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Home visiting and reflective practice:when systems change means practicechangeLeslie Forstadt aa Univeristy of Maine Cooperative Extension, Orono, Maine, USAPublished online: 24 Oct 2011.
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
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Home visiting and reflective practice: when systems change meanspractice change
Leslie Forstadt*
Univeristy of Maine Cooperative Extension, Orono, Maine, USA
(Received 11 March 2011; final version received 20 September 2011)
This paper shares the results of a research study with home visitors on theimplementation of a statewide training in a type of reflective 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 reflective practice with Touchpoints. Increasesin confidence levels and knowledge related to Touchpoints and reflective prac-tice were found. High levels of job satisfaction were present prior to training,and no significant 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 findingssupport 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.
Keywords: home visiting; Touchpoints; reflective practice; job satisfaction
Introduction
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, & 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.
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 field. 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
*Email: [email protected]
Reflective PracticeVol. 13, No. 1, February 2012, 97–114
ISSN 1462-3943 print/ISSN 1470-1103 online� 2012 Taylor & Francishttp://dx.doi.org/10.1080/14623943.2011.626023http://www.tandfonline.com
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visit is generally the family’s 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, & Kitzman, 2007). Universal home visiting is basedon the notion that any parent could be ‘at risk’ at any time, and simultaneously, thatevery parent can benefit from support.
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, & 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 ofreflective 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 & Paradis, 2010). Training in reflective supervision, anda reflective 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.
Success in home visiting
As methods have evolved over time, so have research and the creation of anevidence base in home visiting. This growing evidence base includes measures of‘success’ 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, finding 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 doctor’s 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, & Stojanovic, 2003).
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, & Ashford, 2008; McCurdy,Gannon, & Daro, 2003); parental involvement (Daro, et al., 2003; Tandon, Parilllo,Mercer, Keefer, & Duggan, 2008); factors impacting the efficacy of home visits(Ammerman et al., 2009; Paulsell, Boller, Hallgren, & 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, & Morris, 2000).
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.
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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 findings 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 visitor’s professional quali-fications (paraprofessional, nurse, social worker, other).
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, & Margraf, 2007).
The Touchpoints Approach
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 & Sparrow, 2003). Dr Brazelton’s 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 confidence of parents (Brazelton, 1999).
The TA is based on the premise that during their development, children may‘regress’ 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 first yearsof a child’s 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.
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 finding opportunities to use the child’s 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, & Sands,2002).
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This approach shifts the focus from deficits 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 child’s behavior in the context ofdevelopment, particularly when a child’s behavior may become disorganized andless predictable (Touchpoints, 2008; Brazelton & Sparrow, 2003).
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, & 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 one’s 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 child’sbest 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.
This questioning of assumptions is one way that reflective practice is integral inTouchpoints. In fact, according to Maine’s Touchpoints Coordinator, the TA is con-sidered a type of reflective practice because the nature of the TA involves a greatdeal of self-reflection 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 with a particular family?’ and ‘What worked last time whenI visited this family?’ The role of the supervisor in a TA environment involvesreflective listening, trusting the home visitor as an expert, nurturing the relationshipbetween supervisor and home visitor, and the relationship between the home visitorand the family. By establishing a supportive supervisory relationship, the supervisormodels a trusting and reflective relationship that the home visitors can then integrateinto home visits. This includes listening more, trusting the parent as the expert, andconducting home visits with less of an ‘agenda’. Reflective practice for the homevisitor includes understanding his or her own personal history, expectations of fami-lies, and judgments they may bring into the home visit. With reflective practice, thehome visitor becomes a partner with the parent, and encourages the parent to engagein their own reflective parenting practice to respond to the needs of their child.
Over time, the intention of the TA as reflective practice is that supervisors,home visitors, and parents each learn more about themselves and each other withthe joint focus being on the health and well-being of the child and family. For homevisitors, they consider deeply what they bring into the work, their strengths andchallenges, how they can improve, and what kind of support they need. The modelof reflection and support for home visitors with their supervisors becomes a model
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for parents with their own children. For example, the question, ‘What do you thinkmight be going on?’ can be asked to a home visitor about a frustrating family. Thesame question can be asked to a parent when the child is crying.
