Slide outline: Evidence Informed Practice in Intensive Family Support Programs: Are we there yet?

 CFCA webinar - 21 May 2013

  1. Evidence Informed Practice In Intensive Family Support Programs: Are we there yet?

    • Greg Antcliff, Director Professional Practice, The Benevolent Society, Australia
    • Marie Iannos, Research Assistant, Australian Centre for Child Protection, University Of South Australia
  2. Outline
    • Developing an evidence-informed Practice Framework for intensive family support programs: Resilience approach
    • Uptake of Evidence-Informed Practices- Barriers and gaps
    • Implementing evidence Informed Practices-Are we there yet?
    • Comment:

      Working with vulnerable families at risk of abuse and neglect is intensive and challenging work for family support practitioners.

      • There are many programs and interventions which the evidence tells us are effective, however for many reasons, the best evidence-informed practices are not always being delivered directly to families

      Today's webinar will:

      • Look at how an evidence-informed practice framework  based on the Resilience-Led approach was developed for The Benevolent Society's intensive family support programs
      • Discuss the barriers and gaps which affect the uptake of such Evidence-informed practices then lastly-
      • Examine how evidence-informed practices are implemented in organisations, look at the progress the Benevolent society has made in the implementation process.
  3. Developing a Practice Framework for Intensive Family Support Programs at the Benevolent Society: Resilience Practice Framework.
    • Image: Domains of resilience wheel.
      The centre of the wheel lists the domains of resilience as: social competencies; secure base, education; friendships; talents and interests; and positive values.
      The next layer lists the actions of: assessment; planning; intervention; and reviewing outcomes. These actions are multidirectional and ongoing and without a fixed start or finish point. Actions flow between the domains.
      The outer layer of the wheel lists the principles of: integrity; respect; effectiveness; collaboration; and optimism.
    • Comment:

      We will now turn our attention to how an evidence-informed practice framework was developed for the Benevolent society's Intensive Family support programs. Then Framework was based on the principles of the Resilience -Led Approach which is dervied from Daniel and Wassel (2002) Resilience Practice Framework.

       This Resilience-Led approach is a framework which encompasses and is congruent with other theories and practice methods or interventions.  It is not a method of work or theory in itself. It was formally adopted by the Benevolent Society as it's overarching framework for service delivery across all of it's child, family and community services in 2009.

       The adoption of the Resilience-Led approach occurred following a rapid expansion of the organisation's child and family services between 2006 and 2010.  This expansion resulted in a large diversity of highly skilled professional staff employing a variety approaches to their practice. During this expansion, the organisation had increased it's programs and was establishing itself in a new state where it did not yet have a strong identity. However at this time there was no consistent view or approach to practice across the organisation.

      In response to these issues, the Resilience -Led approach was adopted to align with the organisation's purpose and strategy.  The goal was to achieve a unified approach to child and family practice across the organisation's diverse services and geography, and to improve the consistency and quality of practice.

  4. Practice Framework Programs
    • To Develop a practice framework for the Benevolent Society's intensive home based family support programs which is evidence-informed and designed to ensure children are safe from maltreatment and receiving adequate care in their families. In Partnership with the Australian Centre for Child Protection

      • Reduce the risk of re- notifications or re-substantiation
      • Close the case without court involvement,
      • Prevent removal into alternative care
      • Facilitate Family reunification
    • Comment :

      This Practice framework we are going to discuss today was the product of a collaborative project between The Benevolent Society management and practitioners, and researchers at the Australian Centre for Child Protection (ACCP) at the University of South Australia.

      The aim of the project was to develop a coherent practice framework specifically for the Benevolent society's intensive home based family support and reunification programs, based on the Resilience-Led Approach.

      The framework was designed for programs for families where children were are at high risk of abuse or neglect, or where abuse/neglect had already been substantiated. Although the focus of the programs varied, the core business was essentially to ensure that children are safe from maltreatment and receiving adequate care, where Adequate care was considered sufficiently satisfactory to:

    • Reduce the risk of re- notifications or re-substantiations of abuse or neglect
    • Close the case without court involvement,
    • Prevent removal of children into alternative care or
    • Facilitate Family reunification
  5. Definition of Resilience: "Strength in the face of adversity. The capacity to adapt and rebound from stressful life events, strengthened and more resourceful" (Daniel and Wassell, 2002). High Level outcomes for children for the Resilience -led approach :
    1. Increasing safety
    2. Secure and Stable relationships
    3. Improving coping/self-regulation  skills
    4. Increasing self-efficacy
    5. Improving empathy
    • Comment :

      So how did the resilience-led approach form the basis of the practice framework?

