Audio transcript (edited)

KNIGHT

Good afternoon, and welcome to the CFCA webinar: Evidence Informed Practice in Intensive Family Support Programs: Are we there yet?

My name is Ken Knight, and I'm Senior Communications Officer at the Child Family Community Australia Information Exchange. 
I would like to begin by acknowledging the traditional owners of the lands on which we are meeting. I pay my respects to their elders past and present, and to the elders from other communities who may be participating today.

Throughout May CFCA has focused on Intensive home-based family support. We have released a range of resources on this topic that we hope will assist you in your work. If you haven't checked them out, please see our website - the url is on the slide in front of you.

You will be able to submit questions via the chat box during the webinar. There will be a limited amount of time in which Marie and Greg can respond to your questions, but we will try to get through as many as possible.

It is now my great pleasure to introduce today's speakers, Marie Iannos and Greg Antcliff. 

Marie is a registered psychologist with 8 years experience in the field of child and adolescent mental health.

Marie is a research assistant at the Australian Centre for Child Protection, where her main role is to provide research support across the many ongoing projects in the Centre that have a clinical focus.

Greg is a registered psychologist and Director of Professional Practice with The Benevolent Society, Australia.

His work focuses on the implementation of evidence informed practice across diverse child and family programs in NSW and QLD.

In 2007 Greg was awarded a Churchill Fellowship to investigate programs that integrate early learning and care for vulnerable children and families in North America and Europe.

Greg has extensive experience in the field as a clinician, trainer and supervisor/manager of child and family programs in both government and non-government sectors.

Please give Marie and Greg a very warm, virtual welcome.

IANNOS

The aim of the project was to develop a coherent practice framework specifically designed for the Benevolent Society's Intensive Home-based Family Support and reunification programs, based on a resilience-led approach. The framework was designed for programs for families where children were at high risk of abuse or neglect, or where abuse and neglect has already been substantiated. And, although the focus of the programs varied, the core business was essentially to ensure that children were safe from maltreatment and receiving adequate care.

Where adequate care for this purpose was considered sufficiently satisfactory to reduce the risk of re-notifications or re-substantiations of abuse, close the case without court involvement; prevent removal of children into alternative care, or to facilitate family reunification.

So how did the resilience-led approach form the basis of the practice framework? The resilience-led approach firstly defines resilience as having strength in the face of adversity, a capacity to adapt and rebound from stressful life events, strengthened and more resourceful.

It focuses on maximizing the likelihood of better outcomes for children by building a protective network around them. This approach then, emphasizes nurturing the 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 identifies five high-level child outcomes that support the development of resilient families, and these were applied across all of the Benevolent Society's child and family programs. These high level outcomes are improving safety, which involves physical, emotional and environmental safety; strengthening, secure and stable relationships; improving coping skills for both children and parents (and that's around emotional self-regulation specifically); increasing self-efficacy; and improving empathy.

The project team determined that while working to enhance children's self efficacy and empathy as useful, the core focus of these target programs was essentially to protect children and ensure their safety in care. Thus, three of the five resilience outcomes were chosen to form the basis of the practice framework, and these were: safety, which refers to the child being physically and emotionally safe and free from family violence and all forms of abuse, and where parents are able to manage the problems which are contributing to the abusive or neglectful circumstances within the family.

Secondly, we look at Secure and Stable Relationships. And this refers to where the child is experiencing stable, secure and dependable relationship across the family, school and community levels, and also is experiencing secure attachment with a primary care giver, and where the child and parent interactions are not coercive or harmful in any way.

And lastly, the outcome of coping skills, which refers to where children are receiving the appropriate support to develop the skills necessary to effectively process past abuse or neglect they may have experienced. And also to develop coping skills to deal with stress in a safe and adaptive way so as to foster resilience, and at the same time, this outcome also refers to the capacity for parents to develop their own skills in emotional self-regulation.

With those three broad outcomes as a starting point, the project team needed to establish the outcomes for practice. This required us to identify what the indicators of a safe and resilient family were. So we had to ask how would practitioners know that children and families were safe, strong, and doing well? The line of logic here was that if families receive 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.

