- partnerships
reciprocal and respectful ways of working characterised by openness, mutual expertise, trust, negotiation and shared decision-making. Partnership contrasts with approaches in which professionals set the agenda, make decisions, and occupy the role of ‘expert’ while others’ knowledge is regarded as secondary. In this chapter reference is made to the family partnership model (FPM; Davis & Day, 2010) as a specific partnership framework that has been widely implemented in Europe and Australasia.
- learning
processes that enable people to know more or different things, to be different, and to act differently.
- pedagogy
the theory about the processes that are understood to bring about learning. While it is similar to ‘teaching’, the latter often implies a formal educational setting (like a school) and a ‘teacher’. In contrast, pedagogy points to the idea that many non-teaching health professionals are in fact engaged in helping and obliging colleagues and novices to learn.
Introduction
Relationships between healthcare professionals and the people they help are changing. One important reason for this is that service users are increasingly encouraged and expected to play a role in their own care. They may be involved in the design and planning of their care, and consulted about the appropriate standards of care. Professionals are not seen as the only ‘experts’ in the equation, but as bringing important expertise to a situation in which others have valuable knowledge to contribute, too. This involvement can be referred to as co-production or partnership (Dunston et al., 2009).
- service users
patients, clients, and consumers.
The emphasis on co-production and partnership no doubt results from rising pressures on health services due to an increasing need to manage chronic conditions. There remain many features of health care where a strong expert-led approach is still needed, but when professionals are helping others cope with long-term health challenges and risks, a more consultative and joint process is called for.
Partnership approaches have caught on widely in child and family health services, where there are now several models of care that have been trialled and implemented (Davis & Day, 2010). These approaches play a prominent role in services that specifically aim to enhance health and well-being for families with young children. Child and family health professionals may work in homes, neighbourhood centres, children’s centres, schools, community health or primary care settings, day stay or residential units, hospitals, and via telephone support services. They include nurses, health visitors, social workers, speech and language specialists, occupational therapists, psychologists, and practitioners from a range of medical disciplines such as psychiatry and paediatrics.
Child and family health services can provide support for parents prior to and after the birth of new children, screen for and address mood disorders among parents and children, help families cope with challenges associated with chronic health conditions, and build resilience in families by fostering relationships between families and their communities. Because the family unit is so important in shaping the health and wellbeing of all its members (Bronfenbrenner, 1979, 2005) services engage not with individuals but with families.
When working with parents and children, it is important to make sure they feel listened to and respected, and that they are not disappointed when inappropriate expectations are not met. Research has showed that family members were much less likely to follow through on advice from professionals when they did not feel involved in decisions relating to their care, or when they could not express their views, concerns and desires without being judged (Davis & Fallowfield, 1991).
Communication in partnership with family members requires skills of ‘active listening’ (allowing others to speak and finishing speaking only when they are done). Active listening demonstrates that you are listening attentively, and with empathy. This strategy also means questioning vulnerable people without fuelling anxiety, and showing an unconditional positive regard for the people you are trying to help. This happens verbally and through non-verbal cues, including body posture, gaze, facial expressions and gestures. Parents and children should feel that they can express their feelings and describe their experiences without being judged, and that they have a say in setting the agenda and deciding what happens.
The family partnership model (FPM) suggests there are a number of stages involved in the helping process. All the stages build on a relationship between the professional and the family. The stages also help to maintain and develop this relationship. The process begins with exploration, or listening to parents without judging. Then professionals explore how parents understand their situation, and might work to explore alternative understandings before setting goals. Goals are negotiated and reflect parents’ priorities and values. Strategies to work on those goals are planned jointly, with family members actively involved in their implementation. Outcomes are reviewed, and it may be that further work is then done together, perhaps working on different goals.
Partnership approaches mean that professionals do not solve problems for others. Instead they help to build problem-solving abilities, confidence, and self-esteem by helping family members learn about parent–child interaction and themselves developing strategies to anticipate and cope with challenging circumstances.
In this example Ruth, a nurse, is working with Kirsty who has been struggling to get her 18-month-old son Harry to fall asleep (settle) in the evening, and to self-settle when he wakes up during the night. The setting is a residential service where professionals are on hand to support families around the clock for a period of five days. Kirsty is becoming exhausted; the situation is placing strain on her relationship with her husband, and affecting Kirsty’s ability to join in her local mothers’ group and other community activities with Harry.
Kirsty has told Ruth that getting Harry to ‘self-settle’ is an important priority for her and her family, and Ruth has suggested that they try a different approach to settling. They will give Harry a chance to learn to settle by waiting until his cries indicate distress before going in to comfort him. Ruth has explained that she knows this will be hard for Kirsty, and that if Kirsty feels it is too much at any point they can try something else. They negotiate a goal, which is to challenge the family themselves to try a new settling approach and see how it goes.
Kirsty gives Harry a cuddle, tells him it is time for sleep, puts him down, gives him a kiss, and then turns to leave the room. As she does so, Harry begins to cry gently. Ruth touches Kirsty on the shoulder and nods, indicating they should go and stand outside together. Ruth reassures Kirsty: his immediate cries were expected. Ruth stands in a calm, relaxed posture and makes frequent eye contact with Kirsty, whose body is more tense.
