Home visiting and reflective practice: when systems change means practice change

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<ul><li><p>This article was downloaded by: [University of Chicago Library]On: 31 August 2013, At: 13:37Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK</p><p>Reflective Practice: International andMultidisciplinary PerspectivesPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/crep20</p><p>Home visiting and reflective practice:when systems change means practicechangeLeslie Forstadt aa Univeristy of Maine Cooperative Extension, Orono, Maine, USAPublished online: 24 Oct 2011.</p><p>To cite this article: Leslie Forstadt (2012) Home visiting and reflective practice: when systemschange means practice change, Reflective Practice: International and MultidisciplinaryPerspectives, 13:1, 97-114, DOI: 10.1080/14623943.2011.626023</p><p>To link to this article: http://dx.doi.org/10.1080/14623943.2011.626023</p><p>PLEASE SCROLL DOWN FOR ARTICLE</p><p>Taylor &amp; Francis makes every effort to ensure the accuracy of all the information (theContent) contained in the publications on our platform. However, Taylor &amp; Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor &amp; Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.</p><p>This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &amp;Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions</p></li><li><p>Home visiting and reective practice: when systems change meanspractice change</p><p>Leslie Forstadt*</p><p>Univeristy of Maine Cooperative Extension, Orono, Maine, USA</p><p>(Received 11 March 2011; nal version received 20 September 2011)</p><p>This paper shares the results of a research study with home visitors on theimplementation of a statewide training in a type of reective practice in thenorth-eastern United States. Home visitors (n = 112) participated in a trainingand follow up study of the Touchpoints Approach. All home visiting programsin Maine participated in this research, which used survey methods at multiplepoints in time. The primary research questions examined the effect of training inand application of the Touchpoints Approach on home visitor job satisfaction,competence, and knowledge change. Data were collected immediately after thetraining and after six months of reective practice with Touchpoints. Increasesin condence levels and knowledge related to Touchpoints and reective prac-tice were found. High levels of job satisfaction were present prior to training,and no signicant changes in job satisfaction were found. Home visitorsincreased their ability to critically evaluate their own practice, and qualitativeresponses revealed increased listening and communication skills. The ndingssupport the continuation of the Touchpoints Approach with home visitors. Thisstudy provides insight into a practice approach with children and families thatprovides a foundation for systems change.</p><p>Keywords: home visiting; Touchpoints; reective practice; job satisfaction</p><p>Introduction</p><p>Home visiting is a long-standing effort in the United States (US) to support expec-tant and new parents. The concept of home visiting was developed in England inthe 19th century. By the 1960s and 1970s, home visiting in the US focused on theschool readiness of children, and the needs of at-risk and hard to reach families(Boller, Strong, &amp; Daro, 2010). These needs include the prevention of child abuseand neglect, the healthy social and emotional development of children, and thesupport of young parents. In 2009, the US government dedicated over $8 billiondollars over 10 years for home visitation programs for low-income families.</p><p>Home visiting has evolved over time. It began with homegrown educationalmaterials that were developed by agency professionals. It evolved to includeevidence-based programs developed by universities and in cooperation with federalagencies. Within these evidence-based curricula, there is still a diversity of applica-tion in the eld. There are multiple models of home visiting, with the commonalityof a one-to-one relationship that is built with a home visitor, and the location of the</p><p>*Email: leslie.forstadt@maine.edu</p><p>Reective PracticeVol. 13, No. 1, February 2012, 97114</p><p>ISSN 1462-3943 print/ISSN 1470-1103 online 2012 Taylor &amp; Francishttp://dx.doi.org/10.1080/14623943.2011.626023http://www.tandfonline.com</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [U</p><p>nivers</p><p>ity of</p><p> Chic</p><p>ago L</p><p>ibrary</p><p>] at 1</p><p>3:37 3</p><p>1 Aug</p><p>ust 2</p><p>013 </p></li><li><p>visit is generally the familys home at a weekly or monthly interval. Differencesamong programs include the focus of home visiting programs: while most of thehome visiting models focus on at-risk populations, some are offered universally(Johnson, 2009; Olds, Sadler, &amp; Kitzman, 2007). Universal home visiting is basedon the notion that any parent could be at risk at any time, and simultaneously, thatevery parent can benet from support.