Reflective practice and a motivated workforce
In many high-stress jobs that involve helping relationships, including social work,home visiting and teaching, some of the keys to job satisfaction include the supervi-sory relationship and professional development opportunities. For Head Start homevisitors, Gill and colleagues (2007) found that supervision and professional develop-ment were keys to job satisfaction and staff retention. Ongoing support from col-leagues and supervisors who can act as reflective sounding boards to help homevisitors navigate the daily struggles of families are vital to the experience of homevisitors. When reflective supervision is strongly encouraged within home visiting, itis a positive experience for the professionals. Reflective practices and engagementin professional development provide home visiting professionals with opportunitiesfor skill building and refinement of existing skills; these opportunities contribute totheir job satisfaction, insightfulness and competence (Burrell, McFarlane, Tandon,Fuddy, & Duggan, et al., 2009; Eggbeer, Shahmoon-Shanok, & Clark, 2010; JonesHarden, Denmark, & Saul, 2010; Gould, 2000; Heller, 2010).
While the published research on home visiting and job satisfaction and Touch-points as a reflective practice is not robust, in other fields, the implementation of typesof reflective practice have been evaluated. In their study of nurses and clinical super-vision, Hyrkäs, Appelqvist-Schmidlechner, and Haataga (2006) found that clinicalsupervision that impacted the trust and rapport with supervisees led to higher job sat-isfaction, as well as receiving supervisor advice and support, with higher job satisfac-tion and lower burnout. Another study applying clinical supervision in the nursingsetting yielded responses from nurses of increased job satisfaction, and increased col-legiality among nurses, and an opportunity to share and not feel isolated in the work(Cross, Moore, & Ockerby, 2010). Impactful practice results in increases in job satis-faction, the development of common goals, and a synergy in practice, as well as anincrease of knowledge that is expressed as a ‘not knowing’ (Cross, Moore, &Ockerby, 2010; Langer, 2001). This not knowing means that as the experts come intosituations feeling less like they have to be experts, they increase their capacity to lis-ten more and work with patients, clients, or families, toward a shared solution.
It should be noted that effective implementation of reflective practice, Touch-points or another method, is not achieved by merely conducting a training. Tomlin,Sturn, and Koch (2009) noted in their study of home visitors that ‘providers,although aware of reflective skills. . .state that they would most likely not act in away that promotes [reflective practice] in a hypothetical situation’ (p. 9). Withoutongoing support and continued practice in reflection with consistent reflective super-vision that is with someone they trust, it is unlikely reflective practice will succeed.Tomlin, Sturn, and Koch (2009) mention the need for providers to understand howto implement reflective skills and use them over time.
Touchpoints in Maine
In April 2006, the Maine Children’s Cabinet met with Dr T. Berry Brazelton andfaculty from the Brazelton Touchpoints Center to discuss opportunities for Maine todevelop a statewide system to support the use of the TA by child and family service
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providers. The cabinet members found that Touchpoints aligned with their commit-ment to a family-centered approach and their goal to integrate efforts of the earlychildhood system of care. Home visiting was selected as a pilot to train in TAbecause home visiting was already coordinated, had a family-centered and strength-based approach, and had experience coordinating trainings across agencies for homevisitors.
In 2007, there were 15 home visiting programs in Maine considering the TA.Then as now, some of the programs are operated by different agencies, with differ-ing administrations and funding sources; however, the goals of the programs aresimilar. This type of home visiting is different from Head Start (where participantsalso are in Head Start programs) and Public Health Nursing (where visits areshorter term and have a health-related issue concerning the child).
Home visiting serves any first time parent in Maine, including all teen, foster,adoptive, and kinship parents, with the enrollment period being prenatal to threemonths old. All home visitors must have at least a bachelors degree in a related field.
A decision was made to begin the integration of the TA with home visiting,which already had some experience with Touchpoints, and was a philosophicalmatch. Additionally, the home visiting program was in the process of developing aconsistent approach and quality of service for families statewide. The TA was inline with home visiting’s commitment to being relational, family-centered and cul-turally competent. The TA also provided a common language among all home visit-ing programs to describe the work of home visiting and supported home visitors indeveloping healthy and collaborative relationships with parents.
