Integrated Case Management: A Preliminary Study To Determine What Helps And What Hinders -The Parent Perspective Victor J. Gladish B.Sc. (Kin.), University of Waterloo, 1976 P.D.P., Simon Fraser University, 1977 Project Submitted In Partial Fulfillment Of The Requirements For The Degree Of Master of Education ill Educational Counselling The University ofNorthem British Columbia March 2006 © Victor J. Gladish, 2006 UNIVERSITV 0f IOI=!THERN BR JTI~,,- ,;'- _lJIVit31A LIBPA.RY Prmce George, B.C. ICM: What helps and what hinders? m Abstract This preliminary study explored what helped and hindered the Integrated Case Management Care Team process from the parents' perspective. The researcher conducted 8 semistructured interviews with 10 parents of children who have had an I CM Care Team within the past 3 years. The data was analyzed using Flanagan' s (1954) Critical Incident Technique (CIT). In striving to meet modern standards for the CIT (Butterfield, Borgen, Amundson, & Maglio, 2005), several procedures were used to examine the reliability and validity of the categories. One hundred eighteen incidents were found to be helpful in achieving the aims of the Care Team, while 60 were found to be hindering in achieving those aims. A total of 8 categories and 15 subcategories became the organizational scheme ofthe data. A majority of the incidents are represented by these categories: (a) Structure and Function of the Team; (b) Outcomes; (c) The Team Members; (d) Communication; and (e) Cultural Issues. As in previous studies (e.g., Rutman, Hubberstey, Hume, & Tait, 1998), communication was found to be a vital aspect ofiCM. An overarching theme that emerged is that parents value the care team process and the commitment that the members demonstrate towards their children. However they also all expressed concerns with the agencies providing services to children and with the school system - and this often was related to budgets, power, and bureaucracy. Several helpful hints for successful Care Teams are provided. The parents in this study emphasized that they need to feel valued and respected as members of their child ' s Care Team. Moreover, they stated that this is achieved when they are involved in decision making, when they are treated as equal to other team members, and when they are regarded as being an expert on their own child. ICM: What helps and what hinders? Table of Contents Approval Page 11 Abstract m Table ofContents tv List ofTables v1 Acknowledgment vu Chapter One Chapter Two Introduction Integrated Case Management- Defmition 2 Other Collaborative Processes 3 History of Integrated Case Management 4 Author's Background 7 Purpose 7 ~~~ 9 Method 10 The Participants 11 Procedures 12 Determining the aim ofthe activity 14 Setting the Plans, Specifications and Criteria 15 Collecting the Data 16 Analyzing the Data 16 Interpreting and Reporting 18 Ethical Considerations 21 Chapter Three Results 22 Chapter Four Discussion 47 tv ICM: What helps and what hinders? Communication 49 The Team 52 Outcomes (Resources, strategies, and transitions) 56 Follow Through 58 Cultural Issues 59 Summary 61 Benefits ofthe Current Research 62 Limitations 63 Implications for Further Research 66 Conclusion 68 Footnote 72 References 73 Appendix A Wong ' s Interviewing Protocol 82 Appendix B Informed Consent Form 83 Appendix C Consent to conduct research letter 87 v ICM: What helps and what hinders? List of Tables Table 1. Page The% Agreement Between the Judges' and the Researcher' s Category Scheme 2. 19 Participation Rates for Categories and Subcategories and Number and Proportion of Helpful and Hindering Incidents 23 v1 ICM: What helps and what hinders? vu Acknowledgements Jan -thanks for being such a loving, patient, and supportive wife. You set the standard and convinced me that I could do it too. It just took a little longer! The endless supply of tea and goodies helped a lot. Carl, Jay and Trish- you each helped me in your own, unique ways. Trudy, Corinne, and Rob- I have learned very much from all of this work and you have inspired, coached, and encouraged me through to its conclusion. Thank you. UNBC and especially people like Trudy Mothus and Peter McMillan and the librarians - for going out oftheir way to make it possible for me to do a lot of my learning from home. UNBC beckoned to me 11 years ago when I read that it was being created. The flexibility that was demonstrated by the university community helped me follow this dream. The Abbotsford CIT Group (Rob, Giselle, Mark, Christine, Maryanna, Kristelle, Gordon)Thanks for the support, motivation, and help. And thanks especially to the Parent Participants who saw the importance of this opportunity and who volunteered to be part of my research project. ICM: What helps and what hinders? CHAPTER 1 Introduction "Human beings must be active participants in the unfolding of their own potentialities" (Bopp, Bopp, Brown, & Lane, 1984). Much has been written about, and considerable resources have been dedicated to, integration of services for children, integrated case management and interagency collaboration (Bruner, Kunesh, & Knuth, 1992; Carter, 1997; Franklin & Streeter, 1995; Halfon & Berkowitz, 1993 ; Hubberstey, 2001 ; Meyers, 1993 ; Nelson, McCulloch, & Clague, 1995; Roberts-DeGennaro, 1987; Salmon, 2004; Tate & Hubberstey, 1997). Similar processes such as Wrap-around (Eber & Nelson, 1997; Furman & Jackson, 2002; Pringle et al. , 2002) and Family Conferencing (Bazemore, Griffiths, & Taylor, 1997; Scheiber, 1995) have also been studied. Although the terminology varies, these are all examples of initiatives by schools, communities, social agencies, and health agencies to improve services for children and families in both the United States and Canada in recent decades. Although the aforementioned interventions are planned as collaborative, interdisciplinary approaches for delivery of services to children and families, little is known about what the consumers of these services experience. Whereas " [c] lient satisfaction is a crucial aspect of a competent programme evaluation process . .. and a critical outcome worthy of clinical and administrative attention" (Kapp & Vela, 2004, p.197), the purpose of this study therefore, is to examine the parent experience oflntegrated Case Management (ICM). Using the Critical Incident Technique, this study has attempted to hear, as completely as possible, the voice of one important consumer audience: parents. ICM: What helps and what hinders? 2 Integrated Case Management - Definition Integrated case management has a long history in the medical field and has been used in social work activities since the early 1900s (Halfon & Berkowitz, 1993). These authors state that case management long ago became the practice of choice for high-risk target populations with multifaceted needs requiring the coordination of many services. Integrated case management, as recommended in the Gove Report (1995) and implemented by the newly created Ministry for Children and Families between 1996 and 1998, is a team approach for the integration of mental health, child welfare, probation, education, and other services to children, and goes beyond cooperation between agencies to create something that is greater than the sum of its parts (Tate & Hubberstey, 1997; Woods, 1999). In their report to the Prince George ICM Steering Committee and Ministry of Children and Family Development, Webb, Leeuwen, and Keil (2002) state: The model is characterised by an identifiable philosophical and value base, clear expectations regarding the role of the client in the process and the importance of empowerment, [italics added] and a set of protocols to guide processes such as information sharing, meetings, case planning, and documentation. Formally known as Integrated Case Management, the model is more commonly referred to by its acronym ofiCM (p. iv). Further to this, the British Columbia Ministry ofEducation, in its Special Education Services Manual (n.d.), states ICM is a "preventative intervention process [italics added] which can result in maintaining or returning a young person to a circumstance of least possible intervention". ICM: What helps and what hinders? 3 Other Collaborative Processes Other approaches to collaborative teaming exist and will be briefly described. The wraparound process evolved out of a need for effective school based programming for students with severe emotional and behavioural difficulties (Eber & Nelson, 1997; Eber, Sugai, Smith, & Scott, 2002) and refers to the development of individualized approaches to service delivery for children and families who require help from one or more of child welfare, mental health, special education, juvenile justice, or other agencies. According to Vandenberg and Grealish (1996) there are hundreds of programs in North America that utilize the wraparound philosophy. They emphasize the need for the team to be based in the community and to go beyond the interagency team to also include such stakeholders as clergy and business people while others (e.g., Furman & Jackson, 2002) emphasize the importance of caring for children in their communities with the least restriction possible. Another relevant feature of the wraparound philosophy, especially in light of the topic of the current research project, is the importance of the child and parent voice and ownership in regards to all aspects of planning (Fleming & Monda-Amaya, 2001 ; Vandenberg & Grealish, 1996). The names ofthese two processes (i.e. , ICM and Wrap Around) have been used interchangeably by some practitioners and researchers (e.g. , Hubberstey, 2001). Another form of collaborative practice is Family Group Conferencing (FGC). FGC, a concept that originated in New Zealand, and that is purportedly based in traditional Maori culture (Bazemore et al. , 1997), was to be officially implemented in British Columbia in 1996 (Scheiber, 1995). However, the legislation governing FGC had still not been made law more than a year later (Hansard, 1997) due to concerns about the potential of such conferences for putting children at further risk from family members. According to the ICM: What helps and what hinders? 4 current British Columbia Minister of Children and Family Development (Hagen, 2005), the FGC has now been employed since 2001 in an effort to increase collaboration and parental involvement in planning for their children. The family conference is intended to be a meeting ofthe immediate and extended family groups and selected members ofthe family' s support network with the purpose of developing interventions for child abuse and ensuring the safety of the child. FGC has therefore been implemented as a culturally appropriate intervention for Aboriginal children and families (Waites, Macgowan, Pennell, Carlton-LaNey, & Weil, 2004). Criticism ofFGC in Canada has, nevertheless, been most vigorous from Aboriginal women and has been brought into disrepute and even discredited entirely, in some Aboriginal settings (Bazemore et al. , 1997). Consequently, FGC is being implemented with some caution. All of these forms of collaboration are being used in some form in the Province of British Columbia. History of Integrated Case Management Integrated Case Management, Wrap Around and Family Group Conferencing are examples ofthe movement away from top-down systems of service delivery and towards interagency collaboration. In the U.K. , as in many jurisdictions, collaboration is now either recommended practice or a legislated requirement (Salmon, 2004). Local school boards, such as School District #33, have embraced teaming as part of their student service delivery model (Downey, Mackie, Marchant, & Pratt, 1998), with the result that school based teams, case management teams, ICM Care Teams, and case conferences are now part of the culture of most schools. The collaboration between social service agencies and schools is considered to be an important process in ensuring an adequate social safety net and decreasing the likelihood of children ' falling through the cracks' (Franklin & Streeter, 1995). ICM: What helps and what hinders? 5 In the aftermath of the Gove Report (1995) the implementation of collaborative services, such as Integrated Case Management, to children and families in British Columbia has been supported by a rather subjective "belief' that it works (Burchard & Schaefer, 1987; Carter, 1997). Carter observed that "much of what is documented is opinion driven because innovations are recent, factual data scarce, and evaluations almost non-existent" (p. 2) and Burchard and Schaefer contend that an "ethic of intrinsic goodness" has been considered to be good enough to justify collaborative services in the past. However, there is mounting pressure on agencies providing collaborative services to children to be more accountable and to show that these approaches do what they claim to do (Nelson et al. , 1995). In their study of individualized, community-based mental health services for children, Furman and Jackson (2002) concluded that wrap-around, which is one type of collaborative or integrative service to children, is a step in the right direction. However, they strongly indicated a need for comparative, longitudinal studies examining wrap-around interventions. Other authors also support the need for ongoing evaluation of collaborative services to children (Bruner et al. , 1992; Pringle et al. , 2002; Rutman, Hubberstey, Hume, & Tate, 1998; Salmon, 2004). Bruner et al. contend that evaluations must be interactive and formative and Nicholson et al. (1998) called for more research that includes the client voice in evaluation of practice. The importance of all team members, including the client, in evaluating the process that they have shared through ICM, is emphasized in the Ministry for Children and Families ICM user' s guide (Woods, 1999). Evaluation of the integration of services has been the subject of many studies. For example, one qualitative U.K. study that considered parental views on their involvement in their child' s speech and language therapy provided researchers with both insight into and evidence for the therapy (Glogowska & Campbell, 1999). Another ICM: What helps and what hinders? 6 revealed that "it was the way in which outcomes are achieved that is likely to be both enabling and empowering for parents" (Baxendale, Frankham, & Hesketh, 1997, p. 516) and is even more important perhaps than goal achievement. Interestingly, Schacht, Pandiani, and Maynard ( 1996) looked at parent participation in local interagency teams from the perspective of everyone on the team except the parent. They reported that parents were active participants in the team; however the non-parent members believed that parents did not feel like equal members of the team. Subsequently, Schacht et al. concluded that there was a need for direct assessment of parent participation by the parents themselves and others insist that the parent and client must be heard at all points of the collaborative process (Burchard & Schaefer, 1992; Vandenberg & Grealish, 1996). To ensure that this happens, there has been a movement towards gathering qualitative data through satisfaction surveys and interviews (Burchard & Schaefer, 1992) and some researchers (e.g. , Kapp & Vela, 2004; Measelle, Weinstein, & Martinez, 1998) have developed quantitative instruments that measure parent satisfaction. In a review ofiCM practices, conducted for the Ministry of Children and Family Development, Rutman et al. (1998) found that clients had a variety of positive and negative experiences with ICM. For example, in focus groups some clients reported "feeling supported and that people care" while others felt that action plans were more talk than action. These somewhat vague evaluative comments let us know what the parent felt about the experience; however, it might be difficult to frame definite recommendations for improving the process based on such statements. Hubberstey (200 1) found a focus of interest within the literature on the improvement ofthe collaborative process from the professional perspective rather than that of the client. However, Hubberstey concluded, from a review of social ICM: What helps and what hinders? 7 services policy literature that examined client involvement (e.g. , Carten, 1996), that a significant difference in outcomes can result when the child and parent are included. Furthermore, Burchard and Clarke (1990) and Burchard and Schaefer (1992) have advocated for and developed methods to help children' s mental health agencies improve their accountability. Although they recommended the use of qualitative consumer satisfaction surveys and interviews to assess family reaction and service responsiveness, the literature reveals few studies in the subsequent 15 years that have done so. It can be demonstrated therefore, that this study has the potential to generate outcome data that can contribute to a more factual basis for the viability, efficacy and growth of the ICM intervention strategy. The Author 's Background I have been a secondary school teacher and counsellor in public schools and First Nations schools in British Columbia and Alberta for 28 years. Through my role as high school counsellor, I have been involved with ICM-Care Teams in a school district in the Fraser Valley region ofBritish Columbia, Canada for the past six years and have helped develop Care Plans for several students. A Care Team or Case Management Team is the working group for Integrated Case Management in the Chilliwack school district (Downey et al. , 1998). Dr. Robert Lees is currently the Practice Analyst for Mental Health, Ministry of Children and Family Development, Fraser Region, and has been directly involved in ICM and in the development of Care Plans for children attending schools in the same school district. Purpose of the Study and Research Questions The shortfall of information regarding ' accountability' that is available to agencies serving the needs of children and their families, observed by Burchard and Schaefer (1992) a ICM: What helps and what hinders? 