      The Resilience-Led approach defines Resilience as: (having) "Strength in the face of adversity. The capacity to adapt and rebound from stressful life events, strengthened and more resourceful"..It focuses on maximising the likelihood of better outcomes for children by building a protective network around them.

      This approach emphasises nurturing a child's adaptive ability and capacity to benefit from the resources which are available to them, and to make use of those resources to buffer the effects of adversity.

      The Resilience-Led approach identified 5 high level child outcomes which support the development of resilient families, which can be applied across all of it's child and family programs, these are:

      1. Improving safety (physical, emotional, environmental)
      2. Strengthening secure and stable relationships-
      3. Improving coping skills and emotional self-regulation skills - for both children and parents ( self regulation)
      4. Increasing self-efficacy
      5. Improving empathy
  6. Image: The five resilience outcomes that lead to resilient families are: safety; secure & stable relationships; coping skills; self-efficacy; and empathy. The Benevolent Society's Family Support Programs focus on three of the five resilience outcomes: safety; secure & stable relationships; and coping skills.
    • Comment:

      The project team determined that while working to enhance children's self-efficacy and empathy is useful, the core focus of these target programs was essentially to protect children and ensure their safety and adequate care.

      Thus, three of the 5 Resilience outcomes were chosen to form the basis of the Practice framework these were:

      • Safety- where child is physically and emotionally safe, and free from family violence and all forms of abuse and neglect, and where parents are managing the problems that contributed to the abusive/neglectful circumstances in their family
      • Secure and Stable Relationships- where child experiences stable, secure and dependable relationships at family/school/community levels, has a secure attachment with their primary caregiver, and where the Parent-Child interactions are not harmful in any way.
      • Coping Skills (self-regulation) -Child receives the appropriate support to develop the skills necessary to effectively process the past abuse or neglect they may have experienced, and develop coping skills to deal with stress in a safe and adaptive way so to foster resilience. At the same time, this outcome also refers to the capacity for parents to develop their own skills in emotional self-regulation
  7. Image: What we do - evidence-informed practice that 'works'. How do we know? Child & parent safety indicators. Safety; secure & stable relationships; coping skills. Resilient families.
    • Comment:

      With those 3 broad outcomes as a starting point, the project team next needed to establish the outcomes for practice.  This required us to identify what the indicators of safe and resilient families were. We asked, how would practitioners know that children and families were safe, strong and doing well?

      The line of logic was that if families received the evidence-informed practices that worked, these child and parent safety indicators would occur, thus strengthening family resilience and reducing the risk of abuse and neglect.

  8. Image: Evidence-informed practice that 'works'. Child & parent safety indicators. Safety: safety; environment; and parental capability: Keeping family safe. Secure & stable relationship: parental capability: parent/child interaction; and social support. Coping skills: coping skills (child). Resilient families
    • Comment:

      To determine these safety indicators, the team consulted the literature to determine what it looked like for children to be free from abuse and receiving adequate care in their family. We consulted the family therapy and child protection literature to identify the main areas of family functioning in terms of strengths and needs assessed by practitioners who worked with families at risk. This process identified 6 domains, which were then mapped under the 3 resilience outcomes. These domains included:

      • Physical and emotional safety
      • Environmental safety- (stable housing, hygiene)

      PLUS 2 categories of parental capability which related to

      • firstly to the parents ability to keep their children physically safe from harm
      • and secondly also to the parent’s ability to interact with their child in a positive and nurturing manner which fostered a secure attachment

      then

      • a domain of Social Support-which refers to the family’s connectedness to community and family support networks

      And lastly

      • A Coping skills domain-which refers to the child having the opportunity and support to process past trauma, and develop coping skills to deal with future adversities
  9. Child Indicators-Adequate Care
    Child Indicators-Adequate Care
    Safety Secure & stable relationships Coping skills

    Child is free from physical abuse and sexual abuse and is not exposed to DV

    Child is making progress to achieve developmental milestones (growth, cognition)

    Child receives adequate physical care (nutrition, hygiene, appropriate clothing)

    Child receives adequate parental supervision

    Child is enrolled and engaged in school/preschool/early childhood education and care

    Child’s medical needs are met (doctors, dental)

    Child’s mental health needs are met (access to mental health support)

    Child’s home environment is safe, hygienic and free from hazards

    Child resides in stable housing

    Child experiences consistent parenting

    Child experiences emotionally responsive and nurturing parenting

    Child experiences developmentally appropriate expectations

    Child has increased peer and social supports

    Child’s relationships with siblings are improved

    Child is engaged in school and has developed positive peer relationships

    Child is connected to community services

    Child has opportunity and support to process traumatic events

    Child has developed techniques to manage stress and emotional regulation

    Child has developed more adaptive coping skills

    • Comment:

      This process resulted in the identification of 19 child, and 30 parent safety indicators of resilient families.

