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

Rhys Price-Robertson, Thy Meddick and Elise Parker, Australia, 2019

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This paper provides managers, practice leaders, and other decision-makers with practical guidance on supporting staff to work with children and families with complex needs.
It will be useful in a broad range of health and welfare organisations, particularly those not specifically designed to work with clients with multiple interrelated problems.

Background

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.

What are complex needs?

The term ‘complex needs’ is used in reference to individuals or families who experience numerous, chronic and interrelated problems. These can include mental health difficulties, physical health troubles, disability, substance use, domestic and family violence, social exclusion, poverty, unemployment and homelessness (Bromfield, Sutherland, & Parker, 2012). Those with complex needs are often described as having both ‘breadth of need’ (i.e. multiple interconnected needs) and ‘depth of need’ (i.e.
particularly severe or serious needs) (Rankin & Reagan, 2004).

In 2013, the Australian Productivity Commission estimated that around five percent of Australia’s working-age population experiences multiple forms of disadvantage (McLachlan, Gilfillan, & Gordon, 2013). Such figures help to give some sense of the numbers of families living with complex needs. Yet certain population groups, such as Aboriginal and Torres Strait Islander communities, have higher numbers of families experiencing deep and persistent disadvantage. This is due to numerous factors, including historical and ongoing dispossession, marginalisation, and institutionalised racism (McLachlan et al., 2013).

Domains of support

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.

Infographic depicting the organisational domains for supporting staff working with families with complex needs

Organisational culture

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”.

Uniting Communities offers a range of health and welfare services in South Australia. Although the Adult and Family Counselling team within this organisation is not focused specifically on working with individuals or families with complex needs, many of the clients who access this counselling service face multiple problems in their lives, including domestic and family violence.

Over the last few years, the managers and practice leaders in the Adult and Family Counselling team have taken a number of steps designed to acknowledge that staff routinely
work with clients with complex needs, to normalise the challenges inherent in working with such clients, and to create a culture in which counsellors feel supported to share
their challenges, doubts, and concerns. As one practice leader described:

“It was about very gradually trying to introduce new things while always focusing on what our commitment was, which was improving our practice for our clients, particularly around the safety of women and children. So I think everyone was on board with that.”

One group practice designed to achieve these goals involves a counsellor presenting a transcript of a particularly challenging or interesting counselling session at a practice meeting (after obtaining consent from the client/s). Over the course of a year, each counsellor in the team has the chance to present in front of their peers and receive feedback on their work. Another group practice involves counsellors being interviewed in front of their peers about current challenges or successes in their practice. The rest of the team then provides outside reflection, letting the interviewee know what they have learned from witnessing the interview.

While many counsellors initially felt nervous about participating in these group activities, they are now widely seen as an invaluable aid to working effectively with families with complex needs. Importantly, there is now a strong sense within the team that it is normal to feel challenged when working with clients with complex needs, and that it is a mark of good practice to be able to share these challenges and to ask for help when needed:

“We’re at the point now where counsellors look forward to doing these activities. And the other counsellors report getting a huge amount of support out of that because it enables us to make our practice more transparent. It gets us away from that idea that, I’m the only one who feels like this. I’m the only one who feels like I’m inadequate, that I’m not doing this job properly, that I can’t think of the right things to say at the right time. Because they get to share a sense that this is tricky work, difficult work that we do, and we’re all in this together. We don’t have all the answers. We’re not experts. And we all have a shared responsibility to teach each other and learn from one another. So it’s really added to the cohesion in the team.”

Policies and procedures

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).

Recruitment, retention and training

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.

Search Light Inc is a childcare and parenting support service located in Brisbane. The service is attached to an independent secondary school that caters to young women who have not been able to complete their education in a mainstream schooling environment. Many of the women and children attending the service have complex needs, including significant trauma, mental health concerns and difficulties in their attachment relationships.

Recently, a newly appointed manager conducted a staff skills analysis of the childcare service and identified that while all staff have qualifications in childcare, many did not have experience or training in working with families with complex needs:

“So I guess that all the communications in this organisation were around offering childcare while the mums were at school. And I recognised that while there was great work being done, we could be doing so much more. We’ve got these children here all day, we know that they’re at high risk, and some of them aren’t meeting milestones. We need to change the way we’re thinking about this particular service and really understand that we’re not just dealing with mainstream childcare, that this is a different setting.”

