustainable programs. To further illustrate how the STSIOA can be used to evaluate activities in each area of implementation, the item set was mapped upon the implementation drivers described in the NIRN framework (see Table 2). This illustrates how organizational leaders can integrate the STSI-OA tool into existing implementation processes to measure progress toward sustainability and change at every step. Enacting all of the strategies outlined in the STSI-OA, across all implementation drivers provides for a process that is integrated (the implementation components work together) and compensatory (stronger, more consistent areas of performance can compensate for weaker performance in other areas) [25]. In implementation of the STSI-OA process, as with any tool or approach, the method of implementation contributes as much to a successful outcome as the selected model. It could be argued that many tools, models, or trainings, have little impact upon the STS experienced by workers within an organization because they were not implemented at all; rather, they were simply presented to the staff of the organization without any a defined plan for implementation. Successful change requires change at the practice, organization and systems levels, so these implementation supports must be used purposefully. Specifically, the STSI-OA guides organizations to become more STS informed in the following manner. The STS Informed Organizational Toolkit provides resources to assist organizational leaders and change agents in addressing any deficiencies noted in the baseline assessment. While the STSI-OA, as a data-based decision tool facilitates change, the toolkit provides additional methods to help organizational leaders achieve their goals of being STS informed. A sample of the resources provided in the toolkit are also included in Table 2. To further delineate how the STSI-OA can be used to facilitate implementation success, it is helpful to outline how this tool can be used within the context of the NIRN implementation drivers. These drivers operate in an integrated and compensatory manner to facilitate change.

The STSI-OA Organizational Change Toolkit uses best practice wisdom gained from psychometric analysis, implementation science, active coping theory [24] and research on traumatic stress and secondary traumatic stress to inform the resources selected for each domain of activities. The toolkit includes (a) the STSI-OA, (b) an implementation tool to guide the adoption of STSinformed practices and policies and (c) a means by which to evaluate change towards identified outcomes. Specifically, this resource identifies individual and organizational level outcomes as well as provides action planning worksheets, activities, examples, readings and templates to further guide the training and implementation process. Essentially, the toolkit assists organizations in translating the STSI-OA into practice by identifying tangible and measurable steps and methods that can be used to facilitate the implementation process towards the goal of building secondary traumatic stress informed agencies.

Using the NIRN Framework and STSI-OA to Guide Change The STSI-OA was designed to provide organizations with a blueprint for creating a STS Informed workplace culture. NIRN has developed a comprehensive change framework model that utilizes best practices, science of implementation, organizational change and system reinvention to improve outcomes. The framework is designed to integrate the voices and experiences of diverse communities and consumers to guide implementation. NIRN has identified Implementation Drivers of successful change, Competency, Organization and Leadership, that are key elements of organizational capacity and functional infrastructure supports that enable successful change. These Drivers are processes that can be leveraged to improve competence and enhance organizational environments. The activities identified in the STSI-OA item set can be mapped onto these implementation change drivers identified in the NIRN framework. Implementation towards organizational change in this sense is defined as a specified set of activities designed to infuse STS informed practices into an activity or program of known dimensions seamlessly and in a manner that transforms the organization. According to this definition, the STSI-OA activities are deliberate and purposeful and specified in such a way that external consultants or evaluators could detect and measure the existence of and strength of the enacted STSI-OA item set into the cultural milieu. Organizational change or implementation is an ongoing process and should be viewed as a phenomenon that needs ongoing attention to sustain the new activities or approaches.

Driver #1: Competency Training One apparent attribute of the STSI-OA is that it explicates the competencies that organizations should possess in order to support their workers at risk for secondary traumatic stress. The most direct way to initiate the development of a competency is training in the core skills need to achieve mastery. The STSI-OA explicitly identifies training topics towards development of competencies that mediate secondary trauma exposure. For reference, all 7 items in the resilience-building domain refer to knowledge and skills that can be promoted through training activities in trauma focused environments. Individual items also explicate training related to competency development in 64

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Table 2 STSI-OA items mapped onto NIRN Implementation Drivers

STSI-OA Domain

NIRN Driver #1: Competency

NIRN Driver #2: Organizational

NIRN Driver #3: Leadership

Sample resources to support change

Resilience

Training: 1 a-e Coaching: 1 b-g

Facilitative: 1 a-e

Technical and Adaptive 1b,c,e

List of essential elements of STS101 course Active Coping Skills Inventory

Safety

Training: 2b, 2f Coaching: b, f, g

Policies

Training: 3c Selection: 3f

Leader Practices

Selection: 4h Coaching: 4f, g

Organizational Practices

Training: 5 a, b, c, g Selection: 5 e

Facilitative: 2-a-g Decision Support Data System: 2 c, d System Intervention: 2g

Technical and Adaptive 2 e

Systems and Facilitative Administration: 3 a-f

Technical Leadership 3 c,d,e

Systems: 4-a-i Facilitative Administration: 4 a,b,h,i

Technical: 4 b,c,f,h Adaptive: 4 a,d,e,g,i

Reflective practice and supervision guidance

Systems: 5 a-g and 6 a-d Facilitative Administration: 5 a -k Decision Support Data System: 5 h – k

