Shake, Rattle and Roll: Reorienting a System and Co-Creating a “Whole of Organization” Community of Reflective Practice

Rochelle Matacz, Lynn Priddis, and Kim Wedge, Ngala, Western Australia

Abstract

For infant and early childhood mental health (IECMH) principles to have an impact beyond the dyad, Ngala, a parenting and family-focused agency in Western Australia, embarked on an innovative initiative focused on bringing relationship-based practice to the forefront of all programs supporting families. This article describes the first phase of this journey, which consisted of building a community of practice through offering a series of reflective seminars across 12 months. Qualitative analysis of focus group material revealed organizational growth and the creation of a community of practice that is a safe and trusted place to begin to understand the value of reflective practice.

Reflective practice and reflective supervision are recognized as crucial components of building workforce capacity in infant and early childhood mental health (IECMH) across all settings that work to support the emotional well-being of infants, young children, and their families. Reflective practice in this context consists of the thoughtful awareness of both the needs of the family as well as what the practitioners brings of themselves to the work. In IECMH practice, the parent–infant relationship is at the forefront of all interventions, including the practitioner’s reflective practice and supervision (Laurieu & Dickson, 2009).

Principles of Reflective Practice and Supervision

Reflective practice and supervision play a pivotal role in the development of reflective skills in IECMH practice. Reflective supervision can be understood as a “relationship for learning” (Fenichel, 1992, p. 9) in which practitioners are supported within a collaborative relationship with a supervisor to explore knowledge, ideas, and experiences related to their everyday practice with families (Shahmoon-Shanok, 2009). This relationship-based approach to supervision is underpinned by core principles of (1) holding both the caregiver and infant/young child in mind, (2) understanding of parallel process, (3) professional use of self, and (4) exploration of the emotional content evoked in the work with families (Gilkerson & Ritzler, 2005; Tomlin et al., 2014; Watson et al., 2016; Weatherston et al., 2010). Through full participation in regular reflective supervision, practitioners can develop skills that translate into providing high-quality interventions and supports that are family-centered, resulting in better outcomes for children and their caregivers.

Benefits of Reflective Practice and Supervision

An infant mental health (IMH) model of reflective supervision has the potential to impact staff across a whole organization. Empirical evidence has demonstrated that engaging in reflective supervision supports job satisfaction and decreases burnout in practitioners who work with families (Osofsky, 2009; Shae et al., 2020). Findings from Priddis and Rogers’ (2018) exploratory research with a diverse group of practitioners working with families engaging in reflective supervision revealed “building reflective capacity may indirectly influence job satisfaction fostering a greater desire for improvement” (p. 100).

Researchers and leaders in the field have grappled with identifying the specific components of reflective supervision that are important for professional growth and competence in IECMH. A study conducted by Shea and colleagues (2020) using the Reflective Supervision Self-Efficacy Scale for Supervisees (Shea et al., 2020) with IMH home visitors identified critical components of reflective supervision which included “Use of Supervisory Relationship…,” “Use of Reflective Practice Skills With Families…,” “Use of Observation Skills…,” and “Use of Self Awareness.”

Shea et al. (2020) found that following participation in reflective supervision for a period of 12 months, IMH home visitors reported increased self-efficacy related to their use of observational skills and reflective practice skills with families. This finding suggests a positive relationship between skills developed through a reflective supervisory relationship and the translation into practice.

Implementing Reflective Practice and Supervision Across an Organization

Despite a growing body of literature that recognizes reflective supervision as a core competency in IECMH practice across all stages of professional development (Alliance for the Advancement of Infant Mental Health, 2018), organizations typically struggle to implement a model of reflective supervision that is embedded across the organization and sustainable. For reflective supervision and reflective practice to be an integral part of an organization, it is paramount that the role of relationships is understood, developed, and incorporated across all levels of the system. Embedding an IMH relationship-based framework across an organization is likely to bring about a whole of organization paradigm shift that results in long-term family-focused practice improvements (Overton, 2015). To accomplish such change a theoretical foundation is required to guide the process.