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 families. So we consulted the family therapy and child protection literature to identify the main areas of family functioning - in terms of strengths and needs - which are assessed by practitioners who work with families at risk.

This process identified six domains that were then mapped under those six resilience outcomes. These domains included physical and emotional safety, environmental safety (which included stable housing, nutrition, health care and hygiene), plus two categories of parental capability. One, which related firstly to the parents capability to keep their children physically safe from harm. Secondly, the parent's ability to interact with their child - in a positive and nurturing manner -which fostered a secure attachment.

Then there was a domain of social support, which refers to the family's connectedness to the community and the family's social support networks. And lastly, a coping skills domain, which refers to the child having the opportunity and support to pass trauma and develop coping skills to deal with future adversity. This process resulted in the identification of 19 child and 30 parent safety indicators of resilient families. And this table shows 19 child safety indicators that describe what we would expect children to be experiencing when receiving adequate care. They include the child being free from all forms of abuse; living in a safe environment where their physical and - health care needs are being met; where they are receiving nurturing and consistent parenting; are engaged in their schooling; and have supportive social connections within their families, such as their siblings and also with their peers; and lastly, developed coping skill to foster resilience.

This table here shows some of the parent safety indicators that resulted. These describe what parents would be achieving with the support of family - workers, in order to strengthen family resilience. The line of logic here was that if parents were demonstrating these safety indicators, they would in turn, result in the child safety indicators we spoke about before. The parent indicators include, for example (we're not able to go through all of them but some of them include) parents being able to address those issues which are impacting on the family's safety- namely domestic violence, substance abuse, or mental health issues or intellectual disabilities; parents being able to meet their children's basic physical care needs such as stable housing, adequate supervision, health care and nutrition. And also meeting emotional care needs such as consistent nurturing and developmentally appropriate parenting.

For parents to develop the emotional regulation skills so that they are able to manage stress actively and deal with family conflict and crises appropriately, and develop non-coercive and non violent parenting strategies in times if stress. And for parents to understand the impact of trauma o their child's wellbeing, and lastly, to develop self care skills so that they are able to - the confidence to make the changes that are required to increase their families safety. For example, by being able to access the available community supports and resources around them.

The next step was to find out what the research evidence told us worked in practice to help families achieve these outcomes. So to do this, the research team conducted a literature review of the programs and interventions that had been applied to vulnerable families at risk of abuse and neglect, or to families where abuse or neglect had already occurred. We looked for those that had been rigorously evaluated and where possible, had been subject to randomized control trials. However it should just be noted here that not all of the programs and interventions that were subject to the literature review could be evaluated with a high level of rigor of a randomized control trial.

Nevertheless the literature search identified 13 programs of interventions in total. These came from a range of professional disciplines, including social work, psychology and nursing, and they included not just specialized programs developed for families in the child protection population, but also general parenting programs and family therapies from a variety of theoretical approaches which had been applied to high risk families with positive results. These include for example, cognitive behavioural' and attachment theory approaches.

Briefly, here is a list of the programs and interventions which came up in the literature review, and as you can see, they range widely from generalist parenting programs such as the Incredible Years and Triple P Parenting Program, to tailored programs for parents with substance abuse issues such as Parents Under Pressure, and specific programs developed -families at risk, such as The Homebuilders and Project SafeCare programs. The common thread through all of these programs was that they had demonstrated positive outcomes for children and families who received them - either through a reduction in abusive parenting practices, or the prevention of further abuse or neglect, or that there was a reduction in the re-notification or removals of children back into the child protection system, following participation in such programs.

While it was good to find the programs and interventions which the studies told us were effective, the next step was to find out what made them work, so we asked what are the specific practice components in each these programs which we could identify? It should be noted here that while a program can be conceptualized as a collection of practices performed within a particular theoretical structure or format, practices themselves are the specific skills, techniques and strategies that the practitioner uses within the program of treatment. And it was the practice components themselves that we needed to identify next in this process.