8 decade ago, is even more salient in the present as the provincial government reduces funding for these services (e.g. , Macedo , 2003). Furthermore, the 'ethic of goodness ' that carried ICM and other children' s mental health services into the 21 51 century is not adequate in a more conservative socio-political climate, according to Burchard and Schaefer. The B.C. Ministry of Child and Family Development conducted a review ofiCM (Rutman et al. , 1998) in four regions of British Columbia as part of its push for implementation ofiCM across the province by 1999. The review provided qualitative support for ICM from client and practitioner perspectives; however the focus groups and interviews did not provide specific feedback that could be used to evaluate, guide, and modify the process. Rutman et al. did recommend ongoing evaluation ofiCM implementation, practice, and outcomes for both clients and practitioners while Nelson et al. (1995) identified a need to "involve children, youth and families" and to "empower clients through their involvement in an advisory capacity" (p. 38) regarding direction and evaluation. Not only is it important to study Integrated Case Management in order to provide this needed information, but it is also, as suggested by Franklin and Streeter (1995), necessary for each jurisdiction to evaluate different approaches to determine which will work best. Amundson and Borgen (1988) looked at factors that helped and hindered in group employment counselling and Koehn (1995) investigated helpful and hindering behaviours of counsellors of sexual abuse victims. Both of the aforementioned studies demonstrated the value of such work in that they have provided an evaluation of the intervention and a comprehensive listing of the helpful and hindering aspects of the specific experience for the participants. These studies have, therefore, provided a model for the current work which is the first to look at the helping and hindering aspects of the practice ofiCM and client ICM: What helps and what hinders? 9 outcomes in the Fraser Valley region. Not only might the findings better inform ICM/Care Teams in this school district, they could also be useful to school based teams and other forms oftearning at the school level in this and other regions ofBritish Columbia. Questions The primary research question is: 1. What aspects of the Care Team process have helped? What aspects of the Care Team process have been least helpful (or most hindering)? The secondary questions are: 2. Do parents feel that the ICM/Care Team process is valuable and do parents feel that they are a valued member ofthe Care Team? 3. Is the Critical Incident Technique an appropriate method for evaluating the integrated case management experience? ICM: What helps and what hinders? 10 CHAPTER2 Method Integrated Case Management (ICM) has become an important process in the delivery of services to children and their families in the last decade in British Columbia. During the same time period, researchers at the University of British Columbia have been using the Critical Incident Technique (CIT) to provide qualitative data in a variety of fields, including counselling psychology. In the current study the author utilizes the exploratory strength of the CIT to scrutinize the process ofiCM as it is practiced in one region of British Columbia. In this chapter I will review the CIT, (b) participant recruitment, (c) ethical considerations, (d) data collection and analysis, and (e) reliability and validity checks. Researchers such as Koehn (1995), Wong (2000) and Woolsey (1986) present well documented and extensive rationale for the use of Flanagan' s Critical Incident Technique (1954) as a methodology for research in the field of counselling. Butterfield, Borgen, Amundson, and Maglio (2005) have recently provided an overview of the first 50 years of the Critical Incident Technique that describes the evolution of Flanagan' s classic task analysis technique into a widely used qualitative research method with applications in many fields, including communications, nursing, job analysis, teaching, and counselling. This method of research "focuses on obtaining a comprehensive description ofthe activity under study" (Koehn, 1995, p. 21) and was selected as an appropriate methodology for the current study. The research completed at the University of British Columbia over the past 20 years using Flanagan's CIT (Amundson & Borgen, 1988; Butterfield & Borgen, 2005; McCormick, 1997; Wong, 2000), presents a useful model for gathering and analyzing ICM: What helps and what hinders? 11 information about the experiences of consumers or clients as told in their own words and stories. That empathic listening and perception checking are two main interviewing techniques employed in this type of study indicates that "this approach is a natural fit for the field-based researcher/counsellor as well as a good parallel to the counselling process" (R. Lees, personal communication, June 2003). Further, Woolsey (1986) concluded that the Critical Incident method is "entirely consistent with the skills, experience and values of counselling psychology practitioners" (p. 252) and she characterized the CIT as the gathering of eyewitness information regarding the participants' own behaviour or that of others that they have observed and that they feel are basic to a specified event. In fact, studies using the CIT have been able to generate lists of helping and hindering behaviours which can have very practical applications for similar situations. The Participants The participants in this study were the parents or primary caregivers of children presently or formerly attending public schools within the Fraser Valley region of British Columbia, and who have been part of an Integrated Case Management-Care Team in the past three years. More specifically, the parents were birth parents, foster parents, adoptive parents, or guardians. All of these caregivers will be referred to as ' parents' for the purpose of this study except where differentiation will make discussion clearer or more precise. Care Teams, according to Downey, Mackie, Marchant, & Pratt (1998) are collaborative groups consisting oftwo or more ofthe following: teacher(s) from the child's school, school district staff, a social worker (Ministry of Children and Family Development or Xyolh:meylh 1) a mental health worker, a probation officer, an administrative officer of the school, the child (not in all cases), the parent or guardian, and other family members. Care ICM: What helps and what hinders? 12 Teams are the working group oflntegrated Case Management and are set up to coordinate and enhance services, thereby providing a holistic approach for at risk children and high needs children- that is, those children who require special attention from one or more of the aforementioned agencies. The two terms (Care Team and ICM) will be used interchangeably in this paper. The participants were recruited through the principal of each child's school who, with the help of school counsellors, telephoned prospective parents to invite them to take part in the study. Once the parents indicated their interest in the project, the researcher made direct contact by telephone with each parent to provide him or her with details, discuss confidentiality concerns, and to arrange an interview time. A letter and consent form was then sent to these prospective participants to formally provide: (1) information about the study, (2) the interview questions, (3) a confidentiality agreement, and (4) a demographics questionnaire. Each participant received a $10 gift certificate for Tim Horton's in appreciation for their participation and was told that he or she would have an opportunity to see the results of the research once the study has been completed. The recruitment process depended on the cooperation of various people at different levels in several schools and accordingly resulted in lengthy delays. Over an 8 month period 10 people eventually participated in the study. There were 2 married couples; each couple was interviewed as a unit. Therefore, I conducted a total of eight interviews. Ofthe 10 people interviewed, 7 were female and 3 were male; the average age was 50 years and the ages ranged from 28 to 67 years. There were 7 foster parents, 1 adoptive parent, 1 birth parent and l legal guardian. Of the 10 parents, 7 disclosed their ethnicity as Caucasian or Canadian, l as Aboriginal, and 1 as other. One participant did not ICM: What helps and what hinders? 13 volunteer this information. Three of the 8 interviewees stated that their child was of Aboriginal ancestry, 2 stated that their child was of mixed Aboriginal and Caucasian ancestry and 3 stated that their child was Caucasian or Euro-Canadian. The children ranged in age from 7 to 18 years. Ofthe 10 people interviewed, 4 had a previous relationship with the researcher through involvement in Care Teams and 3 were known to the researcher in other contexts. Procedures Flanagan (1954), as a member of the Aviation Psychology Department of the United States Air Force, originally developed the Critical Incident Technique (CIT) during World War II mainly as a means of analyzing the requirements of specific jobs and particularly the tasks required of fighter pilots. In the 50 years since Flanagan' s pioneering work, the CIT has "evolved and changed ... especially in its use as a tool for counselling psychology research" (Butterfield et al. , 2005). The value of the CIT as a research methodology in the field of counselling psychology is well documented by Woolsey (1986). She states that the CIT is a useful "exploratory method that has been shown to be both reliable and valid (Andersson & Nilsson, 1964; Ronan & Latham, 1974) in generating a comprehensive and detailed description of a content domain" (p. 243). Used extensively in the past 10 years at the Counselling Psychology Department at the University of British Columbia, Canada, the CIT has been modified to include subjective experience, beliefs, attitudes, and feelings about critical events (Wong, 2000). In recent years the CIT has been effectively used to study the client experience ofthe counselling process (Bedi, Davis, & Arvay, 2005; Duplassie, 2004; Koehn, 1995). ICM: What helps and what hinders? 14 The Critical Incident Technique, as developed by Flanagan (1954), consists offive steps: (a) determining the aim of the activity; (b) setting the plans, specifications, and criteria; (c) collecting the data; (d) analyzing the data; and (e) interpreting and reporting. Determining the aim of the activity Flanagan developed a formal approach to accomplish this (seep. 336 of Flanagan, 1954) but the most effective statements of aim, according to Woolsey (1986), use simple everyday language to convey an obvious meaning. Both Flanagan and Woolsey consulted with experts in the field in order to obtain a brief statement of the objectives of the activity that the authorities could agree upon and that the participants would understand. According to Downey et al. (1998), the Care Team is "composed of school based staff, District Student Services staff, and community personnel which plans for and coordinates services for students with Severe Behaviour Disorders" with the responsibility to "develop and implement an intensive school/community/Interministerial plan to manage and change the student' s behaviour" (p 16). Knapp et al. (as cited in Tate & Hubberstey, 1997) described collaborative practice as "an interactive process through which individuals with diverse expertise, experience, and resources join forces to plan, generate, and execute solutions to mutually identified problems related to the welfare of children and families" (p. 140). According to one practitioner, Care Teams are an attempt to support youth and their families in a holistic manner, providing wraparound service; the team is greater than the sum of its parts, with each agency feeling supported through the process resulting in the creation of better outcomes (A. Stein, personal communication, October 27, 2005). For the purpose of the present study then, the aim of the ICM - Care Team is to plan and coordinate services for ICM: What helps and what hinders? 15 youth and their families in a holistic manner so that the child would experience success in school and life. Setting the plans, specifications and criteria The observers were the parents who have participated with their child in the ICM Care Team process. To improve validity I have ensured that the participants have not all had similar experiences--all positive or all negative--and are not all of the same gender, racial, or socio-economic background. In regards to the latter concern, Feinberg, Ruyter, Trappey, and Lee (1995), who used the CIT to research transnational consumer behaviour as it relates to retailing, contend that the CIT is by its nature less culturally biased because it seeks information about the experiences of the respondents in their own words. The observers were provided with a statement of the aim and a list of interview questions in advance to allow time to think about them (Appendix B - Consent Form). According to Woolsey (1986), the sample size should be based on the number of critical incidents and not on the number of people interviewed, which is to say that interviews would be conducted until incidents did not significantly contribute any new information to the categorization scheme. Flanagan (1954) observed that this number could range from 100 to several thousand incidents and believed that adequate coverage was achieved when repetitive patterns began to emerge from the data. Because this study is intended to be preliminary, the sample size and saturation requirements have not been a primary concern and data collection was terminated after the eighth interview. The observations were made by the adult respondents whose children attend, or did attend school, and who have, or did have, an ICM Care Team while in attendance at school. The time frame included incidents within the past three years. Although his initial studies ICM: What helps and what hinders? 16 involved direct observations ofthe activities being studied, Flanagan (1954) believed that if the details as remembered by the observer are full and precise the information can be taken as accurate. The specific behaviours or events to be reported upon were those that were either directly experienced or observed by the participant and that related specifically to the ICM Care Team process. Collecting the data The data was collected by open-ended, semi-structured interview. I followed Wong ' s (2000) interview protocol as presented in Appendix A and I employed empathic listening and perception checking to be sure that I was accurately and fully capturing the fullness of what the respondents were telling me (Woolsey, 1986). Flanagan (1954) refers to the interview as a conversation and advises against asking leading questions, other than the initial ones. With this in mind, I interviewed each participant once and then conducted a follow up interview with three of the participants as part of the validity check. With the consent of the participants the initial interviews were audio recorded. The follow up interviews were not recorded. Six of the interviews were conducted in my workplace office, one interview was conducted at the home of the participant, and one interview was conducted at the participant's workplace. The interviews took an average of 45 minutes each and ranged from 30 minutes to 75 minutes in length, including a short but unrecorded debriefmg. Each interview was transcribed by the researcher within the subsequent two days. Analyzing the data The analysis ofthe data from the interviews focused on the helping and hindering incidents that revealed how participants experienced the Care Team process. Flanagan ( 1954) identified three aspects of the data analysis procedure: (a) Selecting an appropriate and useful ICM: What helps and what hinders? 