Systems Theory of Change

Working toward transformative change across a whole organization requires application of a solid model of change management; a deep understanding of the organizational challenges in embedding reflective supervision as well as applied knowledge of the characteristics of the organization and its clients. Relational Developmental Systems (RDS) is an evidence-based practice framework for understanding complex systems with staff from diverse disciplines and a broad range of services (Overton, 2015). RDS are open systems which means they are dynamic and changeable. Adopting an RDS approach to IMH will provide a theoretical framework for understanding and intervening at a systems level, in order to effect improved human and community service systems which then create better and more equitable outcomes for consumers, in this case infants, young children, and their families and caregivers (Foster-Fishman et al., 2007).

In considering a broader systems perspective and in line with systems change theory (Fitzgerald & Zientek, 2015; Kania et al., 2018; McNall et al., 2015; Overton, 2015), Sparrow (2016) drew upon Brazelton’s Touchpoints approach (Brazelton, 1999) to develop a systems change model specific to the relational approach of IECMH. He argued that focusing on the role of relationships across an organization and using relational, cultural, and systems elements of the Touchpoints approach can result in long-term sustained practice changes in the way practitioners work relationally with families. He explained that “organizational and community wide changes are necessary to support ways of being and working that improve relational quality and, in turn, child and family health and well-being” (p. 607).

Ngala, “We Two”

Ngala is not-for-profit, early childhood education and parenting organization that has been operating for more than 130 years, adopting an evidence-based approach to the provision of services to children, families, and the community. The name Ngala was chosen from a Noongar Aboriginal Dialect, translated as “we two,” to denote the relationship between child and caregiver.

Ngala serves families across Western Australia (WA), the largest state in Australia. Despite its size, the population density of WA is among the lowest in the world. The state covers more than 2.6 million square kilometers and is the combined size of Alaska and Texas with a population of nearly 2.6 million people. Geographical constraints pose significant challenges as WA is not only unique in the vast area is covers but also in the spread of the population and diversity across the state. The organization’s 320 staff provide services from 17 locations across metropolitan area of the capital city, Perth, and regional and remote areas within the state.

Ngala offers a broad range of prevention and early intervention community and early parenting services, in the community and in hospital settings. These services include a state-wide Parenting Line (for parents with children from birth to 18 years old), a 30-bed hospital for infants and their parents, regional counselling services, early literacy and school readiness programs, education and care services, young parent services, and Aboriginal-specific programs. Many of the parents who attend have high screening scores for stress, depression, and/or anxiety, and the impact of these stressors on parent–child and family relationships is apparent.

In the past 50 years Ngala has predominantly been a nursing workforce, however, over time the staff composition has diversified significantly to encompass a myriad of disciplines and skill levels reflecting the diversity of WA and including psychology, social work, education, community work, youth work, and peer home visitor practitioners and volunteers.

Initial Trials of Reflective Supervision

In the last decade, Ngala has demonstrated commitment to the ongoing development of a skilled and interdisciplinary workforce and consistent use of evidence-based practice across all service areas. Increasingly, the level of complexity of family issues that present to the service requires interdisciplinary and transdisciplinary approaches and the identification of best practice initiatives to support the professional development of staff.

In 2014, Ngala implemented a trial of reflective supervision at several sites for practitioners who delivered direct services to children and families, and who wished to participate. An evaluation of the trial suggested that the principles of ongoing reflective practice and reflective supervision were not fully operationalized due to systemic issues. The data identified that a varying amount of commitment existed at all levels of the organization and that there was a lack of clarity as to the parameters required for embedding the reflective practice supervision framework into the organizational structure (Priddis et al., 2018).

Another lesson learned was that supervision provided by an external and experienced supervisor for the internal trainee supervisors within Ngala provided a safe experience as well as a model for the process. This reflective supervision involved a skilled IECMH supervisor (endorsed Infant Mental Health Mentor-Clinical; The Australian Association for Infant Mental Health, 2018), who, on a regular basis, offered supervision that was predictable in format, supportive, and challenging. Through this experience, the trainee supervisors developed an early understanding of what reflective supervision entails. The evaluation concluded that offering reflective supervision in the organization was likely to be a positive and productive experience for all.