</p><p>Many home visiting programs are guided by curricula that suggest a structurefor the visits broadly focused on child development, the parent child relationship,developmental milestones, and supporting the parents in child rearing (Boller,Strong, &amp; Daro, 2010). Some of the curricula are prescriptive, and rely upon thehome visitor presenting information to the parent. In addition to the curriculum thatserves as a guide, home visitors receive professional development in topics such asinfant mental health, prevention of child abuse, and counseling/direct methods suchas motivational interviewing or use of child development screenings. The use ofreective supervision, while not employed in all home visiting settings, is anotherconcrete method used by many programs to support the working relationshipbetween supervisors and home visitors, which in turn supports the home visitor andfamily relationship (Barron &amp; Paradis, 2010). Training in reective supervision, anda reective style of conducting home visits is rare, as is training of all practitionersin a single state or locality to practice a common method that is also highlyindividualized.</p><p>Success in home visiting</p><p>As methods have evolved over time, so have research and the creation of anevidence base in home visiting. This growing evidence base includes measures ofsuccess in home visiting, which is ultimately graded by the impact on the healthand well-being of the child. This is accomplished by helping parents meet variousneeds like securing stable housing, nding employment, and increasing their under-standing of child development. As indicators of well-being, many home visitingprograms look at outcomes related to child safety, abuse, neglect, breast feeding,immunizations, and doctors visits. The relationship between home visitor and par-ent is also an important outcome, as it is this relationship that forms the model andfoundation upon which parents will hear information about their children, and willmake a difference in the interaction with their own children and family (Daro,McCurdy, Falconnier, &amp; Stojanovic, 2003).</p><p>The research in home visiting has largely explored perspectives and outcomesof the recipient, most often the parent and most frequently, but not always, themother. The research on home visiting is typically focused on the relationshipbetween parent and home visitor (Krysik, LeCroy, &amp; Ashford, 2008; McCurdy,Gannon, &amp; Daro, 2003); parental involvement (Daro, et al., 2003; Tandon, Parilllo,Mercer, Keefer, &amp; Duggan, 2008); factors impacting the efcacy of home visits(Ammerman et al., 2009; Paulsell, Boller, Hallgren, &amp; Esposito, 2010); dangersrelated to child abuse and neglect; and other health-related behaviors such as smok-ing, well-child visits, breastfeeding, and immunizations (Olds, 2006; Armstrong,Fraser, Dadds, &amp; Morris, 2000).</p><p>The studies focused on parental behaviors and child well being are very impor-tant in understanding what is effective in home visiting that can improve relation-ships between parents and children and for positive parent and child outcomes.</p><p>98 L. Forstadt</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [U</p><p>nivers</p><p>ity of</p><p> Chic</p><p>ago L</p><p>ibrary</p><p>] at 1</p><p>3:37 3</p><p>1 Aug</p><p>ust 2</p><p>013 </p></li><li><p>Other research studies broaden the focus beyond the parent-child relationship byexploring the relationship between the home visitor and the parent as correlated toparent participation in a program, satisfaction with and continuation in a program,and behaviors related to their children (Armstrong et al., 2000; Paulsell et al.,2010). The ndings are consistent: better relationships between home visitors andparents correlate to improved health behaviors, and satisfaction with and retentionin the program (Korfmacher et al., 2008). The training of the home visitor is also afocus at times, as the correlations between parent engagement in a program and therelationship with their child is investigated with a home visitors professional quali-cations (paraprofessional, nurse, social worker, other).</p><p>How do these relationships evolve? What is it that home visitors do in theirpractice that promotes or inhibits strong relationships? In the literature, there are farfewer studies that explore the experience of the home visitor than the experience ofthe parent, although the body of literature is growing. Increased attention is beingpaid to the aspects of training, support, and professional development of these indi-viduals who are committed to the health and well-being of parents and children.There is something behind the building of strong relationships within agencies andbetween professionals that supports strong one-on-one (Paulsell et al., 2010) rela-tionships or even in settings with a team approach of multiple home visitors, thatcorrelate to families participating in the program longer and having higher satisfac-tion (Gill, Greenberg, Moon, &amp; Margraf, 2007).