This manager identified that the childcare worker position descriptions used to recruit new staff only covered generic childcare activities, without adequately identifying the additional skills and activities required in a service accessed predominantly by families with complex needs:

“So the first thing we did was look at the position descriptions with the staff. What’s in your position description now? Are you meeting the current goals in the position description? How does the position description need to be different moving forward?”

This manager worked with current childcare staff to develop new, more realistic position descriptions, which clearly indicated the problems experienced by families accessing the service, and the kinds of extra support they tend to need. The first staff member to be employed using the new position description had experience in both childcare and child protection, which added a new depth of knowledge and experience to the childcare team:

“When I recruited her, I talked about that type of service that we provide so that she was well aware that we’re not just a regular childcare service.”

Supervision

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).

CatholicCare Sandhurst offers a number of services in the Greater Shepparton region, including funding brokerage through the Communities for Children program. They recently established the ‘One Village Collaboration’ (the Collaboration), which comprises local health and welfare organisations, national peak bodies and
government departments, and which aims to reduce the number of local Aboriginal children in out-of-home care.

The Collaboration steering group identified the need for an Aboriginal family engagement worker, whose role would be to connect local families who face disadvantage with health and welfare services. They decided that the most appropriate place to position this new staff member was in Lulla’s Children and Family Centre (Lulla’s), which is a multifunctional Aboriginal children’s service.

When the family engagement worker began in her role, it quickly became obvious that it was going to be difficult for her to avoid some case management activities in her work with families with complex needs. As a member of the Collaboration described:

“We, in our naivety, thought, Well, all this worker needs to do is connect families with other services and that will be fine. And of course it wasn’t at all like that like that. The very first family that she came into contact with was presenting in a very positive light to the Maternal and Child Health nurse, but took our worker to one side and said, ‘Don’t tell them, but we’re getting evicted’. This family had three children and one was just a little baby. And all of a sudden our worker was plunged into a whole realm of complexity.”

However, the worker did not have training or experience in working with families with such complex needs. The manager at Lulla’s was able to provide the worker with some supervision, though the manager’s background in education meant that she too had limited experience in working with families with complex needs.

The Collaboration steering group decided that the family engagement worker would benefit from fortnightly supervision specifically focused on the challenges of working with families with complex needs. One of the Collaboration steering group members—who has over 30 years’ experience working in the child and family welfare sector—agreed to offer fortnightly pro bono supervision to the family engagement worker:

“This situation is something that just evolved. We’ve just responded to need as it’s arisen. And because of the nature of the Collaboration, and the fact that everyone
wants to contribute something, everyone is contributing in a way that’s appropriate and possible for them. And, in this instance, it was a real gift for the supervisor to be able to offer her services.”

A few months into this supervision arrangement, the family engagement worker is feeling more confident in her capacity to work with families with complex needs, and has a better understanding of good practice in relation to risk management, safety and privacy, and maintaining wellbeing as a worker.

Collaboration

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.

Staff wellbeing

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.

Data, evaluation and innovation

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).

The Salvation Army runs the Communities for Children (CfC) facilitating partner program in Logan, Queensland. The CfC program funds prevention and early support programs and
activities in 52 local communities across Australia via funding from the Department of Social Services (DSS). Activities and programs are designed with community members
themselves and informed by sector best practice and evidence in the area of family wellbeing.

While the support that CfC and their partners provides is dynamic and complex in nature, the reporting requirements largely involve basic output data (i.e. attendance records). Early in their implementation of the program, the Salvation Army CfC team realised that such simple quantitative data do not adequately capture or reflect the complexity of needs that families were experiencing in the Logan community, nor the dynamic responses of frontline service teams.

In response to the limitations of the mandated data reporting system, the Salvation Army CfC team have worked with their funded partner organisations to complete six-monthly progress reports that include a mix of qualitative and quantitative information to sit alongside the output data required by DSS. This has allowed frontline staff to illustrate the broad range of local community needs and the real nature of the work they were doing to support the community. As one member of the Salvation Army CfC team
described:

“Numbers without context just doesn’t make sense; we’re keen to work with the government to understand just how good practice supports and guides good program delivery, and how good evaluation keeps both programs and practice at a high standard. Our frontline staff are really skilled at what they do, and we want to be able to demonstrate this through intuitive and innovative evaluation, not just anecdotal stories”.

One of the biggest learnings for the Salvation Army CfC team has been that data reporting requirements, data collection infrastructure, and program evaluation methods must adequately reflect the nature of the activities being delivered, and capture outcomes relevant to individuals and families experiencing complex issues.

Checklist for organisations

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 & references

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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