PREDICTORS OF QUALITY CAREGIVING IN THE ?FAMILY CHILD CARE PARTNERSHIPS? HOME VISITATION PROGRAM Except where reference is made to the work of others, the work described in this dissertation is my own or was done in collaboration with my advisory committee. This dissertation does not include proprietary or classified information. Ellaine Bailey Miller Certificate of Approval: _________________________________ _____________________________ Marilyn Bradbard Ellen Abell, Chair Professor Associate Professor Human Development and Family Studies Human Development and Family Studies _________________________________ _____________________________ Dorothy Cavender Brian Vaughn Professor Professor College of Human Sciences Human Development and Family Studies _____________________________ Stephen L. McFarland Acting Dean Graduate School PREDICTORS OF QUALITY CAREGIVING IN THE ?FAMILY CHILD CARE PARTNERSHIPS? HOME VISITATION PROGRAM Ellaine Bailey Miller A Dissertation Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Auburn, Alabama December 16, 2005 iii PREDICTORS OF QUALITY CAREGIVING IN THE ?FAMILY CHILD CARE PARTNERSHIPS? HOME VISITATION PROGRAM Ellaine Bailey Miller Permission is granted to Auburn University to make copies of this dissertation at its discretion, upon request of individuals or institutions and at their expense. The author reserves all publication rights. Ellaine Bailey Miller Signature of Author December 16, 2005 Date iv VITA Ellaine Kimbrough (Bailey) Miller, daughter of Dr. William H. Bailey, Ph.D., and Sue (Chapman) Bradley, was born June 3, 1971, in Knoxville, Tennessee. She graduated from Rabun County High School in the top ten percent of her class in 1989. She attended the University of Georgia in Athens, Georgia, and graduated with a Bachelor of Arts degree in Psychology in June 1993. She married Peter Charles Miller, son of Leo and Gene (Slaughter) Miller, on August 3, 1991. After the birth of their son, Peter Charles Miller, Jr., born December 24, 1993, and working in various University of Georgia offices, Ellaine entered Graduate School, Auburn University, in September 1995. After the birth of her daughter, MaryAynne Kathryn Miller, born August 10, 1997, she obtained her Master of Science in Family and Child Development in March 1998. Ellaine continued her graduate studies in the Department of Human Development and Family Studies in the doctoral program and will graduate December 16, 2005. v DISSERTATION ABSTRACT PREDICTORS OF QUALITY CAREGIVING IN THE ?FAMILY CHILD CARE PARTNERSHIPS? HOME VISITATION PROGRAM Ellaine Bailey Miller Doctor of Philosophy, December 16, 2005 (M.S., Auburn University, 1998) (A.B., University of Georgia, 1993) 224 Typed Pages Directed by Dr. Ellen Abell The primary focus of this study is to describe the Family Child Care Partnerships (FCCP) program and examine the possible relations among key features and processes of the FCCP training program in an attempt to identify predictors associated with quality caregiving for program participants. Participants in this study included 203 family child care providers in Alabama and 15 of the home visitors (mentors) working with them. Providers were observed by their mentors during their first month of participation in the program and quarterly thereafter for purposes of collecting quality care information as assessed using the Family Day Care Rating Scale (Harms & Clifford, 1989) and the Caregiver Interaction Scale (Arnett, 1989). Providers and mentors completed demographics surveys as well as a modification of the Helping Relationships Inventory (Young & Poulin, 1998). Each provider was also assigned a rating for accreditation status. Hypothesized models were tested to determine the causal relationships among the vi study variables. A direct-effects model predicting provider accreditation status was the only plausible model fitted which met all conventional model fit tests. vii ACKNOWLEDGEMENTS The author would like to thank Dr. Ellen Abell for assistance with completion of this degree program and her unwavering support. Appreciation is also given for the assistance of many of the faculty in the department of Human Development and Family Studies. Special thanks go to the family child care providers of Alabama and the mentors employed throughout the years with Family Child Care Partnerships as well as the many student and support workers involved in the FCCP program. Thanks also go out to immediate and extended family members Peter, Charles, MaryAynne, Daddy, Mom, and Kathryn for their support, encouragement, and patience during the many years devoted to this endeavor. viii Style manual used: APA Handbook Computer software used: MSWord MSExcel MSAccess SPSS MPlus ix TABLE OF CONTENTS LIST OF FIGURES????????????????????????.....xii LIST OF TABLES?????????????????????..????xiv I. INTRODUCTION???????????????????????.1 II. LITERATURE REVIEW????????????????????..6 Quality Family Child Care??????????????????...6 Home Visiting Training Programs???????????????.10 Head Start Home Visiting Programs??????????????..18 Summary and Conclusions??????????????????23 III. FAMILY CHILD CARE PARTNERSHIPS PROGRAM DESCRIPTION...27 FCCP Mentoring Process????????????????...........29 Program Documentation???????????????????33 Assessment of Benefit and Impact???????????????.34 Participants????????????????????????.36 IV. METHODS???????????????????????..........39 Procedures?????????...??????????????...39 Study Participants???????????????????..........40 Provider Specific Information??????????????40 Mentor Specific Information????????????..........43 Measures??????????????????????.44 x Outcome Measures??...???????????????..44 Quality Care Assessments?...??????????...44 Family Day Care Rating Scale??????????...44 Caregiver Interaction Scale????????????45 Accreditation Status?????????.......................46 Provider Reported Information??????????..47 Helping Relationships Inventory?????????...48 Mentor Reported Information???????????49 V. RESULTS??????????????????????????50 Preliminary Analyses????????????.????????50 Structural Modeling????????????????????...53 Latent Variable Analyses???????????????...53 Structural Model Tests for Mediation???????????55 Accreditation Status??????????????...55 Quality Care?????????????????...62 Post Hoc Analyses??????????????????.65 Accreditation Status??????????????...65 Quality Care?????????????????...65 VI. DISCUSSION???????.?????????????.????73 Implications for Previous Research.??????????????..73 Implications for the Model..?????????????????...78 Implications for the Family Child Care Partnerships Program????..80 Limitations, Contributions, and Future Directions?????????84 xi Summary and Conclusions????????????????........89 VII. REFERENCES??????????????????????........91 APPENDICES???????????????????????????.97 APPENDIX A Appended Literature Review..????????????????...98 APPENDIX B Family Day Care Rating Scale????????????????.141 APPENDIX C Caregiver Interaction Scale?????????????????..190 APPENDIX D Provider Survey?????????????????????...192 APPENDIX E Helping Relationships Inventory for Providers?????????...199 APPENDIX F Mentor Survey??????????????????????.202 APPENDIX G Helping Relationships Inventory for Mentors??????????.207 xii LIST OF FIGURES Figure 1. Illustration of Predictor, Potential Mediating, and Outcome Variables???.25 Figure 2. Hypothesized Model to be Tested Using Study Variables and Data.????.54 Figure 3. Fitted Model with Parameter Estimates and Standard Errors Depicting Latent Variable ?Baseline Quality of Care???????????????..56 Figure 3a. Fitted Model with Standardized Estimates and Errors Depicting Latent Variable ?Baseline Quality of Care???????????????..57 Figure 4. Fitted Model with Parameter Estimates and Standard Errors Depicting Latent Variable ?Quality of Care???????????????????.58 Figure 4a. Fitted Model with Standardized Estimates and Errors Depicting Latent Variable ?Quality of Care?????????????????.....?59 Figure 5. Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Mentor Perception of Relationship???...60 Figure 5a. Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Mentor Perception of Relationship???...61 Figure 6. Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Mentor Perception of Relationship as These Variables Relate to Quality of Care at End of Data Collection???..?63 Figure 6a. Fitted Model with Standardized Estimates and Error Depicting Provider and Program Influence on Mentor Perception of Relationship as These Variables Relate to Quality of Care at End of Data Collection????..64 Figure 7. Post Hoc Model 1 -- Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Accreditation Status??????????????????????.?..66 Figure 7a. Post Hoc Model 1 ? Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Accreditation Status?????.67 xiii Figure 8. Post Hoc Model 2 ? Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Quality of Care at End of Data Collection???????????????.69 Figure 8a. Post Hoc Model 2 -- Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Quality of Care at End of Data Collection??????????????????????????......70 Figure 9. Post Hoc Model 3 -- Fitted Model with Parameter Estimates and Standard Errors Depicting Baseline Quality of Care as a Predictor of Quality of Care at End of Data Collection???????????????.71 Figure 9a. Post Hoc Model 3 ? Fitted Model with Standardized Estimates and Errors Depicting Baseline Quality of Care as a Predictor of Quality of Care at End of Data Collection??????????????????.72 xiv LIST OF TABLES Table 1. Mentoring Achievements????????????????????..36 Table 2. Demographic Characteristics of Participants and Mentors???????...37 Table 3. Employment History and Operations????????????????38 Table 4. Demographic Characteristics of Providers for Study??????????42 Table 5. Employment History and Operations for Providers in Study???????42 Table 6. Correlations Among Study Variables????????????????51 Table 7. Descriptive Statistics for Study Variables?????... ????????.52 1 I. INTRODUCTION Family Child Care Partnerships (FCCP) is a statewide in-home mentoring program funded by the Alabama Department of Human Resources. Since the program?s inception in 2000, the primary goal of the program has been to help family child care providers increase the quality of care they offer and to assist them in attaining national accreditation standards. Participants in the program are licensed caregivers who provide in-home care to young children for a fee. They receive weekly in-home training and technical assistance from trained program personnel (mentors) and have the opportunity to participate in monthly group trainings on subjects relevant to the challenges of providing quality child care in the home setting. In addition, FCCP participants are given an opportunity to apply for and receive up to $500 in equipment and a $495 scholarship to pay for the cost of applying for accreditation from the National Association of Family Child Care. In the five years during which FCCP has been in operation, the number of nationally accredited family child care providers in Alabama has increased from none to 35. Other indications of success include the establishment of a statewide professional family child care provider association and annual conference, recognition of FCCP as a leader in quality enhancement training in family child care, and on-going annual funding of over $1 million awarded through a competitive grant process. In spite of these successes, research-based evidence is absent that would explain the processes responsible 2 for the quality improvements a child care provider enrolled in FCCP makes. The purpose of the current study is to propose and examine a set of relationships among characteristics of program participants and features of the FCCP program that could predict providers? achievement of the quality outcomes that FCCP promotes. Published studies examining the effectiveness of training programs are rare in the family child care field. However, most of the research available evaluates quality of care with the Family Day Care Rating Scale (FDCRS; Harms & Clifford, 1989) and Caregiver Interaction Scale (CIS; Arnett, 1989). Correlational studies looking at factors contributing to quality of care indicate provider regulation, training, group size, adult- child ratio, work commitment, and motivations for being providers are key correlates of high quality care in the family child care setting (Galinsky, Howes, Kontos, & Shinn 1994; Kontos, 1994; Kontos , Howes, & Galinsky, 1996). Researchers have concluded that, in general, providers who seek out and receive specialized family child care training are more sensitive and responsive in their caregiving, receive higher scores on global indicators of family child care quality (i.e., FDCRS and CIS), and report being more committed and intentional than less trained caregivers (Galinsky et al., 1994; Kontos et al, 1996; Taylor, Dunster, & Pollard 1999). Looking beyond the research literature on family child care, studies evaluating training programs designed to enhance or improve quality of caregiving are found primarily in the nurse home visiting literature and, to a lesser extent, the Head Start home visiting literature. The nurse home visiting literature provides a rich body of information that describes the components of home visiting programs; details the effectiveness of intense, one-on-one, hands-on technical assistance types of training programs; and offers 3 explanations for why and how these training programs work by evaluating the processes involved in these programs. Key studies in the nurse home visiting research literature come from the Nurse Home Visiting Program (NHVP) started in Elmira, NY, and replicated in Memphis, TN (see Kitzman, Cole, Yoos, & Olds, 1997), and Denver, CO (see Hiatt, Sampson, & Baird, 1997). These studies describe in detail the relationship process involved in an intensive, structured, home visiting program designed to improve the quality of care new mothers would offer their infants. Home visitors in these studies were professionals and paraprofessionals. Similar to FCCP, home visitors scheduled visits with volunteer participants on a weekly basis, had a limited caseload, documented their activities during visits, and had curricular guidelines and materials provided to them to use with clients but were allowed flexibility to address other issues that came up during their visits. The programs were evaluated at the implementation, process, and outcome levels. At the Elmira site, mothers in the home visiting program were found to have a higher sense of mastery and control over their lives compared to mothers not receiving home visits. Program effects were greatest for children of unmarried, lowest-income mothers and were most prevalent four to fifteen years after the program ended (Olds, Hederson, Kitzman, Eckenrode, Cole, & Tatelbaum, 1998). Further research to determine the reasons for better results being found in the Elmira site compared with the Memphis site revealed that characteristics of the mothers, the nurse home visitors, and the relationships between them were important for successful maternal outcomes. Home visitor variations in program delivery, based on their sensitivity to the individual mother?s culture, environment, needs, and personal context increased maternal receptiveness and supported 4 relationship building and maintenance (Hiatt et al., 1997; Kitzman et al., 1997). Subsequent research focusing on the mother-home visitor relationship suggests that program effects were mediated by the quality of this relationship (Korfmacher & Olds, 1998). While home visiting program research has identified participant characteristics, home visitor characteristics, relationship quality variables, and program features as possible explanation points for successful program outcomes, none of the research available takes a comprehensive view of all of these variables. This is also true in the limited family child care literature. The current study attempts to take a more comprehensive approach and has two objectives. The first objective is to describe the program in detail. The literatures in the fields of family child care, child care in general, and home visiting offer little evidence of educational training programs designed for family child care providers and delivered in the home setting. A description of the development of the program, its implementation, evaluation tools, and outcomes should add significant information to the field of public service programming and child care. The second objective is to examine the possible relations among key features and processes of the FCCP training program in an attempt to identify predictors associated with quality caregiving in the homes of caregivers participating in this mentoring program. A model will be tested to understand the processes involved with improving quality of care using the home-visiting service delivery model. Specifically, independent variables include provider characteristics (e.g., ethnicity, education, and years of experience in the child care field), mentor characteristics (e.g., ethnicity, education, and experience with family child care), evaluation of the provider-mentor relationship from 5 both the providers? and the mentors? perspectives, and other relevant program characteristics (e.g., number of mentors working with a provider and number of contact hours with mentor). Dependent variables to be analyzed will be mentor-reported scores of providers on the FDCRS and CIS--well-established, reliable assessments of child care quality--as well as provider accreditation status. The current study will provide a meaningful addition to the limited amount of literature on family child care and the growing body of literature on home visiting programs as it seeks to explain why some providers make quality improvements in the family child care setting and others do not. The current study attempts to bridge the gap between descriptive information about programs and explanatory research concerning program processes. 6 II. LITERATURE REVIEW The purpose of this literature review is to examine previous research about factors that contribute to the quality of child care practices in family child care as well as about programming methods designed to increase caregiving quality. Because the literature focusing on the practices and training programs used by family child care providers is limited, the review will also examine research on home visitation programs designed to improve parental caregiving practices, since this educational delivery model employs programming features similar to the service delivery model used by FCCP. (Note: Additional information and details about the studies reviewed in this chapter can be found in Appendix A.) Quality Family Child Care As increasing numbers of mothers of preschool-aged children have entered the workforce and need formalized care for their children over the past 20 years, quality child care has been a main topic of interest. Past research has found that children experiencing high quality care have been shown to have better social, emotion, and cognitive functioning compared to children in low quality care settings (e.g., Howes, 1997a; Kontos, S., & Wilcox-Herzog, A., 1997; Peisner-Feinberg, E. S., & Burchinal, M. R., 1997). While much of the research on quality of care tends to focus mainly on center- based child care settings, a few researchers have focused on describing and evaluating quality in the family child care setting. Seminal work in the ecology and quality of family 7 child care is provided by the Families and Work Institute?s Study of Children in Family Child Care and Relative Care (Galinsky et al., 1994; Kontos, 1994; & Kontos, 1996). In their examination of provider characteristics associated with high quality care, Galinsky et al., (1994) found that family child care providers who were observed to offer the highest global quality and showed the most sensitive, responsive and warm interactions with the children in their care tended to have higher levels of education (77% with more than high school education), offered multiple planned activities each day, and actively sought out and participated in professional organizations and specialized training. Those providers who attended specialized child care training were found to offer higher levels of care than those without training, even when controlling for years of experience as a provider. Most professionals in the child care field recognize that education and training are important aspects of quality in child care; however, little published information on effective training programs can be found. Kontos and associates (1996) examined provider characteristics related to change in quality of care offered as a result of participating in two to four group training sessions a year totaling 12 to 25 hours of training. Providers participating in the training group (n=130) and comparison group (n=112) were observed in their natural caregiving environment. Prior to the training, no significant differences between groups were found to be related to the quality of care provided or with regard to demographic characteristics, business practices, commitment to the job, or group size. After the training, program participants were observed to offer higher quality of care and to use slightly more business and safety practices than the comparison group. Kontos et al., (1996) concluded that participating in the training had a 8 small but positive effect on quality of care offered by provider completing the training program which was not influenced by provider characteristics including education and prior experience. In an effort to promote quality standard compliance and determine whether or not specialized training would facilitate that compliance, the state of Georgia implemented a low-level assistance training program (Wilkes, Lambert, & VandeWiele, 1998). Half of the randomly selected providers were assigned to receive a 1 ? hour in-home technical assistance visit by a trained technical assistance data collector while the other half were used as a control group. Wilkes et al., (1998) found that providers who received a technical assistance visit were more likely to be in compliance with state regulations at follow-up compared to the control group, and those at the lowest quality levels before the training had the greatest change in compliance after the assistance visit. From the perspective of the providers themselves, the effectiveness of a training program depends on its capacity for meeting relevant educational and training needs. In their nation-wide assessment of the specialized training needs of Canadian family child care providers, Taylor and associates (1999) conducted interviews with 298 caregivers and collected survey data from 258 organizations about the family child care training they offered. Providers? reports about their past experiences with training suggested that training content too often is focused on child care center-related concerns rather than the special needs and circumstances of family child care homes, their child care experience and expertise is not recognized, and the needs of caregivers who have been in the business for several years are not met (Taylor et al., 1999). Barriers to attending training included geographical distance from training facilities, inability to see how the training 9 will impact their ability to care for children, the cost of attending training, inability to see a financial benefit to attending, and the lack of time or ability to fit training into already busy schedules. Providers reported wanting training that contains relevant content, is delivered in an accessible manner, and does not underestimate the skills and knowledge base of the providers in attendance and saw training as a way to improve their caregiving and business skills as well as boosting their self-esteem and self-concept. Taylor et al., (1999) asked providers who reported actively seeking out and attending trainings what their motivations were for accessing and taking advantage of these training opportunities as well as how they overcame the barriers previously mentioned. Providers reported that they are interested in improving the quality of care they offer, want more credibility in the field and community, and are looking for new ideas and supports for challenges they face in their businesses. These providers also suggested that training be designed to respect their experience and education levels, link to tangible results in their business, and recognize their attendance and excellence in the community. In conclusion, Taylor et al., (1999) recommends that training programs be designed to meet the needs of the clients they serve. The training must be relevant to family child care needs. The training must be accessible to the target audience. The training must be designed to build on the strengths of the providers attending the training. The training must have networking time built into it to foster the support system providers can come to rely on between trainings. While participating in child care training programs is seen as important to quality practice by professional and providers, published research describing actual training 10 programs designed for family child care providers and evaluated for their effectiveness is sparse. Previous research examining specific provider characteristics and effectiveness of training programs that contribute to why some providers offer higher quality care than others does not clearly explain what exactly those characteristics are or how they interact with their participation in training programs. Home Visiting Training Programs The literature focusing on the practices and training programs used by family child care providers is limited; however, the nurse home visiting literature provides a rich body of information that describes the components of home visiting programs, details the effectiveness of intense, one-on-one, hands-on technical assistance types of training programs, and offers explanations for why and how these training programs work by evaluating the processes involved in these training programs. Key studies in the nurse home visiting research involves the Nurse Home Visiting Program (NHVP) started in Elmira, NY, and replicated in Memphis, TN (see Kitzman et al., 1997), and Denver, CO (see Hiatt et al., 1997). Outcome measures for all three program sites focused on children?s health and development and mothers? life course trajectories. The program protocol had specific lessons built in that each nurse was to teach each mother -- through direct instruction or modeling -- concerning specific caregiving skills (e.g., quieting a crying baby or redirecting toddler behaviors). Nurses or paraprofessionals were instructed and trained to deliver these lessons in a way that would promote the self-efficacy of the mothers. The idea was to create an atmosphere of trust and competence in caregiving that would allow the mothers to exhibit appropriate caregiving behaviors and feel competent, willing, and able to continue those behaviors 11 when the nurse was not present in the home (Cole, Kitzman, Olds, & Sidora; 1998; Hiatt, et al., 1997; Kitzman et al., 1997; Olds & Korfmacher, 1998). The nurses in the NHVP sites were trained to work with participants using a solution-focused, strength-based approach while working with the participants (O?Brien & Baca, 1997). This approach was assumed to be at the root of the process by which mothers changed their attitudes, beliefs, and behaviors with their children. Nurses used this idea to promote mothers? self-efficacy and self-sufficiency. This approach is hallmarked by understanding that the participating mothers have the most information about their own lives and situations. Nurses were trained to recognize participants? strengths and capitalize on them. Using the mothers? strengths as a springboard for instigating change was expected to allow for the most success in the program. Each nurse carried a caseload of 20 to 25 families. The home visits included structured curriculum-type lessons that were prescribed for each session. However, nurses were given great latitude in implementing those lessons considering a primary emphasis of the program was to create a close relationship between the nurses and the mothers participating. Nurses were instructed to take individual needs and participant goals into consideration (Campbell, 1994; Kitzman et al., 1997). Program process was operationalized as the ways the nurse home visitors worked with the mothers to enhance, improve, and change their parenting behaviors and competencies. Other processes examined in assessments and analyses were the influences of psychological and family resources on the mothers and the interactions and influences of the child on the mothers. The effect of the program on mothers? context was hypothesized to be mediated by mothers? behaviors. The program was designed to 12 change both the behaviors themselves and the contexts that affect those behaviors (Olds et al., 1997 & 1998; Olds & Korfmacher, 1998). In all three sites of the NHVP, data collection methods consisted of interviews, assessments, and follow-ups. In-home observations and interviews were conducted to assess mother-child interactions (looking at maternal warmth, control, and involvement) and home safety hazards including seat belt and car seat use and control of poisonous substances in the home. Information on client characteristics such as age, SES, and education were included as variables involved in differential program outcomes. At the Elmira site, program effects were greatest for children of unmarried, lowest-income mothers, were most prevalent in the 4 to 15 years after the program ended and were correlated with mothers? sense of mastery and control in their caregiving and life circumstances. Mothers in the home visiting program were found to have a higher sense of mastery and control over their lives compared to mothers not receiving home visits. This implies that the nurse visitation helped poor, young mothers feel more competent and confident in their caregiving skills. Results from the Memphis study were different from the Elmira study. There were no program effects on new-born health, but as children got older and mothers participated in the program longer, children?s health and well-being was more positive. The most significant difference between the Memphis and Elmira programs involved mother-child interaction patterns. In contrast to the Elmira mothers, mothers in the Memphis program were not observed to be more sensitive or responsive during interactions at the laboratory observation when compared to mothers not receiving home visits (Olds, et al., 1998). 