Supporting staff to work with children and families with complex needs: A checklist for organisations

Many people who access health and welfare services present with multiple interrelated problems. Unfortunately, frontline staff are not always adequately equipped or supported to work with such complex cases, which can undermine their confidence and ability to work effectively.

This paper reflects on the critical domains in organisations that allow for the recruitment, development and ongoing support of staff who are confident and skillful at working with children and families with complex needs. The information in this paper is provided in full acknowledgement that organisations operate within complicated policy and funding environments, which in place limits on what they can be expected to offer and achieve.

In some health and welfare sectors (e.g. child protection), it is broadly understood that many clients have complex needs, and that policies and practices should reflect this. In other sectors, although families with complex needs make up a large proportion of the client group, this reality is not always recognised. For example, many child and family welfare organisations are funded to offer universal or early intervention parenting programs, yet their programs are attended primarily by parents with complex needs (Valentine & Katz, 2015). Similarly, many organisations offering specialist services (e.g. crisis support, housing services, disability services) routinely work with families with complex needs which often need to be addressed, at least to some extent, for more specialised interventions to be effective.

When frontline staff do not receive adequate support from their organisations, they are unlikely to be able to provide the best possible care for families with complex needs, who are, by definition, living with significant adversity. This is an important consideration for those promoting children’s health and wellbeing, as the difficulties experienced by families with complex needs can have both immediate and long-lasting detrimental effects on children. Children exposed to difficulties such as parental mental illness, parental substance use and domestic and family violence face increased risk of internalising (i.e. emotional), externalising (i.e. behavioural) and physical health problems in childhood, adolescence and adulthood. They are also more likely than others to experience child abuse and neglect (Bromfield, Lamont, Parker, & Horsfall, 2010).

When organisations anticipate or explicitly acknowledge the realities of working with families with complex needs, frontline staff are more likely to feel supported, confident and able to respond to multiple complex needs. This is especially true if staff are provided with explicit ‘role clarity’, meaning that the expectations and parameters of their roles are clear (Travis, Lizano, & Mor Barak, 2016). When role clarity is provided, staff employed to offer a universal parenting program, for example, will be supported by recruitment, induction, supervision and training to attend to the more immediate concerns (e.g. parental mental illness, substance use) that need to be addressed before the work of parenting education can commence.

For the sake of children, families and frontline staff, it is essential that health and welfare organisations are ‘complex needs capable’ (Network of Alcohol and Drug Agencies, 2013, p. 1). The following section introduces seven domains where organisational capability can potentially be strengthened (e.g. organisational culture, interagency collaboration), and presents brief case studies that illustrate innovative practice examples. This is followed by a checklist outlining a number of actions that managers, practice leaders, and other decisionmakers can take to more effectively support their staff—steps that generally entail little or no cost, and that should not be in conflict with broader policy and funding imperatives.

This paper is organised under seven domains (see Figure 1 below) identified by combining two methods. The first was a literature review of Australian and international literature focused on organisational-level factors that support staff to work with clients with complex needs (e.g. Network of Alcohol and Drug Agencies, 2013; Superu, 2015; Thomas-Henkel, Hamblin, & Hendricks, 2015).

The second was a workforce development needs analysis of the Australian child and family welfare sector conducted by the Emerging Minds: National Workforce Centre for Child Mental Health between March and October 2018, which helped identify the domains that managers and practitioners themselves considered to be most consequential in their work.

Increasing the support provided to staff working with children and families with complex needs will likely involve paying attention to each of the domains outlined in this paper. While these domains provide a useful heuristic, in practice they cannot be neatly separated out. For example, organisational culture is enacted and reflected in almost every other domain. Similarly, while staff wellbeing can be considered on its own terms, it is worth remembering that it is often closely associated with good practice in other domains, such as supervision and interagency collaboration.

In the process of becoming ‘complex needs capable’, it is useful for managers and other decision-makers to reflect on—and in many cases, actively shape—their organisation’s culture. The term ‘organisational culture’ can seem somewhat abstract or intangible, but in essence it simply refers to “the way things are done around here” (Hemmelgarn, Glisson, & James, 2006, p. 75); that is, the “shared norms, beliefs, and behavioral expectations that drive behaviour and communicate what is valued” within organisations (Hemmelgarn et al., 2006, p. 75).

This paper outlines numerous practical steps organisations can take to support staff who work with families with complex needs (e.g. interagency collaboration, complexity-focused supervision). However, these steps are unlikely to be effective if they are not underpinned by a culture that acknowledges and reinforces the idea that a focus on complex needs is important. Decades of research indicate that culture affects whether new ideas or technologies are adopted, how they are implemented, and whether they
are sustained (Hemmelgarn et al., 2006). Understanding, reflecting on, and actively shaping organisational culture is a first step in the process outlined in this paper. It is also a step that must be taken over and over again. As Hall (2013, p. 3) suggests, cultures are “constantly evolving and reacting to shifts in the organisational environment, and the culture that serves an organisation’s strategic goals today may not be the culture it needs to compete in the future”.