Creating a Community of Practice

Ngala’s previous experiences with implementing reflective supervision informed the decisions (1) to develop the current approach to embedding reflective supervision and reflective practice within the organization, and (2) to continue to use a framework grounded in IMH, relationship-based principles, and dynamic systems change to guide this process. RDS (Overton, 2015) and Sparrow’s (2016) Touchpoints approach shaped how Ngala began to mobilize and shift the organization toward valuing reflective practice and reflective supervision for their contribution to professional practice. There was a realization that this new initiative needed to include “collaborative rather than prescriptive processes and interactions, and power sharing, rather than hierarchical roles among interacting system members” (Sparrow, 2016, p. 610). The 6-month planning process centered on thinking about impact and sustainability, which led to the creation of a community of practice focused on reflective practice. A community of practice involves practitioners with shared interests who build relationships to engage in collective learning and develop a common practice through sharing stories, resources, and ways of viewing challenges, which become a toolkit for their practice (Wenger, 2010). The key components of the model included:

• ongoing collaboration and engagement that was broadly inclusive of all staff and across all levels of the organization,
• creation of a strong interprofessional practice–education interface focusing on reflective practice and understanding the value of reflective practice supervision, and
• working toward continuous improvement through systemic innovation that results in improved relational quality and increased capacity to provide high-quality relational-centered practice across the organization.

Developing a Program Logic Model

A program logic tells the story of how the community of reflective practice is intended to work. It links reflective practice activities with outputs, intermediate impacts, and long-term outcomes. Presenting the program logic in a visual format aimed to build a shared understanding across Ngala of how the community of practice was intended to work. A group of Ngala staff and external consultants specializing in IECMH and reflective supervision collaborated to construct a program logic that centered on generating a paradigm shift across the organization in three phases over a 3-year period. Development of the program logic considered the six interdependent conditions (Policies, Practices, Resource Flows, Relationships and Connections, Power Dynamics, and Mental Models) that may impede or enable a systems change (Kania et al., 2018). From the outset, leaders of the initiative understood how imperative it was to have all levels of the organization recognize the importance and value of reflective practice and supervision so that a true community of practice could develop. The program logic was designed as a working document, available to all staff, and presented to management at senior level meetings.

The first phase of the program logic had three goals: To

1. build quality relationships within the organization;
2. explore the organizational system from multiple perspectives to understand what was required to embed reflective practice and supervision as a community of practice; and
3. integrate reflective and relationship-based practice into every learning opportunity, and place-based reflective seminars in a community of practice.

Quality relationships at each program site are important from a systems-change perspective, so that higher levels of trust are built among system constituents (Kania et al., 2018). By taking reflective practice and supervision to each site, educating and sharing ideas with all staff personally, the team planned to (1) build commitment to reflective practice and reflective supervision and (2) create a shared vision of its value across the organization.

In building a community of practice that is truly reflective of the spirit of IECMH, opportunities were created to dialogue with the myriad of groups across the organization on a regular basis, and to create transformative learning experiences. A series of seminars were planned for the meetings. These focused on theory and knowledge, building continuity in commitment and motivation, fostering curiosity and openness, emotional engagement through sharing experiences, and reflective and mutual sense-making processes (Taylor & Cranton, 2012).

As a result of the COVID-19 pandemic and the sudden, dramatic changes experienced by staff and families served within the organization, a three-session COVID series of online seminars was developed to encourage connection, dialogue, and learning and to build the community of practice in a way that was responsive to the situation created by the pandemic. These seminars were underpinned by IMH and reflective practice principles, and focused heavily on providing a safe space to share distress, anxiety, and intense emotional reactions experienced during this unprecedented time.

Seminar Series

The seminar series was developed and delivered by an IECMH mentor and scholar. Eleven monthly, 2-hour seminars were provided to all staff face-to-face or via teleconferencing. The seminar series included topics focused on IECMH theory and research which aligned with core competency areas of IMH and reflective supervision (see Table 1). The creation of this interdisciplinary curriculum was competency-based (Alliance for the Advancement of Infant Mental Health, 2018) and aimed to enhance interprofessional collaborative practice across the organization and build skills in relational centered care, continual reflection, and increasing self-awareness.