17 frame of reference, (b) forming categories, and (c) determining the level of specificitygenerality to be used. Each of these aspects is expanded upon in the following discussion. Selecting an appropriate and useful frame of reference was the first step in analyzing the data. As we hope to eventually use the data to improve the effectiveness of the Care Team process, it was important to keep in mind two overall reference points- those things that were helpful and those things that were hindering in achieving the aims of the Care Team process, from the parents' perspective. The second step in this process is that of category formulation. Flanagan ( 1954) and Woolsey (1986) describe this stage as being very subjective and suggested that the sorting of incidents into naturally occurring groups requires insight, experience, and inductive reasoning. To facilitate this step, each interview was first transcribed verbatim by the researcher. After reading and re-reading the transcripts a number oftimes, meaning units deemed to be significant and having direct bearing on the aim of the activity were extracted from the transcript. Each incident was edited to protect participant confidentiality and to facilitate smooth reading while still being faithful to the voice of the participants (Bedi et al. , 2005). Incidents were then printed, cut, and each pasted onto a 12.5 em by 7.5 em index card. A system for coding each incident and linking it back to its original location in the transcript was developed. After the first four interviews the 95 identified incidents were sorted into tentative categories based on similarities of behaviours or experiences described in these incidents. A tentative name was assigned to each of the emergent categories when the name 'presented itself. Classification of further incidents into these tentative categories was attempted, and additional categories were created as needed. Rules for placing incidents into categories were developed based on my efforts to intuit the criteria for each classification ICM: What helps and what hinders? 18 decision. A journal was kept to keep track ofthese decision rules and the rules became a guide for subsequent decisions. By selecting a prototypical incident for each subcategory, the task of comparing incidents was made somewhat easier (McCloskey & Glucksberg, 1978; Rosch, 1978). However, as McCloskey and Glucksberg pointed out, natural categories are fuzzy sets "with no clear boundaries separating category members from non-members" (p. 466) making categorization of incidents a rather subjective process that was both complicated and perplexing at times. After studying the categorization scheme it became evident that some of the original categories were essentially subcategories that were subsumed by larger categories. Careful review and revision of the headings and defmitions for all large categories and subcategories was conducted after considering the actual incidents in each category. Three of the 30 categories had less than 25% participation and were eliminated (Borgen & Amundson, 1984). After this step, self-explanatory titles were created for each subcategory and category. The third step, as described by Flanagan (1954), was to determine the level of specificity-generality to be used in reporting the findings. This was established as the critical incidents were being classified and categories identified, as suggested by Woolsey (1986). She allowed categories to emerge naturally and, unlike Flanagan (1954), was not concerned with having each category represented by an equal number of incidents. Interpreting and Reporting The results and discussion are presented in Chapter 3 and 4. Validity and reliability, or trustworthiness, of the fmdings was checked in several ways. Andersson and Nilsson ( 1964) suggest that independent raters be able to classify 75-80% of the incidents into the ICM: What helps and what hinders? 19 categories and 60-70% into the subcategories that arise from the data. Six judges--two male and four female, five ofwhom were Masters candidates working in the field and also completing a final project or thesis based in the CIT, and one with an Ed.D. in counselling psychology--were asked to classify 10 random incidents each. As with the method used by Bedi et al. (2005), I provided only limited information about the categories to provide a conservative estimate of reliability. A one word title and brief oral explanation was provided for each category and judges had an opportunity to ask a few questions to clarify any 'fuzziness' . The results ofthis test for reliability, summarized in Table 1, indicate that the criteria for reliability were met. Table 1 The % ofAgreement Between the Judges ' and the Researcher 's Category Scheme %of Agreement Categories Subcategories Judge 1 80 78 Judge 2 80 83 Judge 3 80 60 Judge 4 90 60 Judge 5 90 60 Judge 6 90 70 Average 85 68.5 Note. N = 60 incidents; 33.71% oftotal number ofincidents ICM: What helps and what hinders? 20 Andersson and Nilsson (1964) reported that "when two-thirds of the incidents had been classified, 95% of the subcategories had appeared" (p. 400). Based on this fact, Ronan and Latham (1974) assert that if90% ofthe subcategories have appeared when 75% ofthe incidents have been classified, content validity is satisfactory. In the present study the credibility of the categorization scheme was supported with a test for exhaustion. The 27 incidents (15%) produced by the eighth and fmal interview were held back from the original categorization exercise. A fellow researcher was then asked to attempt to classify all the incidents into the existing categories and subcategories and was able to do so easily. Further support for the credibility of the findings is that they reflect themes in the literature. For example, Bruner et al. ( 1992) identified several aspects of successful interagency collaboration that are replicated by some ofthe headings used in the categories ofthe present study. Similarly, congruence exists between the categories arrived at in the present study and those that were used to describe the results of Rutman et al. (1998) and Jivanjee (1999). One practitioner with extensive Care Team experience verified that the categories and the prototypical incidents were relevant and meaningful. Participant cross-checks were conducted with three of the eight interviewees. With one exception the participants agreed that the categories reflected what they had said and that incidents had been appropriately categorized. The exception was in regards to the subcategory that I had labelled 'Social Workers' and resulted in a change to a more inclusive label- ' Professionals' . Butterfield et al. (2005), as a result of reviewing the extensive body of work done at UBC, have recommended that there be a standardization ofthe credibility and trustworthiness checks that a researcher uses to support the CIT. Of the nine checks recommended in the Butterfield et al. review, five have been used in the present study. ICM: What helps and what hinders? 21 Ethical Considerations As the main aim ofthis study was to learn from the first hand experiences of parents involved in the Integrated Case Management process in School District #33 , those parents with current or recent (past three years) involvement were invited to be interviewed and were asked to speak about their own experiences of being part oftheir child ' s Care Team (ICM team). The information gathered will serve as an evaluation of one aspect oflntegrated Case Management and will provide feedback that will be used to modify and improve Care Teams. The participants' confidentiality was assured through the informed consent form (Appendix B) and ongoing discussions of steps being taken to protect their confidentiality at each stage of the study. Each participant was assigned a number which became the only identifying mark for anyone other than the researcher and his supervisors. Audio tapes, interview transcripts, demographic information and consent forms were kept under lock and key in the researcher's office or the supervisor' s office until the study was concluded and then stored for not more than seven years, at which time the written data will be shredded and the audiotapes will be erased. There were no expected risks to the participants and for those who are part of an active Care Team, there could be the dual benefits of an improved Care Team experience and the chance to be heard in respect to their experiences. Participants were informed that they could withdraw from the study at any time and were provided with contact information to the UNBC Research Ethics Board, in case of complaints about the study. ICM: What helps and what hinders? 22 CHAPTER3 Results The purpose of this study was to learn from parents what has been helpful and what has been hindering in regards to the goals and processes oftheir child ' s Care Team. The Care Team is the working group for Integrated Case Management (ICM) as practiced in the Fraser Valley region of British Columbia. The team comes together to meet the needs of children receiving services from a combination of agencies within the community, including most often, the Ministry of Children and Families. The Critical Incident Technique (CIT) (Flanagan, 1954) has been used extensively in the past 50 years as an exploratory and investigative tool (Butterfield et al. , 2005) in many disciplines including; counselling (e.g. , Koehn, 1995 ; McCormick, 1997), education (e.g., Bedi et al. , 2005; Preskill, 1997), and nursing (Keatinge, 2001). The CIT, in light ofthis history, was employed in the current study to elicit 178 incidents that parents considered to be critical to the functioning of ICM. Ten participants (including two married couples interviewed as a unit) identified 118 helpful and 60 hindering critical incidents regarding their experiences as a member of a Care Team for their child or foster child. The incidents have been classified into eight main categories, specifically: Beginnings, Structure and Function, Outcomes, Tone, The Team, Communication, Follow Through, and Cultural Issues. Four of the major categories contain a total of 15 subcategories which are listed in Table 2. A summary of the categories and subcategories with participation rates and numbers of helping and hindering incidents appears in Table 2. It should be noted here that Borgen & Amundson (1984) utilized a participation rate of 25% of all participants as a guide for retaining a category in their classic study of the unemployed worker. ICM: What helps and what hinders? 23 Table 2 Participation Rates for Categories and Subcategories and Number and Proportion of Helpful and Hindering Incidents Category Subcategory na Partie. Rate (%) No. oflncidents Helpful Hindering %of Nb Beginnings 3 37.5 4 Structure/Function 6 75 15 4 11 Purpose/Aim 4 50 5 1 3 Composition 6 75 7 2 5 Location 3 37.5 4 7 87.5 26 7 19 Resources 5 62.5 6 1 4 Strategies 7 87.5 13 2 8 Transitions 5 62.5 7 4 6 Tone 6 75 11 2 7 The Team 8 100 32 13 25 Birth Parent 4 50 5 Child 6 75 13 Professional 4 50 4 Parent/Guardian 3 37.5 6 6 7 Teamwork 5 62.5 8 2 6 8 100 25 26 29 6 75 13 7 Outcomes Communication Alienation/Conflict 2 2 3 4 10 2 ICM: What helps and what hinders? Praise/Empathy/Valid. 6 75 Contradiction 3 37.5 Sharing Information 5 62.5 Follow Through 4 50 Cultural issues 3 37.5 14 11 3 24 1 8 7 4 5 9 5 3 3 Note. anumber of participants, n = 8; tNumber of incidents, N = 178 (118 Helpful; 60 Hindering) Using this guideline, two ofthe original categories--Opinion valued/sought and Selfperception--were dropped and four incidents were able to be reclassified under other headings. Two incidents from the eliminated categories were discarded as not containing enough detail to be considered incidents. Following the format used by Borgen, Amundson, and McVicar (2002), a description of each of the categories and subcategories follows. The total number of incidents for the category, the percentage of participants who described incidents in the category, and the percentage of all incidents belonging to that category are reported. At least one example of a critical incident is provided for each category and subcategory. When a category includes both helpful and hindering incidents, an example of each type is given. Proper names that appear in the excerpts from the original transcripts have been replaced with pseudonyms and incidents have been edited to provide brevity, smoother reading, and to ensure confidentiality. The word 'parent' always refers to the person who was interviewed for the study and could therefore, be the biological parent, foster parent, adoptive parent, or legal ICM: What helps and what hinders? 25 guardian. Also , each of the two married couples will be treated as a single entity with data arising from interviews with them considered to be from one source. Category 1: Beginnings/Early development (4 incidents - 3% of the incidents; 38% participation rate) This category included helpful incidents that described the early development and initial stages of the Care Team. Incidents often referred to the person who was responsible for bringing together or reactivating the team and described the concomitant actions and events. One example of a helpful incident from this category is provided: Example: [A]t first the meetings were [initiated by the social worker] and then once my children started coming home [from foster care], then it was basically, if something was needed to be discussed, I would initiate it. Participant #5 In some cases the parent was the one responsible for getting the Care Team restarted after school resumed each year, but the school personnel generally responded quickly and favourably to a reminder from the parent. Social workers were also regarded as helpful in ensuring that Care T earns resumed after the summer break. Category 2: Structure and Function (19 incidents - 11 % ofthe incidents; 87.5% participation rate) This category consists of three subcategories: Purpose/ Aim, Composition ofthe Team, and Location, all of which are related to logistical aspects ofthe Care Team. Subcategory 2a: Purpose/A im [5 helpful and I hindering} (4% of the incidents; 50% participation rate) ICM: What helps and what hinders? 26 This subcategory consisted of incidents that related to the participants' stated perception(s) of the purpose or aim of the Care Team and whether the meetings were helpful in achieving their goals or the team' s goals. The helpful aspects in this category emphasized how valuable the Care Team has been in working together to support children, particularly in their school experiences, through the sharing of information. However, one participant expressed concern that the team focussed on the child' s needs while neglecting the needs of the caregiver. Following is an example of a helpful incident Example: [M]eetings at the school [help because] . . .I can see how the kids are doing as far as whether they're coming to school late, if they' re not eating their lunches, ifthey're not packing their lunches to school, ifthey're not doing their homework, or doing part of their homework or need help with their homework, ifthey're having problems with the [foster] kids either being mean to [other] kids or being picked on by the [other] kids. And some ofthis stuff is pretty early in [their development] , so it's important to address. - Participant #6 Subcategory 2b: Composition of the Team [7 helpful and 2 hindering} (5% of the incidents; 75% participation rate) This subcategory consists of incidents that referred to the general composition of the team or that stated who the participant thought needed to be part of the team. It was important to most ofthe participants to have a show of support that represented all aspects of the child' s life as shown by the following examples: Example 1: [helpful] [T]here was a bunch ofus. I had [a social worker]; I had Community Services- a family support worker and another woman; I had the ICM: What helps and what hinders? Ministry of Family and Children Services; I had the foster parents; I had my child; I had myself. Like, when I had my Care Team meeting there were a lot of people [laughter] ... it was awesome! It was wonderful! -Participant #5 Only two hindering incidents were mentioned but an example will be provided as it will illustrate team composition from the negative perspective: Example 2: [hindering] [Probation] was one ofthe agencies working with this kid simultaneously, but because there was not a team that involved all of the agencies ... at the same time, not everybody was at the table at the same time, and often you would get a report from one of the parties to the Care Team, but you don't actually have the body physically sitting there? ...its much better to have the people there to communicate, to brainstorm and to make sure everybody' s on the same path. -Participant #8 It was generally felt to be very helpful to have all of the 'players' at the table and to have each team member provided with an opportunity to report. Parents emphasized how important it was for them to be regarded as equal in importance to all other team members. Subcategory 2c: Location of the Me eting [4 helpful] (3 % of the incidents; 38% participation rate) The incidents in this subcategory refer to the participants' perception of the impact that the location of the meeting had on group dynamics and the team' s success. Care Team meetings were held in a variety of locations including agency offices, schools, and private residences. One participant reported that meetings that occurred at a certain agency office were sometimes subject to a more domineering 27 ICM: What helps and what hinders? 28 and adversarial leadership style than was experienced in school settings. The following example illustrates the ameliorative affect on a social worker' s behaviour of holding the team meeting at the child' s school: Example: [When] the social worker is in the meeting with the school, it' s normally a better meeting than when we meet with the social worker separately; because [at agency offices with the social worker] it's almost a[n] adversary type ofthing, for that type of meeting. Whereas [at the school], it's different, you know. -Participant #3 While this example gives voice to the helpful nature of a school based meeting, it does so by pointing out the negative aspect, for this parent, of meeting at the agency office. The parent recalled that the chairperson of the school based meetings was able to maintain a positive and egalitarian atmosphere that was often lacking at the agency based meetings at which the school was not always represented. On the other hand, one participant stated that he felt safer at the Ministry office when there was the chance of a violent confrontation with a birth parent. Category 3: Outcomes (33 incidents - 19% of the incidents; 87. 