13 Why the Elmira program ?worked? and the Memphis program did not have similarly dramatic effects is not clear. For both programs, the content, service delivery method, and client base were similar. For both programs, mothers in the most dire conditions (youngest, poorest, least efficacious at enrollment) changed their lifestyles and caregiving practices the most in a positive direction. Successful participants and their children were seen in both programs to improve their environments and life courses well after the program had ended. However, not every participant had a positive outcome, and in Memphis, the effects of the program are more difficult to see. Subsequent research was undertaken to determine differences in program efficacy and to identify and evaluate specific program implementation and service delivery processes as they related to differing characteristics of the persons delivering the program (Hiatt et al., 1997; Kitzman et al., 1997). Characteristics of the nurses were identified and included ethnicity, age, and whether or not they had their own children. Researchers collected data on characteristics of the mothers, the nurse home visitors, and the relationships between them, as well as the larger social context in which these interactions take place (Kitzman et al., 1997). Data were gathered about service delivery processes and outcomes between mothers working with professional nurses and those receiving services through a paraprofessional. Parenting status of the home visitor was also noted (Hiatt et al., 1997). Qualitative analyses suggested that those who were flexible and creative in their service delivery methods and sensitive to the individual culture, environment, and personal context and needs of each participant were more successful in obtaining desirable maternal outcomes. When nurses had different backgrounds as compared to participating mothers, nurses reported having to make 14 adjustments to their program delivery style and work hard to understand the context in which the mother lived. Understanding that context allowed the nurse to modify her style to maximize mother receptiveness (Kitzman et al., 1997). Paraprofessionals were found to be as competent as professional nurses in administering the program and obtained similar maternal outcomes, when provided with appropriate supervision and specialized training in relationship building and maintenance (Hiatt et al., 1997). In addition to the effects of mother-reported characteristics (demographics, sense of control, mastery, knowledge, etc.), nurse characteristics (demographics), and aspects of program delivery (e.g., frequency of home visits), Korfmacher, Kitzman, and Olds (1998) chose to explore, explain, and discuss how variations in how nurses delivered program services may mediate program effects. Utilizing the participants from the Memphis site (n=228), these researchers operationalized program involvement as length of time participating, level of services addressing parenting specifically, and the emotional quality of the nurse-mother relationships. Program success was measured with parenting assessments such as attitude toward parenting, home environments, and parenting behaviors as observed during mother-child interactions. Mothers were asked to assess the nurse-client relationship at the end of the program (2 years after the child?s birth) using a 27-item ?Helping Relationships Inventory,? designed to tap how much mothers thought the nurses understood their individual circumstances and how much acceptance and sensitivity the nurses offered. Results suggest that mothers with the lowest levels of psychological resources and who received high levels of caregiving instruction during visits had higher scores on the HOME inventory at the end of the program. Korfmacher et al., (1998) concluded that the program?s effects were mediated 15 by the nurse-mother relationship and the mothers? psychological resources. In addition, when the nurse-client relationship was strong and positive in nature, participants were more actively engaged in the program and had more successful outcomes regardless of contact. It appears that quality versus quantity of contact is most important in program success (Korfmacher et al., 1998). In summary, research designed to assess the differential success of mothers participating in the Nurse Home Visiting Program has gone beyond the standard approaches used to evaluate program success (examining participant characteristics and program features, such as intensity and frequency of visits) to also consider evaluating program processes, in this case, by evaluating the emotional quality of the relationship from both the home visitor and the client?s perspective. The attention given to this aspect of program evaluation has led to further research efforts designed to understand program process in other relationship-based interventions. In a recent review article, McNaughton (2000) examined fourteen home visiting programs in an attempt to explain what the mechanisms are in the nurse-client relationship that effect change. Relevant information about the nurse-participant relationship, nurse role during the visit, participant role during the home visit, and expected results from the interactions were explored. The data analyzed include information from 142 nurse home visitors and their interactions with participants across 59 home visits (McNaughton, 2000). McNaughton identified four stages involved in the nurse-participant relationship ? (1) pre-entry; (2) entry; (3) working; and (4) termination. Nurse-mother relationships could be dichotomously categorized as either ?collaborative? or ?difficult.? In collaborative relationships, nurses and mothers were able to work 16 successfully toward mutual goals; mothers were receptive to the program?s methods and content; they trusted the nurses; and they showed general interest, openness, and improvement in caregiving skills throughout the course of the program. In difficult relationships, mothers would open their doors to the physical entry of the home visitors, but were not receptive to the goals of the program and refused to create a relationship with the nurses; they were observed or reported to be closed to the ideas presented by the nurses; and they did not keep appointments or utilize referrals to outside agencies. Nurses were found across programs to focus primarily on creating and maintaining a collaborative relationship. Relationship maintenance was the primary objective, and delivery of program content was the secondary objective. The mother?s role was identified as making a choice of whether or not to be open to and make changes in her behaviors based on the information and instruction offered by the nurses. As such, she controls the entry, intensity, and frequency aspects of the home visits themselves as well as controlling the level of information reception and behavioral change that results (McNaughton, 2000). McNaughton (2000) concluded that the relationship between the nurse and the participant is the key to success in home visiting programs. She suggests that aspects of this relationship maintenance in combination with the nurses? goals for these mothers (self-esteem and self-efficacy) are mediators of the positive outcomes and recommends (1) further investigation into the processes involved in establishing and maintaining these relationships, and (2) exploration of the mechanisms of service delivery are necessary to identify how and why programs can work with a diverse group of participants. 17 In a study reviewing six home visiting programs and why they may not work for some clients, Josten and associates (Josten, Mullett, Savik, Campbell, & Vincent, 1995; Josten, Savik, Anderson, Bendetta, Chabot, Gifford, et al., 2002) examined home visitor and client-home visitor relationship characteristics that led to approximately one-quarter of enrolled mothers to drop out of the program before completing their goals. Most of the participants who dropped out of the program told their home visitors that they no longer wished to continue the home visits and were leaving the program (n=35). The other 12 mothers who dropped out were dropped by the program administrators because they were never home when the nurses came out for appointments. Josten and colleagues (2002) found that there were differences in the pattern and frequency of service delivery between the mothers who were able to complete the program by meeting their goals and the mothers who dropped out. This was associated both with nurse and mother characteristics. Nurses who had specific personality types and who reported being most satisfied with their jobs tended to put in more work hours and had participants who completed their program goals. Mothers who completed the program goals were more likely to be in more stable, well-off situations than the mothers who did not complete the program. Missed visits resulted in lack of participation in the program and ultimate failure in program outcome areas. The researchers concluded that the nurses? conscientiousness or neuroticism levels, as measured by the NEO personality inventory, influenced their work style with in turn affected the likelihood of being able to work with mothers to the completion of program goals. While not tested in this study, Josten et al., (2002) posit that the nurses? interaction styles may lead to specific types of relationships with the participants in a home visiting program, and this relationship and 18 interaction style may influence, either positively or negatively, the participants? progress in the program. In summary, all of the studies reviewed to this point emphasize that both participants and home visitors bring unique work and interaction styles, strengths, and weakness to the relationship. Mother and home visitor demographic characteristics as well as qualities of the relationship have been shown to impact program outcomes. A variety of research publications identify home visitor characteristics to the same end. There are few studies that examine program delivery processes and characteristics of the interaction styles and relationships that can help explain why a program works and why it might not work, and they only begin to scratch the surface of these issues. Head Start Home Visiting Programs In an effort to look at aspects of home visiting programs specifically related to child care, the literature yields only two articles describing and explaining home visiting programs associated with Early Head Start programs. These articles begin to fill the gap in both family child care home visitation research as well as relationship-based program process evaluation as a whole. Early Head Start programs have recently been employing home visiting techniques to improve the quality of care children in the program receive when family child care is the care setting of choice. The following summaries of two relevant articles offer rich descriptions of the programs themselves and strive to analyze the processes involved within the program between the home visitors and the participants. It is this information about program process that is of interest and is summarized here. 19 In 2001, Roggman, Boyce, Cook, and Jump examined a program administered by Early Head Start (EHS) in Utah and Idaho designed to improve the caregiving skills and parent-child relationships/interactions with low-income mothers in a rural community. Home visitors reported having ?outstanding? relationships with 30% of the participants, ?better than most? relationships with 26%, typical with 23%, adequate with 13%, and tense/difficult relationships with 6%. Home visitors were asked to rate the quality of the home visits in the same manner. They reported that 23% of their home visits were ?outstanding,? 38% ?better than most,? 18% ?typical,? 7% ?adequate,? and 15% distracted/crisis oriented. Roggman et al., (2001) reported that when families were perceived by their home visitor as functioning well at enrollment, they were also rated as showing improvement as the course of the program went on. When the home visitor perceives families positively, they also rate their interactions with the parents and the home visits themselves positively. Parents and home visitors had similar opinions about the quality of their relationships and home visits. Roggman and associates (2001) suggest that it is important to gather information from both the home visitors and the participants in these types of programs. They noted that while there may be bias in the home visitors? ratings of the quality of their work (they rated the level of improvement in family functioning and parent-child interaction), the variation and moderateness of their ratings of their relationships with the participants and the home visits themselves suggests that bias was not a factor. In conclusion, Roggman et al., (2001) emphasizes the uniqueness of each home visitor-participant relationship. Home visits vary in quality, content, process, and 20 perception within and across programs. Only home visitors can rate differences in their home visiting experiences, but it is important to gather information from the participants in order to further explain why some families succeed in a home visiting program and some do not. In this EHS program, parents who were seen as active participants during home visits, were perceived by the home visitor as functioning well and improving, were parents who received effective home visiting training and were rated as improved in caregiving quality at the end of the program. Perhaps the most relevant home visiting evaluation research published to date, comes from Buell, Pfister, and Gamel-McCormick (2002) and is the beginning of the bridge between the family child care and home visiting literatures. It is the only article found in either genre that examines a home visiting program specifically designed for family child care providers. The main objective of this study was to examine the benefits family child care providers received by partnering with Early Head Start programs via training in the homes. The study outlined here utilized Northern Delaware Early Head Start (NDEHS) caregivers and families as participants in the program being evaluated. NDEHS provides a trained home visitor to offer weekly technical assistance to each family child care provider accepting EHS children. These home visitors have background and education in child development, early childhood education, and early intervention. Home visitors, also called Early Care and Education Coordinators, are assigned to no more than 12 family child care homes. The family child care providers in the program develop their own improvement plans and are required to obtain CDA credentials within one year of receiving EHS children. The home visitors are available to facilitate the providers? 21 attainment of goals she has made for herself in the improvement plan. NDEHS offered financial support and assistance to the providers in the program to facilitate their achieving their goals, including obtaining the CDA. Providers used these funds to pay for materials and equipment to use with the children in their care as well as costs of participating in college/CDA classes and training workshops. A total of four family child care providers involved in the program for two years were evaluated individually and interviewed for this study. Buell et al., (2002) note that these women were also leaders in the field of family child care and in their communities. The average score for these four providers on the Family Day Care Rating Scale (FCDRS, Harms & Clifford, 1989) was 5.9. The national average (and scale average) is 3.5. Each of these providers was over 40 years of age, and three were African American. They received more than 580 hours of training in child care, child development, and early childhood education from either in-home training offered by the program or via workshops and college courses paid for by the program. During the course of the program, all four providers earned their CDA credentials and one sought and obtained national accreditation. All providers involved in this study reported very high levels of job satisfaction and enjoyment. They also all reported that they had held other jobs and pursued other career paths prior to becoming child care providers. Researchers interviewed the four participants for approximately 1.5 hours. Questions in the interview session addressed motivations for pursuing a career in child care, opinions about being a child care professional, what types of support the participants felt they received from the program, and what types of support were lacking from the program. All four of the providers reported feeling specific challenges 22 associated with caring for infants and toddlers. They all described caregiving as a profession that was more important than any other career available. They did report that they felt people outside the caregiving world did not value the job nor did they consider it to be a challenging or important career. These providers pointed to their CDA credentials to support their being professionals. Buell et al., (2002) reported a variety of supports that were identified through themes in the interviews. Providers stated that their home visitors helped them to organize their programs, gave them activity and curriculum ideas for working with infants and toddlers, and helped them to identify and acquire necessary materials, equipment, and training. Providers also reported feeling emotional support through their relationships with their home visitors which resulted in increased feelings of self-esteem and self-efficacy. Providers valued above anything else their relationship with their home visitor and reported that that support was tantamount to their being successful in offering the highest quality of care possible. Providers also reported being supported by financial assistance, but these supports were not held as in a high a regard as the support received by having a home visitor. Providers reported changing their attitudes and abilities in caregiving as a direct result of being involved in the NDEHS program. Three of the four providers indicated they felt they had improved their level of expertise in child care knowledge and their sense of professionalism. They extended this idea by reporting that these increases allowed them to feel better and more confident about their being child care providers and professionals in the child care field (Buell et al., 2002). 23 In summary, Buell et al., (2002) note that the purpose of the NDEHS program was to provide economic, training, and emotional support to family child care providers desiring to care for EHS children. The NDEHS program met the needs of the four providers interviewed in this study primarily by offering a technical support home visitor. Providers reported that the home visitor was the most important aspect of the program in improving their caregiving skills and sense of professionalism. Summary and Conclusions Research published about family child care quality and training indicates a need to provide training and quality enhancement assistance to family child care providers. The literature provides solid evidence that training increases quality (Galinsky et al., 1994), children in higher quality care have better outcomes (Howes, 1997a; Howes, 1997b; Howes, Hamilton, & Phillipsen, 1998; Howes, Hamilton, & Matheson, 1994), and one effective way to administer training to this underserved and often isolated group of caregivers is through home visiting (Buell et al., 2002; Gomby, 2000). In reviewing the home visiting research, the utility of this method of training program delivery is clear. The home visiting research offers methods and models to test program effectiveness as well as processes through which home visiting programs work to be effective. Family child care providers themselves report the necessity and desire for continuing in-home training programs for these caregivers. The sparse amount of literature specific to family child care as well as the limited, but new, publications outlining program processes provides justification for more study of predictors and processes at play in program effectiveness. 24 The current research is designed to examine the features of the Family Child Care Partnerships (FCCP) mentoring program, the providers who are its participants and its home visitors (mentors), and the contributions of the provider-mentor relationship as they relate to indicators of provider success in increasing the quality of their child care practices. A visual summary of the key features from the above research literature associated with successful outcomes in family child care or home visiting training programs is found in Figure 1. Specifically, dependent variables include provider characteristics (e.g., child care group size, education, previous experience as a child care provider in the home, age, motivation for becoming a child care provider, martial status, and ethnicity); mentor characteristics (e.g., education, experience with family child care, age, household income, marital status, and ethnicity); and program characteristics (e.g., number of mentors assigned to a provider and contact hours). Independent variables to be analyzed include mentor-reported scores of providers on the FDCRS (Harms & Clifford, 1989) and three sub-scales of the Caregiver Interaction Scale (CIS, Arnett, 1989) ? well- established, reliable assessments of child care quality. In addition, provider accreditation status as a result of participating in FCCP will be examined. The dependent and independent variables will also be examined in relation to potential mediators ? provider perception of the quality of the mentoring relationship and mentor perception of the quality of the relationship ? as measured by a modification of the Helping Relationships Inventory (Young & Poulin, 1998). While home visiting program research has identified participant characteristics, home visitor characteristics, relationship quality variables, and program features as possible explanation points for successful program outcomes, none of the research Figure 1. Illustration of Predictor, Potential Mediating, and Outcome Variables. 25 Provider Characteristics Child care home group size Education level Paid cc work in the home Age Household income Motivation for being a cc provider Frequency of planning activities Marital status Ethnicity Baseline quality of care indicators Program Characteristics # of mentors a provider has had # of contact hours Provider?s perception of relationship Mentor?s perception of relationship Accreditation status Mentor Characteristics Education Family cc experience Marital status Age Income Quality of care indicators at end of data collection Ethnicity 26 available takes a comprehensive view of all of these variables. The present study was designed to describe a targeted training program utilizing the home-visiting service delivery model and bridge the gap between descriptive studies of program evaluation and process-oriented examinations of program effectiveness. 