While it is vital for organisations to develop a culture that supports staff to work with clients with complex needs, this culture is most likely to inform and support everyday practice when it is embedded in organisational policies and procedures (Network of Alcohol and Drug Agencies, 2013).

For the purposes of this paper; ‘policies’ are statements that guide decision making and service delivery within organisations, and which are often informed by legislation (i.e. Acts of Parliament) or administrative bodies (e.g. the government department providing funding); while ‘procedures’ are the more detailed or practical instructions about how policies should be carried out by staff. Among other things, policies and procedures in health and welfare organisations generally address workplace health and safety, codes of conduct, privacy and confidentiality, and emergency procedures.

Victoria is the only state in Australia with legislation specifically focused on working with people with complex needs. The Victorian Human Services (Complex Needs) Act (Australian Government, 2009) provides for the assessment of those with complex needs to implement care plans. However, whether in Victoria or not, leaders in health and welfare organisations may benefit from reviewing—and, if necessary, updating—the policies and procedures that relate directly to staff supporting families with complex needs. Areas for consideration include service eligibility criteria, referral protocols and interagency collaboration (Network of Alcohol and Drug Agencies, 2013).

An essential component of good practice with families with complex needs is a skilled and competent workforce. However, recruitment, retention and training of staff are among the most challenging issues facing health and welfare organisations in Australia and internationally. Staff turnover, high vacancy rates, and inadequate training plans are not only extremely costly to organisations and the health and welfare sectors more broadly, but can contribute to detrimental outcomes for the children and families who access services (Larson & Hewitt, 2012).

Much has been written on recruitment and retention in health and welfare services (for a review, see: Payne, 2015). Without underestimating the challenges of recruiting and retaining the right staff to conduct complex work for limited remuneration, it is interesting to note that many of the strategies outlined in the research literature are simple, practical and can involve little cost. For instance, researchers have demonstrated that ‘realistic job previews’—position descriptions that give the applicant an accurate picture of the position they are seeking—reduce staff turnover and improve job satisfaction (Faller et al., 2009). The following case study provides an example
of an organisation that recognised that their position descriptions did not match the reality of working with families with complex needs, and took simple steps to rectify this situation.

In this paper, training refers to the practice of providing education, workshops, mentoring, coaching, or other learning opportunities to staff to assist them to work effectively with families with complex needs. Effective support for staff often involves training on the specific problems that families commonly face (e.g. mental health problems, substance use, domestic and family violence), as well as more general training on strategies for working with families with multiple intersecting problems.

Supervision is widely regarded as one of the most important elements of effective work with children and families. Quality supervision is positively related to employee job satisfaction, organisational commitment, and intentions to continue working in the field of health and welfare. By allowing practitioners the time and space to own their approach to working with children and families, it also helps to ensure that clients receive optimal care (Landsman, 2007).

In busy organisations, supervision can sometimes become an administrative exercise centred on problem-solving, with little focus on the professional development of staff. In particular, limited attention tends to be given to the organisational processes that ensure supervisors receive the leadership, training, and support to fulfil their roles effectively (Milne & Reiser, 2016).

Given the many challenges of working with families with complex needs, it is important that organisations who work with such families provide quality, reflective supervision for their staff. This will likely entail training for supervisors, the development of organisational frameworks and processes for supervision, administrative support for the supervision process, supervision audits, and regular case file reviews. Beyond this, there are a number of evidence-based practices that can support supervision at the organisational level, such as ‘meta-supervision’, in which “a highly experienced clinician serves as a consultant to a clinical supervisor” (Newman, 2013, pg. 13).

One of the features of families with complex needs is that their needs generally cannot be met by an individual practitioner. Indeed, their needs often cannot be met by a single organisation working in isolation (Superu, 2015). This becomes a problem in an era of increased specialisation, where health and welfare service ‘silos’ are often reinforced, and where practitioners can be inadvertently deskilled. Collaboration—both within and between organisations—is therefore an essential component of effective support for contemporary Australian families with complex needs.

It is important that organisations create an environment in which different forms of collaboration are encouraged and facilitated. Collaboration can take many forms. Collaboration between individuals, within teams, or across teams within the same organisation, can ensure that the wealth of knowledge and experience that exists within organisations is properly utilised. Additionally, interagency collaboration involves a commitment between two or more parties that results in the production of something joined and new, from the interactions of people or organisations, their knowledge and resources’ (ARACY, 2009). The less-formal expression of such collaborative relationships
builds the basis for flexible service delivery and referral pathways that keep families with complex needs engaged and valued. More formal interagency collaborative activities include cross-training of staff, multi-agency working groups, memorandums of understanding to support local initiatives, common financial arrangements (e.g. cost-sharing of services), sharing of administrative data, and joint case management (McDonald & Rosier, 2011).