Two 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 all up identified 36 critical practice components that were effective. The critical practice components were described in terms of worker activities, which would be provided to the family. So, for example, some of the critical practice components identified included developing safety plans with parents; facilitating a families access to concrete resources - including emergency food or accommodation; providing parent skill straining in basic - skills such as basic hygiene, nutrition, home safety and childcare; practitioners helping parents develop skills in conflict resolution, problem solving and stress management; teaching positive parenting and behaviour management strategies; or providing therapeutic interventions which are aimed at strengthening parent-child attachments; and lastly, another example is where workers may facilitate the family's connections to social support networks within their own community, and also within the school environment.

The next phase then involved examining these critical practice components and breaking them down even further, into their individual practice elements or practice activities. A practice activity is a specific trainable activity that comprises micro-skills, or also known as kernels. For example, a micro-skill may be teaching relaxation techniques, or teaching a parent how to use praise or 'time out' effectively. Each of these practice activities is then linked to practice skill guides which from the foundation of the practice framework.

So in summary, the development of this practice framework was a process of both a 'top down' an 'bottom up' approach to applying the research evidence we knew that worked, in a systematic way, and imbedding it into the resilience-led approach framework structure. The end point of the process resulted in the identification of the 44 practice skill guides and resources that underpinned the practice framework for the Benevolent Society's family support programs. The majority of the practice guides were developed collaboratively by the Parenting Research Centre, together with the Benevolent Society, and they were written under each of the five high level resilience outcomes. They were also adapted from practice wise evidence based service database. Three of the guides were developed by the Centre For Child Protection and these were around developing a sound safety plan, parent's skills training and also a guide around the application of motivational interview techniques for engaging families.

When supplemental information was required by practitioners, this framework also refers to the resources which were developed by the evidence- informed Australian parenting websites, in particular the Raising Children Network to which the parenting research centre contributed, and also the Children of Parents With Mental Illness website. The practice guides themselves are highly structured, goal focused, and they're written in a practical step-by-step instructional format that describes the micro skills involved in each practice.

The guides describe who the practice is for, and when and where the practices are to be conducted. They also provide, for some of them, a corresponding supplementary worksheet for workers, which they can refer to, and use with parents and children, if appropriate. This slide here shows an example of some of the practice guide titles that fit under each of those three resilience outcomes. They cover practices, which, for example, aim to foster more secure attachment between parent and children.

ANTCLIFF

For instance, here we've got under Secure and Dependable Relationships, one of the practices is called Following Your Childs Lead, and what we find in a lot of our child protection families or more intensive court services, what parents tend to do is to follow when they should lead, and lead when they should follow. So this practice really helps parents to get into the 'world' of the child and to improve that security and dependability of the relationship.

IANNOS

So here is an example of a practice guide. This one is around assisting parents identifying children's emotional states.

So before me move on to discuss the implementation of the framework, its important first to clarify here, this practice framework is not a prescribed program, but rather an evidence-based - to use as a guide to support workers' interventions with families. It is intended for use by practitioners, after they have first completed a comprehensive family assessment of the families' strengths and needs and develop their case plan. Workers then use their own clinical judgment 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 providing basic concrete resources with the family to establish stability, prior to working on issues around attachment. So, how has this framework been utilized by workers at the benevolent Society? Well next Greg will talk about how the implementation process proceeded.

ANTCLIFF

Thanks Marie. I'm going to talk about the uptake of evidence informed practice and some of the barriers and gaps we have. What you've seen so far is the development that we have great evidence informed practices, but its not enough to have the product. And when we're talking evidence informed practice, I suppose the definition we're working from is that it's the best evidence combined with the knowledge and the experience of practitioners, but also the views and experiences of service users, and the context in which its going to be delivered.

I'll talk a little bit more about the context as we delve more into the implementation. What we also know is when we're working in intensive family support services that the work is challenging, its often difficult and multi-faceted, crisis-driven and (there are) multiple complexities of issues. At the same time, what practitioners have to deal with is an avalanche of evidence informed practice - and how do you know to select which interventions for which family, at which time, to get the required effect?