27 27 Increases in the minimum standards for licensing in Alabama, imposed in January 2001, required that family child care providers receive a minimum of 20 clock hours of training on an annual basis. A majority of providers have been willing to rise to the challenge of meeting the new standards, including the increased training requirements. However, even under the old training standards, many family child care providers had difficulty in finding after-hours (starting after 6:30 PM) training workshops they could get to that met their special needs and interests (i.e., working with multi-age groups and operating a home-based business). Additional barriers reported by family child care providers limiting their participation to accessible training include the perceived relevance of the training being offered to the specific needs and challenges of family child care and limited availability of transportation and time and financial resources needed to attend workshops. III. FAMILY CHILD CARE PARTNERSHIPS PROGRAM DESCRIPTION Project Overview The Family Child Care Partnerships (FCCP) project was designed to provide accessible training relevant to the needs of the family child care setting in a manner that addressed providers? perceived barriers. The primary purpose of FCCP is to assist 28 28 purpose, it is the vision of FCCP that family child care providers will develop and apply their knowledge and utilize available supports to foster the healthy growth and development of the infants, toddlers, and preschoolers in their care. FCCP uses several approaches to promote high quality care and to provide caregivers with the tools and motivation needed to realize these goals. Alabama?s licensed family child care providers to provide high quality child care services with a focus on moving them toward national accreditation standards. By fulfilling this The primary mechanism FCCP uses to teach and demonstrate principles of high quality child care is through individualized, in-home training provided by a knowledgeable mentor (home visitor) familiar with the special needs of family child care providers. Mentors address a variety of subjects during the home visits, including but not limited to the following: 1) health, safety, and universal precautions; 2) space and furnishings for care and learning; 3) child development; 4) facilitation of children?s language, reasoning, literacy, and numeracy; 5) planning and conducting learning activities for mixed-aged groups; 6) positive discipline and guidance; 7) working relationships with families; 8) business practices for home-based child care; and 9) professional development (options for education, certification, accreditation, and membership in professional associations). In addition to the mentoring component of the program, FCCP addresses some of the economic barriers to meeting high quality care standards. It provides its participants 29 29 A third way FCCP promotes quality child care practices among providers is by facilitating their professional development through promoting networking opportunities and their participation in training opportunities provided by other organizations and agencies. Mentor-facilitated group training meetings are designed to support additional educational needs, to encourage provider networking, and to foster provider professionalism. Mentors become familiar with other family child care-related agencies and organizations--including professional development networks and opportunities that serve to educate, recognize, scholarship, and/or reward providers with regard to implementing best practices and professionalism efforts--and facilitate providers? connections with them. with up to $500 to cover costs associated with having enough equipment that is in safe repair and developmentally appropriate for the children. FCCP also provides a full $495 scholarship to all providers enrolled in the program who reach a level of quality qualifying them to apply for accreditation by the National Association of Family Child Care (NAFCC). FCCP Mentoring Processes FCCP has been in operation in the field since April 2000, after 22 mentors were hired, trained, and began statewide recruiting of family child care providers into the program. Since then, influenced by budgetary restrictions and personnel changes, FCCP?s mentoring staff has expanded to as many as 24 and ebbed to a low of 16 mentors, some of whom worked part-time. FCCP mentors are trained to conduct individualized, in-home training on a weekly basis, for a period of time varying according to the individual needs of the providers. The average length of a mentoring visit is between 2 and 3 hours, but 30 30 ? Suggestions for quality improvements are more likely to be incorporated when a mentor with whom the provider has developed a rapport and established a trusting relationship context is available to coach her through the changes. can range from 1 to 5 hours. Mentors average seeing 8 to 10 providers each week but can range from 3 to 15 providers on a caseload. The assumptions underlying FCCP?s use of a mentoring approach are the following: ? A mentoring approach maximizes the opportunity to identify specific needs for quality improvement for individual providers. ? It creates a sense of partnership that can facilitate new ways of perceiving and behaving in the child care setting and provide the impetus for change. ? Such suggestions for quality improvements are more likely to be relevant to a provider?s individual child care setting when given by a mentor who visits regularly and understands the strengths and constraints of the provider?s care giving. ? Assistance that is context-sensitive and addresses the specific, unique needs of family child care providers for information, support, and/or encouragement is more likely to be understood and applied than training addressing topics about which provider may not yet have a concern. Mentors identify goals for improvement based quarterly assessments using the Family Day Care Rating Scale (FDCRS; Harms & Clifford, 1989) (see Appendix B), the Caregiver Interactions Scale (CIS; Arnett, 1989) (see Appendix C) and the NAFCC Quality Standards for Accreditation guidelines. Mentors utilize positive communication 31 31 Mentors are trained to use a combination of original and existing research-based curricular materials to work with providers on specific quality concern issues identified by the providers, mentors, and the Program/Mentor Coordinator. Mentoring staff attend, on average, quarterly training meetings, three times a year (usually two days in length) conducted primarily by the FCCP program coordinator and director. In addition, mentoring staff attend smaller, regional meetings as needed (usually 1/2 day in length, up to 3 times per year) conducted by the program coordinator. Training topics are identified from information gathered through normal supervisory channels, from needs expressed by mentors, from provider feedback, and from issues emerging from the within the family child care community as a whole. and modeling techniques, as well as print and video materials (approved or developed by the FCCP Program/Mentor Coordinator), to offer instruction and improvement opportunities for providers. Between pre-service training in March 2000 (and subsequently held for new mentors as they were hired) and December 2003, mentors received NAFCC observer training and were also educated on the following topics: instructional processes in mentoring and group instructional situations, procedures for quality control of provider group meetings and available training resources, the use of educational television programming in literacy activities, incorporating music and literacy activities in the child care home, provider-parent communication, the how?s and why?s of setting up provider associations, conflict management, goal setting, marketing and business practices, developmentally appropriate practice, language development, universal health and safety precautions, identifying and reporting child abuse and neglect, and a variety of quality 32 32 Mentors encourage and facilitate provider participation in completing the professional development articles/activities presented in the ?Everyday TLC? newsletter. Through the use of this resource, providers are able to earn 40 clock hours toward the CDA credential. Activities in the newsletter include suggestions for program design, child-directed, developmentally appropriate activities for all ages of children (birth through school-age), and professional development articles and activities. Mentors help providers to integrate the programmatic materials in the newsletter into their daily routines. child care activities. These trainings are also an opportunity for mentors to share their successes with each other, to problem-solve their challenges, to learn about new, instructional resources and ways to use them effectively with their providers, and to improve their efficiency and effectiveness in the field. Mentors assist providers in developing appropriate activities that involve language, print materials, and basic math skills, with a focus on how to create reading and math centers/areas in their homes using both provider-made and commercial materials; appropriate use of reading, language, writing, and math materials; and the use of such materials with infants and toddlers as well as preschoolers. Mentors work with providers to identify materials and equipment necessary to meet accreditation standards. Mentors then assist providers in requesting, through an application process, specific equipment from the FCCP program. Mentors also assist provider achieving NAFCC standards in obtaining and completing the application. FCCP makes available the $495 fee required for applying for accreditation. Finally, mentors facilitate connections among providers and between providers and other family child care-related agencies and organizations, through formal and 33 33 informal professional development networks and opportunities that serve to educate, recognize, and reward providers with regard to implementing best practices and professionalism efforts. Mentors identify local resource agencies and foster relationships with those agencies in an effort to coordinate services and act as an informational liaison between the providers and the agencies. Mentors develop relationships and collaborations with organizations and agencies sharing similar goals for child care quality enhancement. Mentors inform providers of opportunities to involve themselves in professional organizations, continuing education programs, and FCCP group training meetings and encourage their doing so. Program Documentation Data collection takes place during the first month of program enrollment to establish a baseline level of quality. Mentors are instructed to observe the provider during the first two visits for a minimum of 8 to 10 hours and complete global quality ratings (FDCRS and CIS ? described below). Providers complete a demographic/child care business survey, a questionnaire about attitudes toward child rearing, and complete a perceived stress and social support interview within the first month of program participation. Quarterly assessments are completed by the mentors for each provider in their caseload including the FDCRS and CIS measures. Providers complete follow up surveys periodically throughout their participation in the program. All measures are described in detail in the following section. After the initial month of visits designed primarily for in-take data collection and for the mentor and provider to begin a trusting relationship, mentors were instructed to schedule weekly visits with their providers. The duration of each visit (on average lasting 34 34 Mentors documented aspects of each home visit on a ?Daily Activities Report? (DAR). Each time a mentor conducted a home visit, she used the DAR to document the date of visit, arrival and departure time (which can be used to determine contact hours), number of children present, number of adults present, topics addressed during the visit, and method of service delivery. There are six categories of topics from which mentors could make a selection. These topics include Child Development, Health and Safety, Quality Care for Children, Child Care Professional and the Family, Language Development, and Positive Discipline and Guidance. Licensed family child care providers are required to receive 20 clock hours of training across these six domains each calendar year in order to maintain their license. 2 hours) as well as the topics addressed at those visits was determined by the mentor in partnership with each provider. When visits could not be kept, mentors were instructed to document the reason for not completing a visit. Assessment of Benefits and Impact Training through in-home visits is expected to result in measurable increases in the quality of provider care giving behaviors. Assessments for structural and process quality for each provider are carried out at provider intake and once per quarter thereafter (see Methods section for detailed information about measures). Changes on the quality measures are documented for each provider over the length of the mentoring partnership. Analyses of changes are documented by provider and reported by quality indicator category and by aggregate change per quarter. Across the course of the program?s existence, we have seen more providers attempt achieving accreditation level status. When FCCP began in the spring of 2000, only 8 providers in the state were accredited. 35 35 By offering and facilitating group training opportunities and encouraging the formation of local and state-wide provider associations, providers gain additional training hours on an ongoing basis. Providers also form informal support groups and/or formal provider associations and increase their levels of professionalism. In the fall of 2003, providers were asked to report their involvement in local provider association groups and whether or not they are continuing their education outside of participating in FCCP. Just over half (51.7%) of the respondents reported that they are members of their local association, and the majority of those involved in their associations reported attending meetings regularly. Many (18.8%) reported holding an office or being a committee member in the association. Of those reporting not being a member of an association, 22% reported there is no known association in the area. Very few providers (28 total) reported being involved in continuing education programs. Now (August 2005), 35 providers in the state have achieved accreditation and many more are in the accreditation process. Information presented in Table 1 summarizes FCCP quality enhancement achievements in the context of 4 prior project years. It includes information about staffing, provider enrollment, number of hours of training offered, and provider achievements and how these aspects of the program have changed over the years. 36 36 Table 1 Mentoring Achievements 2000-01 2001-02 2002- 03 2003-04 Providers enrolled at the end of the year 155 198 161 207 Mentors employed 20 24 18 18 Mentored training hours awarded 5869 7541 7203 6375 Group training hours awarded 1440 4726 2482 1031 Accredited providers 1 0 18 25 Providers in the process of submitting NAFCC applications or awaiting NAFCC visit 0 5 34 36 Average provider FDCRS** score at end of project year 4.65 4.93 5.31 4.89 ** Family Day Care Rating Scale is a 32-item standardized child care quality assessment used by mentors to measure provider progress across a range of specific quality indicators. A score of 7 is the highest possible. Participants Since the inception of the FCCP program, approximately 330 providers have enrolled. Descriptive information is available for just 278 out of these 330, partly because participants in FCCP, while strongly encouraged to do so, are not required to complete in-take surveys and in part because some data were lost. Descriptive information about 15 of the 22 mentors employed by FCCP within the last year of data collection (those who gave permission for their information to be used for this study) is presented in Table 2 along with details and more information about characteristics of providers involved with the FCCP program. Additional information about provider employment history, services 37 37 and operations, job descriptions, involvement in local provider associations, and continuing education is listed in Table 3. Table 2 Demographic Characteristics of Participants and Mentors Characteristic Providers Mentors Ethnicty N =270 N =15 White 46% 20% Black 53 8 Age N =271 N =15 Under 25 3 % 0 % 26-30 yrs 11 0 % 314 27% 20 4-50 yrs 3 6% 516 19% 20 over 0 4 0% Education N = 270 N = 15 Less than high school 6 % 0 % High school graduate 32 % 7 % GED 9 7 % Some college, but no degree 37 % 20 % Associate degree 9 % 13 % Bachelor?s degree 7 % 53 % Master?s degree 1 % 0 % CDA (n=249) 16 13 % Marital Staus N =257 N =15 Mried 80% 73% Single ? not living with partner 20 % 27 % Living Area N = 260 N = 15 Rualrea 33% 20% Town 21 Subrb 1 % 13% City 36 47 Gross household income N = 252 N = 15 Less than $5000 3 % 0 % $5,001-10,000 6 % 0 % $10,001-15,000 9 % 0 % $15,001-20,000 12 % 0 % $20,001-25,000 6 % 0 % $25,001- 30,000 12 % 20 % $30,001 and over 53 % 80% 38 38 Table 3 Employment History and Operations Enrolment Employment History Number of years in paid child care N = 274 X = 9.49 SD = 7.51 Min. =< 1yr Max. =3 yr Number of years as a paid family child care provider N = 272 X = 7.63 SD = 6.72 Min. =< 1yr Max. =3 yr Operations Fee Structure N=264 Fees are set 40 % Fees change when more than one child per family is enrolled or based on age 32 % Fees are set or flexible depending on families enrolling children 22 % Other or more than 1 answer given 7 % Operating Hours N=264 Set and strict hours 36 % Set but flexible hours 35 % Changes based on needs of families 29 % No set hours 1 % Frequency of Planning Activities N=262 Several times per day 18 % At least once per day 32 % 3 to 4 times per week 24 % 1 or 2 times per week 19 % Less than 1 time per week 7 % 39 39 enrolled in the FCCP program between April 2000 and December 2003. Each provider enrolled in the FCCP program (n = 331) was asked to complete a demographics and child care business survey upon enrollment. Quarterly quality assessments were completed by mentors for each provider (see section on measures for more information). Providers enrolled and/or actively participating in the FCCP program between March 2003, and March 2004 (n = 202), were asked to complete a Helping Relationships Inventory for the purpose of collecting information for this study. Mentors in the FCCP program employed between March 2003, and March 2004 (n = 22), were asked to complete a demographics and background survey as well as a Helping Relationships Inventory for each of the providers they were currently working with or had worked within six months of completing the questionnaire. Informed consent was obtained as directed by Auburn University?s Institutional Review Board for all providers and mentors included in the study analyses. IV. METHOD Procedures Secondary data were available for this research protocol from providers Currently employed mentors were contacted in person and given instructions for completing the surveys, as part of their work normal responsibilities. They were also asked to give consent for their information to be used in the current research. Mentors previously employed by FCCP were contacted through a letter explaining the study and 40 40 inviting them to participate. Because the researcher is also the primary supervisor for currently employed mentors, procedures were put in place to protect the identity of all of the mentors and their respective decisions to participate or not participate in the study. Consent forms were gathered separately from the questionnaires, which were numbered with special codes. A graduate assistant collected the consent forms and assigned alternate identification codes to the mentors and providers whose data were included in the study. The assistant turned over to the researcher only those questionnaires provided by mentors who gave consent for their date to be used in this study. The researcher did not have access to the identification codes and is not able to determine the identities of study respondents. Study Participants Participants in this study include 203 family child care providers who were enrolled in the FCCP program within one year of data collection (December 2003) and had a background and business practices survey on file as well as both baseline and one subsequent score on the quality of care outcome measures (see measures section for more information). Fifteen of the 22 mentors employed by FCCP within one year of data collection consented to allowing their information to be analyzed for the current study. Provider Specific Information Upon enrollment in the FCCP program, providers reported information about their demographic characteristics, childcare services and operations, as well as their business and professional practices. Two-hundred-two FCCP providers (enrolled within one year of ending data collection for this study) were asked to complete a survey asking questions concerning their relationships with their mentors. One-hundred-twenty of those 41 41 Table 4 shows that for both the full participant group (those who have information on file about their demographics and outcomes) and the sub-sample of participants (those who have the Helping Relationships Inventory on file in addition to the other study variables), there are approximately equal numbers of white and black providers, the majority of providers for both groups are in their 40s, most have attended some college but have no degree, and the majority are married. Providers in both groups reported an average of seven years of experience in family child care and tend to plan activities at least once per day. Approximately two-thirds of the participants operate group childcare homes, which can serve 7-12 children with at least one assistant caregiver. invited to complete this survey responded, for a completion rate of 60%. Mentors reported information about their relationships with 108 of their providers. Relevant demographic information for providers enrolled in FCCP who were included in the study and for providers who completed information about their relationships with their mentors is presented in Tables 4 and 5. Note that not all demographic information is available for each participant. Providers included in the study had completed enrollment surveys about their backgrounds and business practices. However, not every participant answered every question on the survey. 42 42 Table 4 Demographic Characteristics of Providers for Study Characteristic Full Study Group Sub-Sample Ethnicty N =18 N =84 White 43% 46% Black 56 51 Other 1% 2% Age N =18 N =83 Under 25 2 % 1% 26-30 yrs 8 6% 314 24% 28 4-50 yrs 41 40% 516 20 % 19 over 0 5 6% Education N = 180 N = 85 Less than high school 4 % 4% High school graduate 34 % 27% GED 9 7% Some college, but no degree 40 % 47% Associate degree 7 % 7% Bachelor?s degree 6 % 7% Master?s degree 1 % 1% Marital Staus N =172 N =79 Mried 8% 84% Single ? not living with partner 19 % 17% Table 5 Employment History and Operations for Providers in Study Full Study Sample Sub-Sample Employment History Number of years as a paid family child care provider N = 182 N = 82 X =7.83 X = 7.10 SD 67 SD =6.58 Min.= <1 yr Min <1yr ax3 Max.=3 Frequency of Planning Activities N=175 N = 82 Several times per day 19% 24% At least once per day 31% 29% 3 to 4 times per week 25% 24% 1 or 2 times per week 17% 15% less than 1 time per week 8% 7% Childcare Group Size N = 187 N = 86 Single Family Home 62% 58.% Group Home 38% 42% 43 43 Upon completion of the mentor information survey, 8 of the 15 respondents identified themselves as having worked as a family child care provider or assistant. Twelve had worked in Head Start or child care center classrooms as teachers. Ten mentors reported having been child care center administrators prior to working with FCCP. Ten mentors reported having had prior work experience as consultants or technical assistance specialists working directly with family child care providers, and eight of those responding indicated they had more than 2 years of full-time experience in this capacity prior to working for FCCP. Four mentors reported having no experience in the workforce outside of the child care field prior to working with FCCP. Mentor Specific Information Mentors were asked to report how they saw their jobs as mentors for family child care providers as well as how they saw family child care providers themselves. Almost all mentors reported that being a mentor is their preferred occupation (n=13). One mentor reported seeing her job as temporary employment, and one mentor reported more than one answer. The majority of the mentors (n=11) reported that they believed family child care was something most providers choose to do for their careers, while four mentors reported that being a family child care provider is a good occupation to have when the providers? own children are young. Three mentors reported they were in the process of continuing their education by working on advanced degrees. All but one of the mentors responding reported belonging to at least one professional organization. All mentors received professional and continuing education through the FCCP program during their employment. 44 44 Family Day Care Rating Scale Measures Outcome Measures Quality Care Assessments Mentors collected baseline quality care data during the first month of each providers? participation in the program and again approximately every three months thereafter. Mentors were asked to spend between 8 and 10 hours of observation with each provider before completing the Family Day Care Rating Scale (FDCRS) and Caregiver Interaction Scale (CIS) assessments. Specific information about each measure follows: The Family Day Care Rating Scale is a nationally standardized assessment tool designed to comprehensively measure key aspects of quality in family child care home settings (Harms & Clifford, 1989). The measure consists of 32 items, is broken into six sections, and is scored using a seven-point Likert-scale. The six scale categories are Space and Furnishings for Care and Learning, Basic Care, Language and Reasoning, Learning Activities, Social Development, and Adult Needs. An additional 7-item section is available to score settings in which special needs children are offered care. For each item, a description is offered to guide scoring at the 1, 3, 5, and 7 anchors of the scale. Items are scored as inadequate (1), minimal (3), good (5), or excellent (7). Scores of ranging from 5 to 7 indicate high quality care, 3 to 4.9 indicate average quality care, and 1 to 2.9 indicate inadequate quality care. (A complete listing of the items and instructions for scoring can be found in Appendix B.) Previous research has independently validated the FDCRS (Pepper & Stuart, 1985). 45 45 The Caregiver Interaction Scale is a widely used global measure of caregiver interaction styles published by Arnett (1989). It consists of 26 items and is scored on a four-point scale. Mentors are asked to rate each statement as it applies to the target provider with a score of 1 meaning the statement does not at all describe the provider, 2 describes the provider somewhat, 3 describes the provider quite a bit, and 4 describes the provider very much. A complete listing of the items and instructions for scoring can be found in Appendix C. In the present study, the average of all items scored on the FDCRS is used to measure the overall quality of care being offered. Chronbach?s alpha for the full FDCRS scale in this study was .98. Mentors were trained to use the FDCRS by completing a video training session, a review of the items with a trained and experienced user of the scale, and practice observations in the field. No observer reliability information is available; however, an examination of distributions of scores within each mentor?s caseload indicated variance indicative of mentors using the measure discriminately. Caregiver Interaction Scale The CIS was designed for use in testing the effectiveness of a college-course training program for center-based care providers in Bermuda and piloted in a variety of settings prior to its publication. A factor analysis of the scale yielded a four-factor solution including subscales labeled ?Positive Interaction,? ?Punitiveness,? ?Permissiveness,? and ?Detachment? (Arnett, 1989). This measure has been shown by its developer and in other studies to measure levels of communication, warmth, enthusiasm, harshness, discipline style, and involvement between adult caregivers and the children in their care (Arnett, 1989; Howes, 1997a; Howes et al., 1998; Howes, et al., 1994). 46 46 In the present study, Arnett?s (2004) instructions were used to determine providers? interaction quality on the four pre-determined scales. Chronbach?s alphas were examined for each of the four scales (positive relationships ? = .91; permissive ? = .39; punitive ? = .80; detached ? = .61 with item 13 deleted). Due to its low level of reliability, the permissive scale was not included in any analyses. Mentors were trained to use the CIS by reviewing the items with a trained and experienced user of the scale and practice observations in the field. No observer reliability information is available; however, an examination of distributions of scores in each mentor?s caseload indicated variance indicative of mentors using the measure discriminately. To facilitate appropriate use of this measure in the analyses for the study, the ?punitive? and ?detached? scales were reverse coded and renamed. ?Punitive? was renamed ?non-punitive,? and ?detached? was renamed ?engaged.? Doing so allows for interpreting all CIS sub-scales in a positive direction. High scores on any subscale indicate higher quality interactions than low scores. Accreditation Status Provider accreditation status is a categorical variable ranging from 1 to 4 that is assigned to a provider based on her progress through FCCP?s monitoring process designed to support successful application to the National Association for Family Child Care (NAFCC) for accreditation. Providers apply for accreditation through the FCCP office. Once the application has been received, an observer from the program is assigned to visit with the provider and evaluate her accreditation readiness. Information from this visit about provider needs for improvement is relayed back to the office, the provider, and the mentor working with that provider. Once needs for improvement are addressed and 47 47 For the purposes of this study, a provider was assigned an accreditation status code of ?1? when her FDCRS scores had not yet reached acceptable levels to begin the pre-accreditation evaluation process or, alternatively, when the provider had gone through the process and it was determined she was currently unable to meet accreditation standards. Provider status was coded as ?2? when the provider had applied for accreditation and completed the pre-accreditation process but still needed to make significant improvements before the application would be forwarded to the accrediting agency. Provider status was coded as ?3? when the provider had applied for accreditation, completed the pre-accreditation process, and her application was (or would soon be) evaluated by NAFCC. Provider status was coded as ?4? if the provider had received notification of her accreditation. NAFCC documentation is complete, the FCCP office submits the provider?s application to NAFCC headquarters with the $495 scholarship fee. NAFCC then schedules an official accreditation visit in the provider?s home and, upon being assessed as meeting required criteria, the provider is awarded accreditation. Provider-Reported Information Demographic characteristics and child care business practices were assessed by a 38-question survey which asked provider questions about their education, race, age, household income, child care-related training and work practices, whether or not they describe themselves as professionals, and how they run their child care business (see Appendix D for the complete survey). Providers completed this questionnaire during the first or second home visit and returned it to their mentor who then submitted it to the FCCP office. Details of provider characteristics were reported in the preceding chapter. 