      This table shows the 19 child safety indicators, which describe what we would expect children to be experiencing when receiving adequate care. They include the child being free form all forms of abuse, living in a safe home environment where their physical and mental health care needs are being met (including nutrition, medical care), where they are receiving nurturing consistent parenting, are engaged in their schooling, and have supportive social connections within the family (siblings), and with their peers, and lastly has developed adaptive coping skills to foster resilience and cope with future adversity.

  10. Parent/Caregiver Indicators- Adequate Parenting

    Parent/Caregiver Indicators- Adequate Parenting
    Safety Secure & stable relationships

    An explicit Safety plan in place which addresses (parental issues (MH, DV, AOD)

    Parent can respond to child’s physical and mental health care needs (access services)

    Provide stable, safe, hygienic Home environment

    Adequate Supervision

    Manage household resources

    Provide adequate Physical care (nutrition, clothing, hygiene)

    Provide developmentally appropriate nurturing

    Increased ability to manage own mental health, AOD issues

    Develop adequate coping skills to manage stress/emotional regulation

    Develop adequate self-care skills

    Increased self confidence and capacity for change

    Ensure school attendance

    Interact with child at developmentally appropriate level

    Developmentally appropriate expectations

    Respond with sensitivity to child’s needs

    Provide Consistent parenting

    Utilise Understand adopt non-coercive parenting strategies

    Understand impact of trauma on child’s behaviour and well being

    Connected to social supports in family community
    -develops

    Increased self confidence and self-efficacy to access community resources

    Parent facilitates opportunities for peer/social interaction

    • Comment:

      This table shows some of the 30 parent safety indicators, which describe what parents would be achieved with the support of family support practitioners in order to strengthen family resilience. The line of logic was that if parents were demonstrating these safety indicators, they would in turn result in the child safety indicators. Parent indicators include for example

      • Parent’s being supported to address the issues which impact on family safety, namely Domestic Violence, substance abuse, or mental health issues.
      • Parents being able to meet their children’s basic physical care needs (such as stable housing, supervision, health care and nutrition), and their emotional care needs for consistent, nurturing, developmentally appropriate and non-coercive parenting
      • For parents To develop the emotional regulation skills in order to manage stress effectively, deal with family conflict and crises appropriately, and develop non-coercive parenting strategies
      • For parents To understand the impact of trauma on their child’s well-being
      • To develop self-care skills and build confidence to make the positive changes required to increase their family safety, for example, by accessing the available community supports and resources.
  11. Finding the Evidence
    • Literature review of evidence-based programs and interventions for children and families at risk
    • Identified 13 empirically supported programs and interventions which ‘worked'
    • Comment:

      The next step was to find out what the research evidence told us worked in practice to help families achieve these outcomes.

      To do this, the research team conducted a literature review of the programs and interventions which had been applied to vulnerable families at risk of abuse of neglect, or where abuse/neglect had already occurred.

      We looked for those which had been rigorously evaluated and where possible, had been subject to randomised controlled trials. However it should be noted that not all programs were evaluated with the high level of rigour of an RCT

      This lit search identified 13 programs or interventions.

  12. Programs & Interventions that "Worked"
    • Multi-disciplinary-social work/psychology/nursing
    • General Parenting programs
    • Specialised family support
    • programs for at-risk families
    • Variety of theoretical approaches (cognitive-behavioural, Attachment)
    • Comment:

      They came from a range of professional disciplines, including social work, psychology, and nursing, and included not just specialised programs developed for families in the child protection populations, but also general parenting programs, and family therapies from a variety of theoretical approaches applied to high risk families with positive results (such as CBT, and attachment theory)

  13. Evidence-Informed Programs/Interventions
    • Attachment Interventions
    • Abuse-Focussed Cognitive Behaviour Therapy
    • Child Parent Psychotherapy
    • Early Start Program
    • Family Connections Program
    • Home Builders Program
    • Incredible Years Program
    • Motivational Interviewing
    • Nurse-Family Partnership home-visiting program
    • Parent-Child Interaction Therapy
    • Triple P Parenting Program
    • Parents Under Pressure Program
    • Project SafeCare
    • Comment:

      Briefly, Here is a list of these programs and interventions which came up in the lit review. As you can see, they range widely from generalist parenting programs such as Incredible Years and Triple P, to tailored programs for parents with substance abuse issues (Parents Under Pressure), and specific programs developed for families at risk, such as the Home builders and Project Safe Care programs.