Collaboration can be especially important when assisting families who present to services in crisis. Families presenting with urgent and immediate needs can place pressure on staff to respond in ways that are outside of their professional capacity or job description. Developing good networks with other professionals and organisations assists staff to connect families to the most appropriate supports during times of crisis, and helps to reduce the pressure to respond beyond their skills or capacity.

The health and welfare sector has markedly high rates of sickness absence, staff turnover, dissatisfaction, stress, and burnout, compared to other professional sectors (Brand et al., 2017). When practitioners feel supported in their work with families with complex needs, the chances of them thriving in their roles are increased (Travis et al., 2016). Practitioners who are regularly reminded (either through their own processes or supervision) that their work is leading to positive outcomes are more likely to maintain a sense of fulfillment in their work. To maintain this fulfillment, staff can be supported through a number of mechanisms, including self-supports, organisational supports, and external supports (e.g. confidential counselling through employee assistance programs [EAPs]).

In recent years, the concept of ‘self-care’ has become increasingly popular as a protection against employee stress and burnout (e.g. Skovholt & Trotter-Mathison, 2011). Self-care strategies include time management, mindfulness, physical exercise, healthy eating, informal debriefing with colleagues and friends, and assertiveness training. Some organisations include information on self-care in position descriptions, support their staff to develop self-care plans, and offer staff free self-care activities or programs (e.g. lunchtime yoga classes).

While the explicit promotion of wellbeing and self-care is an important element of supporting staff to work with families with complex needs, it can only be effective if the other supports outlined in this paper are in place. In this regard, it is useful to distinguish between social/emotional support (e.g. providing clear and regular feedback, recognition of contribution) and instrumental support (e.g. appropriate supervision, ongoing training), both of which are necessary in the promotion of staff wellbeing.

Although many organisations collect large amounts of data, this data is not always utilised as effectively as it could be. Data can be used to support staff to work more effectively with families with complex needs – for example by identifying the characteristics of the families that access services, by identifying staff training and support needs, and by assessing the impact that different practices and programs have on families.

Data comes in many forms. Most services collect information on clients during the intake and assessment processes, and continue to collect at least some data for as long the clients engage with their service. Some organisations routinely survey their staff in an effort to understand their attitudes, experiences, and needs. Others conduct evaluations of their programs, using the evaluation data both to justify ongoing funding and to continuously improve their services.

Practitioners who are informed by data are often more aware of the outcomes of their practice. In its simplest form, data gathering may involve the practitioner asking their clients some questions at the end of every session. Not only is this a robust, client-focused practice, but it allows the practitioner valuable insight into their client outcomes. A critical reflection of this data in supervision can support practitioners to develop, improve and gain confidence and skill.

Data collection, evaluation, and innovation in service delivery are essential because many of the problems experienced by families with complex needs are ‘wicked problems’: problems that are multifaceted, deeply entrenched, and highly resistant to resolution. Successfully managing wicked problems generally requires a reassessment of traditional ways of working and problem-solving. Such a reassessment is aided by the effective collection of data and the continuous evaluation and improvement of programs and services
(McCoy, Rose, & Connolly, 2014).

This checklist can be used in any way that helps organisations to support their staff to work with children and families with complex needs (e.g. to stimulate new ideas, guide an audit of organisational processes, structure conversations in planning meetings). It is likely that individual organisations will find some of the suggested actions more relevant than others.

Download a copy of the checklist

Acknowledgments

For advice and contribution, thanks to Morwynne Carlow, Dan Moss, Rebecca Armstrong, Carol Clarke, Angela Obradovic, Stephanie Purcell, Cathryn Hunter, Tony Gates, Sue Chapman, Claire Tarelli, Aerinn Morgan, Jeannette Stott, Chris Dolman, Courtney Schuurman, Derek McCormack, and Geneva Batten. Special thanks to Emerging Minds’ family partners who provided input into this paper.

Rhys Price-Robertson works at the Australian Institute of Family Studies as part of the Emerging Minds: National Workforce Centre for Child Mental Health. At the time of writing, Thy Meddick worked at the Emerging Minds: National Workforce Centre for Child Mental Health. Elise Parker works at The Salvation Army as part of the Logan Communities for Children Facilitating Partner program. Views expressed in this publication are those of the individual authors and may not reflect those of The Salvation Army, the Australian Institute of Family Studies or the Australian Government.

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