</p><p>The Touchpoints Approach</p><p>The Touchpoints Approach (TA) is a method for professionals working with fami-lies based on the work of T. Berry Brazelton, an American physician, author, anddeveloper of the Neonatal Behavioral Assessment Scale. The TA was developed foruse in health-care settings, but has been adapted and used by other disciplines suchas home visiting and child care (Brazelton &amp; Sparrow, 2003). Dr Brazeltons workfocuses on revealing the importance of building a healthy foundation for childrenby concentrating on early child and parent relationships as well as on building thecompetence and condence of parents (Brazelton, 1999).</p><p>The TA is based on the premise that during their development, children mayregress in some areas while simultaneously advancing in others. The fact thatdevelopment is unfolding through bursts and regressions can be very reassuring toparents, who are often (understandably) stressed when they are uncertain why theirchild is fussy or not sleeping well. The touchpoints are times during the rst yearsof a childs life that are linked to points in development and may cause disruptionor stress within the family. They relate to the aspects of child rearing that are signif-icant for parents (such as feeding and sleep) and how disruptions in these aspectscan affect the way the family responds to the child.</p><p>For professionals who work with families in clinical, home, or educationalsettings, the TA places great emphasis on valuing the relationship between the homevisitor and parent and to use the parent-child relationship as a focus. In home visit-ing, the focus would be on nding opportunities to use the childs behavior as astarting point for conversation, and to be willing to not be the expert. Thiswillingness may be expressed as asking questions, acknowledging what you do notknow, and working with the parent to seek answers (Percy, Stadtler, &amp; Sands,2002).</p><p>Reective Practice 99</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [U</p><p>nivers</p><p>ity of</p><p> Chic</p><p>ago L</p><p>ibrary</p><p>] at 1</p><p>3:37 3</p><p>1 Aug</p><p>ust 2</p><p>013 </p></li><li><p>This approach shifts the focus from decits to strengths, from linear develop-ment to multidimensional development, and from an objective to an empathicapproach to working with families. The TA supports professionals to work withfamilies in a collaborative way to understand their childs behavior in the context ofdevelopment, particularly when a childs behavior may become disorganized andless predictable (Touchpoints, 2008; Brazelton &amp; Sparrow, 2003).</p><p>As described above, the TA stresses relationships between parents and children.And it is a systems approach for professionals who work with families because italso applies to the relationships between the home visitor and parent, and betweenthe home visitor and their supervisor. The approach intends to foster shared caregiv-ing partnerships that nurture relationships between all parties to support the childrenand their families (Percy, Stadtler, &amp; Sands, 2002; Touchpoints, 2008). For parentsand providers, the shared focus is the common interest they have in the well-beingof the child and the parent-child relationship. For home visitors and supervisors, theshared focus is the common interest they have in the well-being of the family andthe well-being of the home visitor to work with many families (Brazelton, 1999).There are ways to questions ones assumptions as a professional that can help guidethe work to be more parent-centric and less critical or blaming. These include keep-ing the focus on the parent as expert (the professional does not assume this role),because the parent is the expert on their own child. It is also important to under-stand that parenting is a process, not an outcome, and that parents have their childsbest interest in mind. These same assumption-questioning ideas can be used bysupervisors to respond to home visitors, who will have much to share as the expertsof the families with whom them work, as they engage in an evolving (and some-times up and down) experience of home visiting, and doing their best to buildstrong relationships with families.</p><p>This questioning of assumptions is one way that reective practice is integral inTouchpoints. In fact, according to Maines Touchpoints Coordinator, the TA is con-sidered a type of reective practice because the nature of the TA involves a greatdeal of self-reection on the part of the home visitor. Home visitors are encouragedto ask questions such as, What do I bring to this home visit?, Why am I feelingstressed about working...</p></li></ul>

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