Table 1: Community of Reflective Practice Seminar Series

Each seminar was hosted at a different site, with other sites accessing via video conferencing. Each was also recorded and available for staff to access at any time. Hosting the seminar at different sites was designed as an opportunity to meet staff where they work, offer in-person participation in a reflective practice session, allow deeper reflection on seminar content, understand the needs of each community, and gain a practical sense of what different staff required to engage in reflective and relationship-based practice.

Evaluation Method

Qualitative analysis of focus group material was chosen as the method most suitable to this formative phase of the project (Creswell & Plano-Clark, 2007). The purpose of the focus groups was to determine whether the seminar series was meeting the objectives of Phase 1 and to generate ideas from different groups within the organization that would inform the development and implementation of future phases.

Participants and Measures

• Ngala staff from rural and metropolitan centers as well as staff drawn from managerial and direct service roles (education, psychological, hospital and community services) participated in proportions that reflect the composition of the organization and participation at the seminars.
• Staff attendance at the seminars across the 12 months was examined from attendance records.
• Four focus groups were conducted with facilitators from outside the organization. The questions focused on encouraging exploration of the experience of the seminar series and discussion about how the seminar series relates to reflective practice and application of reflective skills into everyday practice.
• Informal written feedback was also encouraged and included in the thematic analysis.
• Group sessions were transcribed verbatim and themes from emails and transcriptions were identified by two academics experienced in qualitative research using the method described by Braun and Clark (2006).

Findings

On average, 31 staff members attended each seminar through face-to-face, videoconferencing, or video recording mediums. There was a gradual and steady increase in staff attendance to the seminar series across the 12 months, with a dramatic rise in numbers for the three seminars offered during the COVID-19 period in WA (March = 38; April = 52; May = 62). The majority of attendees were those who work with families in a community setting.

Four main themes emerged from thematic analysis of the data from focus group transcripts and written feedback from staff:

Theme 1: Positive Experience

The focus group analysis identified that the seminar series was a positive experience for Ngala staff. Through the focus groups, staff expressed an appreciation of having the freedom to join or not and, when they did choose to attend, found that it was valuable. “Enjoyable” was a consistent word used to describe the experience of attending the seminars and one participant stated

“I did attend quite a few and it’s been incredible…it’s been a journey and they [seminars] are so incredibly well facilitated and the attunement and the reflection and really looking at the processes of what’s happened…so useful.”

Analysis identified several key positive messages that staff took from engaging in the seminar series:

• validation of the work practitioners are engaging in with families and honoring the benefits and challenges in adopting a relationship-based framework
• awareness that reflective practice is important
• supported increased self-awareness and an opportunity to reassess their own practice demonstrated by this reflection;

“…actually be able to sit there and reflect on my own practice, that was really valuable, and I agree with everyone, I think hopefully it can continue”

There were two seminars that resonated in participants’ minds as impactful and valuable to current practice: an introduction to “Facilitating Attuned Interactions: Using the FAN Approach to Family Engagement” (Gilkerson, 2015), and; the “Diversity-Informed IMH Tenets” (Thomas et al., 2019). When thinking back over the seminar topics, a participant reflected

“…just a strong example I just thought of was the FAN model, I think it was called FAN—and so that was really terrific. It’s a great model and so what we did afterwards in [remote site] was staff created their own FAN using their own language…a strong desire to continue…”

Theme 2: Universality

The focus group analysis found that, across the seminar series, Ngala staff recognized and appreciated their shared experiences and feelings, and that staff felt a sense of surprise that there was commonality in practitioners across the organization. Universality is one of Yalom’s primary therapeutic factors in group therapy (Yalom & Leszcz 2005). In line with Yalom’s theoretical model of group work, the current seminar series, with its focus on reflection and self-awareness, served to remove staff members’ sense of isolation, validate their experiences, and raise self-esteem. The benefits of the shared experience in seminars were expressed by the following comment;

“I enjoyed listening to other people in Ngala, their experiences and thoughts as well. It kind of helped me, I suppose, feel more comfortable where I’m at in my thought processes because other people are going through similar things as well. So that’s what I enjoyed about–that’s what I took away from it the most.”