      The common thread through all of these programs and interventions was that they had demonstrated positive outcomes for the children and families who received them. : either through a reduction in abusive parenting practices, a prevention of further abuse or neglect and/or a reduction in re –notifications or removals for the child back into the child protection system.

  14. Evidence-based practice and programs
    • Programs

      • Collections of practices that are done within known parameters (philosophy, values, service delivery structure, and treatment components)
    • Practices
      • Skills, techniques, and strategies that can be used by a practitioner.
    • Comment:

      While It was good to find programs and interventions which the studies told us were effective, the next step was to find out what made them work. We asked- what are the specific practice components in each of these programs which could be identified?

      It should be noted that while a program can be conceptualised as a collection of practices performed within a theoretical structure or format, practices are the specific skills, techniques and strategies a practitioner uses within the program of treatment.

      So it was the practice component themselves that we needed to identify.

  15. Critical Practice Components -what was effective?
    • Developing a safety plan
    • Providing/coordinating concrete needs and resources (food, housing, $)
    • Parent education & skills training (childcare, nutrition, safety, hygiene)
    • Parenting skills-behaviour management, managing stress, enhance parent-child attachment
    • Facilitating social support networks
    • Comment:

      2 workshops with the Benevolent society were held to examine each of these programs and interventions in detail and break them down into their practices, which we called critical practice components. This process identified 36 critical practice components which were effective. Practice components were described in terms of worker activities provided to the family. Examples of practice components included:

      • Developing a comprehensive safety plan with parents
      • Facilitating a family’s access to concrete resources such as emergency food/accommodation/financial support
      • Providing Parent skills training in basic living skills such as home hygiene, nutrition, home safety, and childcare
      • Helping parents develop skills in conflict resolution, problem solving, and stress management
      • Teaching positive parenting and behaviour management strategies
      • Providing therapeutic interventions aimed at strengthening the parent-child attachment, and stress management
      • Worker Facilitating the family’s connections to social supports networks in their own family, school and community
  16. Image: Practice Skill Guides. Practice Activities. 36 Critical Practice Components. 13 Programs & Interventions. Safety; secure & stable relationships; coping skills.
    • Comment:

      The next phase involved examining these critical practice components and breaking them down further into their individual practice elements, or practice activities.

      A practice activity is a specific trainable activity which comprises microskills or kernels, for example teaching relaxation techniques, or teaching a parent how to use praise or timeout.

      Each of these practice activities were then linked to practice skill guides which formed the foundation of the practice framework.

      So in summary the development of this practice framework was a process of both a ‘top down” and ‘bottom up’ approach to applying the research evidence in a systematic way and embedding it into the Resilience Led approach framework structure.

  17. 44 Practice Guides
    • Goal focussed
    • Instructional format
    • Parent/child worksheets
    • Incorporate several practices
    • ACCP developed guides
    • Raising Children Network
    • COPMI website
    • Practice Wise
    • Comment:

      The end point of the process resulted in identification of 44 practice skill guides and resources which underpinned the practice framework. The majority of the practice guides were developed collaboratively by Parenting Research Centre (PRC) and the Benevolent society and are written under each of the 5 resilience outcomes. They were adapted from Practice-Wise evidence-based services database.

      3 of the guides were developed by the ACCP. These were around developing a safety plan, parent skills training and the application of motivational interveiw techniques to engaging families. When supplemental information is required, The Framework also refers to resources developed by evidence-informed Australian parenting websites, particularly the Raising Children network (to which the PRC contributes), and the Children of Parents With Mental Illness websites.

      The practice guides are highly structured, goal focussed and written in practical step by step instructional format which describe the microskills involved in each practice. Practice is for, and when and where the practice is to be conducted. Out who the They set Some guides also have corresponding supplemental worksheets for workers to use with parents and children if appropriate.