48 48 In the fall of 2003, providers were asked to complete the HRI in order to measure providers? perceptions of their relationships with their mentors. The HRI is based on a clinical survey developed by Young and Poulin (1998) for social workers to measure the quality of the helping relationship social workers have with their clients (see Appendix E for complete survey). For FCCP?s purposes, the language in the survey was modified so that it could be filled out from the providers? perspective, reflecting their understanding and involvement in that relationship. Providers were mailed this survey and asked to send their completed survey back to the office without having the mentors facilitate this process. This method of response was deemed necessary to avoid social desirability and preserve the mentor-provider relationship. Helping Relationships Inventory (HRI) The survey contains 20 questions. Nine items address aspects of the provider- mentor relationship in the context of what actually happens during a home visit (eg. ?How much input have you had in determining the goals you are working on??). Providers use a 5-point Likert-scale to indicate how much each question reflects their situation (1=not at all; 5=a great deal). Eleven items address aspects of the emotional or interpersonal quality of the relationship (eg., ?Does talking with your mentor give you hope?). Providers use a 5-point Likert-scale to indicate how they feel about their relationship with their mentor (1=not at all; 5=a great deal). Scores were summed across all 20 items, with higher scores representing higher quality relationships. Total scores on the HRI were used to determine quality of the mentor-provider relationship from the provider?s perspective. Chronbach?s alpha for the total HRI was .96. 49 49 Mentors completed the ?Helping Relationships Inventory? (Young & Poulin, 1998) on each of their provider relationships (with modifications in wording to describe the mentor-provider relationship from the mentor?s perspective). Like the HRI completed by the providers, mentors assessed their individual relationships by responding to 20 questions, nine concerning what actually happens during a home visit (eg. ?How much input have you had in determining how the two of you will work together??) and 11 addressing the emotional or interpersonal quality of the relationship (eg., ?Does talking with your provider give her hope?). The full inventory can be found in Appendix G. Mentor Reported Information Mentors completed a demographics and background survey asking for information such as education, race, age, household income, child care-related training and professional experience, etc. Details about mentor characteristics were reported in the preceding chapter, and Appendix F contains the entire survey. As with the provider version of the HRI, mentors used a 5-point Likert-scale to indicate how much each question reflected their situation (1=not at all; 5=a great deal). Scoring for the mentor version of the HRI was the same as described previously for the provider version. Total scores on the mentor form of the HRI were used to determine quality of the mentor-provider relationship from the mentor?s perspective. Chronbach?s alpha for the total HRI was .93. 50 50 Correlations among the available variables for study are presented in Table 6. Note that variables related to mentor characteristics are not included in these analyses due to the low sample size (n= 15). To determine which indicators of provider and program characteristics would be included in the model tests, correlations among these variables and the potential mediating and outcome variables were examined. Provider and program variables which were related to one or more of the hypothesized mediating or outcome variables were selected for subsequent analyses. Descriptive statistics for these variables are presented in Table 7. IV. RESULTS Preliminary Analyses Provider characteristics meeting these criteria included provider?s level of education, years of paid child care experience, frequency of planning activities, and the four baseline indicators of provider quality. Two program characteristics, number of mentors a provider worked with and total number of contact hours, met these criteria. Correlations among FDCRS and the three CIS subscales at both baseline and final data collection periods indicated potential latent constructs to be present. (Latent variable analyses are presented in the ?Structural Modeling? subsection of this chapter.) No correlations existed between one of the hypothesized mediating variables, provider perception of the mentoring relationship, and any of the other predictor, mediating (mentor perception of the relationship), or outcome variables. Therefore, 51 51 Table 6 Correlations Among Study Variables (N Min = 90; Max = 203) Variables 1 2 3 4 5 6 7 8 9 Provider Characteristics 1. Childcare Group Size 2. Education .153* (179) 3. Paid Childcare Work -.025 -.082 in the Home (181) (174) 4. Age -.070 -.056 .435** (180) (178) (175) 5. Marital Status -.036 .061 .047 .132 (171) (170) (167) (170) 6. Ethnicity .084 .048 -.030 -.059 -.025 (180) (178) (175) (179) (172) 7. Planned Activities -.120 -.146 .167* .036 -.082 .091 (174) (177) (169) (172) (165) (174) Quality Indicators at Baseline 8. FDCRS .064 .2177** -.023 -.035 -.164* -.022 .025 (187) (180) (182) (181) (172) (181) (175) 9. CIS ? Positive Relations -.021 .093 .048 -.098 -.139 .028 .106 .540** (187) (180) (182) (181) (172) (181) (175) (203) 10. CIS- Non-Punitive Rel?s .020 .053 .014 .012 .088 -.087 .032 .227** .359** (187) (180) (182) (181) (172) (181) (175) (203) (203) 11. CIS ? Engaged Rel?s -.029 .094 .073 .097 -.024 .060 -.021 .290** .373** (187) (180) (182) (181) (172) (181) (175) (203) (203) Program Characteristics 12. Number of Mentors -.112 .084 .015 .168* -.014 .247** .026 .170* .123 (187) (180) (182) (181) (172) (181) (175) (203) (203) 13. Total Contact Hours -.074 .016 -.002 -.047 .213** .005 -.138 -.206** -.108 (187) (180) (182) (181) (172) (181) (175) (203) (203) Mediating Variables 14. Provider Perception of -.062 .037 -.070 .096 .018 -.112 -.098 -.137 -.165 Quality of Relationship (86) (85) (82) (83) (79) (83) (82) (90) (90) 15. Mentor Perception of -.020 .045 .009 -.131 -.190 .078 -.129 .159 .151 Quality of Relationship (102) (99) (99) (100) (96) (101) (98) (108) (108) Outcome Variables 16. FDCRS .146* .181* -.167* -.126 -.062 -.077 -.182* .232** .167* (187) (180) (182) (181) (172) (181) (175) (203) (203) 17. CIS ? Positive Relations -.029 .083 -.104 -.061 -.133 -.066 -.112 .122 .324** (187) (180) (182) (181) (172) (181) (175) (203) (203) 18. CIS ? Non-Punitive Rel?s .049 .093 -.094 -.086 -.144 .040 .013 .032 .106 (187) (180) (182) (181) (172) (181) (175) (203) (203) 19. CIS ? Engaged Rel?s -.025 .180* .021 -.039 -.072 .067 .128 .289** .199** (187) (180) (182) (181) (172) (181) (175) (203) (203) 20. Accreditation .106 .268** -.098 .044 -.087 -.054 -.138 .378** .210** (187) (180) (182) (181) (172) (181) (175) (203) (203) 52 52 Table 6 (cont?d) Correlations Among Study Variables (N Min = 90; Max = 203) Variables 10 11 12 13 14 15 16 17 18 19 Quality Indicators at Baseline (cont?d) 11. CIS ? Engaged Rel?s .309** (203) Program Characteristics 12. Number of Mentors .054 .079 (203) (203) 13. Total Contact Hours -.080 -.073 -.053 (203) (203) (203) Mediating Variables 14. Provider Perception of -.088 -.060 -.038 .087 Quality of Relationship (90) (90) (90) (90) 15. Mentor Perception of .199* .158 .099 -.043 .036 Quality of Relationship (108) (108) (108) (108) (63) Outcome Variables 16. FDCRS .157* .047 .040 .022 -.064 .295** (203) (203) (203) (203) (90) (108) 17. CIS ? Positive Relations .205** .188 -.004 .019 -.082 .130 .590** (203) (203) (203) (203) (90) (108) (203) 18. CIS ? Non-Punitive Rel?s .364** .037 .030 -.023 -.096 .217* .366** .535** (203) (203) (203) (203) (90) (108) (203) (203) 19. CIS ? Engaged Rel?s .046 .402** -.174* -.168* -.033 .202* .000 .086 .137 (203) (203) (203) (203) (90) (108) (203) (203) (203) 20. Accreditation .140* .133 .223** .035 .076 .315** .517** .285** .131 .036 (203) (203) (203) (203) (90) (108) (203) (203) (203) (203) 53 53 Table 7 Descriptive Statistics for Study Variables Variables N Min. Max. Mean Std. Dev. Provider Characteristics 1. Childcare Group Size 187 1 2 1.38 0.49 2. Education 180 1 7 3.31 1.32 3. Paid Child Care Work in the Home 182 < 1 33 7.83 6.67 4. Age 181 1 7 4.83 1.07 5. Marital Status 172 1 2 1.19 .40 6. Ethnicity 181 1 6 1.61 .65 7. Planning Activities 175 1 5 2.63 1.20 Quality Indicators at Baseline 8. FDCRS 203 1.31 7.00 4.14 1.20 9. CIS ? Positive Relations 203 12 40 32.58 5.34 10. CIS ? Non-Punitive Rel?s 203 15 26 25.14 1.72 11. CIS ? Engaged Rel?s 203 1 9 7.49 1.97 Program Characteristics 12. Number of Mentors 203 1 3 1.22 .51 13. Total Contact Hours 203 13 467.25 155.99 94.59 Mediating Variables 14. Provider Perception of Quality of Relationship 90 21 100 84.4 18.17 15. Mentor Perception of Quality of Relationship 108 50 98 79.71 10.56 Outcome Variables 16. FDCRS 203 1.40 7.00 5.42 1.04 17. CIS ? Positive Relations 203 16 40 33.38 5.43 18. CIS ? Non-Punitive Rel?s 203 10 26 24.88 2.41 19. CIS ? Engaged Rel?s 203 1 9 6.97 2.36 20. Accreditation 203 1 4 1.57 1.02 54 54 Structural equation modeling was used to test the hypothesized mediation model and examine potential latent constructs among the quality indicators at both baseline and final data collection periods. Analyses were computed with Mplus (Muthen & Muthen, 1998), using the maximum likelihood estimation method. Five indexes were used to assess the model fit to the data. The chi-square statistic examined the general fit of the model. The Comparative Fit Index (CFI) and Tucker-Lewis or Non-Normed Fit Index (TLI) compare the fit of the model being tested to a baseline model (one in which none of the observed variables are correlated with one another). The Root Mean Square Error of Approximation (RMSEA) examines the model with respect to the population allowing the model to be fitted independent of sample size. The Standardized Root Mean Square Residual (SRMR) examines fit in reference to standardized scores for observed variables. A non-significant chi-square, CFI and TLI of 0.90 or higher, a RMSEA close to zero, and an SRMR of less than .05 indicate a ?good? model fit (Bollen, 1989; Keiley, Dankoski, Dolbin-MacNab, & Liu, 2005). provider perception of the relationship was eliminated from all further analyses. Figure 2 presents all of the variables in the models to be tested in subsequent analyses. Structural Modeling Latent Variable Analyses Latent variable analyses were performed to examine whether the four ?quality? indicators yielded a single ?quality? construct with regard to baseline quality. The model provided an excellent fit, ? 2 (2) = 5.02, (p = .08), CFI = .98, TLI = .93, RMSEA = .09, SRMR = .03, indicating that the four quality indicators underlie a single factor. Non- standardized parameter estimates and standard errors for this fitted latent variable model 55 55 Program Characteristics ? Number of Contact Hours ? Number of Mentors Mentor Perception of the Relationship Success in Program as Indicated by Accreditation Status and Quality of Care at End of Data Collection Provider Characteristics ? Childcare Group Size ? Education ? Paid Childcare Work in Home ? Planned Activities ? Quality Indicators at Baseline Figure 2: Hypothesized Model to be Tested Using Study Variables and Data 56 56 Accreditation Status are presented in Figure 3 while standardized estimates are presented in Figure 3a. With regard to end-of-data collection quality measures, the model provided an excellent fit, ? 2 (2 ) = 3.33, (p = .19), CFI = .99, TLI = .97, RMSEA = .06, SRMR = .03, indicating that the four quality indicators again underlie a single factor. Non-standardized parameter estimates and standard errors for this fitted latent variable model are presented in Figure 4 while standardized estimates are presented in Figure 4a. These findings provide construct validity to the quality measures used in the present study. Structural Model Tests for Mediation The correlations among variables (Table 6) show that accreditation status at the end of the program is related to the provider?s education, baseline quality indicators, number of mentors, and mentor?s perception of the quality of the relationship. The mentor?s perception of the quality of the relationship is related to a single aspect of the latent variable baseline quality. Following Baron and Kenny?s (1986) instructions for testing mediation, three models were fitted to examine mentor perception of the relationship as a mediating factor in predicting provider accreditation status. Model 1 (Figures 5 and 5a) tested the hypothesis that provider and program characteristics independently influence the mentors? perception of the quality of the mentor-provider relationship. The model yielded a good fit to the data, ? 2 ( 11) = 17.69, (p = .09), CFI = 0.95, TLI = 0.91, RMSEA = 0.06, SRMR = 0.03; however, a small R 2 (.004) for the mediating variable indicates that no variance is being explained. In addition, the parameter estimates (path coefficients) are not significant. Continued testing for mediation is not warranted. 57 Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .85***(.11) 8.71**(2.82) 2.37***(.26) 3.00***(.34) 1 (0) 5.84***(.90) .98***(.20) 1.21***(.23) Figure 3: Fitted Model with Parameter Estimates and Standard Errors Depicting Latent Variable ?Baseline Quality of Care? X 2 (2) = 5.02, (p=.08), CFI = .98; TLI = .93; RMSEA = .09; SRMR=.03 ** p < .01 *** p <.001 .58***(.14) 57 58 Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .64 (0) .83***(.90) .44***(.20) .47***(.23) Figure 3a: Fitted Model with Standardized Estimates and Errors Depicting Latent Variable ?Baseline Quality of Care? X 2 (2) = 5.02, (p=.08), CFI = .98; TLI = .93; RMSEA = .09; SRMR=.03 ** p < .01 *** p <.001 58 59 Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .64***(.08) 4.05 (3.30) 3.85***(.46) 5.52***(.55) 1 (0) 7.66***(1.17) 2.11***(.30) .34(.23) Figure 4: Fitted Model with Parameter Estimates and Standard Errors Depicting Latent Variable ?Quality of Care? X 2 (2) = 3.33, (p=.19), CFI = .99; TLI = .97; RMSEA = .06; SRMR=.03 .43***(.10) *** p <.001 59 60 Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .64 (0) .93***(1.17) .58***(.30) .09 (.27) Figure 4a: Fitted Model with Standardized Estimates and Errors Depicting Latent Variable ?Quality of Care? at the End of Data Collection X 2 (2) = 3.33, (p=.19), CFI = .99; TLI = .97; RMSEA = .06; SRMR=.03 *** p <.001 60 61 Education level # of Mentors Mentor Perception of Relationship Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged 1 5.32***(.81) .94***(.19) 1.19***(.22) 0(0) 0(0) .01 (0) Figure 5: Model 1 ? Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Mentor Perception of Relationship X 2 (11) = 17.69, (p=.08), CFI = .95; TLI = .91; RMSEA = .06; SRMR=.04 2.37***(.26) 10.45***(2.61) .79***(.12) 2.96***(.33) 0***(0) R 2 =0.04% .63***(.15) ***p < .001 62 BSL FDCRS BSL CIS Pos. Rel. Baseline Quality of Care Education level # of Mentors Mentor Perception of Relationship BSL CIS Non- Pun. BSL CIS Engaged .67 (0) .79***(.81) .44***(.19) .48***(.22) -.06(0) .01(0) .03 (0) Figure 5a: Model 1 ? Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Mentor Perception of Relationship X 2 (11) = 17.69, (p=.08), CFI = .95; TLI = .91; RMSEA = .06; SRMR=.04 R 2 = 0.4% ***p < .001 63 Quality Care The correlations among variables (Table 6) show that quality of care at the end of the program is related to the childcare group size, provider?s education, provider?s experience (as indicated by number of years of paid childcare work in the home), frequency of planning activities, baseline quality indicators, number of mentors, total contact hours in the program, and mentor?s perception of the quality of the relationship. The mentor?s perception of the quality of the relationship is related to a single aspect of the latent variable baseline quality. Again, following Baron and Kenny?s (1986) instructions for testing mediation, models were fitted to examine mentor perception of the relationship as a mediating factor in predicting providers? quality of care. Model 2 (Figures 6 and 6a) tested the hypothesis that provider and program characteristics independently influence the mentors? perception of the quality of the mentor-provider relationship using the variables listed above that were related in a bivariate way to quality of care. The model yielded a good fit to the data, ? 2 ( 23) = 25.60, (p = .32), CFI = 0.98, TLI = 0.97, RMSEA = 0.02, SRMR = 0.03; however, a small R 2 (.09) for the mediating variable indicates that little variance is being explained. In addition, parameter estimates, with the exception of the path between ?total contact hours? and ?mentor perception of the relationship,? were not significant. Because of the low R 2 (.09) and the knowledge that ?total contact hours? is not correlated with the quality of care outcome variable, no further testing for mediation was warranted. Education level Pd Childcare Work in Home Mentor Perception of Relationship Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .45***(.12) 10.69***(2.58) 2.37***(.26) 2.97***(.33) 1 (0) 5.22***(.80) .93***(.19) 1.17***(.22) .04 (4.29) 2.94 (5.98) -.44 (.44) Figure 6: Model 2 ? Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Mentor Perception of Relationship as These Variables Relate to Quality of Care at End of Data Collection X 2 (23) = 25.60, (p=.32), CFI = .98; TLI = .97; RMSEA = .02; SRMR=.03 Childcare Group Size Planned Activities -.76 (2.30) -2.74 (2.53) Number of Mentors Total Contact Hours 3.00 (5.50) .11*** (.03) .65***(.15) 1497.66***(148.93) R 2 = 9% *** p < .001 64 65 BSL FDCRS Baseline Quality of Care Education level Pd Childcare Work in Home Mentor Perception of Relationship BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .67 (0) .79***(.80) .44***(.19) .48***(.22) .00 (4.29) .04(5.98) -.07 (.44) Figure 6a: Model 2 ? Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Mentor Perception of Relationship as These Variables Relate to Quality of Care at End of Data Collection X 2 (23) = 25.60, (p=.32), CFI = .98; TLI = .97; RMSEA = .02; SRMR=.03 Childcare Group Size Planned Activities -.03 (2.30) -.08 (2.53) Number of Mentors .04(5.50) .26*** (.03) R 2 = 9% *** p < .001 Total Contact Hours 66 Because mediation of accreditation status in the tested model was not detected, the R Post Hoc Analyses Accreditation Status 2 for the outcome variable and parameter estimates for the model were examined. The R 2 for accreditation (R 2 = 0.005) indicates that less than one percent of the variance in accreditation status can be predicted from the model. Parameter estimates for the model tested did not indicate any justification for eliminating variables and subsequently testing a model with fewer pathways. However, a direct effects model ? one in which the mediating variable is eliminated ? may yield a better fit to these data. Post Hoc Model 1 (Figures 7 and 7a) tested the hypothesis that provider and program characteristics influence the outcome variable ?accreditation status? directly. Post Hoc Model 1, looking at ?accreditation status? as the outcome variable, yielded a close to good fit to the data, ? 2 (11) = 20.51, (p = .04), CFI = .95, TLI = .90, RMSEA = .07, SRMR = .04. The R 2 (.20) for accreditation status is a reasonable amount of variance being explained in this model, all but one fit indices were within the normal parameters, and all parameter estimates were significant which indicates that this is a good model for predicting accreditation status. Provider baseline quality care indicators and education along with number of mentors significantly predict accreditation status. Quality Care Because mediation of quality of care was not detected, the R 2 for the outcome variable and parameter estimates and path coefficients for Model 2 were examined. The R 2 for mentor perception of the relationship (R 2 = 0.09) in Model 2 indicates that less than ten percent of the variance in that variable can be predicted from the model. BSL FDCRS 67 Education level # of Mentors Accreditation Status Baseline Quality of Care BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .72***(.12) 12.02***(2.44) 2.39***(.26) 2.99***(.33) 1(0) 4.79***(.73) .88*** (.19) 1.10***(.21) .37*** (.10) .15**(.05) .30*(.13) Figure 7: Post Hoc Model 1 ? Fitted with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Accreditation Status X2(11) = 20.51, (p=.04), CFI = .95; TLI = .90; RMSEA = .07; SRMR=.04 .71***(.16) .83***(.09) R 2 =20% * p < .05 ** p < .01 *** p <.001 68 BSL FDCRS BSL CIS Pos. Rel. Baseline Quality of Care Education level # of Mentors Accreditation Status BSL CIS Non- Pun. BSL CIS Engaged .71 (0) .76***(.73) .43*** (.19) .47***(.21) .30*** (.10) .19**(.05) .15*(.13) * p < .05 ** p < .01 *** p <.001 Figure 7a: Post Hoc Model 1 ? Fitted with Standardized Estimates and Errors Depicting Provider and Program Influence on Accreditation Status X2(11) = 20.51, (p=.04), CFI = .95; TLI = .90; RMSEA = .07; SRMR=.04 R 2 = 20% 69 69 Parameter estimates indicate that only ?total contact hours? has an influence on mentor perception of the relationship (? = .26). However, contact hours and the proposed mediating variable are not related to quality of care at the end of data collection. Again, a direct effects model looking at the predictive ability of the provider and program characteristics for quality care may yield a better fit to the data. Post Hoc Model 2 (Figures 8 and 8a) tested the hypothesis that provider and program characteristics influence the outcome variable ?quality of care? directly. Post Hoc Model 2, looking at ?quality of care? as the outcome variable, yielded a poor fit to the data, ? 2 (55) = 176.19, (p = .00), CFI = .72, TLI = .61, RMSEA = .10, SRMR = .07. The R 2 (.18) for quality of indicates that a reasonable amount of variance being explained in this model. The R 2 for quality of care (R 2 = .18) in Post Hoc Model 3 indicates a reasonable amount of variance is being explained, and the only significant parameter estimate between hypothesized predictors and end-of-data collection quality of care is the baseline quality of care variable (? = .35, p=.001), a simpler model was tested. Post Hoc Model 3 (Figures 9 and 9a) tested the hypothesis that provider baseline quality of care may have direct effects on quality of care at end-of-data collection. Results from testing Post Hoc Model 3 yielded a poor fit to the data, ? 2 (19) = 111.93, (p = .00), CFI = .77, TLI = .66, RMSEA = .16, SRMR = .10, R 2 = .13 for quality of care. 70 Education level Pd Childcare Work in Home Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .84***(.11) 9.05***(2.49) 2.35***(.25) 3.02***(.33) 1 (0) 5.75***(.83) 1.00***(.20) 1.19***(.22) .35***(.09) -.03(.11) -.01(.01) Figure 8: Post Hoc Model 2 ? Fitted Model with Parameter Estimates and Standard Errors Depicting Provider and Program Influence on Quality of Care at End of Data Collection X 2 (55) = 176.19, (p=.00), CFI = .72; TLI = .61; RMSEA = .10; SRMR=.07 Childcare Group Size Planned Activities .01(.04) -.07(.04) Number of Mentors Total Contact Hours -.08(.10) 0(0) Quality of Care FDCRS CIS Pos. Rel. CIS Non- Pun. CIS Engaged .63***(.08) 4.52 (2.98) 3.58***(.44) 5.50***(.55) 1 (0) 7.49***(1.09) 2.08***(.30) .38(.27) .58***(.14) .36***(.08) R 2 = 18% *** p <.001 71 Education level Pd Childcare Work in Home Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .64 (0) .83***(.83) .45***(.20) .46***(.22) .41***(.09) -.02 (.11) -.12 (.01) Figure 8a: Post Hoc Model 2 ? Fitted Model with Standardized Estimates and Errors Depicting Provider and Program Influence on Quality of Care at End of Data Collection X 2 (55) = 176.19, (p=.00), CFI = .72; TLI = .61; RMSEA = .10; SRMR=.07 Childcare Group Size Planned Activities .02 (.04) -.12 (.04) Number of Mentors Total Contact Hours -.06 (.10) .07 (0) Quality of Care FDCRS CIS Pos. Rel. CIS Non- Pun. CIS Engaged .64 (0) .92***(1.09) .58***(.30) .11 (.27) R 2 = 18% *** p <.001 Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .89***(.11) 7.28**(2.80) 2.37***(.26) 3.06***(.34) 1 (0) 6.28***(.94) 1.02***(.20) 1.21***(.23) .33***(.09) Figure 9: Post Hoc Model 3 ? Fitted Model with Parameter Estimates and Standard Errors Depicting Baseline Quality of Care as a Predictor of Quality of Care at End of Data Collection X 2 (19) = 111.93, (p=.00), CFI = .77; TLI = .66; RMSEA = .16; SRMR=.10 Quality of Care FDCRS CIS Pos. Rel. CIS Non- Pun. CIS Engaged .63***(.08) 3.36 (3.07) 3.91***(.45) 5.51***(.55) 1 (0) 7.86***(1.15) 2.11***(.30) .37 (.27) .53***(.13) ** p < .01 *** p <.001 .37***(.08) R 2 = 13% 72 Baseline Quality of Care BSL FDCRS BSL CIS Pos. Rel. BSL CIS Non- Pun. BSL CIS Engaged .61 (0) .86***(.94) .44***(.20) .45***(.23) .37***(.09) Figure 9a: Post Hoc Model 3 ? Fitted Model with Standardized Estimates and Errors Depicting Baseline Quality of Care as a Predictor of Quality of Care at End of Data Collection X 2 (19) = 111.93, (p=.00), CFI = .77; TLI = .66; RMSEA = .16; SRMR=.10 Quality of Care FDCRS CIS Pos. Rel. CIS Non- Pun. CIS Engaged .63 (0) .94***(1.15) .57***(.30) .10 (.27) ** p < .01 *** p <.001 R 2 = 13% 73 74 The goals of this study were to describe in detail a mentoring program for family child care providers in Alabama and examine a proposed model of the process through which the program works to help providers improve the quality of care they offer and achieve accreditation. The main findings indicate that a provider?s level of quality upon enrollment in the program is a significant predictor of accreditation status, but this did not hold true for predicting quality of care (at the end of the data collection period). When providers come into the program and are rated as relatively higher in quality, their potential to achieve accreditation is higher than those who come into the program with lower quality scores. The process proposed as a mediating variable ? mentor-provider relationship quality -- was not supported by these data. VI. DISCUSSION Implications for Previous Research Previous research examining family child care provider characteristics associated with quality of care has examined the amount of training providers received, group size, ratio of children to adults, provider work commitment, motivations of being providers, education, frequency of planning activities, experience, and intentionality (Galinsky et al., 1994; Kontos, 1994). Results from the present study?s correlational analyses support the majority of Galinsky?s (Galinsky et al., 1994) descriptive findings. Provider education, aspects of intentionality (motivation, professionalism, and planning activities), and group size were significantly and positively correlated with quality of care in the 75 Previous research examining the effectiveness of workshop-style training programs on child care provider quality has been correlational in nature as well. In the Kontos (1994) study, no significant association between provider characteristics and quality of care measures were found, but caregiver experience approached significance and was included in their analyses for examining correlates of quality of care outcomes. The current study included provider experience as a predictor variable but did not find support for the hypothesis that provider experience predicts quality of care outcomes. Galinsky (Galinsky et al., 1994) study. Group size, provider education, and frequency