Promoting Best Practice in Assessment and Intervention: The Challenges of Working in Times of Cutbacks and Change
Across the UK, health, social care and welfare services are facing considerable pressures as austerity measures often combined with organisational restructuring take hold. Not a day goes past without media headlines reporting NHS pressures, with a recent report highlighting that in the year up to September 2017 more UK nurses, midwives and health visitors left the Nursing and Midwifery Council register than joined it (BBC News, 2017 3 July 2017; Nursing and Midwifery Council, 2017a, 2017b; The Nuffield Trust, 2018). Getting investment for preventative work with children and families is always problematic, but even more so at a time of widespread public sector funding cuts and government austerity (Appleton and Peckover, 2015; Royal College of Paediatrics and Child Health, 2018). ‘Getting investment for preventative work with children and families is always problematic’ In England, the health visiting profession (public health nursing) has seen frontline staff numbers markedly reduced. Many health visitors are no longer situated in general practice and services are being put out to tender by cash-strapped local authorities. In England, there are only five core contacts, with one of these being in the antenatal period; some children and families do not even have access to these. Health visiting in England has been described as ‘a crisis waiting to happen’ (Bryar et al., 2017, p. 102). Yet health visitors' home contacts with children and families to assess health needs are crucially important in recognising when early intervention work with children and families is required and can be central to the prevention of child abuse and neglect. Unfortunately, much nursing work around prevention and early intervention is invisible, ‘in terms of both a robust evidence base and a paucity of relevant literature to articulate the range of nursing roles’ (Appleton and Peckover, 2015, p. xx). Our job as researchers and editors is to highlight some of the apparent invisibility to support our frontline colleagues who are committed to the services that they provide to children and families in these complex and challenging times. The first paper in this issue by Clare Lushey and colleagues (2018) reports on a study which explored pre-birth assessment guidance and practice in England. Pre-birth assessment is undertaken when there are concerns that an unborn child is likely to suffer significant harm. It is recognised as one of the most complex and challenging aspects of social work practice because of the legal and ethical context. The study involved a documentary analysis of the pre-birth assessment guidance issued by all 147 local safeguarding child boards (LSCBs) in England and obtained from their websites; this was followed by interviews with a range of practitioners involved with pre-birth assessments, including social workers, midwives with safeguarding children responsibilities, other health practitioners including psychiatrists and family support workers. ‘[Pre-birth assessment] is recognised as one of the most complex and challenging aspects of social work practice’ The study found that all LSCBs referred to pre-birth assessments in their procedures. However, while the analysis revealed that the local LSCB guidance was generally more detailed than the national guidance, the level of detail regarding timescales varied; furthermore, ethical and legal issues were rarely explored. Interview data revealed some of the complexities surrounding risk assessment of the unborn child, which included barriers to engagement. Interviewees described expectant parents being anxious that outcomes may have already been decided, the stigma associated with social work involvement, and expectant parents' previous negative experiences of social care intervention. Data revealed the fairly short timescales for pre-birth assessments to be conducted and the need for practitioners to be non-judgemental and honest in their attitudes and practices. The study also found that some interviewees ‘regarded pre-birth assessments as less urgent than cases involving infants/older children, thereby increasing delays in decision-making’ (Lushey et al., 2018, p. 97). Few practitioners used standardised pre-birth assessment frameworks or tools to aid complex assessments, despite their potential to improve assessment quality. The researchers conclude by pointing to the potential use of a standardised pre-birth assessment care pathway (e.g. Barlow et al., 2016) as a useful method of evidencing pregnant women's capacity to change and providing the required evidence for safety decisions about the unborn baby. They also refer to the findings from Ward et al.'s (2012) longitudinal study of infants suffering significant harm to illustrate the significance of/need for early and timely pre-birth assessments by social workers to enable them to make decisions about parents' capacity to change their behaviours. Assessment and the need for culturally appropriate assessment tools are reinforced in our second paper in this issue by Aunty Sue Blacklock and colleagues (2018) from Winangay Resources Inc. and the University of South Australia. These researchers evaluated the social and cultural acceptability of the Winangay Kinship Carer Assessment Tool (the Winangay Tool) for practitioners who are responsible for assessing Aboriginal and Torres Strait Islander kinship carers. Kinship carers are assessed in the Australian statutory child protection system to provide out-of-home care for Aboriginal and Torres Strait Islander children. This paper describes an evaluation of 84 practitioners from 23 agencies who participated in a three-day training workshop to explore their views about the acceptability of the Winangay Tool. Forty-two of the respondents were of Aboriginal and/or Torres Strait Islander descent and all participants worked in a range of foster, kinship support worker, child safety, placement support worker or team leader roles. Reponses to pre- and post-training questionnaires indicated that previously a range of kinship assessment tools or locally developed strategies had been used, with outcomes often dependent on the skills and knowledge of the assessor. Both Aboriginal and Torres Strait Islander practitioners talked about the strengths of the Winangay Tool, including how easy it is to use and understand. The tool was also rated as culturally appropriate and an improvement on existing tools and approaches. Blacklock et al. (2018) conclude by drawing attention to the implementation literature which highlights that a key factor in the successful implementation of a new assessment approach is if stakeholders view the new practice as acceptable and it can be conducted feasibly within their practice setting (Proctor et al., 2011). ‘Assessment and the need for culturally appropriate assessment tools are