AUTHORS Jo Corlett, PhD, MSc, BA, RGN, RNT, is postgraduate coordinator; Julie Taylor, PhD, MSc, BSc, RN, is professor of family health; both at School of Nursing and Midwifery, University of Dundee; Brigid Daniel, PhD, MA, CQSW, is professor of social work, University of Stirling; Behailu Abebe, PhD, is research assistant, School of Nursing and Midwifery, University of Dundee.
ABSTRACT Corlett, J. et al (2007) Enhancing self-esteem in vulnerable families. www.nursingtimes.net.
BACKGROUND There are many programmes to support vulnerable parents coping in challenging situations, but limited research on the skills and qualities required by practitioners leading these programmes. This study sought to provide such information and make recommendation on what skills a toolkit for practitioners leading parenting programmes should include.
AIM To provide evidence of best practice in parenting programme provision to support the development of training tools for practitioners.
METHOD Illuminative evaluation was adopted using video-recorded observation, focus groups, interviews and questionnaires.
RESULTS The skills and qualities demonstrated by practitioners facilitating the programmes, such as respecting, being non-judgemental, valuing and having a genuine interest in individuals were critical elements in developing trusting relationships with families.
CONCLUSION Results point to the importance of having highly skilled practitioners, who establish positive working relationships with families, to deliver parenting support programmes.
Numerous parent support programmes have appeared in recent years, designed to help those coping with stressful circumstances develop positive parenting skills. However, there is a limited amount of high-quality research evaluating such programmes (Moran et al, 2004). While identifying the need for highly trained, skilled people to lead them, there is little detail on what these skills are, or what training would be useful in developing them.
This study was undertaken to provide evidence of best practice in provision of parenting programmes when we were commissioned as external evaluators to examine various parenting skills classes offered by a charitable trust in one of their family centres. The aim was to support the development of training tools for practitioners within the organisation, so that recommendations regarding the training of new leaders could be made.
Children living in disadvantaged socioeconomic circumstances and stressful environments do less well than those raised in more affluent situations (Scott et al, 2006). However, even under adverse conditions, children brought up in warm, nurturing relationships can do as well as those in more affluent circumstances (Barlow et al, 2007; Fraser et al, 2007; Spencer, 2006; National Evaluation of the Sure Start Research Team, 2006).
Parenting style is a critical element in children’s emotional and behavioural development (Gage et al, 2006; Patterson et al, 2005; Sanders and Woolley, 2005; Slack et al, 2005; Sprang et al, 2005).
The importance of ‘good parenting’ has been recognised within recent policy development. The National Service Framework for Children (Department of Health and Department for Education and Skills, 2004) requires PCTs and local authorities to use evidence-based parent training programmes focused on child behaviour management, delivered by trained professionals (Ramchandani and McConachie, 2005).
A burgeoning number of parent support programmes designed for vulnerable families have appeared in recent years and some evidence is available on their effectiveness. For example, those adopting family therapy principles, which focus on parents’ ability to provide nurturing parenting styles, have been shown to be effective (Johnson et al, 2005).
The Webster-Stratton parents and children parenting programme demonstrated significant short-term reductions in child behaviour problems and improved mental health (Reading, 2004). However, in their review of over 70 parenting programmes, Pugh et al (1994) highlighted the difficulties inherent in measuring effectiveness due to the multiple issues facing participants, such as mental health problems, drug/alcohol dependency and child abuse. Moran et al (2004) found evaluations tended to be ad hoc and inconsistent, and demonstrated the limited amount of high-quality studies evaluating parenting programmes.
One area in which further research is required is in the identification of the skills and qualities needed by workers leading such programmes. Morgan et al stressed the need for highly trained, skilled staff to ensure parents engage with a programme, but there is little precise detail about what these skills are, or the training needed to develop them.
Sampling, recruitment and ethics
The family centre is situated in an area of regeneration in central Scotland, which has higher than Scottish national average levels of poverty, unemployment and ill-health (Scottish Executive, 2006). Many families attending the centre have a history of drug/alcohol dependency and child abuse/neglect.
The centre provides a range of services, of which three were studied:
A nurture group for children aged 3–5, comprised of children attending the centre nursery who have been identified as at risk of low self-esteem;
An infant massage group focusing on early attachment and bonding between parents and infants, particularly for mothers vulnerable to mental health problems;
A ‘bumps and babies’ group for parents with or expecting a baby.