of planning activities were positively correlated with quality of care, and provider education was correlated with accreditation outcomes in the present study. However, unlike the Galinsky (Galinsky, et al., 1994) study, provider experience was significantly correlated with the outcome quality of care. Research has suggested that providers who seek out and receive specialized training tend to have higher quality scores and report being more committed and intentional than less trained providers (Galinsky et al., 1994), and that participants in technical assistance and training programs experienced more change in the quality of care compared to groups of providers not involved in these programs but who were equal on all background characteristics (Kontos, 1994; Kontos et al., 1996; Wilkes et al., 1998). In the present study, participation in the FCCP training program, as measured by number of contact hours, was correlated with one aspect of quality of care (the ?engaged? sub-scale of the Caregiver Interaction Scale), but was not a significant predictor of program success in the models tested. Regardless of providers? demographic background, frequency of planning activities, or level of participation in the program (as indicated by the number of 76 The nurse home visiting studies reported mother characteristics and relationship quality variables as being significantly associated with positive program outcomes (Josten et al., 1995; 2002; Korfmacher et al., 1998; McNaughton, 2002). It was concluded that the quality of the contact was more important that the quantity of contact (Korfmacher et al., 1998), and that when home visitors worked toward maintaining a positive relationship, the quality of the relationship mediated the mothers? success in the program. While this ?mediational? explanation was a stated conclusion by these researchers, no mediation model was tested to statistically prove this out. The same was true in the early head start home visiting programs. When relationships were positive, the home visitor tended to work more intensely with her clients yielding more successful participants (Roggman et al., 2001). These studies suggest that regardless of provider and home-visitor demographic characteristics, the quality of the relationship between the two is most important in determining who will be successful in a program and who will not. contact hours they had with their mentors), the level of quality upon enrollment in the program was the most important predictor of program success as indicated by accreditation status. None of the other variables in the study were predictive of end level quality of care when placed in a causal model. In light of these findings, correlations found in previous studies may not be meaningful in terms of being able to predict which training programs will be effective and which will not nor which providers will be successful in a particular training program. The results from this study do not warrant a similar conclusion relative to family child care providers. While the quality of the mentor-provider relationship, as reported by the mentor, is positively correlated with both accreditation status and quality of care 77 outcomes as well as number of contact hours providers had in the program, causal analyses do not support the notion that relationship quality is important for the quality of care providers offer. It is possible that the importance of achieving success in the FCCP program is different from that of the nurse-home visitor programs (NHVPs). While participants in both programs volunteered to receive training, there may be more at stake if the participant is the mother of the child in care rather than a paid caregiver caring for someone else?s children. Participants in the NHVPs may be in more dire straits and rely more heavily on their home visitors compared to participants in the FCCP program. NHVPs also had specific end dates of service; whereas, FCCP providers are technically allowed to remain in the program indefinitely. Perhaps if providers were given a time limit to achieve a particular level of quality or be released from the program, they would meet program goals more readily due to a sense of urgency to get the most one can out of a limited-term program. When a participant views their relationship with their home visitor as more or less important, it may affect how invested they become in a program or the relationship itself. Perhaps mothers who are in home visiting programs feel it more urgent and necessary to work to create and maintain a positive relationship with their home visitors because they see it is important to getting them most out of the program. Providers in FCCP might not see the importance or urgency in improving their quality levels; therefore, they may not be as invested or participatory in the relationship creation and maintenance with their mentor. Previous research also has suggested that relationship quality in mentoring-type and home-visiting programs is influenced to some degree by what the participant initially comes to the program with (personal background, individual situation, motivation, and 78 personality) and how the participant perceives the mentor as being able to relate to her and her situation (Olds & Korfmacher, 1998). In the current study, the quality of the relationship as reported by the provider was not correlated with any provider-related, program-related, or outcome variables. A provider who is internally driven toward success may achieve high quality care and/or accreditation despite a less positive relationship with her mentor. Mentors may work with providers they do not have positive relationships with due to external program factors such as needing to keep their caseloads full. Providers may work with mentors they have positive relationships with but never make changes in quality that would lead them to high quality of care scores and/or accreditation. In short, a provider may like her mentor yet not make any changes, or a provider might not like her mentor and make all the changes necessary to become accredited. It may be the case that a mentor-provider relationship may be of relatively lower quality, but for some reason the provider is able to improve her situation resulting in higher quality of care being offered and in some cases accreditation being achieved. It may also be the case that a mentor-provider relationship may be of a higher quality, but for reasons unknown, the provider does not make quality improvements and never reaches accreditation. Although the provider?s perception of her relationship with the mentor was not associated with any other aspect of her participation or quality of caregiving, the mentor?s perception of the relationship was. However, in the models tested, mentor reports of the quality of the relationship were not predictive of provider success in the program as indicated by quality of care. The literature on child care quality, training, and even the home visits for early head start, do not look at a causal relationship among the variables 79 The nurse home visitor and early head start home visitor program literatures begin to suggest that the quality of the relationship is most important in predicting a participant?s quality outcomes, although this research did not statistically examine the causal relationship among these variables. The current study tests the hypothesis that the home visitor?s evaluation of the relationship drives the providers? success in the program. The results from the current study do not support this hypothesis even when the visitor?s perception of the relationship is positively and significantly correlated with the participant?s success in the program. available. No published research is available using a causal model to examine or predict how these factors work together to explain caregiving quality. The current study takes a first step in doing so and, as a result, calls into question the adequacy of prior research in explaining quality outcomes associated with training programs. Implications for the Model The hypothesized model looking at provider, mentor, and program characteristics and their ability to predict accreditation and quality of care outcomes via the quality of the mentor-provider relationship was not fully testable due to insufficient amount of data to test in the model. In addition, the provider?s report of the quality of the mentoring relationship was not correlated with any outcome variables or any predictor variables; therefore, it was not include in model tests. As shown in the results, only a direct effects model predicted provider accreditation status; whereas, quality of care at the end of the data collection period was not predicted in any model tested. While the analyses tested causal models for examining the processes by which home visiting educational programs work for family child care providers, mediation was 80 Quality of care at the end of data collection could not be predicted by any of the provider or program variable sets examined. It is curious to note that while there is a significant path between the quality of care variables (at baseline and end of study period) showing that 13% of the variance in end quality of care is explained by baseline quality of care, the model does not fit the data well. The fact that none of the tested models examining causes of quality of care at the end of the study period indicates that there must be some external or unmeasured influence on whether or not a provider with improve during her participation in the FCCP program. not indicated. Simplified model tests, eliminating the mediating variable, suggested a better set of predictors among those examined for accreditation status. A direct-effects model using baseline quality indictors, provider level of education, and number of mentors predicted 20 percent of the variance in accreditation status. Providers with higher baseline quality, higher education levels, and who had more than one mentor to work with over the course of the study period are getting farther along on the path to accreditation than those participants with lower quality, education, and number of mentors. These findings suggest that models in this study are not good predictors of program successes with the exception of the direct effects model for accreditation status. The models may be strengthened with the addition of other variables not discussed in the literature and not measured in the current study may account for the variability in participant success in training programs such as Family Child Care Partnerships. Further discussion on this possibility can be found further along in this chapter. It can be 81 The most important implications for the FCCP program relate to data collection and measurement issues and provider level of quality upon enrollment in the program. Based on this study, salient program features such as total contact hours are not indicating that they are meaningful in a provider?s path toward accreditation and increasing quality of care. Additional in-take information may be warranted to discover predictors of participant success. Perhaps additional outcome measures would be helpful in determining how participating in FCCP actually does benefit proviers. concluded that common correlates of provider success in programs are not necessarily the causes of that success. Implications for the Family Child Care Partnerships Program First, a closer look at the in-take information gathered for this program is necessary. Additional information about a provider?s home environment (especially stability, person relationships and support, and traumatic events), previous training, motivation for being a family child care provider, motivation for being enrolling in FCCP, client turn over, and provider personality and/or work style may be relevant to determining why some providers are more successful than others in this program. Information should be gathered from all mentors in the program including personality traits and work style. Other program features such as intensity of training, category of training, participation in group workshops sponsored by FCCP, and utilization of other program benefits and opportunities such as equipment grants, specialized in-home training activities, and receipt of program support materials could be examined. Inclusion of different aspects of provider characteristics like prior training (not education but participation in specialized workshops and training sessions before enrolling in the FCCP 82 program), concurrent training (offered by other agencies or through study-at-home programs), personality traits, stress factors, social support and networks, and degree of motivation may yield more insight regarding for whom the program works best. Examination of different program variables such as participation in group trainings, content analyses of training that takes place during the visits rather than just looking at contact hours, and the work style of the mentor (i.e., goal-oriented versus reacting to situations as they arise during visits; planned versus not-planned) may provide more information about how and why some providers are more successful in the program than others. Additional outcome variables might be considered for measurement. Provider stress, social support, personal feelings of satisfaction and confidence, knowledge of best practices at the end of the program as compared to knowledge at the beginning of the program, or whether or not providers have achieved in other areas of professional development (ie., gone back to college to obtain a Child Development Associate credential or higher degree; taking leadership roles in local or state-wide provider and/or child support/advocacy organizations) could all be considered measures of success that may have been influenced as a result of participating in the program or having a mentor working with them. This additional in-take and outcome information may be the key to including variables for study that allow causal model path analyses to be significant. As mentioned previously, the current research supports previous research regarding correlational analyses, but those variables do not work in the causal models and cannot predict significant aspects of participant success in the program as measured. 83 A realistic and cost-effective approach to these suggestions for increased data collection may be to begin with developing brief questionnaires that the providers themselves would complete. A revision to the existing in-take survey of provider background and business practices could be made and used with all newly enrolling participants as well as modified and sent to all currently enrolled participants. A few key questions about motivation for being a child care provider and participating in FCCP and on-going training and education should be included. A set of personality questionnaires could be sent to randomly selected participants in the program. With FCCP serving an average of 200 providers each program year, a fair number of respondents could be asked to participate in answering such questionnaires. Additional or different measures of the quality of the mentoring relationship might be gathered. For example, targeted questions could be asked of the provider during routine semi-annual quality control calls that could be content-analyzed for relationship quality indicators. Identifying the program features, type of mentor, provider, or relationship between the two that has the most impact on a provider?s success in the program would be of utmost importance in streamlining the FCCP program and therefore making it more cost-effective, replicable, and worthy of continued funding. A second approach to a cost-effective and efficient examination of information could be to identify additional outcome information that shows the impact of the program. Perhaps questionnaires could be used to ask providers about their confidence levels in caregiving now that they have a mentor to work with. A re-evaluation of data already collected could be suggested as well. While global quality of care outcomes were not predicted in the existing study, perhaps sub-sets of outcomes can be. If a provider is 84 As stated previously, another important implication for the program found in this study concerns the providers? quality level upon enrollment. It appears from the models tested that quality upon enrollment is the best predictor of whether or not a provider achieves accreditation. It would be important that this finding not drive a program like FCCP to target providers who are already using best practices and offering high quality care to enroll in the program. Doing so would diminish the ability of the program to meaningfully impact providers who really need assistance to improve their caregiving and environments. Offering services to only those providers who are most likely to succeed might serve to maintain the program?s credibility and funding but would, in effect, cheat those who really need assistance out of an important educational service. able to improve her caregiving in one category (eg., health and safety) but not another (eg., social development), the overall quality score may mask an important improvement in the care being offered by that provider. An examination of small categories of caregiving quality could be useful in showing how the program helps providers make changes in the care they give. In the current study, it is difficult to say how FCCP works for providers at the lower ends of the FDCRS-assessed quality spectrum. We do not know whether providers at the lower ends made improvements. Future analyses could be designed to examine only the low-end providers to determine what strides they made in quality improvements and compare those to the levels of change high-end providers made. It may be that low end providers in this study made the same degree of improvement as high quality providers, but because they were equal in magnitude, the providers who were scored low at the beginning of the study period were also comparatively low at the end of the study 85 In light of findings from this study that do not support much of the previous research, limitations of the study must be thoroughly considered. Originally, it was proposed that this study would examine the effectiveness of the mentoring program in light of provider, mentor, program, and relationship characteristics. The data available for study did not allow for any analyses of the mentor characteristics and how they may or may not impact provider success in the program. Because a meaningful analysis of mentor characteristics could not be done due to lower than expected participation rates of mentors, examination of a match or mismatch between mentor and provider backgrounds was not possible. The nurse home visiting literature suggests that participants were more receptive to home visitors who were similar in background, created more positive relationships with those home visitors, and were therefore more successful in the program (Korfmacher et al., 1998). An examination of the predictive ability of this idea in a causal model would let us know whether or not the correlations reported in the literature are meaningful in predicting participant success in home visiting programs. period. Re-evaluating the existing data in light of the current findings and looking at different outcomes that could define success in the program may help us see how our program impacts providers enrolling with lower quality. Limitations, Contributions, and Future Directions Analyzing secondary data, while often convenient, has its limitations as well, especially in terms of how variables were operationalized. For example, providers in this study were asked a single question about their motivation for becoming a family child care provider as a proxy for measuring intentionality (?What would you say was the main reason that you chose to become a family child care provider? ? response options were a) 86 In the present study, variables available for analyses may also be affected by response bias. Mentors are the sole reporters of provider quality of care both at enrollment and throughout the program. No independent observations are available to validate those scores, and no other indicators of program success are collected to corroborate mentor reports of provider quality other than accreditation status. While mentors do score providers in their caseloads differently from one another at any given time in the program, and it would serve no job performance related purpose to inflate or deflate a provider?s quality score, there may be measurement error involved. ?I wanted to stay at home with my own children/grandchildren;? b) ?I wanted to work with children;? c) I wanted to help parents who needed child care;? or d) I wanted to work in my home.? This question was created based on the current conventions in the literature, but upon review of that question for the current study, it was determined that it did not differentiate highly motivated versus not highly motivated reasons for getting into the family child care business. Mentors and providers were asked to report on the quality of their relationships for the specific purpose of collecting data for this study. Social desirability issues may play a role in the response rate and the content of those responses. Mentors who participated may have agreed to participate in the study as well as reported having more positive relationships with their providers because the program supervisors are also the researchers. Mentors who did not participate may have felt, despite a number of efforts to separate participation in the study from job performance evaluations, they needed to portray themselves and their relationships with their providers in a more positive light than in reality. There may be selection bias at play concerning providers who submitted 87 Mentors and providers reported on relationships that may not be current. While many of the participants in the study who were eligible to report on relationship quality were enrolled in the program at the time, several providers and mentors were asked to report on the quality of relationships they had that may have been one year old. The accuracy of remembering what a relationship was like that ended six months to a year ago may be significantly different from the accuracy of remembering aspects of a relationship that is on-going or more current. relationship quality information. Those who completed the Helping Relationships Inventory may have stronger feelings about their relationships with their mentors than providers who did not respond. The current study does make some meaningful contributions to the field and the FCCP program itself. The current study indicates that current conventions in taking correlates of quality care and assuming they are causes can no longer be done. Common correlates of quality are not necessarily causes of that quality. New variable sets and hypotheses must be made to shed light on why and how training programs equal participant improvements in care. A theoretical research based on common sense deductions and extrapolations of findings from center-based care program research can no longer be accepted. Grounded theory and research specific to in-home care settings are a must to developing new hypotheses and tests of causal pathways necessary to explain and support educational training programs. A re-evaluation of the way FCCP administers and monitors its program may be warranted. It is possible that because there is no pre-determined amount of time a participant is allowed to stay in the program that the providers may not be making the 88 changes expected since there are virtually no consequences for not making improvements. Providers are allowed to remain in the program indefinitely. If providers knew that they would only have access to FCCP resources and assistance for a finite period of time, they might make greater strides in improving the care they offer if there is a sense of urgency involved. No consequences for mentors are available either. If a mentor never has a provider achieve accreditation or reach a high level of quality as reported on the FDCRS, there are no negative repercussions for that lack of success. FCCP program administrators may want to consider implementing time limits for provider achievements and provide rewards and ?punishments? (in the guise of negative performance evaluations) for both providers and mentors in the program. Future research in the field of home visiting programs and for FCCP itself needs to include different sets of predictor and outcome variables as well as continue examining process variables in order to determine why and for whom home-visit based training programs work. While previous research and the current study include predictor and outcome variables that make logical sense, these variables are only correlated with one another. When these commonly used variables are put in a causal model for testing, the results are limited in scope. A study designed to examine a match/mismatch between provider and mentor characteristics, including background/demographics, work style, personality, and perception of the relationship may be a more plausible model to test the current hypotheses. If the quality of the relationship is in fact the cornerstone process through which participants are going to be successful or not successful in a program, it would be paramount for program developers and managers to know how and from whom those 89 Future studies examining the effectiveness of home visiting programs, specialized training for family child care providers, and/or the processes through which these programs and trainings help participants be successful could attempt to obtain control group information to make more comparisons about the program?s effectiveness. In the current study, it could be said that participants in the FCCP program are more likely to achieve accreditation than those who are not because there have been no other providers in the state to achieve accreditation during the tenure of FCCP. However, we do not know why that might be the case. It could simply be that the cost of the accreditation fee ($495) or lack of knowledge that an accreditation for family child care providers exists could be the reasons behind the lack of non-FCCP provider accreditation. Without a control group, it is impossible to tell. relationships work best. There may also be additional outcome variables that are meaningful in terms of program success in a non-traditional sense. For example, perhaps the confidence level of a provider could be measured or a change in structure of her social support network. Employing a theoretical framework from which to select variables and collect new or different information may be useful as well. The nurse home visiting literature indicates that aspects of participant and home-visitor personality may be involved in the quality of the relationship and success in the program. This literature also discusses participant self-efficacy and social context as factors in program success. The family child care and training literature indicates that provider motivation and internal drive may be important factors involved in quality of care and success in training programs. 