We also know that there's a significant gap between what we know from research that works and when we get into the world of practice. And I've cheekily put in there "mind the gap". But what we now know is that there's implementation that can bridge the gap between the world of research and the world of practice. There's been some research around the gap between when we know something works, and until its implemented into practice is around 17 years. Now, if we think about that, there are three cohorts of children under the age of five that are gone by the time something's been translated from the world of research to practice. But now what we have is implementation frameworks that help us to bridge that gap and link the world of research to practice.

We also know that often what is known is not what is adopted to help children and families. And that's often because there's barriers to systems or at organisational levels, and sometime practitioners' preferences too - even though they know something works, they prefer to use something else. We also know that investing just in training practitioners, or training alone, doesn't result in the uptake of evidence. It's about a five percent uptake of new skills developed by training alone. However, if you couple that with coaching and supportive systems and processes, you get about a 95% uptake for practice transformation.

So there's a gap. So there's no clear pathways to implementation and what we often know - and I've seen happen in many survives over the time - you implement something, and then within two years' time (because of staff turnover, etc.) it often disappears. So how do we ensure that when we implement something that it's going to be sustainable over time? So what we've got so far then is, we've got evidence on effectiveness. What that does is it helps us select what to implement and for whom. However, evidence on these outcomes, it doesn't help us to implement the program or practice.

I've implemented a program once and we invested heavily in a parenting program, and because it had the best evidence of effectiveness. We trained all the staff and we went "off you go, there it is" and two/three years down the track, it's been a bit of a waste of money because we've had high staff turn over and its not been used in the matter it was intended. So we know that there are critical barriers to implementing evidence informed practice. Some of those can be in our organization setting, or the context, sometimes it could be the capacity of the workforce to implement a particular evidence informed practice.

We need to know that the workforce has the skill to implement the practice that we're asking them to implement. We also need to address organisational policies and procedures, and another barrier is that narrow projects or practice standards and guidelines -or a procedure-orientated approach to introducing new evidence - can be really limited. I know once you've got a practice guide you think "well everybody know about it", but how often does it not translate into meaningful practice change on the ground?

So in order to implement the evidence informed practice, so far what we have is ...program or practices that we know are effective (in and of themselves) to achieve those five level outcomes. Now I want to focus the attention "well how do we effectively implement these practices?" and these are strategies to maintain and change behaviour of the practitioners to ensure that it's a hospitable organisational systems that are going to support it. And in order to do that there's a "who?" part there that we need expert implementation assistance to do it.

So I just wanted to show you a picture here of ... how once an evidence informed practice has been developed, close attention needs to be paid to the process of the implementation. And largely, we focus on training staff...training staff. But as you can see, implementation drivers (from this diagram) that there's many more things that we need to address in order for it to lead to improved performance, and to get the improved outcome for children and families.

On one side you've got your competency drivers, so its not just training its "what's the coaching you out in place to sustain the skill development of staff over time" and then "what implications does that have about who we select in our staff selection processes? On the other side, we need to identify what are the systems or the facilitative drivers or what data are we going to collect to inform our decision making? (so they're the organisational drivers). And that requires a technical type of leadership to achieve all those things. So, buy training staff, its not implementation, its only one small element of a larger process if we're going to have sustainable practice transformation over time.

What we've learnt from implementation science is that - and there's a science to how we implement that - that implementation occurs in stages. Here's a model outlined by Dean Fixson and his group, and they say to have effective implementation, it takes a two to four year process. Well when I first heard this I thought, "that's absolutely crazy"- we've got these practices and we'll be done and dusted in twelve months. But I sit here now and we're three years in, and we're just about to go live, so I now have a much greater respect for the science behind the implementation.

So The Benevolent Society has been working closely with a parenting research centre, and we're using an implementation framework called the Quality Implementation Framework. This has been a recent synthesis of 25 different implementation frameworks, and one that we're applying to roll out is the resilience practice framework. As you can see here, there are four stages - four phases - to implementation. Phase One is where you can have all the initial considerations regarding the host setting; Phase Two is when we start looking at our structures, and what structure we need to create for effective implementation; Phase Three is the ongoing structure once the implementation begins; and Phase Four is how we improve the applications

We're straddling between Phases One and Two at the moment with our implementation. I mean, we've done the self-assessment strategies...we needed to have a consistent practice framework. It fits across our organisation and aligns with our organisational strategy. And I'm going to focus on "Are we ready?" an undertaking readiness assessment and then looking at the structural features implementation as well.