Ethical approval was obtained via the research institution’s non-clinical research ethics committee. Information sheets were developed and families attending the three groups were invited to participate. All the families agreed to take part and signed consent sheets, but those actually participating depended on who turned up for a class when researchers were collecting data. Participants were assured their involvement was voluntary and they could withdraw at any stage. All data was kept securely and transcripts were anonymised. The same process was adopted for centre staff and health, social care and education professionals involved in the study.
Four methods of data collection were used:
1. Observation and video-recording. The infant massage and bumps and babies groups were video-recorded on two occasions, and the nurture group three times. Three 10-minute periods were recorded on each occasion and analysed to identify key points of interaction between the teacher and parents and/or children. These key points were captured as video clips onto computer and used as prompts throughout an interview with the teacher to explore the skills used to facilitate the group. Seven qualitative interviews were conducted with three different teachers.
2. Focus groups with parents (n=7) of children attending the nurture group were conducted at the beginning, middle and end of the eight-week programme to explore parents’ perception of how the group was helping their child.
3. Qualitative interviews. A purposive sample (n=7) of local education, social and health professionals involved with the centre were individually interviewed to explore their perception of how the centre supported vulnerable families. Parents (n=2) observed during the infant massage and ‘bumps and babies’ classes were also interviewed to explore how they felt their parenting skills were developing as a result of the class.
4. Pre- and post-test Insight Pre-School Indicators (IPSI). IPSI is a standardised tool consisting of 24 questions assessing self-esteem in children (Morris, 2002). These were completed for each child attending the nurture group (n=12) by the child’s parents and group teacher before and at the end of the eight- week course.
Triangulation of these data collection methods illuminated the context within which the groups developed and facilitated the description of examples of good practice.
Donabedian’s model (Donabedian, 2005), often used to evaluate the quality of healthcare services (Keating, 2006), provided an appropriate theoretical underpinning to this evaluative study. Quality is evaluated in three domains. Structure refers to internal and external features that support what is being evaluated, process refers to how services are provided and outcome is the degree to which stated standards are met and how this is measured.
Focus group and interview data was transcribed and entered into Nvivo qualitative software. Each transcript was analysed line by line and a coding frame generated. Over 200 codes were generated and collapsed into 96 nodes. These were then further collapsed under the domains described above. Data from the IPSI were subjected to t-testing to establish any significant differences between pre- and post-group self-esteem scores.
Transcripts were checked against the video-recording to ensure an accurate record had been made and the principal investigator and research assistant met weekly to compare and agree emerging themes and codes. In addition, two experienced qualitative researchers viewed samples of the transcripts and agreed with the codes and themes and how these were being grouped.
The results are organised according to the three domains of Donabedian’s model.
Structural factors included: physical aspects such as location and appearance of the centre, the way services were provided and the philosophy and culture of the organisation.
The centre has well-established links with various statutory services and works hard to maintain these. It has more autonomy than statutory services in deciding what services to offer and can focus on meeting the particular needs of the community, providing services unavailable elsewhere:
‘They offer some quite unique settings within the centre.’ (Interview 14, health professional)
Staff and statutory professionals interviewed felt the centre’s location was advantageous as it was situated within the community needing its services. Parents, however, thought this might be off-putting as it might be regarded as a place for ‘problem’ families:
‘All the houses are boarded up and really it doesn’t look a nice area, so people wouldn’t like to go into it.’ (Interview 17, parent)
The centre has tried to overcome this misconception and has been extensively refurbished. Parents commented that its décor was bright and welcoming and the interior comfortable and relaxing.