90 As previously stated, finding grounded theory from which to select variables and design models for testing is important. Previous research in the home-visiting literature and family child care literature suggests that motivation, intentionality, and feelings of self-worth and competence are key to program success. Social cognitive theory, more specifically the self-efficacy aspect of this theory, may help future research develop predictor and outcome measures and variables better. Coming from a social cognitive theoretical perspective, Bandura defined self-efficacy as "judgments of how well one can execute courses of action required to deal with prospective situations" (Bandura, 1982, p.122). Bandura's perspective emphasizes cognitions about reinforcements, rather than the reinforcements themselves, indicating that motivators for action are not just in the environment, but also in the thoughts about the environment. As a result, self-efficacy is not a fixed measure, but is constantly adapting to the acquisition of new information (Lipsmeyer, 2005). Summary and Conclusions It is important for practitioners to understand the contributions the clients, staff, and program make to the success or failure of a training program. Previous research shows that when child care providers receive specific, relevant training, they offer higher quality care (Kontos, et al., 1996; Taylor, et al., 1999). Results from the current study indicate that it is the provider?s initial level of quality that is most important in predicting whether or not a provider will achieve accreditation. In spite of its limitations, the study makes an important contribution in questioning the findings of previous research in explaining why some providers make quality improvements in the family child care setting and others do not. 91 While additional research is needed to explore other aspects of program processes that may explain additional variation in provider success in programs such as Family Child Care Partnerships, the current study continues to bridge the gap between descriptive information about programs and explanatory research concerning program processes. The current study could not shed light on many provider or program variables nor any relationship variables statistically significant to a provider?s ability to obtain accreditation, but it is important to point out that when FCCP began in 2000, there were no nationally accredited providers in Alabama. At the end of the data collection period for this study, there were 28. At the conclusion of writing this report, there are 35 accredited providers in Alabama with 13 more having submitted their applications to the National Association for Family Child Care and waiting to hear that they have obtained accreditation. Considering the importance of children being cared for in high quality environments, the FCCP program is a valuable instrument in creating a strong foundation from which children will embark on their journey in the world. FCCP?s ability to assist Alabama?s family child care providers in their quest for accreditation should not be dismissed or minimized. 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Home visiting: Recent program evaluations ? analysis and recommendations. The Future of Children, 9 (1), 4-26. Harms, T. & Clifford, R. M. (1989). Family Day Care Rating Scale. Teachers College Press. New York, NY. Hiatt, S. W., Sampson, D., & Baird, D. (1997). Paraprofessional home visitation: Conceptual and pragmatic considerations. Journal of Community Psychology, 25 (1), 77-93. Howes, C. (1997a). Teacher sensitivity, children?s attachment and play with peers. Early Education and Development, 8, 41-49. Howes, C. (1997b). Children's experiences in center-based child care as a function of teacher background and adult-child ratio. Merrill-Palmer Quarterly, 43, 404-425. Howes, C., Hamilton, C. E., & Phillipsen, L.C. (1998) Stability and continuity of child- caregiver and child-peer relationships. Child Development, 69 (2), 418-426. 94 Keiley, M. K., Dankoski, M., Dolbin-MacNab, M., & Liu, T. (2005). Covariance structure analysis: From path analysis to structural equation modeling. 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L., Cole, R., Korfmacher, J., & Hanks, C. (1997). Prenatal and early childhood home-visitation program processes: A case illustration. Journal of Community Psychology, 25 (1), 27-45. Kontos, S. (1994). The ecology of family day care. Early Childhood Research Quarterly (9), 87-110. 95 Kontos, S., Howes, C., & Galinsky, E. (1996). Does Training Make a Difference to Quality in Family Child Care? Early Childhood Research Quarterly (11), 427- 445. Kontos, S. & Wilcox-Herzog, A., (1997). Influences on children?s competence in early childhood classrooms. Early Childhood Research Quarterly, 12, 247-262. Korfmacher, J., Kitzman, H., & Olds, D. (1998). Intervention processes as predictors of outcomes in a preventive home-visitation program. Journal of Community Psychology, 26 (1), 49-64. Lipsmeyer, K. (2005). Adolescent co-parenting relationships and their effect on parental self-efficacy. Unpublished master?s thesis, Auburn University, Auburn, Alabama. McNaughton, D. B., (2000). A synthesis of qualitative home visiting research. Public Health Nursing, 17 (6), 405-414. Muth?n, L. K., & Muth?n, B. O. (1998). MPlus User?s Guide. Los Angeles, CA: Muth?n & Muth?n. O?Brien, R. A., & Baca, R. P. (1997). Application of solution-focused interventions to nurse home visitation for pregnant women and parents of young children. Journal of Community Psychology, 25 (1), 47-57. Olds, D., Henderson, c., Kitzman, H., Eckenrode, J., Cole, R., & Tatelbaum, R. (1998). The promise of home visitation: Results of two randomized trials. Journal of Community Psychology, 26 (1), 5-21. Olds, D., Kitzman, H., Cole, R., & Robinson, J. (1997). Theoretical foundations of a program of home visitation for pregnant women and parents of young children. Journal of Community Psychology, 25 (1), 9-25. 96 Taylor, A. R., Dunster, L., & Pollard, J. (1999). ?And this helps me how?: Family child care providers discuss training. Early Childhood Research Quarterly, 14 (3), 285- 312. Olds, D. L., & Korfmacher, J. (1998). Maternal psychological characteristics as influences on home visitation contact. Journal of Community Psychology, 26 (1), 23-36. Peisner-Feinberg, E. S., & Burchinal, M. R. (1997). Relations between preschool children's child-care experiences and concurrent development: The cost quality, and outcomes study. Merrill-Palmer Quarterly, 43, 451-477. Roggman, L. A., Boyce, L. J., Cook, G. A., & Jump, V. K. (2001). Inside home visits: A collaborative look at process and quality. Early Childhood Research Quarterly, 16 (1), 53-71. Wilkes, D. L., Lambert, R., & VandeWiele, L. (1998). Technical assistance as part of routine inspections of family child care homes. Early Childhood Research Quarterly, 13 (2), 355-373. Young, T. M. & Poulin, J. E. (1998). The helping relationship inventory: A clinical appraisal. Families in Society, 79 (2), 123-133. 97 APPENDICES 98 APPENDIX A Home Visiting Programs, Procedures, Processes, and Outcomes Meta-Analyses and Review Articles Recent literature reviews and meta-analyses in the nurse home visitor field have focused on creating a greater understanding of common factors involved in home visiting programs. The purpose of these reviews and analyses is to synthesize the current research in the home visiting area in an attempt to explain why and how home visiting programs work. These articles identify target participant populations, program goals/objectives, life stage in which the participants are enrolled and receive program services, outcomes/evaluations, and to the degree available, information about the specific processes involved in these relationship-based programs. Many of the articles evaluated in these reviews and meta-analyses offer rich descriptions of what the program was designed to do, who the program was designed to serve, who the participants and the home visitors were, and what the outcomes were. It is much more difficult to determine program processes and mechanisms by which participants receive information that causes change in attitudes, beliefs, and behaviors. It is one thing to describe individual aspects of a program and evaluate it. It is quite another to explain why and how a program worked or did not work. The majority of empirical home visiting research since the mid 1960s identify outcomes primarily for the mothers involved in the programs (Byrd, 1997). These 99 Byrd (1997) found in her review of three decades of research, that mothers? personal health (status of physical health, knowledge of health, and utilization of health care services), knowledge of prenatal care, and compliance with prenatal health care recommendations were universal variables measured in home visiting program evaluation. Child outcomes variables universally included (starting in the 1970s) basic health, including diet/nutrition, and basic development. As programs became more sophisticated and the empirical demands for research programs required, child outcomes such as number of reported abuse and neglect cases, number of emergency medical visits, and children?s self-esteem/confidence were measured. programs measured mothers? knowledge, beliefs, and attitudes about children and child rearing. It was not until the 1970s that the research turned to examine child-related outcomes. These outcomes were indirect in nature. When mothers participated successfully in the programs, their children were less likely to have negative health problems. It was not until the 1990s that the researchers began to examine the interactions between mothers and their newborns as salient outcomes variables (Byrd, 1997). Byrd (1997) also found that home visiting programs throughout the years evaluated the basic environment in which participants lived. Various aspects of the environment were measured including utilization of health care services for well children, completion of immunizations for children, and mothers? return to work or school. Mothers? education and employment, health, and utilization of health care services continued to be evaluated. More recently, programs evaluated the individual home 100 Byrd (1997) summarized her review of home visiting programs by noting outcomes measured indicate mother-child home visiting programs affect various characteristics and qualities of the mothers, children, and the interactions between them, as well as the environment surrounding them. Missing from the outcomes measured in these programs were evaluations of how families may have been affected overall (outside of the specific mother-child relationship), differences in outcomes as a result of service delivery being offered by professionals versus paraprofessionals, and participant reported information about how they perceive the program to have affected them. environments using the widely known HOME inventory, and aspects of the mothers? support and social competence were measured. Home visiting research published since the Byrd (1997) article shows a recognition of these missing pieces in understanding more fully the impact these programs have on mothers, children, families, and communities. The home visiting programs outlined in the Gomby and associates? article (Gomby, Culross, & Behrman, 1999) have similar goals and utilize similar methods. They all target high risk families, operate in multiple locations, and use random assignment to treatment or control/comparison groups. As delineated in Gomby?s review article (Gomby et al., 1999), the program goals, background of home visitors, and training requirements for the visitors were very similar. All programs were designed to assist parents with raising healthy children, decreasing abuse and neglect, and helping parents prepare their children for school. With the exception of the Nurse Home Visitor Program, all home visitors were paraprofessionals. The NHVP used professional nurses for the initial program and utilized paraprofessionals in later trials. All home visitors were required to attend 101 The target population served by each program varied from only high-risk families to being open to all parents across the country. Service delivery varied from one program to another as well. While all programs require participants to open their homes to the home visitors, the frequency of those visits ranged from weekly to quarterly, and, in the Parents as Teachers program, visits were determined based on family needs. Home visitation start dates varied across programs. For example, most of the programs began upon the birth of the child and continued until the child turned five years old. The HIPPY program did not start until a child was three or four years old, and the NHVP and PAT programs begin with prenatal home visits and continue until the child is two or three years old respectfully (Gomby, et al., 1999). pre-service training and received on-going training and supervision throughout the program (Gomby et al., 1999). Each of these programs has produced outcomes showing increases in parent (usually mothers) knowledge of child-rearing practices and child development principles as well as decreases in abusive or neglectful parenting practices. Because the trials are randomized, program researchers conclude that the positive outcomes resulting from participating in the nurse home visiting program are causal in nature. Parents and children in control and comparison groups did not show changes in rates of abuse and neglect, health care concerns, and children?s development (Gomby et al., 1999). Gomby and associates (1999) concluded that identification of families who would both most benefit from a home visiting program and would be most receptive to the resources and information offered in these types of programs would afford a researchers and program administrators with more success stories. Matching programs to fit the 102 Gomby (2000) noted that many of the published home visiting programs only involve 20 to 50 clock hours of home visitation across a number of years. And, often only half of the prescribed number of visits actually take place. Gomby (2000) reports that on average, families receive between 20 and 67 percent of the visits programs protocols recommend. It is suggested that more intense and frequent visits may yield more substantial results. This limited number of contact hours may be at the root of why home visitors report frustration in administering the protocols and the slow rate of improvement that is perceived as well as measured. If more intensity or frequency in service delivery is not allowed for in a program, Gomby (2000) recommends that program administrators expect more modest results. needs of receptive and targeted families should yield positive outcomes for a greater percentage of its participants. In addition, the identification of the level and frequency of service delivery will assist in program implementation and on-going training and program development. Explicit information about these aspects of programs can also assist others in replicating these programs through other agencies. McNaughton in 2000 published an article examining fourteen home visiting programs in an attempt to explain what the mechanisms are in the nurse-client relationship that effect change. McNaughton?s goal was to look at a variety of home visiting programs in a meaningful way to explain what happens during the course of a home visiting program at that makes the participants change their attitudes, beliefs, and behaviors targeted by the program as a result of the interaction with the home visitor. The fourteen studies examined are qualitative in nature but analyzed in a quantitative way. 103 McNaughton (2000) identified four stages involved in the nurse-participant relationship. First, a pre-entry category was identified. Factors influencing the relationship included participant experience with other program staff or medical professionals in any setting, participant relationships with other relatives or friends and interpersonal style, participant perceived need to be involved in a program, the level of influence and support offered by the participant?s family members, and reasons the participant is participating in the program. The results sections of the fourteen studies in this analysis were coded in a way that allowed each classification to be statistically tested. Relevant information about the nurse-participant relationship, nurse role during the visit, participant role during the home visit, and expected results from the interactions were explored. It is important to note that five of the fourteen articles reviewed stemmed from one study. These fourteen articles reviewed include information from 142 nurse home visitors and their interactions with participants across 59 home visits (McNaughton, 2000). The second stage was labeled ?entry.? During the second stage, the nurse must establish or create the relationship and gain entry into the participant?s home. There is a physical and relationships aspect to this entry. It is one thing to be allowed into the participant?s home, and another to be received into the participant?s personal life. McNaughton (2000) noted that both physical entry into the home (making and keeping a first appointment) and the entry into a relationship with the participant can take quite a long time. The third stage was labeled ?working.? During this stage, the nurse and the mother work together to identify needs (primarily health-related) and establish a plan for 104 The final stage of the relationship is ?termination.? Like the working stage, termination may be dictated by the program protocol itself or as a result of the quality of the nurse-mother relationship. Termination may happen at a prescribed time if the participant remains involved in the program until the end of the protocol. However, termination may happen prior to the completion of the program as a result of participants not being interested in what the program has to offer, not having a positive relationship with the nurse visitor, or external factors such as moving, change in schedules, or even community or household hazards that may make it unsafe for the home visitor to return (McNaughton, 2000). addressing those needs. Nurses must continue to maintain the relationship during the working part of the process so that she can continue to gain entry into the home of the participant. The working part of the service delivery program can vary in length and intensity both based on the program?s protocols and the specific needs and quality of the nurse-mother relationship. McNaughton (2000) noted that nurse-mother relationships could be dichotomously categorized as either ?collaborative? or ?difficult.? When the relationship was collaborative, nurses and mothers were able to work successfully toward mutual goals. The mothers were receptive to the program?s methods and content, trusted the nurses, and showed general interest, openness, and improvement in caregiving skills throughout the course of the program. The length of collaborative relationships was significantly longer than those classified as difficult. Difficult relationships were classified as such when mothers would open their doors to the physical entry of the home visitors, but were not receptive to the goals of the program and refused to create a 105 McNaughton?s article (2000) examined both British and American home visiting programs. She found that the actual frequency or total amount of home visits was limited in many cases by the home visitor?s workload and by the wishes of the mothers. Nurses had to balance the demands of the program and the demands of the workload and the demands of the mothers. The American programs were also constrained by funding issues. In addition to these demands, nurses reported they often had to weigh the demands of program protocols and service delivery against the demands of keeping the relationship maintained. Pushing too much or trying to force participants to maintain a particular level of involvement and progress often resulted in the termination of the relationship. Nurses reported that their main goal throughout the program was to maintain the relationship with the mothers on their caseloads. This sometimes conflicted with the demands of the programs, but it protected the relationship and ability to offer some level of service to the participants. relationship with the nurses. Mothers in difficult relationships were observed or reported to be closed to the ideas presented by the nurses, actively rejected them and their information in some cases, did not keep appointments, and did not utilize referrals to outside agencies. Mothers who were uninvolved and inattentive during the visits and showed no effort toward improvement in the program were also classified as difficult. Nurses were found across programs to focus primarily on creating and maintaining a collaborative relationship. Nurses reported that the participants were more receptive to program information and change if the nurse was perceived to be sympathetic and understanding of the participants? individual needs in all areas of their lives. In order to create and maintain that type of relationship, the nurses often had to get 106 Relationship creation and maintenance was one aspect of the role nurses had in home visiting programs. The other role nurses had was to deliver program content. Most often, this was health-related information designed to improve the quality of care and environment the infants and children in the home experienced. The participant?s role was identified as making a choice of whether or not to be open to and make changes in her behaviors based on the information and instruction offered by the nurses. The participant holds all the controls in the relationship with her home visitor. The participant controls the entry, intensity, and frequency aspects of the home visits themselves as well as controlling the level of information reception and behavioral change that results (McNaughton, 2000). to know the participants on a personal level, interact with relatives that either lived in the participant?s home or influences them greatly, and address aspects of the participants? lives and individual circumstances outside the range of the program. Relationship maintenance was the primary objective unless a specific or urgent health matter required the nurse to confront the participant in such a way that may jeopardize the relationship and continuation in the program (McNaughton, 2000). In this meta-analysis, McNaughton (2000) looked at the outcomes included in the fourteen studies. She noted that the program goals and research outcomes were not reported by the nurses to be the goals nurses had for the participants. Program goals and research outcomes focused on changes in caregiving behaviors, attitudes, and beliefs that lead to the improved caregiving and environment experienced by the participants? children. Nurses reported that their goals for the mothers were to empower them, instill problem-solving skills, and enhance mothers? self-esteem. Researchers reported they 107 McNaughton (2000) concluded that the relationship between the nurse and the participant is the key to success in home visiting programs. She suggests that aspects of this relationship maintenance in combination with the nurses? goals for these mothers (self-esteem and self-efficacy) are mediators of the positive outcomes. Further investigation into the processes involved in establishing and maintaining these relationships along with continued exploration of the mechanisms of service delivery are necessary to identify how and why programs can work with a diverse group of participants. This information can also lead to program improvement and individualization so that programs can show stronger results in a more efficient manner of service delivery. McNaughton (2000) points readers to two models with which future home visiting research can be tested. First, Peplau?s relationship model can be utilized to examine the process of forming and maintaining the nurse-mother relationship. Second, the ?Interaction Model of Client Health Behavior? can be used to describe and examine the nurse-mother interactions that lead to positive outcomes as a result of the home visiting program. (See the Proposed Analyses section for explanations and applications of these theories.) wanted to see improved or positive child outcomes such as birthweight, APGAR scores, general health, and decreased instances of abuse and/or neglect. In summary, the review articles and meta-analyses point to specific and universal variables examined in home visiting programs. Mothers? are typically the main target of programs and evaluations of program effectiveness. Mothers? personal health, knowledge of caregiving and child development, as well as compliance with program goals and basic health practices are the most common outcomes measured. Children?s basic health and 108 In the following reviews of home visiting programs, characteristics of the mothers, home visitors, environment, and relationships between these variables will be highlighted. The studies chosen for review most closely match the purpose, methodology, and evaluation found in the Family Child Care Partnerships program. A detailed contextual picture will be painted to provider general background information and a theoretical context from which to interpret the specific program reviews. While the individual studies reviewed here may have a variety of facets and interesting details to report both descriptively and methodologically, only a brief contextual outline and relevant pieces of information that related directly to goals, methods, and analyses involved in the FCCP program will be brought forth for the purpose of the current proposed study. development are universal child outcomes measured in these programs. More recently, programs researchers have examined aspects of program success or failure. Specifically, programs are implementing evaluation procedures in order to predict participant success, environmental impact on program effectiveness, and relationships between service deliverers and the participants which may affect program effectiveness. Nurse Home Visitor Programs Background and Theoretical Underpinnings In 1977, a comprehensive, theory-based nurse home visiting program was begun in Elmira, NY, with 400 pregnant women. This prevention program was designed to educate low-income, primarily young, first time mothers in order to decrease the likelihood of pregnancy problems and poor infant health and development, as well as assist participants in making choices to improve their own lives. Outcome measures for 109 The theoretical foundations for the Nurse Home Visitor Program were originally based on Bowlby?s (1969) attachment theory and Bandura?s (1977) self-efficacy theory. The Elmira study was designed, carried out, and analyzed with these theories guiding research decisions. The Elmira program was improved upon and replicated in two subsequent randomized trials ? Memphis, TN, and Denver, CO. In each of the later two trials, the influence and application of both attachment and self-efficacy theories were expanded upon and Bronfenbrenner?s (1992) person-process-context model of human development was incorporated into improvements in the program. the Elmira program were focused on children?s health and development and mothers? life course trajectories and were used to determine the success or failure of the program itself. Subsequent programs modeled on the Elmira program also included measures of the program processes in order to explain how and why the program yields those outcomes in children and their mothers. The theoretical underpinnings and description and results of this study were published in two seminal articles led by Olds and Kitzman (Olds, Henderson, Kitzman, Eckenrode, Cole, & Tarelbaum, 1998; & Olds, Kitzman, Cole, & Robinson, 1997) and are summarized next. Attachment theory (Bowlby, 1969) was used to guide much of the content of the program. Nurses were trained in appropriate caregiving practices that would enable them to model such practices for their clients. Nurses were also trained in self-efficacy theory (Bandura, 1977) explicitly in order to implement the protocols and effect change in the mothers? behaviors. The program protocol had specific lesson built in that each nurse was to teach (through direct instruction or modeling) each mother concerning specific caregiving skills (e.g., quieting a crying baby or redirecting toddler behaviors). Nurses 110 Self-efficacy theory alone was not sufficient to explain why some mothers and children had successful outcomes during and after the program was administered. The introduction of Bronfenbrenner?s (1992) theory encouraged Olds and company (1997) to look at the ecological aspects of program participation and results. Participants? culture, school and work environment, community services, family and friends, and influences on parenting were the relevant aspects of context assessed and analyzed in the Memphis and Denver trials. The parents? (mothers?) psychological resources were examined as aspects of the ?person? part of the model. Those resources included adaptive behavior such as health-related behaviors, qualities of caregiving, and education, work, and pregnancy as well as influences of program process and the child involved. Program processes included the nurse-mother relationship, education received as a result of the home visits, goal-setting skills, problem solving practices, and changes in influences in