5% participation rate) This category consists ofthree subcategories; Resources, Strategies, and Transitions. Included in the category are incidents related to interventions and results of Care Team meetings. The parents reported that meetings were an opportunity to gain insight into: (a) things that they could do with their children that would improve or deepen their relationship, and (b) things that they could do that would improve conditions for the child both at school and at home. ICM: What helps and what hinders? 29 Subcategory 3a: Resources [6 helpful and I hindering] (4% of the incidents; 63% participation rate) The incidents in this subcategory involved referrals by the Care Team to specific programs and services in the school and community. Several participants stated that the Care Team provided an invaluable pool of knowledge about resources and could be very helpful in connecting them with those resources. Following is an example of a helpful incident: Example: [W]e had outside agencies and we had MCF come in and we had the school counsellor, the teacher, the principal and it was really nice knowing that they had ... access to services that we necessarily didn't know about. [A]t the end of the year one of the school counsellors for that school gave us a form to fill out so he could go to a camp at no cost to us, because, you know, fmancially its [expensive] having a [child in the home of a relative]. And it was just nice to have that information because we wouldn't have had it otherwise. So it gave us an opportunity to do something for him that was positive because I think that he really needed that. And as a parent, you don't know what the options are. So, that was nice. -Participant #7 The one hindering incident in this subcategory referred to counselling services that had been available until funding cutbacks resulted in the loss of that service: We're (foster parents) not professionals so we can only go so far with the child, and we do that, but then after that? Like (our son) going to (a play therapist) and other children that we've had also went to counselling ... and a ICM: What helps and what hinders? 30 lot of them are going there, and then all of a sudden the funding was cut for that. So that was no longer available. That was all of a sudden just cut. - Participant #3 The affect of tighter government budgets on the services that agencies can offer, arises as a concern in one other category below (Category 7: Follow through) . This issue is further elaborated upon in Chapter Four. Subcategory 3b: Strategies [13 helpful and 2 hindering} (8% of the incidents; 88% participation rate) This subcategory includes incidents that describe specific strategies and ideas that the parent or other team members could use when working with the child. Following is one example of a helpful incident and one example of a hindering incident: Example 1 [helpful]: ... ideas that I was given by the people that attended the meetings, different ideas of school work help, activity wise to do with my children, ways to talk to my kids, to get them to open up - because with being an addict and cleaning up, my kids [built up a wall] ... between us and the [team], they gave me ideas of what I could do to slowly break down that wall. ... [T]here was a couple of things, like, one of them was to just leave them a note, like, pin it to their pillow in the morning before they would get up saying, "I love you- please talk to me", or just simple things like spelling out "HI" in alphabet cereal, or whatever. .. .It was just little ideas of stuff that could break that ice with my children. And because I was actually willing to do that, at that time, it helped a lot. -Participant #5 ICM: What helps and what hinders? Example 2 [hindering]: And then they took her out of classes in grade 9. She sat in the resource room .. . for the whole year, because several teachers said they didn't want her in the class. So ... she was in the RR and then not getting any of the regular curriculum, you know ... she was just on the computer, I think all the time. -Participant # 1 The parents recalled in detail the helpful strategies that came out of Care Team meetings. These were mostly little things that might seem obvious in retrospect, but that sometimes needed a brainstorming session to become evident. These strategies helped to resolve ongoing problems for the child such as homework, tardiness, lack of achievement and/or organization skills, curfew and interpersonal issues. Strategies that backfired or that were arrived at unilaterally by the school, as in example 2, were recalled as hindering the child's development. Subcategory 3c: Transitions [7 helpful and 4 hindering] (6% of the incidents; 63% participation rate) The incidents in this subcategory refer to times such as graduation from school or when the child is in transition from one setting to another or from one phase of life to another. An example of a helpful incident follows: Example 1: [helpful] [I]fyou don' t know where to go a lot won' t ask. Because we didn't know [that Pathways - a program offered through Community Living] was there .. .I think we stumbled on it in one of the meetings. Like, have you seen this, or looked at that. .. .[I felt] a lot better. Because it was another light, another way to go. Because I was so worried that. .. like, he, we always have stuff to do in the summer. But [after 31 ICM: What helps and what hinders? 32 graduation from high school] when that September came, for his mental wellbeing, for his health, what were we going to do? -Participant #2 Example 2: [helpful] It wasn' t always just about their school work. It was mostly centred (around the) fact I put my kids in care. I wanted them back. And it wasn' t [that] I had to earn them back, it was, because I was an addict. But when it all came down to it, it was a fact I needed to know my children again, and [the team] gave ideas of how we could do that. . .. At home [I could see those ideas were working] .. . because ofthe smiles on their faces. The fact that my teenager would actually come and curl up on the couch with me? My 11 year old came home and then the youngest came home and my oldest didn't want to come home yet? She wanted basically to see that I was gonna do it, and I wasn't just going (to) with all this pressure ... go use. Once I did that she wanted to come home. - Participant #5 Transitions also present opportunities for hindering incidents to occur. Incidents that hindered smooth transitions between settings tended to be associated with a breakdown in communication or contradictory messages from adults to children as can be observed in the following example: Example 3 [hindering]: One [foster child] lashed out at us that we trying to put down rules and regulations and this type of thing, you know. But, (the Agency) said every home was different - and that they had a right to [be different] .... And so [the foster child] was made to look good and us bad, you know . .. .It really hurt a lot because . .. every foster parent tries their absolute best with the child they have in their home .. .. [T]hings would be going very ICM: What helps and what hinders? 33 well when that child left [for respite] and then that child returned to your home, and- and you can expect some ... difference between the two homes [but not to the extent that we were seeing] .. .. Not only is it hard for the child because now the child is put in the middle ... between us and the other home they' ve gone to ... but it also affects ... us as caregivers as well, because we have to deal with that for maybe 2 to 3 weeks after that. -Participant #3 Transitions are very important periods in the lives of children in care and are often fraught with emotion and stress. The critical transition times, and according to the parents the time when the ' system' sometimes falls short, are those between elementary and middle school, between middle school and high school, and then from high school to community or post secondary training. Parents saw themselves as being an important part of transitions when the next level was not picking up where the previous one had left off. Transitions between foster home and respite home were the most problematic and distressing. Parents described the discrepancies in expectations of the child, between home and respite, or between home and residential treatment, and considered these differing expectations as hindering the aims of the Care Team. Category 4: Tone [II helpful and 2 hindering] (7% of the incidents; 75% participation rate) The incidents in this category refer to the atmosphere or the mood of the meeting. The participants tended to prefer a relaxed and informal Care Team meeting where they were made to feel on an equal basis with other team members as shown in the following examples: Example 1 [helpful]: Because [teachers] had such limited time for lunch, and the same with parents ... [having lunch provided] was great because ... it sort of made it more relaxed, and not a stuffy meeting- sharing a meal together. .. it ICM: What helps and what hinders? 34 sort of lowers defenses, you know, everyone ' s eating and I think if you' ve got a meeting [at mid-day], and there ' s nothing ... to eat, people are going to be thinking about food, puts your mind off that, and I think a lot more things come out. .. -Participant #2 Example 2 [hindering]: [B]ecause I was the addict and they were the professionals they didn't hear it. They heard it but they didn't hear it. [T]hey could hear me talking but they didn't understand what I was saying, and I felt when I went into that meeting that they just wanted to say what was on their mind. They did not want to hear me, they did not want any justification, they just wanted to tell me that what I did was wrong, and that it ' s gonna take even longer for my children to come home and all this stuff, because oftwo little tiny drinks. And so when a person goes into a meeting, a Care Team, or anything else like that and have all that pressure of negativity put on them, its really hard, and like - you don't (feel like part of a team), you feel like you're in that little tiny corner and everybody is hounding you. And you just want to get out ... if there was anything good, said, I didn't hear it. . . .if, I wasn't as strong willed as I was at that moment I would have gone out and, my whole life would have been over right then and there. - Participant #5 The preponderance of reported helpful incidents indicates that, from the perspective of participants in this study, Care Team meetings tend to have a positive tone. However, as Example 2 above illustrates, there are times when a negative atmosphere prevails and serves to alienate one or more members of the team. Category 5: The Team (49 incidents - 28% of the incidents; 100% participation rate) ----'..--~------------------------- ICM: What helps and what hinders? 35 This category subsumes the second highest number of incidents of all categories and is one of only two categories to have incidents reported by all participants. This category includes incidents that refer to specific members of the team or to behaviours and actions that involve a combination of members of the team. Subcategory 5a: Birth Parent [5 helpful and 1 hindering] (3% of the incidents; 50% participation rate) This subcategory includes incidents that refer specifically to the birth parents' role and contribution to the meeting or Care Team. The birth parent was the parent participant in one ofthe eight interviews. The other seven parent participants reported both helpful and hindering aspects of having the birth parent present at meetings; however, they reported that it was usually helpful to have the birth parent(s) present. Conversely, the birth parent reported that for her, having the foster parent present at meetings was very helpful, particularly when there was a conflict between her child and the caregiver. An example is provided: Example 1 [helpful]: [It's helpful for Joey as well, to have his mother transition into that role and attend Care Team meetings] ... because you know his mother was never involved in his schooling; his attendance was really poor and it really wasn't important to her at all. So I think for her to go to the school and have a conversation about him with his teachers, meet all these people, brings her into that circle for him. And I think that's important to help him be successful. ... So I think, when a parent doesn't go they miss the opportunity to say what needs to be said in order to help guide other people in assisting that kid .... So I think for [Joey] it just sort of brought up from ICM: What helps and what hinders? 36 [where] school was just somewhere you went for a little while, to Mom knows what the hell' s going so don't even bother pulling .. .the wool over her eyes because she will see .... Whereas before that was never a concern because .. .there was no way ... she ' d ever go to a meeting before. So I think it's going to benefit him quite a lot. -Participant #7 Having the birth parent present was regarded as being very helpful by those reporting in this category especially in regards to the sharing of information and getting that information first hand. One participant qualified this by saying that, "It depends on where the birth parent is at that particular time you know; if they' re [even] capable of coming to a team meeting" and another described a situation in which the birth parent became violent. He stated that meetings at which the birth parent was going to be present were always held at a Ministry site to avoid the anxiety of an uncomfortable or violent incident occurring in his home. Subcategory 5b: Child {13 helpful and 4 hindering] (10 % of the incidents; 75% participation rate) The incidents in this subcategory refer to the role and contribution of the child to the Care Team or meeting. Incidents indicate that there are both helpful and hindering aspects to having the child attend the meeting. Generally, the older the child the more important it was considered to be for him or her to be part of the team. The presence of the child was reported by some participants to be a hindrance to the open exchange of information about the child, especially for preadolescents. Examples of both viewpoints are provided: Example 1 [helpful] [l]t was helpful to have John there as part of the team ... cause especially with kids like him they need to feel included and j ICM: What helps and what hinders? know what ' s going on and not that you ' re having a meeting [about him] and then their mind runs and they have no idea what' s going on in [the meeting] you can tell them- [but] I think there ' s always that doubt- what are you discussing? [John] enjoyed knowing that we were going to discuss [him] ; he didn ' t feel so alone, so to speak. -Participant #2 Example 2 [hindering] I did fmd it a little ... hard for Bob to be [in the meeting] when we had to talk about [his disability] in front ofhim because we never .. . brought up in front ofBob, that there was a problem. Sometimes he did have problems in school and that was addressed, but not in that category where he was, mild mentally handicapped .... [It] was probably a helpful thing. I just personally found that difficult for my own self.... [j]ust in case we thought that was going to label him. I didn't want him to be labelled. I didn' t want that for him. And so that was hard for myself, but you know it was a positive because of, .. . I think the way it was approached -it was done very, very thoughtfully ... Bob may have not even have got the message [regarding his mental disability]. - Participant #3 Subcategory 5c: Professionals [4 helpful} (3 % of the incidents; 50% participation rate) The incidents in this subcategory refer to the role and contribution made by professional members ofthe team. The professionals who were most frequently referred to are teachers, administrators and social workers and their contributions were generally regarded as helpful. Although their presence and role on the team was generally reported as 37 ICM: What helps and what hinders? 38 helpful, it will be evident under other categories, for example Communication, that these same team members can make a negative contribution to the Care Team process. Example 1 [helpful]: [T]he social workers involved themselves at the school.. .as soon as September hit, our social worker was at the school letting the school know, I am the children' s social worker, I need to know exactly what goes on with this child in school. Because like, the last thing you need is a child going downhill because of foster care or anything like that, and it happens a lot. .. so the school based meetings were initiated by [the] social worker. -Participant #5 Subcategory 5d: Parent/Guardian as Advocate [6 helpful and 6 hindering} (7% of the incidents; 38% participation rate) This subcategory includes incidents that refer to the role and contribution of parents to the team and particularly in their role as the child's advocates and how they were perceived by the team in that role. Parents experienced their own advocacy role, at different times, as both helping and hindering in the Care Team meeting. A helpful outcome of parent advocacy occurred when the child was able to see the parent in this role, thereby reinforcing their relationship. The subcategory includes reports of professionals reacting defensively when they perceive that the parent is being too aggressive, or is questioning their professional competency. The parents regarded this negativity towards their advocacy role as being a hindrance to the Care Team process. Examples follow: Example I [helping]: I know what I am and I know the way I'm perceived and that's fme because you have to be like that with kids in care so they get what they need and you get used to being aggressive and sometimes I'm a little too ICM: What helps and what hinders? 