Technical 5f, g Adaptive 5 j,k

Hot Walk and Talk exercise New Employee Orientation training outline Individual STS assessment tools

Low Impact Debriefing protocol Sample safety surveys Descriptions of critical incident response protocols for staff (Schwartz rounds, Blainet groups, PFA for staff)

Sample policy statements Sample strategic plan statements

Selection

the domains of physical and psychological safety, policy and organizational practices. There is evidence to suggest that training in trauma informed principles and practices and evidence-based trauma treatments, is associated with lower levels of STS [26,27]. The NIRN model makes clear, however, that training is a component of competency, but training alone is not sufficient to establish a competency. Implementation efforts often begin with training, but must not end there.

The assessment highlights many foundational characteristics of resiliency that can readily be applied to the recruitment and interviewing process, for example, sense of professional wellbeing, mission orientation, maintaining hope in a patient’s potential for recovery and sense of professional competency in providing services to traumatized populations. Specific items point to opportunities for senior leaders to use personnel selection to match caseload to need (STSI-OA item 4h) and provide discussion of STS during new employee orientation (STSIOA item 5e). Any selection process is, ideally, a mutual selection process and an organization with well-defined supports for a worker has an important selling point to recruit talent when it is identified in a potential hire.

Coaching The use of coaching is commonplace in clinical practice with trauma victims, as it is a component of several evidence informed trauma interventions [28]. However, coaching is not just an interaction between clinicians and patients. A natural next step to follow any training effort, is coaching by senior leaders in the skills that comprise competency in practice in the workforce. The STSI-OA defines the knowledge components of an organization’s developing competency in STS intervention, but it is the follow-on support delivered after the training that will move the knowledge into an applied skill. Coaching and supervision are defined or implied in the resiliencebuilding domain of the instrument, which assesses such activities as monitoring STS impact and coaching of specific professional competency skills.

Driver #2: Organizational Systems Intervention A key component of effective implementation is alignment of the internal and external supports that will sustain the

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Table 3 Proposed STS focused Process, Individual and Organizational Outcomes (compared to baseline) Domain

Resilience

Level I Process

STSI-OA indicators 1a - g

Level II Individual Outcomes

Level IV Organizational Outcomes

•

Improved staff resiliency

•

Utilization of Active Coping

•

Increased knowledge of coping/STS interventions

•

Increased sense of professional competency

•

Increased sense of perceived support

• • • • • • • •

Decreased absenteeism Decreased staff turnover Increased productivity Increase quality of care and client outcomes Increased job satisfaction Decreased occupational distress Increased overall organizational traumainformed practice Increase sustainability of trauma-focused practice within an organization

•

Safety

Policy

Leader Practices

STSI-OA indicators 2a through g

• •

Increased sense of psychological safety Increased sense of physical safety

STSI-OA Indicators 3a –f

• • •

Increased resiliency Perceived physical and psychological safety Workers feel that organizational policies support STS-informed practice

• STSI-OA Indicators 4a-i

•

• Organizational Practices

STSI-OA indicators 5a-k

•

• • •

Decreased turnover Less safety breeches Perceptions of safety are enhanced at staff level

•

STS Informed policies drive evaluation process and quality improvement measures

Improved perceptions of level supervisor and leader role modeling and support Employee perceives STS policies and procedures are integrated into supervision and core organizational practices

• • • • •

Decreased turnover Increased job satisfaction Increased productivity Lower levels of STS in leaders and staff Increased use of reflective supervision

Increased individual sense of resiliency, physical, and psychological safety Individual perceives that organizational practices actively address STS in the workplace

• • •

Decreased turnover Increased job satisfaction Increased productivity

implementation effort. A singular attribute of the STSI-OA is that, by identifying and defining the qualities of a STSInformed organization, this alignment can occur in a manner that is trauma responsive. The operating premise of the instrument is that the domains are synergistic in that, for instance, policies that promote physical safety of staff will influence an item in another domain, the worker’s sense of physical safety. Because of the synergy between domains, an articulated and comprehensive STS effort results that is internally aligned in approach. That is to say, alignment is defined and guided by the assessment itself. The assessment is designed so the policies of the organization are aligned with the practices of the workers; that practices of the leaders promotes resilience building activities in the programs and that practices within the domains are occurring in alignment at all levels of the organization.