Support emerged as an important structure theme. Some families had received support from the centre over a number of years, enabling them to develop trusting relationships with staff. This prolonged, regular support was seen as a unique feature of the centre, which statutory services could not provide. Being able to leave their child at the nursery or crèche was also appreciated by parents:
‘It gives us a wee break and all. It does us good… she is here two days a week. That’s great.’ (Interview 9, parent)
Having time related to the theme of support. Teachers felt it was crucial to give individual time and attention to people when they needed it in order for trusting relationships to develop:
‘It’s about being there, it’s not about saying to the family or parent, oh I see you’re really upset but actually I can’t meet with you for another three hours. They’re needing someone at that time and it’s about us being there for families.’ (Interview 6, staff)
parents regarded small class sizes as beneficial:
‘It’s difficult to get to know people in a bigger group but, with it being a smaller group, I’ve got to know a few of the mums much better.’ (Interview 16, parent)
Classes were parent-led and although teachers would plan each class, they took their lead from the parents. If parents had particular concerns they needed help with, these shaped how the class progressed. For example, in the bumps and babies class, a session on playing with your child was abandoned when a mother suffering from postnatal depression became distressed and the teacher focused on trying to help her.
These results demonstrate the importance of considering structural issues when planning a parenting support programme. Strategies designed to help parents feel less pressurised, such as childcare facilities, small group size, time and an informal approach were critical in encouraging parents to engage. The way services are perceived is also important. Families may not attend a centre or class if they feel stigma is attached to it.
Process themes centred around helping families develop confidence and self-esteem. Before these could be fostered, teachers had to establish a trusting relationship with parents. While physical elements were integral to this in helping people to feel relaxed and safe, teachers’ interaction with families was even more important. While teachers had their own individual style, all displayed demonstrated respect and value for the families they worked with.
Teachers were always open and honest with parents, which helped parents to trust them:
‘You know where you stand with her. It makes it easy to be open with her as well.’ (Interview 16, parent)
Teachers also demonstrated respect and valuing by acknowledging but being non-judgemental about parental behaviour, such as drug/alcohol dependency. For example, where parents were participating in methadone programmes, this was discussed, focusing on its impact on the family and how to deal with this, rather than judgements being made about the parents’ behaviour.
Another important quality they displayed was genuine interest in the people they were working with. This related to the time element, in that teachers spent time listening to parents’ stories and discussing difficulties they were experiencing. Part of this skill was the ability to tune into and take cues from individuals, responding to their needs:
‘I could see she just was quite anxious and we didn’t do massage, we just sat and talked. She wasn’t in a good place and what she needed was to talk through how she was feeling.’ (Interview 1, staff)
Sharing experiences and demonstrating fallibility also helped teachers to develop trust. For example, one shared her experience of postnatal depression. Sharing experiences demonstrated that teachers had common ground with parents, encouraging parents to identify with them. This also linked to enthusiasm. For example, the infant massage teacher was very enthusiastic about the effect of massage on her granddaughter and often talked about how much they both enjoyed the experience. Demonstrating fallibility was about being able to laugh about mistakes. For example, the infant massage teacher did a stroke incorrectly, but made a joke about it, which helped parents feel less pressured to get everything right – they saw it was OK to make mistakes.
The videos demonstrated that all the teachers were highly skilled in using positive non-verbal skills such as active listening, body position, eye contact and use of silence, to enhance their interactions. These skills were so highly evolved that they appeared to be unconscious and instinctive in staff who found it difficult to explain them. Teachers often had to view the videos several times before they could articulate what they were doing.
For example, the bumps and babies teacher always sat on the floor, even though parents sat on chairs. When asked why, she initially commented:
‘It’s very difficult. I just do things, I don’t think about what I’m doing at a particular time.’ (Interview 3, staff)
Having viewed the video several times she was able to identify it was the easiest way to interact with the babies and that this was important as she was acting as a role model for parents having difficulty bonding with their child.
These findings demonstrate that the qualities and personalities of staff running parenting support programmes are critical in building trusting relationships – a prerequisite of developing confidence and self-esteem. Some of these traits such as showing fallibility, using humour and acting as a role model develop from experience. Others, such as genuine interest and enthusiasm, are inherent qualities which, it could be argued, cannot be taught. They are, however, essential ingredients and thought should be given to how they can be fostered in leaders of parenting support programmes.
Outcomes are the means by which an organisation provides evidence of the quality of its service provision. Information collected within the infant massage and bumps and babies classes related to assessment of the family and their needs, rather than on the quality of interventions. However, it was possible to measure the impact of the nurture group from the pre- and post-group IPSI results. These demonstrated a significant increase in children’s overall self-esteem (t>2.571 at 0.05 level of significance with five degrees of freedom), although it is impossible to say that this was simply as a result of being involved in the nurture group.