39 pushy. But once they got to know what I was doing and what I was about, they jumped right on board, and not only did they jump on board, they were yanking me up there too. And .. .I could not in any way imagine having got through the last six months without them. I had the counsellor phoning me at night, the principal was phoning me .. .and I'm at the school like every day or every other day. -Participant #4 Example 2 [hindering]: ... perhaps I was being a big pest, you know, going around with my little handouts, but I didn' t think I was .... Well, that principal, when she said that to me that day about other parents aren' t acting like I am, not doing .. .the things that I'm doing. That made me feel like I was being a pest. -Participant # 1 The parents generally felt supported by the Care Team but two of the eight interviewees identified incidents that demonstrated that other team members sometimes reacted defensively when the parent presented as a strong, vocal advocate for the child. Defensiveness was always regarded as hindering. Subcategory 5e: Teamwork [8 helpful and 2 hindering} (6% of the incidents; 63% participation rate) The incidents in this subcategory refer to examples ofteam members working together as a whole or subgroups ofthe whole to solve problems. Some incidents describe examples of cooperation between two members of the team to increase the power of a weaker member. An important aspect of teamwork for some parents was that children were discouraged from being deceitful in regards to such things as school work and illegal activities. On the other hand, team processes were shown to be hindered when one agency or ICM: What helps and what hinders? 40 individual was clearly at odds with the Care Team. An example of a helping incident and a hindering incident is provided: Example 1 [helpful]: I'm very blunt about stuff and I told [my] foster child that...you have an option, you' re 14 years of age and you could choose to go to jail or you can choose to go on the straight and narrow and smarten up .. .. . . . so the team pulls together ... [and told the child] - you cannot go to school here and behave this way. You will be out ofthis school, and I backed the school up, and [told the child] - you will be out of my home, I won't have a drug person in my house .... [W]as that helpful! It was very helpful. And I find with children, honesty is helpful. -Participant #4 Example 2 [hindering]: [W]e also had [a foster child] who decided to go awol when her brother got out of jail, and there were all sorts of interventions that could have been taken by the courts to work with us so that we could have ensured that this one kid stayed on track, but we didn't get the support from the court system at that time, and the Ministry couldn't do much more than they were doing .... [E]ven in our Care Team meeting about her, their response was, "well there' s nothing we can do , so you just leave her". She was only 14 and so she ended up ... on the streets too. So that was an issue. But I don' t know that there is anything they really could do , so it ' s not really faulting them, but it really felt like ... there [was] no coordinated effort, working together, where you put some teeth into it? -Participant #8 Category 6: Communication (51 incidents - 29% of incidents; I 00% participation rate) Considering the high number of incidents and the maximum participation rate for this ICM: What helps and what hinders? 41 category, it appears that the parent participants' most vivid memories of their experiences are related to the verbal and non-verbal exchanges between members of the team, regardless of those exchanges being of a positive or a negative nature. Subcategory 6a: Alienation/Coriflict [I 3 hindering} (7% of the incidents; 75% participation rate) This subcategory contains incidents that describe communication that tended to alienate the parent participant or that created roadblocks to further communication. An example follows: Example 1 [hindering]: I remember one morning, we had a meeting, just at the beginning ofthe year, and [one of my daughter' s teachers] came in and sat down and said "I don't see what all the fuss is about- I've got a farm to run", and I was really upset about that. Well, I thought, this should be your flrst obligation; it's what you get paid for, not to run your farm. I was upset and she just seemed to- and I found this quite often. Some teachers knew about [F AS/FAE] and understood and others didn' t know and didn't really believe it. -Participant #1 These incidents tended to be perceived as very hindering by the five reporting participants who became emotional and had difficulty moving off these stories once they came to mind. The incidents were reiterated, in some cases three or more times, during the interview. Subcategory 6b: Communication - Praise/Empathy/ Validation [I 5 helpful} (8% of the incidents; 75% participation rate) ICM: What helps and what hinders? 42 The incidents in this subcategory provide examples of communication that contributed to building a positive relationship with the parent and that provided encouragement to the parent in the role as primary care giver to the child. Example 1 [helpful]: [W]e have had a lot of. .. teachers, especially . .. Ms. A [who] indicated there several times, "Billy is just so lucky to live in your home" ... and you know, that does something for you because you do put a lot of work into the child, and when you have something positive come back to you like that, [it] helps you and spurs you on ... -Participant #3 Example 2 [helpful]: I would have given up a long time ago if had not been for [the Resource Worker's] feedback saying, "This is a really difficult case ... it's a very difficult case but you're doing a really good job." [She is] very specific- you're doing this, and this, and this meeting that child' s needs and we see the effect that it's having in this way; now the child no longer does this, and this and this. So, that kind of feedback is absolutely invaluable. -Participant #8 Subcategory 6c: Communication - Contradictions [7 hindering] (4% of the incidents; 38% participation rate) This category included descriptions of situations in which the parent had been told one thing and then the school or the social worker did or said something different. Also included in this category are incidents that reveal inconsistent and/or conflicting ideology of team members. Example: [W]hat we' d experience sometimes, is, you ' d be dealing with one social worker and then there ' s a change of social workers, and one has one j ICM: What helps and what hinders? 43 philosophy and one has another and the new one comes in and feels that the other one didn't have any good ideas, and so all of a sudden we ' re sorta supposed to flip from one thought to another, and then another one'll come in with a lot of different ideas. And so we feel like, maybe a dog being dragged around on a leash a little bit that way sometimes. - Participant # 3 Subcategory 6d: Communication - Sharing iriformation [II helpful and 5 hindering] (9% of the incidents; 63% participation rate) This category included incidents that describe the respectful sharing of information between members of the team on one hand and incidents that expressed the caregiver' s frustration with the lack of sharing of information at other times. Example 1 [helpful]: I think it was really nice when a counsellor, the teacher, I really liked the fact that when they were paraphrasing back to us what we were saying .. . because then I could see, you know, the information that we gave them, how they processed it and sent it back to us. Because I think oftentimes what happens is there ' s a miscommunication and the message you sent isn' t the one that' s received, so for me it was really helpful for them to sort of come back at me with my comments, so I could say, well no that's not quite what I meant. .. oh, I'm not saying he's that way, but, you know, they get the general idea .. . so, so for me it was, I found that, the paraphrasing really helpful. .. I'm sure it slowed the process down but for me, as the parent, trying to be communicating with the school, it was nice not to have that frustration, you know, from going away from the meeting thinking, you know, I don't think they quite got it. -Participant #7 ICM: What helps and what hinders? 44 Example 2 [hindering]: [One] thing I have a real problem with ... is you' ll go to the Care Team, and [the school] will say they're doing a certain thing and then you find out. . . [t]hey' ve decided to take her out [of classes] and put her on a cooking program, but they don't tell me they' re gonna do that, or they don't tell me which parts of the day they're gonna do that. So [if] they taking her out of computers because she ' s disruptive, no problem ... but if they're taking her out of math because they think she can't do it and I know she can and she thinks she can and she thinks she ' s smart in math, I have a problem with that. .. . [B]ut when I raised that issue, "so when did that plan change .. . and who had input to changing that plan?'' ... [T]hen there's that big defensive thing again. . . -Participant #8 Parents have recalled slightly more incidents that were regarded as ' conflicting' than those that were interpreted as empathetic or validating. They regarded it as very hindering when professionals became defensive, or appeared to be on the attack. Category 7: Follow Through [1 Helpful and 5 hindering} (3 % of the incidents; 50% participation rate) This category included incidents that were related to whether or not the team members actually carried through with strategies that were discussed at Care Team meetings. Example! [helpful]: Everybody was there; it all got dealt with at one meeting and then everybody could go to their separate offices and do whatever they had to do, but it never got misguided or anything like that. I had very positive people at my meetings and people did what they said they were going to do. -Participant #6 ICM: What helps and what hinders? 45 Example 2 [hindering]: I don' t know if[that particular strategy] was successful or not cause there was no closure for us. You know, we didn't get to hear at the end, "oh, you know what, after we stopped sending the book home he was way better, way more successful" .... [W]e would have really appreciated [some follow up analysis] , just so we would ' ve known .. . it really was successful, or it also wasn' t successful, let ' s try the next, the next route come September. So, for us ... we were left hanging ... -Participant #7 Category 8: Cultural Issues [3 hindering] (2 % of incidents; 38% ofparticipants) The three hindering incidents in this category pertained to children of Aboriginal background being placed in Aboriginal foster homes or being repatriated to the Reserve community of their relatives. Example: I mean there ' s nothing wrong with having the children in an Aboriginal setting; it's wonderful; however you need to go there yourself too. [M]ost ofthe social workers here were raised in [Ourtown]. [Ourtown] is a fairly progressive little town, albeit little [but the workers] really don't have a concept. When I asked a social worker what she thought of [the far-away Reserve community that the children would be returned to], she said it made her skin crawl. [The social worker] went and visited there for 3 days. I said, "But you' re going to send the kids there?" "Oh well, they belong there", she said. But these children have grown up in [Ourtown]. -Participant #4 Although few in number, the incidents reported in this category were among those considered to be most controversial as parents recalled these incidents during interviews. The procedures for this study provided time for parents to be debriefed following their interview. ICM: What helps and what hinders? 46 Issues, such as those in the latter category, that arose during the interviews, frequently needed to be discussed further once the tape recorder was shut off On two occasions the interviewee requested that the recording be stopped while they elaborated upon particularly sensitive incident. Most parents (87.5%) stated that their participation in this study has fmally provided them with an opportunity to voice their opinions, both on and off the record, about their experiences with Care Teams. This chapter has provided a description of each category and subcategory along with prototypical examples of incidents that comprised each of these classifications. An overwhelming majority of the reported incidents (76%) were related to the three large categories of communication, outcomes, and the team (roles and contributions). The discussion in the following chapter will show that this fmding is consistent with other studies reported in the literature. However, this observation is not intended to take away from the significance ofthe other categories. ICM: What helps and what hinders? 47 CHAPTER FOUR Discussion In this chapter I will discuss the salient findings of my critical incident study of the Care Team process as well as the implications of those fmdings for Integrated Case Management Care Teams and other forms of collaborative teaming. The results of the present study are consistent in many ways with the few similar studies found in the literature. The 178 critical incidents (118 helpful and 60 hindering) that emerged from eight interviews with parents and foster parents of children in care resulted in the formation of eight major categories: (a) Beginnings, (b) Structure and Function, (c) Outcomes, (d) Tone, (e) The Team, (f) Communication, (g) Follow Through, and (h) Cultural Issues. See Table 2 (p. 23) for a summary of categories, subcategories, participation rates, and proportions of helpful and hindering incidents. The limitations of the study will be presented and topics for future research will also be considered. Themes Nearly all of the themes that arose in the current study reflect those that other researchers have identified. Of the eight major categories (see Table 2) that arose from the data of the present study, four in particular: Outcomes (Strategies and Resources), Communication, The Team (Teamwork), and Structure and Function, coincide, respectively, with the following five characteristics of successful interagency collaboration identified by Bruner et al. (1992): 1. Develop and implement strategies that will empower families to make appropriate decisions leading to self sufficiency ICM: What helps and what hinders? 2. Know the resources available within the community to meet special needs which cannot be met directly 3. Communicate with other workers who can provide resources to the family 4. Establish teamwork with other workers when children and families need services from several organizations at once 5. Build community relationships and connections with organizations and individuals who can help support children and families Similarly, parent-professional communication and information sharing both emerged as themes in Jivanjee ' s (1999) investigation into parent perspectives on family involvement in therapeutic foster care adding further validation of the current work. Furthermore, Rutman et al. (1998), in their Review of Regional Integrated Case Management Services conducted for the Ministry for Children and Families, interviewed children and parents who , demographically, were very similar to the sample of parents used in the current study; they identified key elements ofthe ICM that are reflected in the categories that emerged during the present study. Their key elements were: holistic approach; development of trusting relationships; clarity of roles; common goals; shared decision making; respectful and consistent involvement of clients; shared responsibility and accountability; information sharing and frank communication; follow up and follow through; proactive assessment, planning, review and implementation of case plans; multidisciplinary case conferences. These elements intersect with several of the categories and subcategories that have appeared in the current study. For example: "common goals" and "holistic approach" coincides with Structure and Function; "respectful and consistent involvement of clients" is 48 ICM: What helps and what hinders? 