The systems change that was being initiated was the formal adoption of the TAas an approach for every home visiting program in Maine. This required the coordi-nation of multiple agencies, different program managers (some of whom who alsosupervise home visitors), clinical supervisors and organizing a common training andmentoring for all home visiting professionals. It also required the supervisors toconsider incorporating the TA into the supervisory relationship, which was a shiftin approach for some supervisors. The decision to introduce the TA to home visit-ing (as opposed to child welfare or Early Head Start for example) was based on theunderstanding that the philosophical approach of home visiting was not unlike thatof the TA: rather than implementing a massive philosophical change programmati-cally, this training and implementation would support the ongoing program, benefit-ing families, home visitors, and supervisors. The hypothesis was that home visitorswould become more reflective about their work, and home visiting could serve as amodel for other professionals to serve families in a reflective, thoughtful, and nottop-down approach. Ultimately, for true systems change, a multidisciplinaryapproach of all practitioners who work with families within a community wouldadopt this model of practice (Brazelton, 1999).
Methods
This study explored the effect of the TA training and implementation on homevisitor job satisfaction, confidence, and perception of the supervisory relationshipbefore training and after six months of reflective practice. In addition, the studyexplored the perceptions of home visitors’ experiences over a six-month period thatcontributed to their work experience. The mixed methods study incorporatedsurveys using closed and open-ended items. The study was independently
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conducted and was not a formal Touchpoints evaluation. The design, measures, andanalysis were not part of the current Touchpoints Method evaluation program.
Sample and participant selection
Participants in the study were home visitors from the state of Maine who workedfor the 15 home visiting programs throughout Maine. Every home visiting programparticipated in the Touchpoints training. Survey data were collected from home visi-tors before the training (T1) and six months after attending the trainings (T2). TheTouchpoints trainings were not offered to all home visitors at a single training.Instead, the trainings were offered at different time points with small groups oftrainees. The trainings began in March 2007, and the first data collection was inJuly 2007, which missed data collection from the March and May trainings. Of thegroups surveyed before the training, 59 of 74 participants returned pre-training sur-veys (a return rate of 80%). Six months after each training session (T2), surveyswere mailed to home visitors from all of the training groups. At T2, 63 of 112home visitors completed six-month surveys (an overall return rate of 56%). Table 1has return rate data for both time periods.
Assessments and measures
Job satisfaction
Job satisfaction was assessed with the Jobs in General scale, a validated, eight-itemmeasure of overall job satisfaction (Russell et al., 2004), and the Work on PresentJob subscale of the Abridged Job Descriptive Index (aJDI) (Russell et al., 2004;Stanton et al., 2001), a five-item measure reflecting the perception of an individuals’job at the present time. Each scale was totaled, with some items reverse-scored, andhigher scores reflected higher job satisfaction. Job satisfaction was measured at T1and at T2.
Confidence
Confidence was assessed by an investigator-designed 23-item measure of confidenceabout aspects of home visiting (�= .95). The items were rated on a five-pointLikert-type scale of strongly disagree to strongly agree. Some items were adaptedfrom the Provider Self Assessment Scale (Brandt, Napa, & Murphy, 1997), and
Table 1. Final Survey Sample of Home Visitor Responses by Training Group.
Number/Percent HomeVisitors who completedpre-training survey (T1)
Number/Percent HomeVisitors who completed
six-month reflective practicesurvey (T2)
March 2007⁄ Not available 10 / 48%May 2007⁄ Not available 13 / 65%July 2007 14 / 64% 13 / 68%September 2007 17 / 85% 12 / 67%November 2007 16 / 76% 7 / 35%March 2008 12 / 80% 8 / 57%
Total Responses 59 63
Note: ⁄Two training sessions (March and May 2007) occurred prior to evaluation implementation.
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included, ‘I am confident I can describe a Touchpoint’, ‘I am confident I can talkwith parents about the stress in their lives’ and ‘I am confident I can work with par-ents to manage their frustrations around parenting.’ Higher confidence scoresreflected higher confidence. Confidence was measured before the training and at T2.The complete measure is included in the Appendix.