Participants said that, during the seminars, they had the opportunity to share their responses to reflective questions and activities within the wider group. This discussion resulted in a level of personal disclosure that was helpful in creating a common understanding of staff experiences across the organization. It also enabled a process in which there was a sharing of minds, articulated in this participant’s reflection;

“Hearing myself think aloud and then hearing how it resonates and how other people’s stories resonate with mine. ”

This in turn, evoked a strong sense of empowerment and trust with each other. One participant reflected:

“Even though we are doing this remotely largely, I was really struck by the level of trust that was in the group.”

Theme 3: Structure and Process

Participants reported that they found the length of sessions appropriate. However, they also articulated that scheduling challenges made it difficult for part-time staff and those facilitating parenting groups to attend on a regular basis. When considering the model of delivery, many liked videoconferencing, which gave those who were participating face-to-face an opportunity to appreciate that they were part of a large and diverse organization and also enabled those attending across other sites to actively participate. This feeling was demonstrated by the following statement:

“When were face-to-face…I really appreciated it…hearing the facilitators in the same room I can actually really also appreciate…seeing…you know…being connected with staff that I didn’t normally work with you know in other offices. So …..I prefer face-to-face, [but] it wasn’t bad when it was televised in a room with other people.”

When asked about their expectations of the sessions, many staff expressed that they were uncertain about this, because it was different from the typical professional development sessions offered previously. Participants shared that they expected seminars to be mostly content driven, and were surprised at the emphasis on process and reflection on their own personal experiences. They reported that the experiential nature of the seminar series brought the content alive and gave participants the freedom to wonder about their personal and professional roles within the work with families. One participant reflected on the value of the seminars and the emphasis on reflection:

“Particularly around how the work impacts on me personally as well as professionally so and just to be able to give attention to both. The fact you know both are equally valued and acknowledged in the reflective space.”

Staff highly valued the reflective component and felt at times the seminars included too much content which limited the time available for reflection and process-oriented work within their teams, as per this quote:

“…too much information…maybe more time for discussion amongst our own teams”

Those who attended the post-seminar face-to-face reflective session found it valuable, and those sites that did not have this opportunity requested more time to discuss and process the content after the seminar finished. One participant reflected:

“I think what is important is that you build in time to pull it apart afterwards.”

Ngala staff expressed a desire to have the seminar content and post-seminar reflective session specifically tailored to each site and their identified needs. This desire demonstrated the importance of recognizing and valuing staff at each site for their unique contribution to supporting families in their community. Furthermore, through the focus group dialogues, a number of subcultures emerged within Ngala staffing groups. These included metropolitan, rural, professional, and non-professional staff. Whilst there is value in recognizing shared contributions across the organization, each team’s individuality was just as important.

Theme 4: External Trainer and Reflective Supervisor

Participants spontaneously brought the facilitator’s skills to the forefront of the focus groups. Unsolicited comments were overwhelmingly positive and focused on both technological skill and capacity to use an experiential style. Comments included praise for the facilitator’s appropriate use of language level, being physically present, having capacity to create a safe space, building trust in the groups, bringing relevant content, flexibility, and responsiveness to feedback. Within this theme, several participants commented that the richness of post-group discussions was entirely dependent on the facilitator being culturally respectful, sensitive, and curious as well as knowledgeable in the field of IECMH, and specifically skilled in reflective supervision. Statements related to facilitator competence included:

“Her presentations were very…at a very understandable level but the language that was used behind that was quite challenging so [she] responded brilliantly to that … it then became very understandable…”

“They found it difficult to understand some of the presentation but when she stayed with them afterwards and pulled it apart it made a lot more sense.”

Discussion and Future Directions

Our organizational approach to embedding reflective practice principles and reflective supervision within Ngala began with efforts to develop a community of practice. To do so, we offered a seminar series grounded in IMH principles that was process-oriented and reflective in nature, to create a safe and trusted place to begin to understand the value of reflective practice. The seminar series offered opportunities for engaging in learning, observation, and self-reflection through interaction with a skilled mentor and reflective supervisor and with other staff members. The focus group material suggests that Ngala staff are motivated to continue learning through the seminar series and consider themselves part of an ongoing development process to build and sustain a community of reflective practice.