49 reflected in The Team and in Communication; while "proactive assessment, planning, review and implementation of case plans" can be seen in Outcomes and in Communication. The importance of frank and respectful communication, trust, teamwork, follow through, and shared responsibility is evident in the literature and supported by the current study. Trusting relationships, as a category, appeared in the literature (e.g. , Jivanjee, 1999; Rutman et al. , 1998) but has not been identified specifically in the present study. Incidents that describe trusting relationships and the importance ofthese were elicited, but have been categorized in relation to communication, teamwork, and tone. One of the participants mentioned the lack of this specific category during a cross-check interview but was satisfied that this significant theme was adequately reflected in existing categories, including Tone and Sharing Information. The following discussion will solidify the comparison between the present study and the key elements and aspects of the other cited works. Communication Care teams are, of course, all about discourse, with and on behalf of children who are at risk. As one parent stated, " it ' s good for everyone to be able to say what they need to say. Otherwise you don' t get a full picture, and well then, what ' s the point?" The parent participants in this study strongly endorsed the practice ofiCM, and in particular, the opportunity that Care Team meetings afford for communication and the sharing of information. All of the participants reported incidents in this, the largest category (29% of all incidents). Parents have stated through this study that they want to be actively involved and appreciate it when they are asked for their views and opinions. They have also indicated that ICM: What helps and what hinders? 50 they appreciate in return, the time that professionals, especially teachers, devote to Care Team meetings. Five of eight parent participants in this study reported incidents that described an openness and willingness to share information in their meetings. Team meetings consist of a complex of written, verbal, and non-verbal communication that has been reported, by the participants, to include both helpful and hindering qualities. Negative forms of communication such as contradicting or alienating remarks by practitioners were reported as often as was positive or helpful communication such as praise and validation. Providing foster care for difficult children and youth is extremely challenging and the parents in this study all indicated the need for positive reinforcement to encourage them to go on. Having regular team meetings assured the parents that they were not alone in the work that they do, since, and despite their dedication to the task, most felt undervalued by the larger agencies that they were answerable to . The importance of communication in the functioning ofiCM and collaborative practices has been shown in previous studies (Bruner et a!. , 1996; Fleming & Monda-Amaya, 2001 ; Hubberstey, 2001 ; Nicholson eta!. , 1998; Rutman eta!. , 1998) and is underscored in this study by the high participation rate in this category. Nicholson et al. observed that a "commitment to communication is essential for effective collaboration" (p. 59) and that team members must recognize and accept that this will be time consuming. In variance with the fmdings in regards to the importance of communication is a concern about confidentiality of information. The controversy related to the sharing of confidential information in the ICM process is evident in the literature (Hubberstey, 2001 ; Rutman eta!., 1998; Webb eta!. , 2002). In all three of these studies practitioners reported ICM: What helps and what hinders? 51 that a lack of open communication between members of the team was undermining the effectiveness of the ICM process. Interestingly, Rutman et al. (1998) observed that parents did not share the same perception of the situation. They, in fact, reported the experience of openness within the team with respect to communication and placed a high value on that aspect of the team process. The fmdings of the current study are congruent with the Rutman et al. fmding and might therefore indicate that parent members of the Care Team are unaware of the underlying reluctance of agencies to freely share information with each other. However, both viewpoints have some validity as one participant pointed out by stating, "When all the people are gathered together, all the people need to have all the information .... [Members should not] be hiding certain aspects of a child' s information" (Participant #4, personal communication, July 11 , 2005). She had observed that school personnel did not always know about an F AS/FAE diagnosis or a history of abuse, for example, that would impact a child ' s school programming. Although participants of this study did not specifically mention ' confidentiality of information', it is one of the concerns for professional participants in ICM and other forms of collaborative teaming and has, for legal reasons, influenced the free flow of information (Rutman et al., 1998; Webb et al., 2002). Moreover, the Gove Report recommended that "the province's child protection, income assistance, and freedom of information and privacy legislation need to be amended so that social workers can access any information necessary to investigate and plan for children" (p. 34). Ifthe parents do not express concerns around this issue, social workers and other professionals certainly have. Webb et al. , in their study of the impact ofiCM training on practitioners, noted that "fear of inadvertently sharing information which is beyond the bounds of confidentiality seems to be a stumbling block for ICM: What helps and what hinders? 52 some teams. Different agencies have different levels of interpretation of confidentiality and what can or cannot be shared" (p. 33). However, Tate and Hubberstey (1997) maintain that the presence of the client reduces or removes the issue of confidentiality, and should not present an impediment to communication. Further to this, discussion about the confidential nature of the information that is shared at Care Team meetings is required at the outset of each meeting, and each member's signature on the minutes is their agreement to maintain confidentiality. The concern expressed by Participant #4, above, indicates that this discussion needs to be taken a step further to ensure that parents become better informed about the issues affecting interagency interactions because these in turn, affect communication within the Care Team. Communication is a fundamental part ofiCM. Ten years ago the Gove Report (1996) implicated the "lack of interagency communication and cooperation, particularly between social workers and the medical community" (Volume 1: Matthew' s Story) as a contributing factor in the deaths of29 children in the Ministry' s care. The fmdings ofthe current study provide support for the belief that, in the ensuing decade, we are doing better in terms of interagency communication and cooperation, and that parents view the Care Team as the appropriate forum for communication. The Team .. .there was a bunch of us. I had (a social worker). I had CCS- a family support worker and another woman. I had the Ministry of Family and Children Services. I had the foster parents. I had my child. I had myself, like, when I had my Care Team meeting there were a lot of people (laughter) ... it was awesome! It was wonderful! (Participant #5) ICM: What helps and what hinders? 53 The words of the parent participants say it best when the composition of the team, and the roles, and contributions of each team member are being considered. That 28% of all incidents formed the Team category supports its relative importance. The fears of practitioners that the ICM meeting might overwhelm the client (Rutman et al. , 1998) have not played out for the clients interviewed for this study. More often, concern was expressed by parents in regards to professionals who did not show up for meetings in this and previous studies (see also Rutman et al.) because the absence of key players caused disruptions or delays in implementation of plans and thus reduced the positive effect ofthe team. As in this study, Webb et al. (2002) reported that their "survey respondents and key informants offered a total of23 responses that supported strong team cooperation and the inherent value of relationships (p. 32)". Webb et al. (2002) more recently found that service providers see their involvement in the ICM as providing "important opportunities for interagency role awareness, improved relationship building, and an understanding of different agency mandates and purposes" (p. 32). Further to this, Fleming and Monda-Amaya (2001), who found team roles and membership to be more critical than communication, recognized the importance of each member' s commitment to the team process. Notably, having the child participate as a member of the team came up in seven out of eight interviews, with both helpful incidents (13), and hindering incidents (4), being mentioned. It was generally regarded as important, necessary, and helpful for middle and high school aged children and youth to be actively involved in their Care Teams although there was some discomfort with sharing of sensitive information such as IQ scores and special needs designations. Parents appreciated that their children were treated with respect ICM: What helps and what hinders? 54 and that they were included as equals in the discussion and asked for their input during meetings. Information that only the child could contribute to a meeting was considered to be instrumental in making appropriate decisions and to avoid pitfalls such as jumping to conclusions. Rutman et al. (1998) also noted that the "opportunity to be involved in information sharing and decision making, to contribute, to be listened to, and to be kept informed" (p. 24) is an important benefit to clients ofiCM and the Care Team process. However, an opportunity to meet without the child present was considered by some parents as necessary for younger children in particular, or for the sharing of information that might embarrass or upset the child or youth. Consideration for the child ' s safety is very important, as pointed out by one participant, and the child ' s participation would be contraindicated in some situations. The parents in the present study reported that they sometimes came up against a defensive attitude from professionals, in particular teachers, when they were engaging in attempts to educate the team about their child ' s needs or disabilities (seep. 39). This is a theme that also appeared in a previous category regarding communication. Parents in my study, who have become knowledgeable about their child ' s special needs, want to be heard and respected by the professionals on the Care Team, and to be regarded as having something of value to contribute to the team but did not always experience this. Being able to make this contribution was seen by parents as helpful in achieving the aims ofthe Care Team. However, some parents spoke oftheir ' struggles' and others ofthe ' fight' to achieve a desired outcome or to being regarded as expert on their child. Similarly, Duncan (2003) used a qualitative design to study the conflict that families had experienced with special education professionals and found that the ' unhelpful people' ICM: What helps and what hinders? 55 [of his Helpful and Unhelpful People category] were professionals who were unreceptive to learning skills that would improve their ability to meet the child ' s needs. This habit, which was observed also in the present study, created a somewhat adversarial relationship for some parents, with certain members at some meetings, but did not result in the outright warfare and resultant stress reported by Duncan. And although no parents reported that they actively avoided conflict, they did report being sometimes tired ofthe ' fight' . That ICM Care Teams are inadequately prepared or trained to make constructive use of controversy in the group process, is highlighted by the nature of the conflicts reported. Johnson and Johnson (2006) opined that society in general views conflict in a negative way and groups, therefore, tend to be uncomfortable with controversy and will avoid it. However, as revealed in this study, conflict does arise in groups, including Care Teams, the conflict is often poorly managed, and it results in divisiveness and hostility (Johnson & Johnson) . Interestingly, Webb et al. (2002) found that most service providers responded positively to training that was intended to help them prepare their clients for ICM activities and meetings. Several respondents in the Webb et al. study thought that more training for themselves in these skills would be helpful. As all the participants in ICM become more knowledgeable and more skilled in the practice, it follows that the Care Team will be better equipped to achieve its goals. In particular, Eber et al. (2002) recommended that facilitators of Wraparound, a comparable process to ICM, be skillful at: "(a) recognizing and blending differences in perspectives among team members, and (b) guiding consensus and problem solving" (Integration Guidelines section, ~ 2). In addition, training for groups in the use of conflict as a problem solving device is advocated by Johnson and Johnson (2006). ICM: What helps and what hinders? 56 That the client and the client's parent(s) will be fully involved is essential to the practice of case management (Roberts-DeGennaro, 1987) and this study shows that active involvement in their child's Care Team is important to parents (see page 38). The most helpful way to encourage them to be actively involved, from the parents' perspective, is to be treated as equal members of the team. Outcomes (Resources, strategies, and transitions) The third largest category (19% of all incidents) to emerge from the results of this study includes a large majority of helpful incidents that are related to resources, strategies and transition plans that resulted through Care Team processes such as brainstorming, goal setting, discussion, and sharing. It was the "little things" that the team came up with- the ideas and strategies that helped their children overcome a problem at school (e.g., a course change to alleviate a stressor) or that helped them help their children (e.g. , fmding a tutor, suggestion to ' back off' on homework)- that were readily recalled and that counted the most for many parents (also seep. 29). The subcategory with the highest number of hindering incidents was Transitions. The subcategory included negative incidents that arose from abrupt endings (e.g. , lack of closure) and different expectations from adults at different settings (e.g. , foster home vs. respite home) in a child' s life. As with the present study, Fleming and Monda-Amaya (2001) found that outcomes are important indicators of effective wraparound team process, reporting that 46% of their sample cited team outcomes as an indicator of success. Although they differentiated between outcomes related to team processes such as group decision making and outcomes that are related to interventions that the team comes up with and implements, they stated that previous research did not make this distinction. The current study yielded incidents that were ICM: What helps and what hinders? 57 more concerned with the specific interventions that the team suggested and one or more members then implemented. The following interview excerpt provides a clear illustration of this process: ... backing off from homework demands came as a group decision after brainstorming and we just laid it on the table- this is what' s happening in the home, [violence in response to requests to complete homework or to study] , we need to talk about this and we need to get some input from everyone as to what should happen here. [Someone suggested that it] was essential that we pull back on that. Well then, you know once we weren't doing the pushing, he of course didn' t do the work and of course didn't get the grades ... but the home was more positive, was more pleasant. Rutman et al. (1998) found the outcomes ofiCM case conferences to be very profound for clients and motivating for practitioners while Webb et al. (2002) found that, among surveyed service providers, 82% observed that integrated case management led to positive outcomes for their clients and furthermore, that: When survey respondents were asked to identify their greatest reward so far in practicing ICM, the vast majority made reference, in some form or another, to the idea that client's needs were being met. As one service provider expressed, "it is rewarding to me to see the client's needs/issues are being addressed by all the professionals involved ... that they are improving their lives - that they are becoming healthier" (p. 30). Outcomes are perhaps the most easily identifiable and observable aspect of the Care Team and are often measurable indicators that something positive is ICM: What helps and what hinders? 