Donabedian’s model provided an appropriate theoretical underpinning for this study, with the domains of structure, process and outcome clearly emerging in data analysis.
Structural components related to the service’s geographical site and structure. Located within an area of poverty and regeneration, the centre is ideally situated to develop services most needed by the community, although some parents thought this might be off-putting. The centre also has the resources to provide intensive support for clients over a prolonged period. The small class size, flexibility in provision and availability of staff are all major determinants in its success. However, these structural elements could also be seen to be restrictive in that the centre can only provide services to a small percentage of those needing them. An expansion may result in the loss of those features that make it so successful.
The process elements were the strongest to emerge. The attitudes and skills adopted by teachers were pivotal in developing trusting and open relationships with families. Respect, valuing, a non-judgemental approach, honesty and openness were evident in the way they interacted with families. A willingness to share experiences, the use of humour, fallibility, enthusiasm and a genuine interest in others were also demonstrated. The importance of working in partnership, being non-judgemental, showing respect, good interpersonal skills and being able to empathise with others have all been identified as essential elements in the success of a parenting support programme (Moran and Ghate, 2005; Patterson et al, 2005; Moran et al, 2004; Quinton, 2004). The results of this study not only support previous findings, but also help define in more detail how these qualities contribute to the development of trusting, nurturing relationships.
Outcomes in terms of directly measurable quality indicators were less obvious within the data and this is perhaps an area of development for the centre. However, the views of staff, professionals and families involved were extremely positive in terms of the services and support offered. Such views were further supported by the data from the videoed interactions between families and teachers.
This was a relatively small-scale evaluation, conducted within only one centre. While the intensive scrutiny of one setting enabled a detailed picture of it to emerge, the results cannot be generalised to other areas, which could have different geographies, cultures and needs.
However, the results add to the growing body of evidence demonstrating the elements necessary to successfully implement a family support programme.
The centre is very successful in the services it provides because of the small size of classes, flexibility of provision and time availability.
However, they can only provide services to a small proportion of those needing them – those identified at most risk. Catering to a larger clientele might result in the centre losing those unique features which make it so successful. It is the usual challenge inherent within the ethical principle of beneficence: doing a great deal of good for a few, or a little bit of good for the many. There are no easy answers to this conundrum, but this study demonstrated that providing intensive support to those most in need had a beneficial effect. What is perhaps needed are more resources to set up similar services.
The study aimed to provide evidence of best practice in parenting support provision, identify the skills needed by practitioners and make recommendations on the development of training tools for frontline practitioners.
The qualities and skills demonstrated by teachers were essential and, while some of these can be taught, it could be argued that many are inherent within individuals and cannot easily be taught.
The importance of recruiting appropriate people to an organisation and the need to provide continued support for them cannot be underestimated. A range of recommendations regarding a toolkit were made to the organisation, based on the findings of the study and the wider literature.
A toolkit for training and development needs to address all the process issues identified within the study. Here we make recommendations for what a toolkit could contain. This would focus on the personal qualities of teachers, particularly the need to demonstrate a genuine interest in others. This could be facilitated within a training programme that fosters:
Openness and honesty;
Negotiation and consultation;
Verbal skills in information-giving and sharing experiences;
The toolkit also needs to focus on the intended outcome of the working relationship, which within this study was to build confidence and self-esteem. Training therefore needs to develop practitioners’ ability to:
Create a trusting relationship;
Create a relaxing environment;
Interact positively with families;
Respect and value families.
It is recommended that the skills, attitudes and attributes identified above are explored and developed within this toolkit via the use of discussion, anonymised case studies and vignettes.
Skills could be illustrated using extracts from the video recordings which, together with theoretical and research information, would give staff opportunities to identify and practise some of the skills which enhance relationship-building. Reviewing the videotapes would allow practitioners to develop their ability to become more attuned to cues from parents and children. Teachers could also video their own work in order to become more adept at recognising their own skills and further enhancing these.
Specific messages can be set out as pointers for facilitating parenting support programmes, such as the need to:
Be flexible in the timing and running of groups;
Consider the size of classes;
Allow parents to lead some activities;
Be aware of the community’s needs when planning a support programme;
Provide a relaxing and friendly environment.
Overall, the toolkit would help them gain further knowledge about parenting support and how to implement this practically.
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