So, when I'm talking about organisational readiness, it's a readiness for change... refers to organisational members resolved to implement a change, or "what's their commitment to a change and their shared belief in their capability to do it?" when organisational readiness is high, organisational members are more likely to initiate the change, exert greater effort, exhibit greater persistence, and display more cooperative behaviour. And failure to actually establish sufficient readiness in organisations can account for about a half of all unsuccessful, large-scale organisational efforts. So that's why we've put significant focus on "are we ready?"

We conducted an organisational readiness assessment of the staff about "well how do staff actually feel about implementing these evidence informed practices? And the readiness measures that we used were from Holt (2007), and it asked four questions: How appropriate do staff feel the practice of change is? What degree of management support is there? How confident does the staff feel to implement the practice change? (that's the change efficacy); and lastly, how they feel about the impact on them personally.

So, the result of this study went out to over 300 of our practitioners and largely, we got great results saying that we were ready. The majority of respondents were supportive of the changes and they believed that they be good for the organization. Most employees felt confident about their ability in terms of integrating the changes into their practice. They also indicated that they didn't think their jobs would be adversely impacted by the changes. Staff in three regions (one in a rural, regional and metro area) were unsure if senior management were supportive of the changes. Now this is quite relative, as the changes were quite high, so we still had 60-70% positive responses, and staff in one regional and metro area - they were the least positive about the changes.

So what this told us is that we needed to go back and do some readiness testing, or something, to combat that in those areas. So what we did then is...our readiness is high, its telling is "all systems go" to implement. We needed to create the structures for implementation, and what we've learnt is that too many times we've pushed out changes on to staff, rather than getting them involved in the decision-making. So we created three local implementation teams, in our three areas that we selected to go first. Two are in regional and rural contexts, and ones in the metropolitan context. And those regional implementation teams have their managers and senior practice staff on there. What we do there is we've got some expert implementation and support from The Parenting Research Centre, and we've been having fortnightly meetings to discuss all of those elements - 14 elements - of the quality implementation framework.

We take each element to ensure that we're ready - that we've addressed it - and then all the conditions necessary for us to implement. So what this has resulted in, is increased the readiness of each of these areas and identified things that we have to adapt for the context in which the evidence informed practice are going to be delivered in. one of the learnings that we've had on this is a realization that we needed t go back and do more training, that the assessment tool that we were using was not being implemented or used in the manner in which it was meant to. So we actually needed to go back and rewrite the assessment tool and adapt it. So now it's called The Resilience Assessment Tool and Resilience Outcomes Tool. So now there's a clear line of sight between the engagement assessment and analysis and planning interventions and reviewing outcomes.

We realized that we couldn't just train people in practices, because if they've had more skills in their bag, but we needed to realise the information you collect and analyse has implications for what interventions you use, for which families, and when. So that was a very important learning for us that slowed down the implementation process, however, staff now feel more ready, and we've just finished rolling out their pre-innovation training on their tool, and the practitioners have just been reporting back that they can now see the line of sight between what you collect information in, and then selection of practices.

So this is what I mean by linking assessment analyses to intervention and its just an example of our analysis tool. You'll see up there it says Secure and Stable Relationships -well that's one of the outcomes that we're trying to improve in, and its got room there to record strengths, needs, the conclusions from our analysis, and areas to work on together. The middle column there is a prompter for the practitioners - there the information domains that we collected information in - that's we're your going to be pulling your information on to populate the strengths/needs areas to work on. And over on the other side, are the practices that are known - in and of themselves - to improve and secure in unstable relationships.