parenting behaviors. The influences of the children?s characteristics were also examined with reference to the person-process-context theory. Child characteristics included status of birth weight or gestational age at delivery, any health or behavior problems caused by child maltreatment, injuries, or developmental delay, and influences on child behavior by parenting practices. were instructed and trained to deliver these lessons in a way that would promote the self- efficacy of the mothers. The idea was to create an atmosphere of trust and competence in caregiving that would allow the mothers to exhibit appropriate caregiving behaviors and feel competent, willing, and able to continue those behaviors when the nurse was not present in the home. 111 A key element of the nurse home visiting program trials that were designed, implemented, and evaluated after the Elmira program was a focus on the program?s processes and the processes external to the program that affected mothers? abilities to raise their children appropriately. Program process were operationalized as the ways the nurse home visitors worked with parents to enhance, improve, and change their parenting behaviors and competencies. Other processes that were included in assessments and analyses were the influences of psychological and family resources on the mothers and the interactions and influences of the child on the mothers. The effect of the program on mothers? context was hypothesized to be mediated by mothers? behaviors. The program was designed to change both the behaviors themselves and the contexts that affect those behaviors (Olds et al., 1997 & 1998). The nurses in the NHVP sites were trained in a solution-focused approach while working with the participants (O?Brien & Baca, 1997). This approach is at the root of the process by which mothers changed their attitudes, beliefs, and behaviors with their children. Nurses used this idea to promote mothers? self-efficacy and self-sufficiency. This approach is hallmarked by understanding that the participating mothers have the most information about their own lives and situations. Nurses were trained to recognize participants? strengths and capitalize on them. Using the mothers? strengths as a springboard for instigating change was expected to allow for the most success in the program. O?Brien & Baca (1997) further explain this working style in their article. Nurses utilized interview questions and objective evaluations upon participant enrollment (see further details below) and at the first home visits to establish the needs the participants 112 Nurses used these simple, early interactions to establish positive relationships and also to determine the mothers? ability and motivation to make changes. When nurses were able to recognize the mothers? motivation for change early in the program, they could gear their expectations to the ability and motivational level of the mothers. Appropriate goal setting and presentation of points for change were noted to be critical for the maintenance of a positive working relationship (O?Brien & Baca, 1997). have as well as the resources (strengths) they have available. Nurses used a question and answer format to get the participant to offer her own solutions to problems. For example, the nurse may perceive a need for the mothers to allow their infants to have ?tummy time.? The nurse presents the information about the importance of offering this activity and asks the mother how she thinks she can include this activity for her baby during the day. When the mother is able to offer reasonable solutions to this ?problem,? she gains self-esteem and self-confidence which can be built upon for future solution-focused interactions concerning more difficult situations. O?Brien & Baca (1997) do an excellent job of describing the specific interaction techniques nurses and other home visitors used in the NHVP sites. As previously mentioned, nurses used a question and answer technique to help participants understand the importance and nature of the problems as well as allow them to offer their own solutions. These questions can be classified into several categories. ?Pre-session change questions? are questions the nurses asked participants in an effort to show the mothers that they had made some positive changes in their situations, even if the changes were very small. These questions allowed the nurses to find out how ready for change the mothers might be as well as identify goals they could set together at the beginning of the 113 program. ?Miracle questions? were asked when during conversation or evaluations the mothers expressed concern about a specific problem. Nurses asked questions that would assist the mothers in developing their own action plan for changing their behaviors so that the problem will be solved. These questions allowed the nurses to show the mothers that they can make changes, they can make good decisions to make those changes, are in control of their own behaviors, and can envision a future with the problem solved. ?Exception questions,? ?scaling questions,? and ?coping questions? were also utilized to assist mothers in feeling competent in their abilities to change or have success in addressing/conquering their problems. Nurse also used several ?language techniques? when working with the participants. Nurses tried to reflect back what the participants had said using the participants exact verbiage. When home visitors use the same words participants had used, they are able to reach the participant in a personal and meaningful way. This showed that the nurse was listening to and accepting the participant, which strengthened the relationship (O?Brien & Baca, 1997). When it is time for the nurse to offer information and assistance with a specific intervention point, she tried to convey a message to the mother with whom she is working. Nurses offered the mothers ?compliments? specific to the goal they were trying to attain. Nurses emphasized mothers? competencies and reinforced their belief that the mothers could make necessary changes. The nurses, along with the mothers, identified an action plan with prioritized tasks designed to make progress toward achieving a specific goal. The nurses also provided an explanation for why the goal is important as well as how the tasks identified are designed to achieve the goal. The challenge for the nurses in 114 All of these techniques are evaluated at subsequent visits. Techniques were deemed appropriate and productive if the mother was able to complete the tasks assigned and achieves the goal that was set. When goal completion did not occur, nurses were required to evaluate their own communication and goal setting techniques and make adjustments. O?Brien & Baca (1997) stated the program administrators did not view lack of goal attainment as failure, but useful information that is now to be used to make adjustments in the program service delivery. The techniques identified and described in the O?Brien & Baca (1997) article are those used in all of the Nurse Home Visiting Programs described in the following section. this process was to set goals that would be attainable by the mothers, present the goal in a way that will be received positively by the mothers, and identify and assign tasks that match the mothers? motivation and ability to change (O?Brien & Baca, 1997). The Original Elmira Nurse Home Visiting Program Participants in the Elmira program were recruited from private obstetrics offices and free clinics in a moderately sized county in Appalachian New York State. Pregnant women were invited to participate if they had had no previous live births, were less than 26 weeks pregnant at enrollment, and were any one of the following ? young (under 19), single parent, or low SES. If women not meeting these requirements requested to be in the program, she was enrolled as long as she had not previously had a live birth. The final sample consisted of 400 enrollees. Eighty-five percent of those enrolled met at least one of the risk criterion (teenage, single, or low SES). No participants had previously had a live birth. Eighty-nine percent were white. 115 The sample was stratified and participants were randomly assigned to one of four treatment groups. Group one (n=94) received sensory and developmental screening for their children at 12 and 24 months of age. Group two (n=90) received sensory and developmental screenings for their children at 12 and 24 months of age and free transportation for prenatal and well-child care appointments through the child?s 2 nd birthday. Group three (n=100) received the same screenings and transportation as group two, and also received a nurse who came to their homes during their pregnancies. Group four (n=116) received the same treatments as group three, and they continued to receive nurse home visits through their children?s second birthdays. For the purposes of analysis, groups one and two were combined and compared to the combination of groups three and four. Nurse home visitors provided prenatal home visits for 206 participants and continued visits for another two years with 116 participants. Five registered nurses were hired though an independent agency to work exclusively with this program. Each nurse carried a caseload of 20 to 25 families and was supervised in the clinical (home visiting) setting regularly. The home visits included structured curriculum-type lessons that were prescribed for each session. However, nurses were given great latitude in implementing those lessons considering a primary emphasis of the program was to create a close relationship between the nurses and the mothers participating. Nurses were instructed to take individual needs and participant goals into consideration (Campbell, 1994; Kitzman, Cole, Yoos, & Olds, 1997). The Elmira study involved a number of interviews, assessments, and follow-ups. Children and their mothers from the study were followed, interviewed and tested until the 116 In-home observations and interviews were conducted to assess mother-child interactions (looking at maternal warmth, control, and involvement) and home safety hazards including seat belt and car seat use and control of poisonous substances in the home. Results from the Elmira Nurse Home Visiting Program are outcome-oriented, focused on children?s health and well-being. Women who were active participants in the program prenatally improved their own health and had healthier babies especially if the mothers were smokers. Program effects were greatest for unmarried, low-income mothers. These effects were most prevalent in the 4 to 15 years after the program ended. This result was correlated with mothers? sense of mastery and control in their caregiving and life circumstances. Mothers in the home visiting program were found to have higher senses of mastery and control over their lives compared to mothers not receiving home visits. This implies that the nurse visitation helps poor, young mothers feel more competent and confident in their caregiving skills. children?s 15 th birthday. Interviews and assessments were completed upon enrollment (or the 30 th week of pregnancy), and at the 24 th , 36 th , 46 th , and 48 th month, and 15 th year of the children?s lives. The study completion rate was 81% for the originally randomized participants overall; 90% of women carrying to full term and who did not give their children up for adoption completed the all assessments. The majority of the assessments were completed without the interviewer knowing which treatment group the mothers were originally assigned to. The Memphis Nurse Home Visiting Program The Memphis Nurse Home Visiting Program utilized the Elmira program as a model. The description and results of this study were published by Olds, Henderson, 117 Participants in the Memphis study were assigned to one of three treatment groups during three different time frames of the recruitment period (15 months). An additional treatment group was created during the later months of the enrollment period intended to decrease the mothers assigned to the home visiting groups. Mothers assigned to group one only received free transportation to and from prenatal appointments (n=166). Mothers assigned to group two (n=515) received free transportation for prenatal appointment and their children were developmentally assessed and referral services were provided when the child was 6, 12, and 24 months. Mothers assigned to group three (n=230) received all services offered to group two, and they participated in intensive home visits prenatally, were visited once in the hospital after delivery, and visited once at home after discharge. Mothers assigned to group four (n=228) received all the services described for group 3 as well as home visits for the two years after the child?s birth (until child?s second birthday) (Olds et al., 1998). Kitzman, Eckenrode, Cole, & Tatelbaum (1998). It was designed to service a different demographic from the Elmira study, and modifications were made to address the specific needs of this new participant group. Participants in the Memphis program were recruited from the obstetrical clinic at the Regional Medical Center in Memphis and were subject to the same selection criteria as those in the Elmira study. The final sample consisted of 1139 enrollees. The majority of participants were African American (92%), single (97%), young (age 18 or under at enrollment; 65%), and low income (85% at or below federal poverty line). Like the Elmira program, mothers in the Memphis program were interviewed and assessed by research staff at enrollment and throughout the program. At enrollment, 118 mothers were asked demographic, mental health, personality, and child-rearing beliefs and practices questions. Mothers were interviewed at the 28 th and 36 th weeks before delivery and 6, 12, and 24 months after their children were born. Mothers were also assessed on their cognitive functioning and maternal control, self-efficacy, and childrearing confidence and competence. The results of these assessments functioned as an index for mother sense of mastery. When children were 6 months old, they and their mothers were interviewed and observed in a laboratory setting to determine rates of breast feeding, beliefs about child abuse and neglect and child rearing, and mothers? childrearing practices as they were involved in a developmentally challenging activity set up by the researchers. Mothers were observed and scored on their caregiving behaviors such as sensitivity, responsiveness, and quality of instruction. Children were observed and scored on their responsiveness and level/quality of communication toward their mothers. Mothers completed the interview assessments in the research offices again when their children were 12 and 24 months old. The mother-child interaction task and observation were repeated as well. During home visits at these time points, researchers completed the HOME inventory (Olds et al., 1998). Results from the Memphis study were substantially different from the Elmira study. In the Memphis program, 96% of the participants in the home visitation conditions completed assessments through the child?s second birthday. There were no program effects on new-born health. Mothers participating in home visiting were less likely to have beliefs about child-rearing and practices associated with child abuse and neglect, their homes were rated as more environmentally acceptable for children as measured by the HOME, and they had the least number of emergency medical incidents with their 119 It is clear when comparing the two programs that more success, as measured by child outcomes, were found with the Elmira program. Why the Elmira program ?worked? and the Memphis program did not have as dramatic of effects is not clear. For both programs, nurse home visitors were trained to model and educate mothers on appropriate caregiving behaviors and practices. For both programs, mothers in the most dire conditions (youngest, poorest, least efficacious at enrollment) changed their lifestyles and caregiving practices the most in a positive direction. Successful participants and their children were seen in both programs to improve their environments and life courses well after the program had ended. However, it is left to speculation as to how or why some participants have these positive results and others do not when the program is designed and delivered similarly to all participants. children. Children?s health and well-being was most positive for mothers participating in home visits. Children of mothers who had the fewest psychological resources were observed to be more responsive and higher quality communication toward their mothers, however, their mothers were not observed to be more sensitive or responsive during interactions at the laboratory observation (Olds, et al., 1998). Comparing Elmira to Memphis An attempt to explain the differences between the Elmira and Memphis programs is outlined in the Kitzman, Cole, Yoos, & Olds (1997) article by taking a qualitative look at the Memphis program. To do so, full-time nurses were asked to choose two families and report in a systematic, structured way detailed information about service delivery. The nurses chose one family exhibiting typical progress in the program and normal family processes development. The other family to be chosen was to be one at high risk 120 In the Kitzman et al (1997) article, the main purpose of the analysis was to determine global challenges common to all participants in the program. In this process the characteristics of the nurses were identified. Seventeen nurses were hired by the Memphis-Shelby County Health Department. Ten of the nurses were white, seven African-American, ranged in age from 28 to 50 years, and 13 had children of their own. Their clients were all African-American and ranged in age from 13 to 26 years. The nurses tape-recorded their descriptions of each visit with the chosen sub-section of mothers and these comments were recorded after each visit from start to finish. The tape recordings were begun after the first visit during the pregnancy and ended when the mother completed the program. Mothers participated in the program from 7 to 29 months with an average participation of 17.3 months. Over 100 pages of transcription for each of the families were gathered. for having positive outcomes even though they were receiving the home visits. Part-time nurses were asked to choose one family in the high risk category. A total of 27 families were chosen for this analysis. The transcriptions were analyzed for content concerning nurse-mother interaction types. Specific themes were identified that characterized the interactions over time. These themes were then interpreted by looking at cultural and social theories in the literature, discussions with other experts in the field, and the nurse home visitors themselves. Characteristics of both the mothers, the nurses, and the relationship as well as the greater social context in which these interactions take place are identified as contributors to the successes and challenges reported in the nurse narratives. Kitzman et al (1997) identified nine main challenges reported throughout the narratives. 121 The primary, and chronologically first, challenge identified by the nurses in working with their clients concerned creating the relationship in the first place. Nurses were asked to visit low income, young, first time mothers in their homes over a period of two years. It was reported that nurses often had difficulty making and keeping appointments with their clients at the beginning of the home visiting process. Even though mothers had committed to the program, nurses reported problems in gaining the mothers? trust and working with mothers who took the program seriously enough to make keeping appointments a priority. When appointments were kept, nurses were hard pressed to complete the objectives for that visit because the client was in control of the timing of that visit. Because the visits are at the clients? homes, the clients are in control of nurses gaining access to them. Nurses reported that mothers frequently cancelled or missed appointments for a variety of reasons. Sometimes mothers simply forgot or had other obligations that got in the way of the home visits. Sometimes mothers were described as not being organized and not used to keeping schedules or appointments in general. Making and keeping appointments was not part of the mothers? repertoire of social skills. Often nurse reported that mothers would change the location of the visits at the last minute as the mothers decided to stay with friends or other relatives on the day of the visit. On some occasions, nurses reported they felt the cancellations and missed appointments of some of their clients were intentional. Nurses viewed this behavior as a result of not being committed to the program. Again, the main purpose of the home visiting program was to regularly visit mothers in their homes over a period of time. Part of making this happen involved 122 Kitzman et al (1997) reported that nurses attempted to identify why mothers cancelled or missed visits. Once the nurses were able to identify the nature of the challenges in this domain, they were able to develop an individualized plan to address the problem in a way that would be most beneficial to the nurse-client relationship. Nurses described a type of ?risk/benefit ratio? decision making rule in how and when to address the situation. Nurses reported feeling they could not confront these issues because they were afraid of losing a client altogether. Nurses also reported they did look at the cause of the missed visits and would confront clients with the situation if the cause was thought as harmful to the client even if the risk of having the client drop out of the program was great. Analysis of the narratives indicated that nurses based their decisions about addressing the challenge of keeping appointments on the type of conflict and cause that was associated with the missed visits. No association with nurse characteristics was noted in the method, timing, or results of nurses addressing this specific challenge. gaining the trust of the mothers. Nurses had to balance the demands of the program with the individual relationships and needs of the mothers. If nurses pushed program goals too hard, mothers might decide the program was too demanding and drop out. If nurses were not flexible to the mothers? scheduling issues, nurses might never be able to make an appointment that could be kept. If nurses broached a subject required by the program in an insensitive or offensive way, the mothers might be turned off to the program and the nurse and no longer be an active participant during the remainder of the program or drop out completely. Nurse narrations identified the home environment as a significant challenge to being successful in the program. Frequent difficulty in finding a private or even quiet 123 location to discuss program objective was cited. Nurses were often unable to demonstrate a program objective due to the lack of resources within the home. For example, nurses might not be able to demonstrate reading to the child if no books were in the home. Nurses reported having to prioritize the health and safety concerns they had so not to overwhelm the mothers with environmental improvements that must be made. For example, nurses would address the need for the mother to make poison hazards (cleaning supplies, insect poisons, etc.) inaccessible, but would not address less dangerous hazards such as temperature of the hot water in the bathroom until the nurses felt the mothers would have more resources (physical and psychological) to deal with that issue. The third challenge identified in the nurse narrations involved extended family members and multiple caregivers in the home. Nurses reported they often had difficulty in identifying and understanding the multiple caregivers in the homes. Fathers, grandmothers, and other extended family member and even friends were often involved in the children?s care. Nurses expressed difficulty in determining which issues needed to be brought up with the mothers alone and which should involve the other caregivers. Nurses often were not aware that the mothers wanted or did not want a grandmother or father involved in the program objective for the day. When extended caregivers wanted to be a part of the program, nurses reported being unsure of how much of the program?s resources should be invested in direct service delivery to non-mothers. Frequently these other family members had their own sets of problems and needs for intervention and assistance that was within the skill level of the nurses but outside the scope of the program. Time spent addressing these issues meant time not spent with the mothers and program goals. An opposite type of challenge by these same extended family caregivers 124 As previously stated, the nurses were required to deliver the program goals and lessons while being sensitive to the individual needs of the mothers. The program was designed with over-arching goals and objectives but enough flexibility was built in to address client-specific needs not part of the program itself as well as client-specific needs in method and timing of service delivery. The nurses main objective in service delivery was to teach new mothers self-help skills in promoting the health and well-being of their newborns. Some of the client-specific needs that presented challenges to service delivery were limited literacy skills, acceptance of the program?s teachings, and time investment. Nurses reported that mothers and their families were often unreceptive to the program objectives because they did not agree with these ways of caring for children and because they felt the goals would take too much time and effort to implement on their own. Mothers expressed that they would not or could not meet program goals because they were already spending all of their time simply trying to survive. Nurses did not report mothers to be uncaring or unconcerned about their children, rather mothers did not understand how to implement program goals in light of their other commitments and stresses. Nurses then had to provide service deliver in such as way as to show mothers that they could change their routines and activities to meet both the basic needs of the family and the program objectives. was noted when these people were not open to the objectives and suggestions offered by the nurses. In these cases, the other family members created a barrier between the nurse and the mother resulting in lack of service delivery. Nurses reported another aspect of the balance of the relationship and service delivery protocols concerning the mental, economic, and psychological abilities of 125 mothers to implement program objectives. Nurses often had difficulty in determining what was too much and too little information and instruction and assignment to give the mothers. It was reported to be difficult to gage the amount of instruction relevant to program objectives during any given visit because nurses were evaluating the ability of the mothers to be able to understand and complete program objectives. Nurses battled the desire to ?take over? and do too much for the client, thereby hampering the client?s ability to learn self-help skills and be independent, and the desire to not present any material at all, thereby not giving the client the chance to receive or participate in a particular aspect of the program. Nurses stated that they made their decisions on their levels of involvement based on perceived client needs, resources, abilities, and previous experience with the client in carrying out program tasks. Nurses reported two main reasons for doing tasks for the mothers that the program protocol assigned for the mothers to do. First, nurses noted they would do a task for the mothers in an effort to show the mother that the nurse cared for her and wanted to give the mother a sense that the nurse was invested in her success. Second, nurses noted they would do a task for the mothers when the nurse thought the mother would experience failure in attempting the task and that failure would risk the mother?s participation in the remainder of the program. The sixth main challenge to completing the program successfully is also related to the idea of balancing program demands and client needs. Nurses reported that there were times during the program that mothers were unable