58 happening in the Care Team and that the aim is being achieved. After all, parents attend Care Team meetings and case conferences in order to make certain that actions are planned and carried through for their child. Parental influence on the outcomes for their child is in itself an empowering experience for the parent that in turn can further encourage positive change for the child (Taub, Tighe, & Burchard, 2001). Follow through Since ' Outcomes' have been shown to be an important aspect ofiCM, it is evident that Follow through would also appear as a concern. The Care Team experience of one participant was that "people did what they said they were going to do" while others were more likely to report that something was left hanging or "just never happened". As mentioned earlier, trust and trusting relationships did not emerge as a category on its own in the present study, but trust has been mentioned in the context of several categories. Trust in the Care Team process was undermined by a lack of follow through as expressed by participant #8 who stated, "There was no coordinated carry through of [the plan]. We can decide whatever we want at a Care Team? But unless it's actually implemented, when you get back to the different organizations, you might as well not have a Care Team meeting." In one case the failure to follow through meant that the counselling intervention that the team included in the proposed care plan had never taken place. Inconsistent follow through on care plans was one of the challenges to clients that Hubberstey (200 1) highlighted from the 1998 Review ofiCM which included ' follow through' as one of the key elements around which the Review was focussed. Rutman et al. (1998, Appendix E) emphatically state that "ICM is more than case conferencing! All participants need to take responsibility for follow through on their portion of support or implementation to the plan". ICM: What helps and what hinders? 59 Cultural issues While 20% (2 out of 10) of the parents interviewed for this study disclosed that they were Aboriginal or part Aboriginal, 87.5% (6 out of 8) of the children in their care were Aboriginal or part Aboriginal. And although all of the participants had had Ministry of Children and Family Development/School District Care Teams at some time, four had also had an association with Xyolh:meylh 1, the St6:l6 First Nation agency responsible for Aboriginal child welfare. While only three incidents comprise this category, they are noteworthy in that they are the only incidents out of 178 that specifically relate to a child' s Aboriginal heritage. In addition, these three incidents were elicited from emotion-laden, lengthy, and oft-reiterated anecdotes. Two out of the three incidents refer to the current practice of placing Aboriginal children in Aboriginal foster homes, wherever practicable, while the remaining incident was an expression of concern about the perceived insistence of a member of the team to include a child in Aboriginal programming when the parent and child were adamantly not interested. One Caucasian parent stated that he was empathetic with the underlying position for placing Aboriginal children in Aboriginal settings, but as this is not always possible, he believed that it would be helpful for him if the Care Team could "just confirm that [his home] is a good placement for the child, [that] the child is doing well, he ' s doing good in school, or as well as can be expected" (Participant #2, personal communication, May 24, 2005). It appears that well-intentioned government initiatives such as; (a) support and cultural programmes targeted at Aboriginal students in public schools, and (b) repatriation of foster children to Aboriginal communities, do not always meet with the real life needs or wishes of these children and their parents. ICM: What helps and what hinders? 60 The challenges represented by these issues are much greater than the low number of reported incidents indicates and they go beyond the scope ofthe current study. That there are challenges in serving the mental health needs of Aboriginal people is acknowledged by Smye and Mussell (2001) who have noted (among other things) that: 1. Provincial/ Regional jurisdictional debates continue to be a major barrier to service provision to First Nations and other Aboriginal people; 2. Also in relation to regional boundaries, little acknowledgement is given to the barrier those boundaries impose to those individuals moving between reserve and urban life. 3. Interministerial jurisdictional debates also continue to be a serious barrier to the provision of service. 4. There is a lack of coordinated services related to the well being of children. 5. Distinctions between the urban and rural experience remain poorly understood. 6. The traditions, values and health belief systems of First Nations and other Aboriginal people are poorly understood by many providers and often are not respected or considered. 7. Aboriginal knowledge tends to be devalued and marginalized. (p. 34) The bicultural (Caucasian and Aboriginal) composition of many ofthe Care Teams in the school district provides a unique opportunity to address some of these challenges (see Implications for Further Research, p. 51). Smye and Browne' s (2002) advice to nurses that "in every encounter they need to reflect on their own values and beliefs as ICM: What helps and what hinders? 61 one interacts with the values and beliefs ofthe 'other'" (p. 54) is relevant for members of Care Teams if we are to provide a 'culturally safe ' venue for Aboriginal parents and youth. Cultural safety refers to a situation in which the dominant cultural group empowers and supports those from another ethnocultural group, rather than demeans and diminishes them through its actions and processes (Smye & Browne, 2002). In order to begin building cultural safety into the ICM process and to meet some ofthe challenges enumerated above, the Aboriginal voice must be actively included in any further studies. Summary Although a majority of the parents who were interviewed spoke negatively about the services provided for their children by the Ministry of Children and Family Development (MCFD) and Xyolh:meylh 1, particularly in regards to foster children, they were very positive overall in regards to the Integrated Case Management (ICM) - Care Team process. Changes in the funding formulae for foster homes, waiting times for counselling, repatriation of Aboriginal children, and outright cuts to services such as play therapy, were targets for parents' negative criticism. The client focus groups that Rutman et al. (1998) brought together for their review of regional ICM services articulated a similar general negativity towards MCFD. Many of their participants were critical of the Ministry overall yet "spoke of important outcomes ofiCM and case conferences" and stated that "these outcomes were quite profound" (Rutman et al. , 1998, p. 26). Some of these profound outcomes included validation of self (parent) and child, improved relationships and communication between family members and greater involvement in decision making. The ambivalence in regards to MCFD and Xyolh:meylh 1 described here is underscored by the findings of Webb et al. ICM: What helps and what hinders? 62 (2002) who pointed at the poor relationship between community agencies and MCFD (seep. 18) that was observed by the practitioners within these entities as a negative influence on clients. The high proportion of helpful incidents relative to hindering (66%) suggests that parents viewed ICM in a positive light, particularly when school personnel were case managing, as suggested by two participants. Similarly, Measelle, Weinstein, and Martinez (1998), in an attempt to develop an instrument to measure parent satisfaction with case managed systems of care, found that "approximately 75% of the parents and primary caregivers of severely emotionally disturbed children were quite satisfied with their families' case management services" (p. 464) and with their case manager. Satisfaction with case management was positively correlated to the number of contacts that families had with case managers and inversely related to the length of hospitalizations experienced by their child. Based on these findings, it can be argued that an integrated system for managing and delivering services to children and families is valued by parents. The present study has provided a vehicle for these parents to contribute to the evaluation ofiCM services, from their perspective, and to provide feedback that will serve to highlight and to improve the experience for other parents and Care Team members. Benefits ofthe Current Research The present study provides data that will let parents and practitioners know what helps and what hinders the Care Team process in meeting their goals for children. Bruner et al. ( 1996) concluded that "formative, or process evaluations not only are helpful in charting the course of collaboration, they also provide a valuable record so that lessons learned in the process are not forgotten at a later date" (p. 13) and Vandenberg and Grealish (1996) point ICM: What helps and what hinders? 63 out that the measurement of basic outcomes of wraparound can be used by the team to modify the process and develop the service system in the community. This study is an example ofthe kind of work that can be done to meet these objectives. The present study has (a) provided valuable feedback to the Care Team participants, (b) provided a forum for the parent voice, and (c) demonstrated how the CIT approach could be used to evaluate and monitor the Care Team process insitu. That is to say that ICM Care Teams, as well as School Based Team case conferences, could use the language - what is helpful and what is hindering -as a self assessment tool during a meeting or as a periodic check with team members, including parents and youth. One of the ethical considerations discussed above was that this study would pose no risk to the participants and that it could, to the contrary, provide a benefit by providing the participants with an opportunity to be heard. In fact, several participants stated at some point during their interview that they had never been asked for their opinion about the ICM process before and others stated that they were thankful for the chance to get some things off their chest. The provision of a formal opportunity for the parent voice to be heard has been an important aspect of this study. Limitations Of the 10 participants in the study seven had had a prior relationship with the researcher, either through co-involvement in the ICM process or in other contexts within the school district. These relationships could introduce a source of bias into the results while at the same time facilitating the researcher ' s ability to understand participant constructions of meaning because of the shared context and the established rapport (Morrow, 2005). Furthermore, Haverkamp (2005) cautions the scientist-practitioner of the potential for the ICM: What helps and what hinders? 64 research interview to be a "disruptive intrusion into a participant's world" (p. 153) and also warns that "researchers may be faced with difficult decisions about dual relationships" (p. 147). Although the prior Care Team client-researcher relationship facilitated the recruitment of some participants, others were not contacted by the researcher until a neutral person, such as a school counsellor or administrator, had initiated contact. Interviews were conducted at a time and place determined by the participant to minimize disruptive intrusion. The validity of the results, in light of these concerns, could be supported by the fact that participants contributed an average of22 critical incidents in 30-60 minute interviews with no obvious difference in quantity or quality whether a prior relationship between the researcher and the participants existed or not. Two participants who had a prior Care Team relationship with the researcher expressed concern during their interviews that they were being too negative even though they ended up contributing both positive and negative incidents. That the study involved only 10 individuals presents a further limitation to generalizing the fmdings ofthe current study. Although some ofthe fmdings will be of interest to those doing ICM in other jurisdictions, generalizing to all ICM teams is not the intention. Despite the small sample size of 10 participants, a test of exhaustiveness of the data was attempted and the test indicated that the study had yielded enough data after the seventh interview to exhaust the possibilities of new categories arising. It is also important to note here that useful data can result prior to achieving redundancy. Several of the more recent CIT studies (Jivanjee, 1999; Keatinge, 2002; Preskill, 1997) seem to be unconcerned with this parameter, but rather are more interested in the quality of the data generated. For example, the qualitative study by Jivanjee utilized a semi-structured interview of 10 parents of children placed in therapeutic foster care to learn more about family involvement from the ICM: What helps and what hinders? 65 parent's perspective. Although he was able to identify a range of parent perspectives, (e.g. , approval oftheir involvement; anger about not being invited to participate) he did identify the small sample and local context as limitations to his study. Preskill (1997) describes the use of the CIT in gathering information about effective teaching practice from his student teachers which he then used to develop categories for evaluation of student teaching. The student teachers' resulting awareness of the perspectives of other student teachers, which became apparent through the weekly journaling and analysis of critical incidents, provided concrete validation for the existence of individual differences. And finally, Keatinge (2002) presents the fmdings of three studies in which nurses utilized the CIT to gather qualitative data regarding their practices in three different clinical settings. One of the studies involved five nurses observing 29 elderly patients in order to document incidents of patient agitation and action taken by the nurse. The value of the CIT was shown to be, according to Keatinge, its flexibility and versatility in allowing the nurses to participate in research of their own practice. The trustworthiness of the data gathered in the current study was checked in several ways as is the current trend in CIT studies (Butterfield, Borgen, et al., 2005). Although the study's reliability was checked through the use of six additional raters reviewing the data (see Table 1) it should be noted that inter-rater reliability has been shown to be low in a quantitative analysis ofthe CIT (Ronan & Latham, 1974). Ronan and Latham attributed this to differences in perspective when two groups of observers are looking at the same phenomenon. ·- ICM: What helps and what hinders? 66 Implications for Further Research There are many possibilities for further research suggested by the results ofthis study. Further research might be able to determine how the ' what helped and what hindered' form of self-reflection could generalize to other types of school based teams as suggested by Fleming and Monda-Amaya (2001). They suggest identifying successful school based teams (and I would extend that to include Care Teams), observing them in action and interviewing the members to study team effectiveness. Because teachers are expected to be part of Care Teams and case conferences that take place at school, it would be of some interest to look at these processes from their perspective also. Practitioners have had opportunities to receive training in the ICM process and studies have been conducted to determine the efficacy of that training (Webb et al. , 2002) as reported above. Similar work is needed to determine if parents could also benefit from a program that would train them to be more effective participants in ICM. Such a study is now in the proposal stage (R. Lees, personal communication, November 2005). Although this study did not do so, I now recognize that it might be helpful to differentiate between the experiences of foster parents, biological parents, and adoptive parents, as each of these groups offers their own unique perspective and will have varying expectations of service providers and ICM. Further research using larger sample sizes for any one of the subgroups just mentioned could produce results with greater potential to generalize throughout these specific subgroups and to compare the experiences of members of different subgroups. Considering the disproportionate numbers of Aboriginal children being cared for by non-Aboriginal caregivers in this study (six out of the eight children were Aboriginal or part ICM: What helps and what hinders? 67 Aboriginal while two out of the 10 parents were Aboriginal or part Aboriginal), and the concern pointed out by Smye and Mussell (2001) regarding case coordination, coordinated services for children, and an overall lack of coherence in mental health programs, future research should perhaps separate out the ethnicity factor and look at some aspects of the imbalance. The impetus for the present study came from Dr. R. Lees, the individual responsible for regional mental health service quality for Ministry of Children and Family Development, Fraser Region. However, several of the participants had involvement with Xyolh:meylh 1, the St6 :l6 Nation branch responsible for social services for Aboriginal children within St6:16 territory, further supporting a need to approach the St6 :l6 Nation to partner in a qualitative study of services that they provide for children. In support ofthis suggestion, Smye and Mussell have recommended research that determines what is working and that seeks input from "Aboriginal people to develop program standards, outcome measures and evaluation criteria and methods" (p. 5). It should be noted here that McCormick (1997), in a critical incident study, found that First Nations healing was facilitated by "getting beyond one' s own world and connecting with other people" and "through encouragement, acceptance, validation and/or reassurance from another person" (p. 177). It seems obvious that the Care Team process provides this opportunity, but how well the Care Team accomplishes this for Aboriginal participants begs further study. In addition to further critical incident studies, quantitative studies that look at graduation rates, achievement of individual goals, and post secondary destination or track for children in care, with and without regular Care Team support, could provide statistical data as one more measure ofthe success ofiCM. ICM: What helps and what hinders? 