reinforced’ The importance of stakeholder buy-in to a new programme intervention is similarly highlighted in the next paper. Also focusing on children who are cared for in residential out-of-home care, Rachael Cox and colleagues (2018) from Australia, in the second of two papers published by this team in Child Abuse Review, describe a randomised trial of the Healthy Eating, Active Living (HEAL) programme for young people and their carers. HEAL is a 12-month intervention programme which aims to help young people make positive choices in relation to their physical activity and eating behaviours, and provides a range of resources for their professional carers to support them in raising young people's awareness of weight-related behaviours. This paper describes the evaluation of stakeholders' experiences and opinions of the HEAL programme and their understanding of the barriers and enablers to its successful intervention. Qualitative semi-structured interviews were conducted with 17 carers and ten HEAL programme coordinators. Findings indicated strong agreement about the importance of addressing the eating and physical activity behaviours of young people. HEAL was considered a useful addition to the residential care programme, and was successful in raising awareness about the importance of leading a healthy lifestyle, particularly among care home staff. The authors also report healthier eating habits and more engagement in physical activity amongst young people and carers. The major barriers to implementing HEAL were the ‘need for better programme ‘buy-in’ from key stakeholders both within their unit and the broader organisation’ as there was a general feeling that not all carers and team leaders/managers ‘actively endorsed the programme’ (Cox et al., 2018, p. 129). Only five young people agreed to participate in post-intervention interviews. The HEAL study really ‘highlights some of the difficulties of recruiting vulnerable young people to take part in intervention trials as well as their implementation in complex environments’ (Appleton and Sidebotham, 2017, p. 168). For an analysis of this, see Cox et al. (2017). To ensure sustainability of the programme, participants described the need for more training of carers and having a Champion in each unit who would have a better knowledge of the young people and the residential unit, to work with the external HEAL Coordinator. As Blacklock et al. (2018) also concluded, ensuring the engagement and buy-in of all stakeholders is a central feature of effective interventions and implementation science. ‘Ensuring the engagement and buy-in of all stakeholders is a central feature of effective interventions and implementation science’ The final full paper in this issue by Catherine Thompson-Walsh and colleagues (2018) from the University of Toronto, Canada, is a small but very interesting study examining the features of post-separation co-parenting from fathers' perspectives in men with and without a history of domestic violence (DV). Interview data from 20 fathers who were separated from their child's mother were randomly selected from the larger Toronto-based ‘Fathers and Kids’ longitudinal study, investigating how violent factors impact on children's development. Ten fathers came from the clinical sample (DV) with an officially documented history of DV perpetration recruited from court-linked intervention programmes and ten from a comparison sample of community fathers with no history of DV or involvement with child protection services. As well as interviews, both groups of fathers also completed the Parenting Alliance Measure (Abidin and Konold, 1999) – a self-report measure of the strength of the co-parenting relationship. ‘DV fathers lacked insight into how their co-parenting impacts their children which, in combination with high levels of denigration, sets the stage for children to have ongoing exposure to harmful, distressing and fear-provoking co-parenting interactions.’ (Thompson-Walsh et al., 2018, p. 146). Other research published in Child Abuse Review by Holt (2015) and Morrison (2015) has also highlighted continued abuse of women and their children during post-separation contact. Thompson-Walsh et al. (2018) conclude their paper by arguing that involving DV fathers in post-separation parenting should be preceded by thorough assessment, which ‘should carefully query the nature of ongoing co-parenting conflict as well as fathers' insight, or lack thereof, into the impact of past and ongoing behaviour on his children’ (p. 147). Indeed, Broady et al. (2017) have previously called for DV intervention programmes to help men to confront the impact of their violent behaviour on their children's wellbeing and their relationships with them. ‘Involving DV fathers in post-separation parenting should be preceded by thorough assessment’ The short report in this issue by Moira Little and colleagues (2018) describes a small qualitative evaluation of community nurses' experiences of child safeguarding supervision. The majority of the 25 participants were either health visitors or school nurses and data were gathered using a survey and interviews. Safeguarding children supervision was regarded by the participants as child focused and largely a very helpful and supportive activity often leading to improvements in their practice. Many suggested expanding supervision to include discussion about children whose healthcare is of concern but who are not involved in formal safeguarding procedures. Robust supervision is a key aspect of the professional development of staff working with vulnerable children and their families. The papers in this issue of Child Abuse Review explore a number of important practice issues: acknowledging the complexity of good assessment when working both with professionals and children and families; the importance of reviewing the evidence critically and getting all stakeholders on board when planning new interventions; and the difficulties of recruiting vulnerable young people into programme interventions. All of this becomes increasingly challenging in times of cutbacks, reorganisation and service constraints. This makes it even more important to ensure that practitioners are supported through high-quality supervision, training and professional development. This issue concludes with a training update by Hilary Eldridge (2018) of Seen and Heard (e-Learning Course and Supplementary Training Materials on Building Awareness of Child Sexual Abuse and Exploitation) by the Department of Health and the Children's Society, 2016. Eldridge critically reviews this freely available training resource, and finds it to be an excellent vehicle for healthcare professionals to help children feel safe about disclosing sexual abuse. ‘Even more important to ensure that practitioners are supported through high-quality supervision, training and professional development’
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