  18. Practice guides by resilience outcome
    Practice guides by resilience outcome

    Secure and Dependable Relationships

    Descriptive Praise

    Engaging and infant

    Family Routines

    Following Your Child’s Lead

    Listening, Talking and Playing More

    Parent Skills Training

    Teachable Moments

    Increasing Safety

    Developing a Safety Plan

    Effective requests

    Injury prevention and Child Proofing

    Natural and Logical Consequences

    Reducing unwanted behaviours – time Out

    Social connections Map ( Child and Adult)

    Improving Self-Regulation and Coping

    Promoting Better Sleep routines ( Infants and Children)/adult

    Problem Solving (Child)/Adult

    Active Relaxation -Progressive Muscle Relaxation

    Active Relaxation- Mindfulness and Visualisation

    Active Relaxation – Exercise (Child)/adult

    • Comment:

      This slide shows an example of some of the practice guides titles which fit under the 3 resilience outcomes. They cover practices which aim to foster more secure attachment between parent and child. For example following your child’s lead….(Greg)

  19. Labelling a child's emotions
    Labelling a child's emotions
    Who: Child & Parent Where: Agency, home setting How: Practitioner lead, one-on-one

    A critical factor in developing emotional competence is the ability to recognise and label one's own emotions. Importantly, if a child can recognise their own feelings, he or she can also begin to empathise with feelings seen in others. Recognising feelings allows the emotion to be processed by higher order cognitive functions, rather than impulsively expressed as felt. When mastered, they provide the child a vehicle with which to regulate emotions because they have experiences in attaching a label to internal emotions and therefore can bring feelings into consciousness.

    Outcomes

    • Increased child ability to regulate own emotional states
    • Less likely to develop internalising or externalising disorders
    • Increase empathy dut o increased ability to decode and label another's experience
    • Increased ability to chose socially appropriate responses to other children
    • Increase peer acceptance by enhancing children's social skills
    • Decreased behavioural problems, such as impulsive or aggressive responses
    • Increased parent-child emotional bond and attachment
    • Increased academic competence

    How you do it

    Step 1

    Teach the parent the skills of recognising their child's emotions states

    See also: Recognising child's emotional states (Step 1 of 2, Emotion Coaching practice guide)

    Step 2

    Assist the child to label the emotion

    Once the parent feels confident to identify the way their child is feeling, help parents find words to described and extend on how their child is feeling.

    For example, when a child is angry, they might also be jealous, frustrated or betrayed. When a child is sad, they might also feel left-out, hurt, or feel 'abnormal' or different to other kids.

    Suggest to the parent that they clarify each statement with a question to ensure they have been correct in labelling the emotion. This also shows the child that the parent is really listening and interested in how their child is feeling.

    For example,

    I can see by your face that you are -
    It seems like you are feeling -
    It sounds like you felt - , is that right?
    Did you feel - when - ?
    Were you feeling - when - ?

    Step 3

    Encourage parents to ask specific questions about feelings

    - Have parents ask their children specific questions about feelings, rather than general questions such as "How was school?" which can often lead to closed answers.

    - Specific questions about the child's life work well because they draw on the child's unique experience and therefore draw specific responses from her.

    For example, suggest the parent refer to something that happened recently, such as, 'At soccer, who did you talk to today?'

    Fun and interactive strategies to help a child label their emotions

    • Comment:

      Here is an example of a practice guide. This one is around about assisting parents to identify children’s emotional states.

      It is important to clarify that this framework is not a prescribed program, but rather an evidence-based framework as a guide to support Interventions with families.

      It was intended for use by practitioners after they have completed a comprehensive family assessment of the family’s strengths and needs, and developed a case plan accordingly. Workers use their own clinical judgement to determine which Practices are required, and at what phase of the intervention they should be applied. For example, a practitioner may first work on establishing safety and basic concrete resources with the family prior to working on attachment issues.

      So how is the framework been utilised by workers? Next, Greg is going to talk about the implementation of the practice framework.

  20. Uptake of Evidence-Informed Practice
    • Barriers and Gaps
  21. What is Evidence Informed Practice?
    • Evidence-informed practice is the use of best evidence combined with the knowledge and experience of practitioners, the views and experiences of service users and the context in which it is to be delivered.
    • Adapted from What Works for Children? Evidence Guide. Economic & Social research Council et al 2003
    • Comment

      Evidence-Informed practice has been defined as: “the use of best evidence combined with the knowledge and experience of practitioners, the views and experiences of service users and the context in which it is delivered’. EIP is a concept which has been increasingly cited in the community service arena in recent years. It is based on the principle that community service programs and interventions should be informed by the most current, relevant and reliable evidence.

      The Origins of EI Practice lie in the health and social science field, which are driven by orgs like the Cochrane Collaboration who establish an evidence bases for drug interventions, and the Campbell Collaboration whose work is to establish the efficacy of social and educational interventions.

  22. Evidence-Informed Practice in Intensive Family Support
    • Intensive family support work is challenging, confronting, crisis-driven
    • Families have multiple complex issues and needs
    • An avalanche of evidence informed practices that staff have to filter  when seeking to find ‘what works' with children and families in different contexts
    • Comment:

      So how is evidence-informed practice being applied to family support programs?