Supervisory relationship
In the initial survey, three items assessed aspects of the supervisory relationship.One asked about ‘satisfaction with support I get from my supervisor’ and anotherasked about ‘satisfaction with feedback I get from my supervisor’. The third askedabout the ‘confidence to express thoughts and feelings about home visiting effec-tively with my supervisor’. All three items were scored on a five-point Likert-typescale ranging from strongly agree to strongly disagree. The T2 follow-up surveyincluded these three items and included an additional question about an increasedconnection with the supervisor, to which the home visitor responded on a five-pointLikert-type scale of strongly agree to strongly disagree.
Open-ended items
Two open-ended items were asked at T2. Both items were designed to capture thehome visitors’ reflections in their own words. These items were, ‘What (if any)change in professional relationships has occurred over the last six months?’ and‘What was the most beneficial experience in the past six months related to work?’These written responses were analyzed for categories and themes using an inductiveprocess. Responses were sorted, coded, and examined, using the constant compara-tive method (Glaser, 1965). The inclusion of these questions allowed for possibleresponses that had not been considered by the researcher, and allowed for answersunrelated to Touchpoints.
Results
Participants
At T1 (prior to training), 59 surveys were returned. At T2 (after training), 63 sur-veys were returned. Of the home visitors who provided demographic data, (n=85,74% response rate) 98% were female and 99% were Caucasian. Of the 88 uniquehome visitors who provided information about their education level, 3% had lessthan college and had worked as home visitors for over 10 years (they had been‘grandmothered’ into the position despite the later requirement of a BA degree towork as a home visitor in Maine), 77% had some or four years of college, 10%were masters or post-masters, and 9% had a nursing background. One-third (31%)had worked with children five years or less, 24% six to ten years, and 45% had ele-ven or more years of experience.
Prior to training, a majority of home visitors reported that they had adequatetime to meet with families (86%), and felt the number of families in their caseloadswas ‘about right’ (81%). More than half (58%) reported that their work was ‘some-times challenging’, and 25% reported that their work was ‘often challenging’.Scores for job satisfaction were high for most home visitors, with little variability
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for the group as a whole. Prior to training, on the Jobs in General Scale, scores ran-ged from 10 to 24 (M=20.05, SD=4.16), and on the Work on Present Job subscale,scores ranged from 6 to 15 (M=14.17, SD=1.8). On the Jobs in General items atT1, 79% (n=59) of respondents were most satisfied with what their job in generalmost of the time.
At T2, the scores decreased slightly, but not statistically significant. Responsepatterns are illustrated in Figure 1, and Table 2 summarizes some of the job satis-faction scores at T2.
Among the home visitors, at T1, 69% (n=59) had some exposure to or knowl-edge of the Touchpoints Approach prior to the training, and were confident theycould ‘describe a Touchpoint’ (M=3.38, SD= .88). Prior to training, home visitorsexpressed high levels of confidence on skills related to their jobs, with the meanscores exceeding 4.0 on a five-point scale on 17 of 23 items. Each item was subse-quently examined independently for changes between the T1 and T2 surveys.
In general, satisfaction with supervisor feedback and support in the home visit-ing programs was consistently strong. Some 87% (n=50) of home visitors agreed orstrongly agreed that they were satisfied with their supervisors’ support at T2, whichwas not significantly different from responses prior to training. Additionally, at T2,88% of home visitors reported receiving adequate feedback from their supervisors,which was not significantly different than responses prior to training. Over 90% ofhome visitors ‘agreed’ or ‘strongly agreed’ that they can express their thoughts andfeelings to supervisors before the training as well as at T2. Table 3 summarizes thesupervisory relationship items.
At T2, home visitors reported increases in new skills and competence, time spentlistening, and making a difference with clients over the previous six months. Homevisitors indicated increased confidence to intervene effectively with families whenthere was a crisis and in their confidence to teach parents skills to relieve their ownstress. In particular, response to the item, ‘I am confident I can critically evaluate myown practice and seek guidance appropriately’ saw a statistically significant increaseat the p > .05 level. Table 4 summarizes a selection of confidence items.
Open-ended items
The open-ended items were asked at T2, after six months of integrating Touchpointsand reflective practice into home visits and the professional setting. Home visitors(n=53) responded to the open-ended questions by writing their responses of anylength. Responses were analyzed using the constant-comparative method (Glaser,
0102030405060708090
11 12 13 14 15 16 17 18 19 20 21 22 23 24
Perc
ent R
espo
nses
Index of Job in General Responses
pre-training 6 mos post-training
Figure 1. Home Visitor Job Satisfaction Scores (Range 11-24).