68 Conclusion The aim of this study was to learn about the Integrated Case Management/Care Team process from the perspective ofthe parent participants. Specifically, it was intended that the study would determine what was helpful and what was hindering in the achievement of the Care Team' s aims in respect to the parents' children. Using a modified version of Flanagan's (1954) critical incident methodology, 10 parents were interviewed, yielding 178 incidents, of which 118 were helpful and 60 were hindering in terms ofthe work ofthe Care Team. These incidents were then sorted into eight categories and 15 subcategories. Several reliability and validity checks were implemented to ensure the consistency and trustworthiness ofthe categories. In consideration of this work as a preliminary study, it could be stated that a rich array of data that contributes to our knowledge about ICM/Care Teams has been revealed by the participants. In addition, the participants have expressed gratitude for the opportunity to voice their opinions and to tell their stories, whether positive or negative. Based on the results, themes and incidents that arose in this study, a summary of helpful hints for conducting successful meetings is provided (please remember that ' parents', for the purpose of this study, refers to the child ' s caregiver--whether birth parent, foster parent, adoptive parent, or guardian--at the time ofthe Care Team involvement): 1. Help the parents to feel valued and of equal importance to other members of the team. (seep. 26) 2. Consider the parents to be experts who have important information to contribute to the team about their child (e.g. , knowledge about their child's disabilities or needs). (seep. 37) ICM: What helps and what hinders? 69 3. Encourage middle and senior high school students to be actively involved in their own Care Team. (seep. 35) 4. Provide time for meeting with and without the child present, especially for younger children. Seek permission from the child to have them present or not for specific discussions. (seep. 35) 5. Invite all players to attend each meeting and include birth parents when appropriate. (see pp. 33-34) 6. Be honest about what can and cannot be done by members of the team so as to avoid making promises at a meeting that cannot be carried through. Then, do what you say you are going to do. (see pp. 42, 54) 7. Accentuate the positive; focus on the child ' s and parent' s strengths and provide positive feedback to the both the child and the care giver. (seep. 39) 8. Consider the needs of the foster parent as well as those of the child. (seep. 31) 9 Avoid unilateral decisions or decisions made between meetings without parent involvement. (seep. 30) 10. Provide confidential opportunities for the parent to debrief the ICM experience. (see p. 44) 11. Consider holding Care Team meetings in school settings when practicable as this has been reported as being a more neutral location. (seep. 27) 12. Provide a facilitator who will govern the group process with no vested interest in the outcomes ofthe group. (see following paragraph) After conducting this study, I can affirm my agreement with Webb et al. (2002) who suggested that ICM would be well served by an "external facilitator who would not only free ICM: What helps and what hinders? 70 up all team members to participate equally in the ICM meetings, but who would also bring a more objective perspective to the situation" (p. 50). The need for direct observation as an objective measure was also proposed by Schacht et al. (1996). This person would be an observer and guide not otherwise involved in the case, but who could provide feedback about process, communication and relationships. For the time being, the results presented in the current study serve this purpose and pave the way for a system of ongoing summative and formative evaluation of Integrated Case Management. As this paper was being written, British Columbian legislators were dealing with a crisis regarding the deaths of children in care that has been linked to a government decision 3 years ago to eliminate the children' s commission and the child and family advocate (Willcocks, 2005). It was the job of the commission to audit care plans, to investigate deaths and to conduct research into suicide, alcohol and drug related deaths of children and youth in care. The recently released B.C. Children and Youth Review (Hughes, 2006) concluded that: The impact of budget constraints reverberated throughout the child welfare system from 2002 until recently. Those responsible for the transition were under pressure to meet deep spending cuts across the board and as a result, this small program got lost in the shuffle. (p. 128) Considering the magnitude ofthis issue it could be concluded that most ofthe criticism levelled by the participants in the present study, against the agencies responsible for children in care, was a reflection of how cutbacks in the Ministry have impacted families and children. To illustrate this, Participant #3 stated: What it boils down to [only] they know, but, you know, a lot of children really need help desperately ... We ' re not professionals so we can only go so far with ICM: What helps and what hinders? 71 the child, and we do that, but then after that, like [our foster son] was going to [a play therapist] and other children that we've had also went to counselling .. . a lot of them are going there, and then all of a sudden the funding was cut for that [italics added]. So that [service] was no longer available. That was all of a sudden just cut. Notwithstanding this pervasive theme of dissatisfaction with the bureaucratic level of services for children, and in particular the effects of government cutbacks, the participants of the current study identified proportionately more helpful incidents than hindering incidents when looking specifically at the experience ofiCM. That they were being involved in a study of the ICM process was perceived by the participants as an opportunity to instigate change from the grassroots level and to confirm their support of what the Care Team does. Participant #2 stated, "Hilary Clinton [said] ' it takes a village' .. .. [The team] can sorta reach out and help guide the child" as she attempted to sum up the importance ofthe work being done by the Care Team, for her child. 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Integrated case management: A user 's guide (Draft for discussion). Ministry of Children and Families, Victoria, British Columbia. Retrieved June 26, 2004, from http://www.mcfgov.bc.ca/icm/users guide l.htm Woolsey, L.K. (1986). The critical incident technique: An innovative qualitative method of research. Canadian Journal of Counselling, 20, 242-254. ICM: What helps and what hinders? 82 Appendix A Interviewing Protocol (from Wong, 2000) Introduction: This is a semi-structured interview study. The interview will require about 1 hour. The interview will be audio tape recorded, transcribed and given a code number. You can ask to have the interview terminated at any time. The tapes and transcripts will be stored in the faculty advisor' s research office and erased seven years after the completion of the study. Starting Questions: 1. Can you think of something that happened or something that someone did or said that worked for you? Was helpful? Please tell me about that. 2. Can you think of something that happened or something that someone did or said that got in the way for you, or was a problem? Was not helpful? Please tell me about that. Follow-up and probing questions: Tell me about a time when .. .. (a) What happened? (b) What went before? after? (c) How did it tum out? (d) What was it like for you? (e) How has that affected your family? ICM: What helps and what hinders? 83 Appendix B University ofNorthern British Columbia (letterhead) Informed Consent Form Title: Integrated Case Management: What helps and what hinders- from the parent ' s perspective Investigator/ Contact Persons: Vic Gladish - Investigator Home: 604-792-3890 Work: 604-858-9424 vg lad ish@sha w.ca Dr. Rob Lees- Mentor MCFD Office: 800-782-4138 Robert .Lees@gems l. gov.bc.ca Trudy Mothus - Supervisor UNBC: 250-960-5639 mothust@unbc.ca You have been asked to take part in the present study because of your past and/or present involvement in your child ' s Care Team. Your participation is entirely voluntary. You may decide to participate or not to participate, and you may withdraw from the study at any time without consequences of any kind. You are also free not to answer any questions, if you are so inclined. Purpose The present study is being conducted as one of the requirements for Victor Gladish to complete his Master' s Degree in Educational Counselling. The research is to determine what helps and what hinders in the integrated case management (also known as Care Team) process from the perspective ofthe child ' s parent or guardian. Procedure This is a semi-structured interview study. The interview will require about 1 Yz hours and you will be asked two main questions, specifically: 1. Can you think of something that happened or something that someone did or said during Care Team meetings that worked for you? Or was helpful? Please tell me about that. 2. Can you think of something that happened or something that someone did or said during Care Team meetings that got in the way for you, or was a problem? Was not helpful? Please tell me about that. What happened? ICM: What helps and what hinders? 84 In order to help you elaborate on your answers the interviewer will ask questions such as: What went before? after? How did it turn out? What was it like for you? How has that affected your family? The interview will be audio tape recorded, transcribed and given a code number. The tapes and transcripts will be stored in the faculty advisor' s research office and will be shredded or erased at the completion of the study. Potential risks I benefits There are no direct or potential risks to the participants in this study. However there are possible benefits of taking part in this study and these include: having the opportunity to voice your opinions about Care Teams, and contributing to the improvement ofthe Care Team process which improves the experience for other families. Compensation Participants will receive a small gift as a token of appreciation for their time and effort. Confidentiality All names and identifying information will be altered in the transcript to protect the confidentiality of your identity and others mentioned in the interview. In any publication resulting from this research, the participant's identities will be kept strictly confidential. Each participant is given a code number and will not be identified by the use of names or initials. Audio tapes, interview transcripts, demographic information and consent forms will be kept under lock and key in the researcher's office or the supervisor's office for not more than 7 years, at which time it will be shredded (paper) and erased (audiotapes). You will be debriefed during a follow up interview regarding the main fmdings and you can request a summary of the research fmdings from the Investigator. If you have any questions or concerns, you may contact me at 604-858-9424 or Dr. Rob Lees at 800-787-4138. If you have any concerns about your treatment or rights as a research participant, you may contact my UNBC supervisor, Professor Trudy Mothus at 250960-5639 or the Vice President Research at the University ofNorthem British Columbia at 250-960-5820. ' :. I have read the above information, and have had an opportunity to ask questions. This study has been fully explained to me by _ _ _ _ _ _ _ _ _ _ . I fully understand the purpose of the study and what my participation will involve. All aspects of confidentiality have been fully explained and I am aware of who will have access to the information that I have provided. ' ICM: What helps and what hinders? I willingly consent to participate in the study and hereby acknowledge receipt of a copy of the consent form. Signature of participant Date Signature ofwitness Date Demographic Information: Please provide any ofthe following information that you are comfortable with sharing with the researcher. The researcher will use the information in a general way to describe the population being studied so that no identifying information will be used in the published study. This sheet will be shredded at the conclusion of the study. Name ofParticipant: _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ Participant Number: ___ (will be assigned by the researcher) Postal Code: - - - - - Phone: - - - - - - - Gender: - ------- Age: _ _ __ Marital Status: - -- - Your ethnicity: (e.g. First Nations, Indo-Canadian, French-Canadian, Dutch): Child ' s ethnicity (if different than parent/guardian): During what year(s) did your child have a Care Team? (e.g. 02/03, 03/04) Is your child in Middle School or Senior High School?: _ _ _ _ __ _ Are you the birth parent__ ; foster parent_; guardian_ ; other_ 85 ICM: What helps and what hinders? How many other children do you have?: __ boys; _g irls 86 ICM: What helps and what hinders? 87 Appendix C Letter to Superintendent of School District #33 Seeking Consent to Conduct Research Form 46392 Topley Avenue Chilliwack, British Columbia V2P 3R8 Ms. Jacquie Taylor Superintendent, School District #33 Chilliwack School District 8430 Cessna Drive Chilliwack, BC V2P 7K4 Monday, June 14, 2004 Dear Ms. Taylor As a candidate for the degree ofM.Ed. (Counselling) at the University ofNorthern British Columbia, I am seeking permission to conduct a research study within School District #33. The aim of my project is to determine what helps and what hinders in the integrated case management process (also known as Care Team) from the perspective of the target child' s parent or guardian. The title of this project is "Integrated Case Management: What helps and what hinders- from the parent' s perspective". The design of the research, based on Flanagan' s Critical Incident Technique, will require semi-structured interviews with the parents of children who have had or who presently have a Care Team. Each interview will require about 1 Y2 hours and the participants will be asked two main questions, specifically: 1. Can you think of something that happened or something that someone did or said during Care Team meetings that worked for you? Or was helpful? Please tell me about that. 2. Can you think of something that happened or something that someone did or said during Care Team meetings that got in the way for you, or was a problem? Was not helpful? Please tell me about that. What happened? In order to draw out as much information as possible, the interviewer will ask questions such as: What went before? after? How did it turn out? What was it like for you? How has that affected your family? The interviews will be audio tape recorded, transcribed and given a code number. There are no direct or potential risks to the participants in this study. However there are possible benefits oftaking part in this study and these include: parents having the opportunity to voice their opinions about Care Teams, and contributing to the improvement of the Care Team process which improves the experience for other families. ICM: What helps and what hinders? effort. 88 Participants will receive a small gift as a token of appreciation for their time and All names and identifying information will be altered in the transcript to protect the confidentiality of individuals' identities and others mentioned in the interviews. In any publication resulting from this research, the participants' identities will be kept strictly confidential. Audio tapes, interview transcripts, demographic information and consent forms will be kept under lock and key in the researcher' s office or the supervisor' s office until the study is concluded, at which time it will be shredded (paper) and erased (audiotapes). Each participant will be given a code number and will not be identified by the use of names or initials. Participants will be debriefed during a follow up interview regarding the main findings and will be able to request a summary ofthe research fmdings from the Investigator. I am required to include an indication of the School Board' s consent for me to carry out this research with the submission of my proposal to the university Ethics Committee and therefore I would appreciate a timely response. If you have any questions or concerns, you may contact me at 604-858-9424 or Dr. Rob Lees at 800-782-4138 or Professor Trudy Mothus at 250-960-5639. Yours truly, Vic Gladish Ilwe hereby give consent to Vic Gladish to conduct the above described Research Project titled: "Integrated Case Management: What helps and what hinders - from the parent ' s perspective". Signature of Superintendent Date Signature of School Board Chair Date Signature of Date Signature ofwitness Date