The outcomes and main themes in the first phase are informing the development of the second phase which is planned to include:

• continuation of monthly seminar series across Ngala,
• exploring a range of tools to facilitate building relationships such as FAN (Gilkerson, 2015), and
• collaboration with sites that have requested reflective supervision and support implementation of group and individual reflective supervision in line with best practice principles in IECMH.

While the community of practice continues to grow we are exploring ways of maximizing engagement and growing leaders across all levels of the organization. To ensure sustainability, long-term funding is an important on-going consideration. Creating systems change to implement reflective practice and supervision across the organization is a constantly evolving and dynamic process, and through long-term commitment it has the potential to transform and improve practice with families.

Suggested Citation

Matacz, R., Priddis, L., & Wedge, K. (2021). Shake, rattle and roll: Reorienting a system and co-creating a “whole of organization” community of reflective practice. ZERO TO THREE Journal, 41(Supp.).

Authors

Rochelle Matacz, MClinPsy, IMHE^® (IV-C), is a clinical psychologist and endorsed Infant Mental Health Mentor-Clinical^®. She is an external consultant for Ngala and manager of the Edith Cowan University Pregnancy to Parenthood Clinic, a training center and community perinatal and infant mental health (PIMH) service. Through her many positions she strives toward creating long-term, sustainable social change for infants, young children, and their families in Western Australia (WA), through building workforce capacity and offering innovative interventions targeting both parental and infant mental health concerns. Ms. Matacz is a recipient of the World Association for Infant Mental Health (WAIMH) Award in recognition of her significant contributions in establishing and promoting PIMH as a field in Ireland. She co-founded the Irish Association for Infant Mental Health (IAIMH) and is past president of the Australian Association for Infant Mental Health West Australia Branch (AAIMHI WA). She was the project manager and co-lead researcher of the Wanneroo and Joondalup based “Better Together” Project (2019), a systems-change effort funded by the WA Primary Health Alliance. She holds a bachelor’s degree in psychology and a master’s degree in clinical psychology. She is a member of the 2016–2018 ZERO TO THREE Fellowship Class.

Prof Lynn Priddis, PhD, IMH-E^® (IV-C), is an adjunct associate professor at the University of Western Australia Law School.

Dr. Priddis has more than 30 years of experience working with infants, children, adolescents, and their families in health, education, and private practice contexts in Western Australia. Dr. Priddis has recently left full-time academia to work in her private psychotherapy practice where she works with infants, young children, and their families and supervises practitioners who work in this field. Dr. Priddis is an accredited supervisor in mentalizing based treatment (MBT) and in delivery and supervision of the MBT based Lighthouse Parenting program. She enjoys working with others to facilitate mentalizing skills via clinical practice, teaching, and local and international supervision. Dr. Priddis collaborates with the University of Western Australia mediation clinic to apply mentalizing practice to mediation in families with young children. She consults with agencies about the clinical applications of mentalizing and perinatal-infant-early childhood mental health perspectives to young children and their mothers, fathers, and caregivers as well as dynamic systemic approaches to how they may be better supported by the communities and systems in which they live. Dr. Priddis continues to play a significant role in advocacy for infants and young families and is a member of the working group that has bought, modified, and introduced the Michigan Association for Infant Mental Health Competency and Endorsement Guidelines for Culturally Sensitive, Relationship-focused Practice Promoting Infant Mental Health^® to Western Australia. She is a past president of the Australian Association of Infant Mental Health (AAIMH) and of the West Australian Branch of AAIMH.

Email : lynn.priddis@uwa.edu.au

Kim Wedge, RN, RM, CHN, is a registered nurse, midwife and child and family health nurse. She is the practice governance lead for quality and impact at Ngala. Ms. Wedge provides support and mentoring for practice staff across Ngala with a focus on education, reflective practice, and critical thinking to foster a culture of safe, collaborative, and responsive services to families. She has worked with families across metropolitan, rural, and remote Western Australia. In the past 25 years, Ms. Wedge has been a clinical champion for evidence-based practice, professional development, and transformative learning to facilitate the translation of research-based knowledge into practice. She is a member of the Australian Association for Infant Mental Health.

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