Facilitative Administration The NIRN definition of facilitative administration is the “proactive, vigorous and enthusiastic attention by the administration to reduce implementation barriers and create an administratively hospitable environment for practitioners” [29]. The very act of conducting this assessment, analyzing the results and defining an action plan operationalizes the concept of “facilitative administration”. The items that comprise the STSI-OA provide an operational definition of the “administratively hospitable environment for practitioners”, at least as it relates to implementation of STS-supporting functions. Because the STSI-OA assessment evaluates the practices of the organization, the onus for the supports and STS practices is upon the organization and does not rest upon the individual worker. This is especially important in the trauma field, where clinicians and other providers can be overburdened and under-resourced [7,9]. Thus, it is clear that the responsibility of the leaders of the organization is to develop the administrative supports that create the hospitable environment for practitioners. While this is 66

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intrinsic within the STSI-OA items, application of the process should explicitly honor the role and responsibility of administrators in this effort.

proactive ways. This prevents leaders from relying on authoritative practices and allows leaders to the initiators of corrective action. The STSI-OA can provide the data for a decision support process that can be repeated across multiple data points, reducing the complexity that creates great uncertainty. Little in the way of prescriptive approaches exists to reduce that complexity in organizations that serve traumatized populations. The STSI-OA interventional framework attempts to provide a map through this complex environment, but it cannot eliminate the need for flexible and adaptive leaders. Such adaptability will always be required to navigate the inevitable but unpredictable barriers that will be encountered in provided trauma-informed services.

Data Driven Evaluation The STSI-OA assessment can be viewed as a data-based decision support activity that is the link between identified need and the mechanism of action needed to address STS in the workplace. Inherent in the NIRN framework is the integration of strategies across areas of focus so that the organization may use or build upon areas of strength to compensate for deficits in other domains. For example, the STSI-OA item set represents a broad range of activities ranging from macro level policies to micro level strategies that can be used by organizations who are seeking to become trauma responsive and realize that being STS informed is an integral part of this process. If the identified policy or practice is insufficient or inappropriate, SWOT analyses or other organizational level evaluations that are already being used could provide convergent data regarding the nature of these deficiencies so that remediation can occur. Organizational policies provide external pressure on an organization to sustain initiatives without complete buy-in from all parties (though this is not recommended), but the viability of these policies must be evaluated with the end goal in mind. Structured regular evaluation provides a lens through which CEOs and senior leaders can identify and compensate for weaknesses within a specified driver. Table 3 identifies the evaluation goals driven by the STSI-OA that organizations can use to measure process, individual and organizational outcomes related to STS policy and practice implementation.

Preliminary Findings The STSI-OA has excellent internal consistency and very good reliability. The Cronbach’s alpha, or lower bound estimate of reliability for the STSI-OA, is very good (0.977) for the combined set of items, indicating that calculating a total score by summing the items is appropriate and reliable. Domain scores are also in the excellent range: Resilience Building (0.94), Promoting Safety (0.89), Organizational Policies (0.9), Leader Practices (0.94), Routine Organizational Practices (0.96). Test-retest reliability analyses showed total scores were stable across time with intraclass correlation coefficients estimated at 0.813 ({95% CI: (0.772 to 9.54), n = 111}). The STSI-OA provides sensitive test-retest reliability to detect changes in practice as early as 90 days postimplementation, so that the capacity of an organization to be compensatory and integrated is enhanced.

Driver #3: Leadership

Conclusion

Technical Leadership

In this article, the STSI-OA is presented as an organizing framework for systematic intervention into the STS within an organization. Integration of the STSI-OA and the NIRN implementation framework provides a model for creating success in the implementation of STS prevention and intervention practices. To facilitate this process, the STSIOA Organizational Change Toolkit was developed to provide organizational leaders with activities, resources and evaluation strategies and outcomes for improving their STSI-OA scores and achieving their goals of becoming an organization that is trauma responsive to the workforce. The STSI-OA, the NIRN framework and the subsequent toolkit, are evidence-informed tools that were built on the foundation of research regarding STS, psychometric analysis, coping theory and principles of implementation science. Future research will investigate the utility of the tools singularly and in combination as best practice approaches to addressing STS in the workplace.

A good technical leader operates in a zone “where there is substantial agreement about what needs to be done and reasonable certainty about how to do it” [29]. To date, there has been little articulated best practice wisdom to guide such actions in the field of secondary trauma interventions at the organizational level. In other words, many managers, even those who were aware of the impact of trauma work on the workforce, do not act because they simply did not know what to do about STS in the workforce. The objective of the developers of the STSIOA is that this instrument could offer some definition of “what needs to be done and how to do it”, which provides guidance to the technical leader. Adaptive Leadership Fixen and Blasé [29] assert that “when organizations and systems are being changed on purpose, adaptive leadership is needed to manage the change process”. Adaptive leaders need tools to monitor the change process so they can anticipate trends, self-correct and problem solve in 67

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Conflicts of Interest

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The authors declare no conflicts of interest.

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