Home visitor readiness, job support, and job satisfaction across three home visitation programs: A Retrospective Analysis

Accepted Manuscript Home visitor readiness, job support, and job satisfaction across three home visitation programs

Laura Nathans, Sukhdeep Gill, Sonia Molloy, Mark Greenberg PII: DOI: Article Number: Reference:

S0190-7409(19)30214-2 https://doi.org/10.1016/j.childyouth.2019.104388 104388 CYSR 104388

To appear in:

Children and Youth Services Review

Received date: Revised date: Accepted date:

4 March 2019 19 June 2019 19 June 2019" role="suppressed

Please cite this article as: L. Nathans, S. Gill, S. Molloy, et al., Home visitor readiness, job support, and job satisfaction across three home visitation programs, Children and Youth Services Review, https://doi.org/10.1016/j.childyouth.2019.104388

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ACCEPTED MANUSCRIPT Home Visitor Readiness, Job Support, and Job Satisfaction Across Three Home Visitation Programs

Laura Nathans, Ph.D.

[email protected]

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CORRESPONDING AUTHOR

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Penn State Scranton

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Sukhdeep Gill, Ph.D.

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Penn State York

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Sonia Molloy, Ph.D.

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Penn State York

Mark Greenberg, Ph.D.

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Pennsylvania State University

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This project was supported by grants from the Dorothy Rider Pool Health Care Trust (Grant #490), Allegheny Lutheran Social Ministries (Grant #21CC), William Penn Foundation (Grant #16), and Commission on Crime and Delinquency (Grant #2000-PC-ST-10865) to the Edna Bennett Pierce Prevention Research Center, Penn State.

ACCEPTED MANUSCRIPT

Abstract Home visitation programs are recognized as a preferred model for delivering services to children, parents, and families identified as at-risk. This study compares home visitors’ (N=82)

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perceptions of their job readiness, initial training, supervision and support, commitment to the

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intervention model, and job satisfaction from ten sites that included Nurse–Family Partnership

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(NFP), Early Head Start (EHS), and Healthy Family America (HFA) programs. Results revealed differences among the three groups with NFP and HFA home visitors reporting the highest

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scores on commitment to the intervention and job satisfaction. There were no significant

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differences between programs on frequency or quality of supervision. Qualitative data indicated a need for more initial training on challenging topics, a greater attention to supervision and

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support, clearer articulation of the intervention model, and issues related to job satisfaction.

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Implications for improving the experiences of home visitors are discussed.

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Keywords: Home Visitation, Job Satisfaction, Supervision Quality, Early Head Start, Healthy

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Families America, Nurse-Family Partnership

ACCEPTED MANUSCRIPT Home Visitor Readiness, Job Support, and Job Satisfaction Across Three Home Visitation Programs 1. Introduction Home visitation is recognized as a preferred model of service delivery in early childhood

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for reaching at-risk children and their families (Sweet & Applebaum, 2004). Home visiting

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programs provide a wide range of services from health, nutrition, parenting, and family support

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services to working directly with children to boost their early development (Love et al., 2005; Olds, 2006). The focus on home visiting has grown dramatically due to the federal investment of

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over $8 billion in home visiting programs (Forstadt, 2012; Haskins & Margolis, 2015) as a result

foundational years (Azzi-Lessing, 2011).

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of research highlighting the importance of sensitive-responsive parenting during the early

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While home visiting programs are being implemented throughout the country, the mixed

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results of their effectiveness remains a concern (Gomby, 2007; Minkovitz, O'Neill, & Duggan, 2016). Research indicates that effectiveness of programs varies by implementation factors

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(training, supervision, and fidelity) and the target population (Casillas, Fauchier, Derkash, &

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Garrido, 2016). Meta-analyses have shown improvements in health, community supports, and parents’ overall self-esteem for those receiving home visiting services (Samankasikorn et al.,

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2016; Stubbs & Achat, 2016). However, the receipt of home visiting services has shown relatively small gains for such areas as child maltreatment, parenting stress, birth outcomes, and child physical health (Filene, Kaminski, Valle, & Cachat, 2013; Robling et al., 2016; Sweet & Applebaum, 2004). Home visiting program success in achieving outcomes can be linked with quality of program implementation. Achieving high quality implementation for positive parent and child outcomes in home visitation programs depends to a large extent on the effectiveness of

ACCEPTED MANUSCRIPT service delivery (Jones Harden, Chazan-Cohen, Raikes, & Vogel, 2012), which necessitates an understanding of the factors that contribute to home visitors’ success. Although home visitation is utilized by numerous programs such as Nurse–Family Partnerships (NFP), Hawaii's Healthy Start, Healthy Families America (HFA), and Early Head

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Start (EHS), relatively few studies have focused attention on the home visitors despite

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widespread recognition of their critical role in the successful implementation of these