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1965), with multiple categories and themes emerging in each question. This formatallowed for the potential inclusion of other trainings, and the possibility that theimplementation of Touchpoints had not made a significant impression in professionalwork. Multiple categories emerged, including specific behaviors of home visitors,Touchpoints-specific concepts, the impact of trainings, and relationship building.Themes emerging from the categories included ways of listening and reflecting withother home visitors and with parents, specific types of trainings and their impact,and the nature of relationships with each other, supervisors, and families.
Beneficial learning experiences
Responses to the first question, ‘What was the most beneficial learning experienceyou have had in the past six months related to your work with children age 0-5 and
Table 2. Summary of Job Satisfaction Following Six Months of Reflective Practice⁄.
Description of Job atPresent
DescribesYour Work
Does NotDescribe Your
WorkCan NotDecide
Satisfying 95% 1.6% 3.4%Gives sense of accomplishment 93% 5.2% 1.8%Challenging 95% 1.8% 3.5%Dull 0 100% 0Uninteresting 0 98.2% 1.7%
Description of Work in GeneralGood 98.2% 1.7% 0Undesirable 1.7% 96.5% 1.7%Better than most 68% 5.2% 26%Disagreeable 1.7% 93% 5.2%Makes me content 72% 5.1% 22.4%Excellent 58% 17% 24%Enjoyable 91% 3.5% 5.3%Poor 1.7% 96.4% 1.7%
⁄No significant changes from T1 to T2.
Table 3. Home Visitors and Supervisory Relationship⁄.
I am satisfiedwith thesupport
I get from mysupervisor
I am satisfied withthe feedbackI get from mysupervisor
I am confidentI can express mythoughts and
feelings about thework of home
visiting effectivelywith mysupervisor
PRE 6 MOPOST
PRE 6 MOPOST
PRE 6 MOPOST
Strongly Agree, Agree 52 50 52 51 53 5489.6% 86.2% 89.6% 88% 91.4% 93%
Neutral, Disagree, StronglyDisagree
6 8 6 7 5 410.4% 13.8% 10.4% 12% 7.6% 7%
⁄No significant changes from T1 and T2.
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their families’ reflect the impact of the Touchpoints training for some of the homevisitors and provided additional information about what was meaningful in theirwork. Home visitors wrote about increases in their listening skills, and their abilityto be more ‘specific’ and ‘ask for clarification’ in a home visit. One home visitorreported a new skill of reflecting prior to a visit, and another noted the benefit ofreflection in the supervisory setting. Multiple home visitors noted their willingnessto question their own stereotypes and be a strength-based home visitor, focusing onthe parents’ desire to ‘do well by their child,’ to ‘do their best,’ and that ‘parentsare the experts’. One home visitor reported that ‘being a strength-based providerhas strong positive implication for the families’.
In the Touchpoints training, the reflective nature of supervision was emphasized,as was the emphasis of treating the parents as experts. Some of the Touchpoints-specific concepts that were reported by home visitors included the noting of parentsas experts, mentions of reflection as a practice after home visits, and ‘letting go ofmy agenda’. Nine home visitors specifically mentioned Touchpoints as the mostbeneficial learning experience. Other trainings noted by home visitors includedmotivational interviewing (nine responses) and infant mental health, fetal alcoholsyndrome, and postpartum depression.
Professional relationships
Home visitors’ responses to the second question, ‘What (if any) changes have youexperienced in your professional relationships over the past six months,’ suggestsome impact of the Touchpoints training. The primary emergent themes focused onrelationships, and the ways coworkers related to one another. Specifically, theyreported behavior changes that increased the quality of interactions, and made refer-ence to aspects of Touchpoints that were integrated into the work. Home visitors spe-cifically referred to skills that improved their relationships with one another,including ‘listening more effectively’, ‘supporting one another’, and ‘we are a com-munity, have more open communication’. One home visitor reported about her rela-tionship with her colleagues and supervisor that there were ‘positive words, moresmiles and laughter, more relaxed. . .recognizing my supervisor is here to guide, giveideas, listen, strategize – very similar to what I do in the family setting’. Another
Table 4. Selected Home Visitor Confidence with Means Near or Below 4.0 on 1-5 Scale(1-Strongly Disagree to 5-Strongly Agree).