to meet program goals because of the mothers? developmental progress. On some occasions, mothers had returned to work or school making it difficult to schedule a time to visit when the mother was home and 126 Nurses also reported it was difficult to help these mothers understand that the skills and goals involved in the program were designed to help the mother in the future. Often the needs of the mothers and their families were immediate and pragmatic. Nurses were faced with trying to teach long-lasting problem-solving skills while needing to make immediate changes for which the mothers were not yet skilled in handling. The home visit program is future-oriented while circumstances the mothers and families are in are more immediate. It was difficult to teach mothers how to prevent problems and gain the skills to work through things that might come up in the future when today the mother is needing electricity restored to her home or has run out of formula and has no money with which to get more. difficult for the mother to have additional tasks other than work/school and raising a child. Nurses had to balance the needs of the family and mother against needs of the program and the child. While several of the nurses in the Memphis Trial were of similar ethnic background with their clients, the nurses reported a need to understand the cultural background and surround of the clients. Nurses, as previously reported, were older than their clients, were professionals, and may or may not have children of their own. The clients were all young and of low-income, African-American background. Nurses noted that they had to understand and learn about the mothers? culture and lifestyle in order to provide workable solutions to problems. Nurses frequently had to find ways to offer assistance and suggestions that did not conflict with the clients? cultural upbringing and would not change their lifestyles drastically while maintaining program goals and objectives. However, nurses reported that it was challenging at best to determine if a 127 The final challenge identified by Kitzman, et al., (1997) focused on the mothers? psyche. Nurses stated that they often felt that mothers and their families needed a break from the regularity of the home visits and wanted time to assimilate the lessons learned from earlier participation in the program. Some nurses reported that mothers were overwhelmed with day-to-day activities of survival and often felt pressure when the goal- oriented program approach was presented by the nurses. When these conflicts arose, mothers often resisted change and the assistance offered by the nurses via the program. Nurses had to design service delivery methods that would convey the information in a way that individual mothers would best receive and use it. Nurses had to be creative in their methods and almost make the mothers believe they had come up with the technique or information or idea on their own rather than it having been something they were taught by the nurse as part of the program. Mothers had to be prepared to receive the information before they became receptive to it and actually put the lessons and techniques into practice. caregiving practice stemmed from a culture belief or lifestyle that was in and of itself damaging to the mother and her child. These challenges identified by the nurses in their collective 2700 pages of narrative were pervasive and ever-present in the two-year protocol with the selected families. No distinction was made between challenges presented by families nurses thought would be high risk for completion and success and those nurses thought were ?average? participants. The challenges were bigger than just the mothers or the mother- nurse relationship. They involved a broader social, cultural, family, and environmental context. The nurses met these challenges by being flexible and creative in service 128 In conclusion, Kitzman et al. (1997) stated that it was of utmost importance to the success of the program that the nurses be sensitive to the individual culture, environment, and personal context and needs of each participant. Flexibility was key. In order for the program objectives to be delivered successfully and have mothers improve their caregiving abilities, nurses had to be sensitive, flexible, and creative in service delivery methods. delivery with their clients with an overarching goal of maintaining the relationship even at the cost of no longer offering all aspects of the program protocol. Nurses had to work hard at recruiting other family members into the program to support the mother in making behavioral and environmental changes. Nurses had to work even harder at retaining the mothers in the program for the entire protocol. In order to examine more closely what processes may be taking place within the nurse-client relationship Kitzman, Yoos, Cole, Korfmacher, & Hanks (1997) followed a single nurse-client relationship qualitatively through the course of the program. In this case study, Kitzman and colleagues (1997b) took an in-depth look at the many facets and challenges involved in administering this type of program in a single nurse-client relationship. The nurse had to plan for both short- and long-term goals relevant to both the program and the client?s needs. Each activity or lesson brought to the mother at her home was carefully designed and administered in an effort to promote problem-solving skills and more positive caregiving behaviors for the mother. The activities were designed to build upon one another and have an additive effect so that mothers would be able to cope successfully with stresses and offer adaptive and developmentally appropriate caregiving behaviors to her child after the protocol was complete. 129 In the case analysis, Kitzman et al (1997b) determined that the relationship had to be based on trust in order for the client to be open to the information and be engaged in the lessons in the context of the home visit. The nurse involved in this case study constantly reported that external factors (family and environmental context) and the mother?s personal goals and agendas often interfered with the administration of the program protocols. The nurse reported she frequently had to assist the mother with balancing her own needs, her family?s needs, and the needs of the program and her child. By helping the mother problem solve challenges posed by her family and environmental context, the nurse veered away from the program protocol. In the long run these deviations served to strengthen the relationship between the nurse and the mother as well as create more opportunities to administer the program on subsequent visits (Kitzman et al., 1997b). Kitzman et al., (1997b) began the conversation of program processes. Olds and Korfmacher (1998) took the next step by applying a ?person-focused? perspective with which to examine the questions ?for whom did the intervention best work?,? ?under what conditions did the intervention work?,? and ?how did the intervention bring about change?? Olds and Korfmacher (1998) explored aspects of the participating mothers? internal characteristics as contributors to program success or failure. The authors acknowledge that most intervention programs focus their analyses and results on program outcomes rather than program processes. While intervention program outcomes are often reported in reference to the entire group of subjects, person-focused analyses are done looking at individuals and individual relationships. Olds and Korfmacher (1998) looked at the conditions in which individuals 130 in the program had the best and worst outcomes. The theoretical background guiding their analyses included the idea of mastery and sense of control as well as availability and utility of psychological resources (e.g., intelligence, mental health stability, and positive coping abilities) in the participants. Using the mothers enrolled in the Elmira sample (see previous description of the Elmira Nurse Home Visitor Program), Olds and Korfmacher (1998) hypothesized that mothers would participate differently in the program based on their level of mastery and control and psychological resources. Mothers (as perceived by the nurses delivering the program to them) with fewest psychological resources and lowest sense of control were expected to have nurses interact with them more intensely, schedule more visits with them, and would be more actively involved in facilitating the mothers? success in the program. It was expected that nurses would see these mothers as needing the program the most. Mothers (as perceived by the nurses) with the most psychological resources and sense of control were expected to participate more actively in the program by keeping scheduled appointments and initiating contacts with the nurse as opposed to the nurses always contacting these mothers. In the Elmira trial, 400 young, pregnant, low-income, white, first time mothers were enrolled in the program. Olds and Korfmacher (1998) utilized the sub-section of mothers assigned to the complete, 2-year nurse home visiting program to explore their hypotheses (n=99 in the final sample). Nurses visited their clients approximately bi- weekly, but this schedule could be modified to meet the individual needs of the mothers and their families. Completed visits ranged from 0- 67 for this sample. The average number of completed prenatal visits was nine; postnatal visits was 23. Nurses also contacted their clients by phone between visits. Phone consultation lasted an average of 131 5.2 minutes per call, and the average number of completed nurse-client calls was 14 (range, 0-58). Total contact time by phone and in person was used to calculate level of participation and involvement in the program by both the nurses and the mothers. Phone calls were subdivided into those made by nurses and those made by the mothers. Contact time was the dependent variable in these analyses. Maternal sense of control was used as the independent variable in these analyses. Mothers? sense of control and mastery was measured using a modification of the Rotter?s Locus of Control scale. High scorers were labeled as feeling more in control than low scorers. The variables of social class and support from a male significant other were used as controls (Olds & Korfmacher, 1998). Olds and Korfmacher (1998) found that mothers? sense of control predicted the number of home visits that were completed. Mothers with the lowest levels of control received the most visits by the nurses. Some mothers at the highest end of the control measure were found to receive more visits by the nurses than mothers at just lower levels. The high control mothers also spent more time in phone conversations initiated by the mothers with the nurses than their lower control counterparts. Time spent in phone conversations initiated by the nurses was not significantly different for high and low control groups. The control variable of SES was not related to the duration and frequency of visits or phone calls for either group of mothers. However, when a male support person was involved, it negatively impacted the frequency and duration of calls initiated by the nurses. Male support was not related to duration or frequency of calls initiated by the mothers. Olds and Korfmacher (1998) also tested their hypotheses on participants in the Memphis Nurse Home Visitor Program (n = 207 who completed the 2-year home visiting 132 program). These analyses were aided by the narrative reporting and record-keeping systems employed by the nurses in the Memphis trial. Investigators were able to determine not only the frequency and duration of the phone contacts, but also the frequency and duration of the home visits themselves. Number of completed home visits and length of telephone contacts were used as two indicators of program involvement when comparing mothers from the Elmira and Memphis programs. Mothers in the Memphis program were seen by nurse home visitors slightly more than the mothers in the Elmira program. Mothers in the Memphis program received 4 times as much phone consultation when compared to the Elmira program. Olds and Korfmacher (1998) found that as Memphis program participants? psychological resources improved or increased, home visitation participation decreased, but for mothers with the highest level of psychological resources throughout the program?s duration, nurses completed the most visits. Memphis program mothers who were lowest in SES were visited by nurses more often than those in a high SES category. SES in the Memphis program did predict number of visits mothers would complete. Support from a male significant other did not predict participation in the program in any way. When mothers? work status was factored in, it predicted number of visits completed and was related to psychological resources. Mothers who worked the most months during the program?s duration received the fewest home visits but had high levels of psychological resources. There were no relationships found among the predictor variables and nurse-mother phone contact after babies were born. Olds and Korfmacher (1998) summarized that when mothers? level of control and psychological resources are identified by nurses, number of completed home visits can be 133 predicted. Nurses who perceived mothers to be low in control and low in psychological resources attempted to schedule more contacts with those clients and actually completed more of those contacts than with mothers having higher levels of control and psychological resources. Mothers with the highest level of control and psychological resources were more apt to make and keep visits with the nurses when they could be made, but making these appointments was often reported to be difficult due to mothers? outside-the-home commitments. These high control/high psychological resources mothers also initiated more contacts with their nurses than the low control/low psychological resources mothers. In conclusion, Olds and Korfmacher (1998) made the following suggestions for program improvement and development. Flexibility in program delivery and scheduling is important to facilitate participation in the program. It is recommended that people administering the program, in this case nurses, be given a balanced caseload. Nurses need a client base with differing levels of need so that each participant can receive adequate levels of service. Those on the front line administering programs perceive their clients in different ways. These perceptions influence how program services and resources are parceled out. In the case of the Elmira and Memphis programs, when nurses perceived mothers to need the most assistance, they attempted to meet those needs by scheduling more service delivery points (in person and by phone). To follow up, Korfmacher, Kitzman, & Olds (1998) published an article designed to explore, explain, and discuss how the variations (identified in previously reviewed articles above) in how nurses delivered program services may mediate program effects. Korfmacher et al. (1998) utilized the participants from the Memphis Nurse Home Visitor 134 Korfmacher et al. (1998) operationalized program involvement as length of time participating, level of services addressing parenting specifically, and the emotional quality of the nurse-mother relationship. First, the investigators sought to determine whether or not the program was effective, then determined for whom it was most and least effective, and finally explored the program processes that lead to program success or lack thereof. Program success was measured with parenting assessments such as attitude toward parenting, home environments, and parenting behaviors as observed during mother-child interactions. Korfmacher and associates (1998) hypothesized that program processes or variability in service delivery could predict program effects. It was expected that the quality and the quantity of service delivery would explain the differences in program outcomes. Specifically, investigators expected that mothers who participated more often and actively and received targeted programmatic instruction (information on appropriate caregiving) would be assessed at the end of the program as offering a more warm, nurturing, safe environment and have overall better child health and development outcomes than mothers who participated the least (both qualitatively and quantitatively) or received information not directly related to caregiving. Program (n=228). In this article, the authors describe in detail the program itself ? participants and procedures ? and evaluate the program in terms of the processes to identify differences in service delivery and how those differences are related to differential program outcomes. Associations between differential program outcomes and program participation and whether or not the nurses actually delivered the program as designed are analyses and discussed. 135 Mother participation was measured by calculating the amount of time spent actively participating during home visits with respect to time on program-specific information (i.e., caregiving skills). Mothers? emotional participation in the program was measured by having the nurses complete a 12-question survey on involvement after each visit. These items included mothers? attentiveness, attitude (positive or negative) toward the nurse and the information presented, nurse perceptions of what the mothers actually understood about the information presented in each session, and the amount of problem- solving skills instruction and practice that took place during each session. The mothers were asked to assess the nurse-client relationship at the end of the program (2 years after the child?s birth). Investigators utilized a 27-item ?Helping Relationships Inventory.? This measures was designed to determine the mothers? perception of the quality of their relationship with the nurses, how much they thought the nurses understood their individual circumstances, and how much acceptance and sensitivity the nurses offered. Outcome measures included assessments of mothers? caregiving/parenting beliefs (including empathy toward child) and behaviors, quality of mother-child interactions, demographics, psychological resources, and maternal empathy (Korfmacher, et al., 1998). The average amount of nurse-mother contact was 32 hours from time of enrollment (prenatally) to the child?s second birthday. Twenty-six of those contact hours were spent during home visits. Most mothers only received half of the prescribed number of visits as per the original home visiting protocol. Investigators found that during the visits that were kept, mothers were described as emotionally engaged and actively participating in the visits. Mothers with high levels of empathy toward their children and 136 nurses level of empathy with the mothers was significantly related to program outcomes. Psychological resources accounted for 28% of the variance in empathy scores at the end of the program. Psychological resources, mother engagement level, nurse empathy, and quality of service delivery (staying focused on targeted instruction on caregiving skills) contributed to variability in scores on the HOME inventory (17% of variance explained). Specifically, results suggest that mothers with the lowest levels of psychological resources and who received high levels of caregiving instruction during visits had higher scores on the HOME inventory at the end of the program. Korfmacher et al., (1998) concluded that the program?s effects were meditated by the nurse-mother relationship and the mothers? psychological resources. Investigators focused some discussion on the finding that most mothers did not received the number of visits deemed necessary for program delivery and success. This is an important aspect of programmatic evaluation in that it is critical for programs to determine as near as possible the required number of visits to ensure effectiveness. It appears that while nurses were flexible in their scheduling, it was not damaging to the objectives of the program. Investigators concluded that different participants with differing needs, individual abilities, and resources, may require different levels of intervention and services to achieve the same positive outcomes. Results also indicate that when the nurse-client relationship was strong and positive in nature, participants were more actively engaged in the program and had more successful outcomes regardless of contact. It appears that quality versus quantity of contact is most important in program success (Korfmacher, et al., 1998). 137 To this point, investigators involved with these studies have examined mother characteristics, nurse characteristics, environmental influences, and characteristics of the nurse-mother relationship in an effort to describe and explain program effectiveness and processes. The addition of the Memphis site to the Nurse Home Visiting Program has been beneficial in the effort to determine and explain how this program works and can produce successful outcomes for its participants. The Memphis site offered researchers a unique demographic of participants that could be compared to the participants in the Elmira trial. As the programs evolved, so to did the research questions. In 1997, the Nurse Home Visiting Program was expanded to a third site ? Denver, Colorado. The addition of this third site resulted in additional opportunities to replicate studies assessing program effectiveness and process. The Addition of the Denver, CO site and Comparison to Elimra and Memphis Hiatt, Sampson, & Baird (1997) utilized information gathered in the Home Visitation 2000 program which was administered in Denver, Colorado. This nurse-home visitor program was modeled on the Elmira and Memphis home visit program trials. Home Visitation 2000 was developed in such a way as to be able to identify and evaluate specific program implementation and service delivery processes as they related to differing characteristics of the persons delivering the program. Home visitors in the Denver program were all paraprofessionals. The main point of replicating the Nurse Home Visitor program in Denver was to determine whether or not the program could be successful using paraprofessionals as home visitors. Hiatt et al. (1997) compared the service delivery processes and outcomes between mothers working with professional nurses and those receiving services through a paraprofessional. In addition to this goal, 138 All nurses employed in Home Visitation 2000 had bachelor?s degrees or higher. The paraprofessionals had high school degrees, but no professional training or education in the health professions, education, or social work fields. The paraprofessionals were all familiar with their communities and the community resources available to new mothers. All of the paraprofessionals were mothers. Over 70% of the nurses were also mothers themselves. Paraprofessionals were younger on average than the nurses. Hiatt et al. (1997) expected that when those administering the home visit s (nurses and paraprofessionals) were also mothers, that shared experience of motherhood was facilitate a closer and more productive relationships with the new mothers participating in the program. Hiatt and colleagues (1997) found many challenges associated with implementing a program designed to be delivered by professional nurses being delivered by paraprofessionals. A description of hiring practices is outlined in this article. Parapro?s who were hired as home visitors came from a variety of ethnic, SES, and experiential backgrounds. Program administrators specifically looked for and hired paraprofessionals with personalities and work-styles that would facilitate creation of a trusting relationship. Staff must be excellent communicators, be good role models for their clients, and have the ability to gain the trust of their clients. Formal interviewing protocols did not lend themselves to gathering this information. While the program described here sought to hire parapro?s with these characteristics, it was not always successful in doing so. Denver program administrators found that paraprofessionals needed assistance with being seen as credible by the community agencies they interfaced with as well as their nurse counterparts within the program. Parapro?s in the program reported they felt 139 Program administrators addressed credibility issues through a process of professionalization and training. Administrators had to find ways to allow parapro?s development to take place without damaging their self-esteem and image as well as keep their momentum going. Training included assistance in developing appropriate social skills, monitoring feelings and self-evaluation in order to facilitate positive work-place interactions, and instruction on creating and maintaining boundaries so as to keep personal and professional relationships separate. Pre-service training took place in a classroom setting. Parapro?s attended over 50 clock hours of training before beginning work with clients. Once this formalized pre-service training was complete, the parapro?s delivered program services to two or three pilot families before administering the complete protocol to program families. Home visitors were supervised regularly and received on-going training throughout the program?s length. other agencies and the nurses did not believe they were competent or trained enough to do their jobs appropriately. This perception may have been something within the parapro?s themselves (and not a real feeling nurses or other agencies had about them), but this feeling resulted in anxiety in the workplace. Program administrators reported they had to design support systems within the program to train and support the parapro?s specifically to alleviate these feelings (Hiatt, et al., 1997). A key component of the training protocol involved assisting parapro?s with their relationship skills. The relationship between the client and the service provider is paramount to the success of a program. Visiting clients in the comfort of their own homes goes far in the process of creating a comfortable environment for clients to receive information and evaluation. Hiatt et al (1997) articulated that the first visit was vital to 140 Significant levels of training on professionalism are required when employing paraprofessionals. Parapro?s were hired in this study in part because their ability to relate to their clients resulting from the parapro?s congruent backgrounds with the target client population. When people have shared experiences, they may tend to blur the boundaries between the client-mother relationship and be involved in more of a friendship. Friendships can result in developing a close, trusting relationship, but they can also prohibit offering criticisms and suggestions for correcting behaviors as is required by the program protocols. The empathy a parapro can feel with a client can be a strong asset in the relationship-building process, but also can be a deterent to offering the necessary criticisms involved in a training and behavior modification program. setting the relationship off on the right foot. Training parapro?s in relationship building and maintenance is necessary to setting the foundation of the relationship at that first visit. In summary, results from this study showed that parapro?s were equally competent, given appropriate training and supervision, as professional nurses in administering the program as delineated in the program protocol. However, additional and specialized training was required to achieve that result. Parapro?s required assistance in relationship building and maintenance skills as well as developing boundaries with their clients. Parapro?s were reported to have addressed the program content in unique ways compared to the nurses, but program outcomes were similar for mothers in both groups. Comprehensively, the Nurse Home Visiting Program as administered in all three of its locations, has been a success. The research coming out of evaluating a variety of 141 aspects about this program has started a conversation about processes involved in implementing relationship-based interventions. The detailed descriptions of all aspects of the program and depth of information available to test a variety of hypotheses offers other researchers interested in program design, implementation, and evaluation a firm foundation on which to base subsequent research. 142 APPENDIX B Family Day Care Rating Scale