For instance here, you've got a descriptive praise, attending to your child's needs, engaging an infant, etc. so that's how we're linking the line of sight to the assessment analyses and intervention. So where are we at in the next steps? We're going to continue to roll out the resilience assessment tool with a quality assurance wrapped around it to ensure that we know that people are using it in the manner its intended. We continue our detailed project planning to address all the areas of the elements of the implementation that we need to for each area. We're currently co-designing the training framework with the Parenting Research Centre, and because its a skill development base for our practitioners, it will be observed practice feedback...just like when we want parents to learn new skills, it requires first to see it, then to practice it, and then get feedback so you can improve on it.

After the training, because that in itself is not enough, we need to have a coaching framework that's wrapped around it, that's going to support staff to be able to reflect on where they're at in their skill development, and then improve upon that in applying all the 44 evidence informed practices. We're also identifying practice coaches in each area and he'll be providing that coaching to staff on a monthly basis. I think one of the other important things that we do within the Benevolent Society - we're developing a new case management, or computer system, and the assessment tool and all the interventions will front-end loaded and built in to the new system. So this will help us determine which of the interventions that we're using are more likely to lead to which outcomes, for which families. Which will be very exciting down the track, as of January next year, that we can really start collecting that data and using it for a quality improvement framework to really wonder about our practice and to improve upon it.

We're also designing an evaluation and an outcomes framework around this. How did we know that we would use the intervention framework effectively? Because if something's not implemented effectively, you're not going to get the outcomes you intended. And its very exciting, and nerve wrecking, that we go live in 2013. So we're going to have to watch this space about where did this land? Hopefully, that we're addressing all the necessary conditions for it to be very successful. So I did want to point out before we finish that there are some limitations to this approach.

The evidence informed practices that have been developed for this framework - they've not been tested or bundled together before. There's evidence of their efficacy in and of themselves, but packaging-up of these practices - to improve on those five outcomes - is yet untested. I suppose our outcomes and our process evaluation will actually shed light on that. The other thing is, we could have gone and selected one of those thirteen programs off the shelf that Marie talked about. Its very expensive to do that, and often prohibitive for not-for-profit organisations to do that, because of licensing fees, etc. but implementing a framework like we've developed, like this, I mean it is innovative in nature, but it means that it's been a long and hard and quite often slow process, so we're asking people to trust in the approach that's going to reap the rewards.

The last one that we're addressing there - that there has been no cultural adaptation of these evidence informed practices for Aboriginal clients or culturally and linguistically diverse families. We have tested the resilience practice framework and the notion of resilience with our Aboriginal clients and staff, and they've said that the notion of resilience resonates with them because they regard themselves as resilient people. However, the practices that we've now identified...we're going to have to go through a process with our internal Aboriginal network and also engage in some clients from culturally and linguistically diverse backgrounds to test whether these interventions are culturally appropriate.

So are we there yet? No, but we're well on the way to implementing evidence informed practice framework, with the help of the Australian Centre for Child Protection and The Parenting Research Centre, and of course with the staff at the Benevolent Society.

Thank you, Goodbye

END OF TRANSCRIPT

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Slide outline

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
• 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.

1. 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.

1. 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

1. 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
   6. 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

1. 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.

1. 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)
• 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
• a domain of Social Support-which refers to the family’s connectedness to community and family support networks
• 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

1. Child Indicators-Adequate Care

• 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.

Parent/Caregiver Indicators- Adequate Parenting

• 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.

1. 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.

1. 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)

1. 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.

1. 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.

1. 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

1. 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.

1. 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.

1. Practice guides by resilience outcome

• 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)

1. Labelling a child's 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.

1. Uptake of Evidence-Informed Practice
   • Barriers and Gaps
2. 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.

1. 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.

1. 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.

1. 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.

1. "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

1. 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)
2. Implementation of Evidence-Informed Practice
3. 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
4. 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).

1. 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

1. 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)
2. 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)
3. 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

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

1. 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?)
2. Linking Assessment, Analysis to Interventions

1. 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!
2. 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)
3. Are we there yet? No, but we are well on the way!
4. Questions?
   • email Greg Antcliff
   • email Marie Iannos
   • www.benevolent.org.au 
   • unisa.edu.au/childprotection