      Families referred to intensive support services are often complex, with multiple issues and needs. Working with this population is often crisis driven and can be confronting at times, leaving some workers feeling overwhelmed with how much work there is to do, and also importantly how they are going to go about doing it.

      Despite there being what has been described as an “avalanche” of good evidence-informed programs and practices out there, family support workers often have heavy workloads, and little time to filter through the research evidence of “what works” and incorporate it into their practice.

  23. Research to Practice Gap
    • World of Research
    • Implementation
    • World of Practice
    • Comment:

      Not just in UK, we too, have to Mind the Gap… In the community services sector, there is a significant gap between what are known to be effective interventions for children and families (research) and what is being delivered on the ground (practice). This is known as the research to practice gap. Barriers to achieving evidence informed practice occur at a systems level, organisational level and at the individual practitioner level. Even where there is a high quality evidence base to inform practice, the incorporation of this into practice is frequently low, slow, incidental or haphazard.

       Traditional methods to facilitate the engagement of practitioners in evidence-informed practice (such as stand-alone training) have been demonstrated to be ineffective on their own. A more structured process that addresses systemic and organisational issues is required to make sure new practices are implemented.

  24. Science to Service Gap
    • Often what is known is not what is adopted to help children, families and caregivers
    • Creates barriers at systems, organisation and practitioner levels
    • Practitioner training alone does not work
    • Often, what is adopted is not used with fidelity and good effect
    • Implementation Gap
      • There are no clear pathways to implementation.
      • What is implemented often disappears with time and staff turnover
    • Comment:

      This gap, known as the “science to service gap”, can create barriers to uptake of evidence informed practice at the systems, organisational, and individual practitioner levels

      Even when a high quality evidence base exists, the incorporation of this into practice is frequently low, slow, incidental or haphazard- so that what is adopted is not utilised with fidelity and good effect, meaning that children and families may not receive the best programs and support, or at best receive evidence-based practices delivered in fragmented, piecemeal manner.

      Furthermore, traditional attempts to engage practitioners in evidence-informed practice with just training alone has been shown to be an ineffective strategy.

      Presently, an ‘implementation gap “ exists whereby there are no clear pathways to implementing evidence-informed practices in community service organisations,. This often results in situations where practices are adapted quickly, but then lose momentum with high staff turnover and disappear over time.

  25. "Evidence" on effectiveness helps you select what to implement for whom however "Evidence" on these outcomes does not help you implement the program or practice
    • Fixsen & Blase (2008)
    • Comment:

      Evidence helps identify the what but doesn’t tell you how

  26. Critical barriers to EIP
    • Organisational setting or context
    • The capacity of the workforce to implement EIP
    • Addressing organisational policies and processes
    • Narrow project, practice standards, guidelines, or procedure-orientated approach to introducing evidence (Johnson & Austin, 2006)
  27. Implementation of Evidence-Informed Practice
  28. Are we ready?
    • To successfully implement and sustain evidence-based practice
    • The What: What is the program/practice?
    • The How: Effective implementation framework (e.g strategies to change and maintain behaviour of practitioners and create hospitable organisational systems)
    • The Who: Expert Implementation assistance
  29. Implementation Drivers
    • Image: Implementation drivers. Adaptive: integrated & compensatory. Technical. Leadership. Competency Drivers: Coaching; Training; and Selection. Organisation Drivers: Systems Intervention; Facilitative Administraion; and Decision Support Data System. Performance Assessment: Improved outcomes for children and families.
    • Comment:

      Once EIP’s have been developed, close attention needs to be paid to the process of implementation. In recent year, researchers have increased their efforts to outline the process of Implementation. These have often been in the form of descriptions of the main steps in implementation and/or refined conceptual frameworks based on research literature and practical experiences ( i.e., theoretical frameworks, conceptual models).

      Frameworks for implementation are descriptors of the implementation process including key attributes, facilitators, and challenges to implementation ( flaspohler et al, 2008). They provide an overview of practices that guide the implementation process and in some instances, can provide guidance to researchers and practitioners by describing specific steps to include in the planning and/or execution of implementation efforts, as well as pitfalls or mistakes that should be avoided ( Myers, et al., 2012).