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interventions (Azzi-Lessing, 2011; Harden, Denmark, & Saul, 2010; Zeanah, Larrieu, Boris, & Nagle, 2006). Home visitors are generally mentioned only as a vehicle for service delivery with

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the exception of a few studies that have documented home visitors’ professional backgrounds,

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role perceptions, training, and supervision needs (Alitz et al., 2018; Gill, Greenberg, Moon, & Margraf, 2007; Harden et al., 2010). In order to be effective in their jobs, home visitors require a

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wide array of skills including interpersonal skills to form trusting relationships with families;

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problem-solving skills to respond to family issues; and organizational skills to juggle multiple tasks (Harden et al., 2010; Tandon, Parillo, Jones, & Duggan, 2005). Professional readiness,

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ongoing support, and job satisfaction are required for the home visitors to effectively use these

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skills (Thomasson, Stacks, & McComish, 2010; Woodgate, Heamon, Chalmers, & Brown, 2007). Thus, the present study aims to compare home visitors’ perceptions of readiness, support

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and supervision, and job satisfaction in three home visiting programs. 1.1 Home Visitor Readiness Several factors have been identified that impacts home visitor readiness, including (a) educational background and experience, (b) initial on-the-job training, and (c) understanding of, and commitment to, the intervention model that they are expected to implement (Korfmacher et al., 2008). First, home visitor education and experience merit attention because home visitors

ACCEPTED MANUSCRIPT come from diverse educational backgrounds and prior job experiences, which may contribute to variation in their preparedness. For example, Gill and colleagues (2007) found that lower education levels were associated with less knowledge of child development during the first two years on the job. In another study, Latimore et al. (2017) found that home visitors in NFP with a

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bachelor’s degree or higher provided a higher dosage of services to families than home visitors

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with less education. Local programs often struggle to find qualified home visitors (Duggan et

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al., 2018). In addition to education, models of home visitation vary substantially in their expectations regarding training and experience for job readiness. The NFP program requires

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previous experience as a nurse (Olds, 2006), while HFA and EHS employ home visitors who are

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either professionals or paraprofessionals with practical experience working with and/or being a parent from the population they will serve (Lee, Crowne, Faucetta, & Hughes, 2016).

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Second, well-planned and effective pre-service and ongoing training contributes to home

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visitor readiness and prepares them for the demands of the job. Woodgate and colleagues (2007) stressed the importance of providing an initial orientation soon after the home visitors are hired

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that focuses on basic skills, such as curriculum delivery, case management, and relationship

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building. Targeted training is needed on specific psychological and relational stressors faced by families in disadvantaged and often traumatic circumstances (Tandon et al., 2005; Thomasson et

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al., 2010). West et al. (2018) found that home visitors who participated in training focused on such topics as mental health, substance abuse, and cultural sensitivity had more favorable attitudes towards discussing these topics with parents. Lack of adequate training to support specific needs can impede family engagement (Harden et al., 2010) and can adversely impact program retention (McGuigan, Katzev, & Pratt, 2003). Third, home visitors’ commitment to the intervention model is an important area of home

ACCEPTED MANUSCRIPT visitor readiness as research indicates that employees who are committed to organizations and their underlying philosophies are more likely to remain in their positions, expend greater effort, show greater motivation, and contribute more to their organizations (Tarigan & Ariani, 2015). Families’ receipt of a higher dosage of services is associated with home visitors’ commitment to

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their organization (Latimore et al., 2017). Korfmacher et al. (2008) explained that home visitors

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effectively implement programs when the programs’ theory of change is aligned with their

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strengths and abilities. Program fidelity requires adherence to the curriculum, staff training, and program adaptations, which are all important components of intervention models. Aspects of

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home visiting programs that are found to increase fidelity include clear guidelines and policies

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for implementation, training and technical assistance, and well-defined frameworks (Goldberg, Bumgarner, & Jacobs, 2016).

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1.2 Supervisory Support

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In addition to initial readiness, consistent, high quality supervision is a necessary aspect of professional support for home visitors (Harden et al., 2010; Tandon et al., 2005). Feeling

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supported at work bolsters home visitors’ ability to handle challenging and stressful situations

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(Coffee-Borden & Paulsell, 2010). Alitz et al. (2018) found that reflective supervision and supportive coworkers play an important role in home visitors’ coping with job demands (Alitz et

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al., 2018). In contrast, home visitors’ perceptions of lack of support from supervisors negatively impacts work performance (Harden et al., 2010). In a study of EHS, NFP, and HFA, home visitors received fewer supervision hours than their models required (Duggan et al., 2018). Within the context of EHS, home visitors have reported insufficient structural and emotional support while facing excessive work responsibilities, which compromises quality of service delivery (Harden et al., 2010). Lee and colleagues (2013) found that supervision support and

ACCEPTED MANUSCRIPT empowerment were related to lower staff burnout. Duggan et al. (2018) reported that supervision, including reflective supervision, was related to lower levels of burnout, an increased sense of personal accomplishment, lower levels of depression, and greater retention of families. Conversely, home visitors’ emotional exhaustion has been related to decreased engagement with

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clients (Burrell et al., 2018). Frequent and high quality supervision plays a critical role in

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providing timely guidance, maintaining professional competence, and lowering stress (Boyas &

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Wind, 2010; Ellett, 2009; Lee et al., 2013). Overall, provision of support and supervision enables effective home visitor service delivery.