MeanResponseScore Pre
MeanResponse
Score 6 MOPOST
I can intervene effectively with families when there is a crisis 3.93 4.2⁄I can teach parents skills to relieve their own stress 3.78 4.1⁄I can help parents anticipate situations that can cause problems 3.89 4.2⁄I can demonstrate to parents how to express their thoughts andfeelings to others
3.71 4.0⁄
I can engage fathers in the lives of their children 3.97 4.1I can describe a “Touchpoint” 3.38 4.3⁄I can critically evaluate my own practice 4.3 4.4
⁄(p < .05)
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home visitor noted improvements in listening skills with colleagues: ‘I am more ableto express my needs and feelings. I also feel I am listening more effectively.’
Specific reference to how Touchpoints was integrated into the professional set-ting included using the methods in staff meetings, and finding a ‘common lan-guage’. It was a way that they ‘came together as a program’. One home visitornoted that a supervisor ‘used Guiding Principles to tease out situations brought intosupervision – very helpful’. Another comment related to supervision is that the‘supervisor seems much more understanding. . .has more confidence in me’.
Of the 53 respondents, four responded that no changes in professional relation-ships had occurred over the six-month period. For one respondent, much of theTouchpoints methodology was already in use in the program: this home visitor said‘the training really reinforced professional performance with families’.
Discussion
Home visitors play an important role with families, and their job satisfaction andengagement in professional development are important variables in their job reten-tion (Daro et al., 2003). This study was part of an evaluation of the implementationof training in the TA to explore the relationship between implementing Touchpointsand a number of outcome variables, including job satisfaction (Forstadt, Beamer, &LaBrie, 2009).
The lack of variability in job satisfaction scores made it difficult to conductadditional analyses about factors that influence job satisfaction, an original goal of theresearch. While troubling from a statistical perspective, this finding reflects an overallsatisfied workforce in home visiting. Home visitors in Maine were initially satisfied asa group, as evidenced by their mid to high job satisfaction, and as well the longevityof their employment, with the average length of time in the job over nine years.
The impact of training in and implementation of Touchpoints on daily practicewas evident in the comments by home visitors. Results of the study suggest thathome visitors did become more confident and reflective in their work after sixmonths of reflective practice. This finding is important for those in the field:because of the training in Touchpoints, many of the home visitors changed theirlanguage about their work, and altered how they worked with colleagues andengaged in supervision. The training was immediately effective in teaching Touch-points-specific information related to child development and reasons for a child’sbehavior. Beyond that, six months after the training, home visitors continued tobenefit and integrate the TA in to their daily attitudes about home visits and abouttheir work environments.
The themes that arose from the open-ended questions related to Touchpoints andother trainings (specifically Motivational Interviewing) that were identified asimportant in the work life of the home visitor. These types of professional develop-ment have the potential to increase confidence and increase the ‘tools in the toolkit’that are used in the work between the home visitor and families, between col-leagues, and in supervision. Trainings that focus on reflective practice as an integralpart of the work of home visiting strengthen the ability of the home visitor to trusta more internal process and rely less on external materials and ideas. Or as Emde(2009) writes, home visitors learn to ‘use themselves as a tool’.
As other researchers have noted, the ability of home visitors to work withfamilies with complex needs affects the effectiveness of home visiting (Eckenrode
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et al., 2000; Jones Harden et al., 2010). Thus, increasing these abilities is worthwhileto increase the effectiveness of home visiting. Ways to increase these capacitiesinclude training and also continued support related to trainings. The six-monthfollow-up provided a glimpse into the implementation of a method beyond thetraining.