Ruth asks Kirsty what she thinks Harry’s cries mean. Kirsty isn’t sure. Ruth says, ‘Well, he’s not screaming, and there are some silences there, so I think he’s just protesting.’ Kirsty nods, and Ruth explains that although it can be distressing for parents when their children cry, protest cries are very normal – children are just like adults and find change hard, and crying is a way to communicate this.
Over the next 15 minutes, they listen to Harry’s cries, and go into the nursery each time they become more distressed. Ruth reminds Kirsty of the strategy they had chosen: Kirsty will pat the mattress next to Harry and offer gentle ‘Sush-sush-shusssshh’, ‘Time for sleep’, ‘It’s OK mummy’s here’, and to leave again when Harry calms down. Throughout the process Ruth reassures and praises Kirsty, asks her how she is feeling, and closely monitors her body language for signs of anxiety; she reminds Kirsty that at any time she can go in and cuddle Harry if she feels that is what she wants to do.
After coming out of the nursery for the fourth time (see Figure 11.1), Ruth asks Kirsty how she feels it is going, and Kirsty responds, ‘OK but it’s hard because he’s still crying when I leave.’ Ruth says, ‘I noticed that time that Harry didn’t lift his hands up when you went in.’ Kirsty hadn’t noticed this, being more occupied with Harry’s cries. Ruth explains that this means Harry isn’t wanting or expecting to be picked up for a cuddle any more, and that this learning has been prompted by Kirsty’s consistent actions of going in and patting the mattress whenever Harry indicates distress. Harry is learning that Kirsty isn’t far away and is there when he needs her, but also is becoming more at ease in his cot as he settles for sleep.
Figure 11.1 Ruth (right) and Kirsty (left) outside the nursery
Analysis and reflection
Looking at practice example 11.1, we can see different features of partnership-based communication in action. It enables us to reflect on how these features compensate and counteract situations where experts set the agenda for families, tell them what to do, or assume there is a need to solve problems for them.
Right from the start this episode is strongly shaped by Kirsty’s particular needs and challenges. Indeed, she herself sets the priority to be Harry’s learning to self-settle. Within the ecological approach, respecting Kirsty’s own understanding of the problem – Harry’s difficulty settling – is critical for her to begin moving towards restoring the whole family’s well-being and connectedness, including restoring connections with other families in their community. If Harry can self-settle, then he and his parents will be better rested, Kirsty will have more energy to play with Harry in the daytime, she will feel more able to be the mother and wife she wants to be, and she will be more confident in joining in her mothers’ group and other activities.
- ecological approach
an approach that takes account of contexts within which events take place. Ecology pays attention to a variety of contexts, including social, cultural, historical, political and environmental contexts.
Helping Kirsty to realise her priorities, Ruth contributed her expertise drawing on a repertoire of settling strategies and offering several alternatives. While Ruth was there to support Kirsty throughout the process, Ruth was not the one settling Harry. While Kirsty might have learned something by watching Ruth settle Harry, the experience is much more meaningful because she is acting it out herself. This is a significantly more effective preparation for when Kirsty and her family return home.
Significantly, too, Ruth asked Kirsty how she interpreted Harry’s initial cries. Even though Kirsty wasn’t sure, this simple question showed that Ruth was interested in Kirsty’s understanding of the situation. Ruth then didn’t simply say, ‘He’s protesting’, but instead pointed to features of the crying, features they both could hear. This enabled Kirsty to ‘read’ Harry’s cries such that she knew that he did not need her immediate physical presence. This way of directing others’ attention is important, not just because it brings part of Ruth’s expertise out into the open, but also because it helps Kirsty learn what to listen for in future.
Likewise, when Ruth mentions Harry not lifting his hands, she is again drawing on her professional expertise, showing she knows what to look for and why it is important. Importantly, this is used to help shift the situation as Kirsty perceives it (Harry is still crying, so progress isn’t being made) to one in which signs of positive change may become apparent.
Then when Ruth adds how normal this is and likens Harry and other young children to adults in finding change hard, she recognises that Kirsty finds the crying hard to cope with, and provides multiple forms of reassurance. Here Ruth is communicating her empathy for Kirsty; she does not dismiss Kirsty as overly sensitive or a bad mother, but rather shows an unconditional regard that acknowledges that Kirsty’s tension comes from her strong maternal instinct. Rather than saying her anxiety around crying was ‘wrong’, Ruth helps Kirsty ‘read’ the cries at multiple levels. This helps to move Kirsty’s anxiety to the background to some extent.
In all, Ruth questions and monitors Kirsty for physical cues indicating anxiety. In doing so, Ruth exploits several communication channels: language, emotion and touch. These multiple channels ensure that Kirsty is not confronted with language alone, and help her connect what is going on to her own bodily responses. Although Ruth has offered support, and reassurance that Harry’s cries do not all indicate distress, Ruth does not assume that Kirsty’s experience is the same as hers: she makes use of all available signs to assess the need to stop or try a different approach.
Most importantly, Ruth creates a transformative event for Kirsty: she is able to expand Kirsty’s impact on the world by assisting Kirsty in recognising and acting on real-world cues. In effect, Ruth enacts a strengths-based approach, using Kirsty’s way of being in the world as her starting point, and not doubting that Kirsty is capable of using her own resources to enhance how she relates to and manages Harry.
- strengths-based approach
a strength-based approach focuses on those aspects of people’s own behaviour that show promise and use these to scaffold (support) changes in knowledge and behaviour, rather than work from idealised models and predetermined behaviour goals.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