  30. Implementation Science
    • Implementation occurs in stages: 2-4 years

      • Exploration & Adoption
      • Installation
      • Initial Implementation
      • Full Implementation
      • Innovation
      • Sustainability
        • Fixsen, Naoom, Blase, Friedman,  & Wallace, 2005
    • Comment:

      These are the stages through which almost all implementation initiatives travel, and each stage of implementation does not cleanly and crisply end as another begins. Often they overlap with activities related to one stage still occurring or re-occurring as activities related to the next stage begin. And depending on the factors and variables in the environment, implementation efforts may completely drop back to an earlier stage. For example, if there is significant staff turnover at the practitioner level, then the effort may move from an effort that is fully implemented back to an effort or initiative that is again in the stage of initial implementation.

      • Exploration and Adoption

        • Articulate the need for an Organisational approach to our work
        • Discuss at Operations meeting and fit with Strategic Plan
        • Adoption at a leadership level – Senior Managers and GM Operations
        • Define evidence base and Evaluation Framework
        • Project Scoping – Paper (internal Operationalising Resilience) Program Installation
        • Stakeholder Analysis – Define stakeholder groups to inform future planning
        • Change process designed
        • Development of Communications Plan
        • Development of Learning and Development Plan
          • Pilot Training
          • Develop Learning Circle Framework
          • Brief learning Circle leaders
          • Evaluation Plan for Learning & Development
        • Engage Regional Leads
        • Develop Evidence Based Resources and tools
      • Initial Implementation
        • Implement Resilience Learning and Development
        • Circulate toolkits for managers and Learning Circle Leaders
        • Communication Plan implemented
      • Full Operation
        • Learning Circles implemented
        • Resilience reflected in all Area and service Business Plans
        • Position Descriptions reviewed to reflect Resilience Practice Framework
        • PDR process reviewed to reflect practice framework
      • Innovation
        • Learning Circles evaluation and reviewed
        • Explore the application of Resilience Practice Framework across lifespan
      • Sustainability
        • E-learning module developed
        • Round table with stakeholders
        • Business Systems review for development of future Information Systems
        • Repeat survey of staff and compare results from base line data
  31. The Four Phases of QIF
    • Image: The Four Phases of QIF. Phase 1 Initial considerations regarding the host setting. Self-assessment strategies: Conducting a needs and resources assessment; Conducting a fit assessment; Conducting a capacity readiness assessment. Decisions about adaption: Possibility for adaption. Capacity-building strategies: Obtaining explicitly buy-in from critical stakeholders & fostering a supportive climate; Building general/organisational capacity; Staff recruitment/maintenance; Effective pre-innovation staff training. Phase 2 Creating a structure for implementation. Structural features for implementation: creating implementation teams; Developing an implementation. Phase 3 Ongoing implementation support strategies: Technical assistance/coaching/supervision; Process evaluation; Supportive feedback mechanism. Phase 4 Improving future applications. Learning from Experience. (Meyers, Durlak & Wandersman, in press)
  32. Organisational readiness
    • Readiness for change refers to organisational members resolve to implement a change ( change commitment) and a shared belief in their capability to do so ( change efficacy).
    • When organisational readiness is high, organisational members are more likely to initiate change, exert greater effort, exhibit greater persistence, and display more cooperative behaviour.
    • Failure to establish sufficient readiness can account for one-half of all unsuccessful, large scale organisational change efforts ( Weiner, 2009)
  33. Readiness assessment
    • Assess the readiness of the staff to adopt new EIP's across child and family programs in NSW and QLD.
    • Holt ( 2007) Readiness of Organisational Change questionnaire is a validated 25 item scale which measures the beliefs among employees in four areas using a seven point likert scale ( strongly disagree to strongly agree)
    • Questions addressed were:
      1. How do staff feel about the practice changes being introduced? (Appropriateness)
      2. The degree to which staff perceive Senior Management to be supportive of this practice change ? (Management support)
      3. How confident staff feel to implement this practice change ? (Change efficacy)
      4. How staff feel this change will impact on them personally (Personal valence
  34. Key Messages

    • The majority of respondents are supportive of the changes and believe they will be good for the organisation
    • Most employees feel confident of their ability to integrate the changes into their practice
    • Most employees indicated they didn't feel their jobs would be adversely impacted by these changes
    • Staff in 3 regions ( Regional, Rural and  a Metro ) are particularly unsure whether senior management are supportive of the changes
    • Staff in one Regional and Metro Area are least positive about the changes
  35. Creating a structure for Implementation
    • 3 Local Implementation Teams established ( 2 Regional and Rural, one Metro) - Managers and Senior Practice staff
    • Expert Implementation support from the Parenting Research Centre
    • Fortnightly meetings to discuss each QIF element
    • Increase readiness and have the local adaptation for the context
    • Realisation -  more pre-innovation training is needed ( Resilience Assessment Tool & Resilience Outcomes Tool , Practitioner process skills & What works in Child Protection workshop?)
  36. Linking Assessment, Analysis to Interventions
    Linking Assessment, Analysis to Interventions
    Resilience Analysis Tool