One of the strengths of Touchpoints is that the approach allows the parent toguide the conversation, where the home visitor follows the parent’s ‘lead’. Thisphilosophical approach differs in home visiting from other areas of work with fami-lies, where the professional is often viewed as the expert and is the ‘lead’ in a visitwith the parent. Instead, with Touchpoints, the parent is the expert of the child; thisapproach aligned well philosophically with home visiting. The description of homevisiting program makes this point explicit: Maine Families ‘works to find a matchbetween addressing parent concerns within a supportive and parent-driven agenda’(Maine Families, 2011). Touchpoints, through the reflective nature of the practice,supports relationship building between families and home visitors, and is also thefoundation for the relationships between supervisors and home visitors, where theagenda in supervision would be more ‘led’ by the home visitor than the supervisor.The built-in organizational support provides much of the emotional support neededby home visitors to sustain this sometimes emotionally challenging work (Johnson,2009; Jones Harden et al., 2009).
The home visiting programs in Maine have continued to receive training, men-toring and support with Touchpoints implementation, which leads to additionalquestions that emerge from this initial study, including: what is the long-termimpact of the TA in home visiting? In what specific ways do home visitors imple-ment Touchpoints in their work? Future research could explore the impact of con-tinued support as both supervisors and home visitors engage in the work of homevisiting with the TA. This implementation of a statewide effort in home visiting isunique and reflects system-change efforts that could be examined. Possible researchquestions include: in what ways has the implementation of the TA affected thefunctioning of supervisors of home visiting programs? And what is the relationshipbetween implementation of the TA and the functioning of home visitors and super-visors as a common program and in individual work?
Conclusion
The integration of Touchpoints within home visiting statewide was intended todevelop a cadre of professionals in Maine who were thoughtful, reflective, andstrength-based. Aspects of this were already in place, as the data showed little sig-nificant change in items such as job satisfaction that was initially high or the levelsof many of the confidence items that were already high. However, there were sig-nificant changes on items related to the training and implementation of the TA.Home visitor confidence to critically evaluate their practice and to describe aTouchpoint both increased.
Since the initial training, continued support of supervisors and home visitors intheir ongoing implementation of Touchpoints has led to some anecdotally reportedlong-term changes. These outcomes are worth further formal investigation. Forexample, ongoing ‘boosters’ or trainings quarterly in the first year and decreased toone booster for home visitors and two for supervisors annually have been reportedto lead to increases in TA language and integration of question asking and self-care.
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Attention to the supervisors seems to be an important component of Touchpointsimplementation. Because of the significant role of leadership in a program, thedegree to which the supervisors understand and apply reflective methods is pivotalfor the home visitors to use reflective methods thinking about themselves and inworking with their families. At the beginning of implementation of the TA (duringthe timeframe of the data collection T1 and T2) the focus was on the ‘principlesand assumptions’ of the approach, as evidenced by the knowledge change andincreases in confidence that home visitors reported.
Over time, home visitors and supervisors have ‘deepened’ their understanding ofthe work, and are now thinking specifically about how focusing on strengths withfamilies and in supervision not only supports the family or supervisee but also thehome visitor and the supervisor. As stated earlier, for home visiting this was not aparadigm shift for most of the programs. However, for some of the supervisors, ithas taken more time to adjust to the reflective practice. If such an approach wereintroduced into a program whose ‘culture’ was less strength based, it would takesome time to shift away from a deficit approach. According to the statewide train-ing coordinator, ‘Something happens when professionals and supervisors recognize[identifying strengths] as a skill and strategy – they find that instead of feelingstuck, they know where to go next with a family or with a supervisee.’ Anotherstory is of a home visitor with many years’ experience who would go into visitswith her bag full of the same educational materials for parents and games for thechildren, and she would arrive with her ‘expert identity’ intact. After implementa-tion of the TA, she began to stop and think about what each family needed individ-ually. It changed her practice, and she got less ‘expert’ in working with families,and repacked her bag with each visit.
These anecdotal insights provide seeds for continued formal inquiry into theefficacy of the TA within home visiting and to expand to other fields, such as childprotective work, the foster care system, and pediatrics. Although there were not sig-nificant changes in job satisfaction, the home visitors began with high scores as agroup. Using this training approach with professionals who may have lower levelsof job satisfaction could lead to significant changes in job satisfaction and the expe-rience of the work environment. The implementation of supervision and supportmethods involving reflective practice has been useful in high-stress fields to reduceburnout (Cross, Moore, & Ockerby, 2010). These changes could be artifacts of theparallel process that is put into place in reflective settings, which is an importantaspect of the TA (Weatherston, Weigand, & Weigand, 2010). Supporting profes-sional home visitors with a variety of methods and professional development activi-ties creates a high degree of competence and builds quality relationships to supportthis important work.
And systems change? The functioning of home visiting did change, as individ-ual programs developed a common identity and service model that reflected theircommon mission and method. In 2010, each home visiting program in Maine beganto use the name Maine Families, changing their way of working by coming togetherunder a common name instead of a different name for each county of the state.Though still funded and run by different agencies, the common identity helps tofocus the purpose and goals of the work. This change to come together under theirpurpose became a function that was effective in lobbying for funding when it wasin jeopardy, and also serves the public better, because the program is much lessconfusing to talk about and direct people to.
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This effort has potential to influence other agencies and organizations. As otherproviders see how Maine Families has integrated this methodology into supervisionand practice, the possibility of working from this strength-based approach could beof great benefit. Particularly because of the ‘trickle up’ nature of this work; forwork that is extremely stressful and where professionals are at risk for burnout,turning to an intentionally reflective practice such as the TA could be quite benefi-cial. Although the work seems centered on the family, it is the attention paid ateach level of relationship (child/parent; family/provider; provider/supervisor) thatnurtures the organization and truly supports the work as it trickles up, fromstrengthening parents to strengthening systems.
AcknowledgementsThank you to the Brazelton Touchpoints Center, Sheryl Peavey-Director of the EarlyChildhood Initiative, Sheri Smith-Maine Touchpoints Coordinator, Pam LaHaye-StatewideCoordinator for Home Visiting, and the home visitors and supervisors who participated inthis project. Funding for this project was provided by the Maine Department of Health andHuman Services.
Notes on the contributorLeslie Forstadt is an assistant extension professor with University of Maine CooperativeExtension. Her interests include positive human development, mindfulness in relationshipsand life, and the prevention of early adverse experiences.
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Appendix.
For questions 32a – 32w, what best describes your ability to successfully completethe task if you were asked to complete the task TODAY?
How confident are you that you can perform the following tasks successfullytoday?
StronglyDisagree Disagree Neutral Agree
StronglyAgree
a. I am confident I can maintain self-awareness in practice, recognizing myown personal values and biases.
s s s s s
b. I am confident I can initiate andsustain empathic, culturally sensitiverelationships with clients.
s s s s s
c. I am confident I can interveneeffectively with families when there isa crisis.
s s s s s
d. I am confident I can criticallyevaluate my own practice and seekguidance appropriately.
s s s s s
e. I am confident I can teach parentsskills to relieve their own stress.
s s s s s
f. I am confident I can help parents toanticipate situations that can causeproblems for them.
s s s s s
g. I am confident I can advise a parenton the appropriate expectations of a10-month old child.
s s s s s
h. I am confident I can work withparents to manage their frustrationsaround parenting.
s s s s s
i. I am confident I can work withparents on their communication skillswith their children.
s s s s s
j. I am confident I can demonstrate toparents how to express their thoughtsand feelings more effectively toothers.
s s s s s
k. I am confident I can treat parents asthe experts of their own children.
s s s s s
l. I am confident I can express mythoughts and feelings about the workof home visiting effectively with mysupervisor.
s s s s s
m. I am confident I can reflect thoughtsand feelings to help parents feelunderstood.
s s s s s
n. I am confident I can employ empathyto help parents feel they can trust me.
s s s s s
o. I am confident I can provideemotional support for parents.
s s s s s
p. I am confident I can identify successin complex families.
s s s s s
(Continued)
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Appendix. (Continued).
StronglyDisagree Disagree Neutral Agree
StronglyAgree
q. I am confident I can identify strengthsin a family that is in crisis.
s s s s s
r. I am confident I can engage fathers inthe lives of their children.
s s s s s
s. I am confident I can describe a“Touchpoint.”
s s s s s
t. I am confident I can work with theparent to find a solution to aparenting problem.
s s s s s
u. I am confident I can conveyinformation on parenting and childdevelopment.
s s s s s
v. I am confident I can talk with parentsabout the stress in their lives.
s s s s s
w. I am confident I can reach out toparents who may be hard to engage.
s s s s s
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