    Resilience Outcome (Summary Points) These should come from the strengths and needs completed throughout the assessment

    Assessment Domain

    Resilience Practices Relevant to Resilience Outcomes and Assessment Domains (please select planned practice)

    Secure and Stable Relationships

    Strengths

    Needs

    Conclusions and areas to work on:

    • Community Links and Resources
    • Family Resources Management
    • Family life and relationships
    • Child Health and Wellbeing
    • Parenting
    • Caregiver Health and Wellbeing
    • Adult Relationships
    • Descriptive praise
    • Attending to your child
    • Engaging an infant
    • Family routines
    • Family time
    • Following your child’s lead
    • Listening, talking and playing more
    • Teachable moments
    • Other__________

     

    Increasing Safety

    Strengths

    Needs

    Conclusions and areas to work on:

    • Community Links and Resources
    • Family Resource Management
    • Family Life and Relationships
    • Child Health and Wellbeing
    • Parenting
    • Caregiver Health and Wellbeing
    • Home Physical Environment
    • Adult Relationships
    • Relationships tensions or violence
    • Substance Use and Misuse
    • Tangible rewards
    • Effective requests
    • Creating effective child and family rules
    • Developing a safety plan
    • Injury prevention and childproofing
    • Basic child health care
    • Implementing natural and logical consequences
    • Reducing unwanted behaviours–planned ignoring
    • Reducing unwanted behaviours–time out
    • Social connections maps
    • Supervising children
    • Other_________
    Increasing Self Efficacy

    Strengths

    Needs

    Conclusions and areas to work on :

    • Community Links and Resources
    • Family Resource Management
    • Child Health and Wellbeing
    • Parenting
    • Caregiver Health and Wellbeing
    • Adult Relationships
    • Setting goals for success
    • Praising for effort and persistence
    • Identifying negative thinking traps
    • Challenging negative thinking
    • Strategies to challenge negative thinking traps
    • Other_________
    Improving Empathy

    Strengths

    Needs

    Conclusions and areas to work on:

    • Family Life and Relationships
    • Child Health and Wellbeing
    • Parenting
    • Caregiver Health and Wellbeing
    • Tuning in: identifying a child’s emotions
    • Naming a child’s emotions
    • Modelling empathy
    • Praising empathy
    • Using emotions as a teaching opportunity
    • Emotion coaching
    • Other_________

    Increasing Coping/Self Regulation

    Strengths

    Needs

    Conclusions and areas to work on :

    • Family Life and Relationships
    • Child Health and Wellbeing
    • Parenting
    • Caregiver Health and Wellbeing
    • Adult Relationships
    • Promoting better sleep routines (toddler and young child)
    • Promoting better sleep routines (adolescent and adults)
    • Problem solving (child)
    • Problem solving and decreasing aggression (younger child)– The turtle technique
    • Problem solving (adult and family)
    • Active relaxation – progressive muscle relaxation
    • Active relaxation- mindfulness and visualisation
    • Active relaxation­–physical exercise (child)
    • Active relaxation–physical exercise (adult)
    • Active relaxation–controlled breathing (child)
    • Active relaxation–controlled breathing (adult)
    • Other_________
  37. Next Steps!
    • Roll out the Resilience Assessment Tool ( with quality assurance)
    • Detailed project planning to address each QIF element and organisation agreement on resourcing and pilot.
    • Co-design the training framework with the Parenting Research Centre (Observe; practice; feedback)
    • Co-design the coaching framework with the Parenting Research Centre( ongoing skills development and fidelity checks)
    • Identify practice coaches in each Area 
    • Alignment with other change initiatives in TBS eg. SDMS
    • Design the evaluation, monitoring and outcomes measurement framework
    • Go live in June 2013!
  38. Limitations of the Approach
    • EIP's developed for the Resilience practice Framework have not been bought together before and the packaging up of these practices to be used by practitioners is untested ( Outcome and process evaluation will determine this)
    • Implementing the Resilience Practice Framework has been slow and its innovative nature means that it can be hard for staff within the agency to trust the approach will reap the rewards
    • There has been no cultural adaptation of the EIP's for Aboriginal and Culturally & Linguistically diverse families ( planned but not commenced)
  39. Are we there yet? No, but we are well on the way!
  40. Questions?

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