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1.3 Job Satisfaction

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Job satisfaction is another factor that is associated with lower staff turnover, organizational effectiveness, and families’ receipt of a higher dosage of services (Latimore et al.,

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2017). Several factors play a critical role in home visitors’ job satisfaction and performance

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including home visitor readiness, support and supervision, and training (Curry, McCarragher, & Dellmann-Jenkins, 2005; Davar & Bala, 2012). Job satisfaction has been found to have a direct

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negative relationship with burnout (Hombrados-Mendieta & Cosano-Rivas, 2011). Aarons and

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Sawitzky (2006) found that positive work attitudes predicted lower job turnover rates in a sample of clinical and case management service providers. In contrast, frustrations with supervisor

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control and lack of job autonomy were associated with higher turnover rates among home visitors (Aarons, Fettes, Sommerfeld, & Palinkas, 2012). Further, staff turnover is associated with large training costs (Aarons & Sawitzky, 2006) and interruption of home visitors’ alliance with families (Holland, Christensen, Shone, Kearney, & Kitzman, 2013). Given the research emphasizing the importance of home visitors’ readiness, supervisory support, and job satisfaction, we examined home visitors’ experience in three different home

ACCEPTED MANUSCRIPT visitation models with the goal of identifying similarities and differences in these three areas. 1.4 Key Elements of the Programs in the Study 1.4.1 Early Head Start (EHS). EHS is a family support program that aims to improve family functioning and health, cognitive, language, and social-emotional outcomes for children

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ages three or younger from low socioeconomic backgrounds (Charles & Peabody, 2016; Jeon,

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Choi, Horm, & Castle, 2018). Home visitors address parenting skills (Raikes et al., 2014),

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connect families to community resources (Fenichel & Mann, 2001), and provide direct service provision to children. Home visitors’ qualifications vary from paraprofessional to professional

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training and experience. Their normal caseload comprises 10-12 children and their families

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(Bradley, Chazan-Cohen, & Raikes, 2009). EHS programs typically provide both pre-service and in-service training on site and encourage off-site training opportunities. Training varies

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across local programs due to lack of a prescribed curriculum (Duggan et al., 2018). Preservice

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training focuses on program philosophy and curriculum implementation (www.homvee.org). Home visitors receive weekly supervision on case management.

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1.4.2 Healthy Families America (HFA). New and expecting parents identified as at-risk

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for child maltreatment are the primary recipients of HFA services (Goldberg, Bumgarner, & Jacobs, 2016). HFA focuses on teaching parenting skills, enhancing parent-child attachment,

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and creating a supportive home environment (Cullen, Ownbey & Ownbey, 2010). HFA offers intensive services that decrease in frequency over time (Goldberg et al., 2016). Home visitors are often paraprofessionals from the visited communities (Duggan et al., 2018) and carry an average caseload of 10-15 families (Daro, 2000; Howard & Brooks-Gunn, 2009). Home visitors receive pre-service and in-service training including practice in addressing risk factors (Goldberg et al., 2016). Local programs’ implementation of training is not based on a standard curriculum

ACCEPTED MANUSCRIPT (Duggan et al., 2018). Weekly supervision focuses on supporting home visitors in helping their families meet program goals (homvee.acf.hhs.gov). 1.4.3 Nurse Family Partnership (NFP). NFP seeks to link recipients to family and external community supports, increase parents’ confidence in their parenting abilities, and model

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appropriately empathetic and responsive caregiving for parent-child relationships in order to

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improve pregnancy outcomes, foster child health and development, increase family economic

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self-sufficiency, and improve maternal health and life course outcomes for first time mothers (Olds et al., 2015). Visits occur as early as possible during pregnancy through age two (Olds et

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al., 2015). NFP home visitors primarily have a nursing degree (at least a BSN) and tend to carry

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a caseload of no more than 25 (Howard & Brooks-Gunn, 2009; Olds, 2006). NFP home visitors complete three core education sessions for pre-service training in both face-to-face and distance

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formats over a nine-month time frame and within the first eighteen months after the program

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begins (homvee.acf.hhs.gov). New staff are oriented to the well-defined program model and trained to use home visit guidelines and client-centered interventions (Duggan et al., 2018; Olds,

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Hill, O’Brien, Racine, and Moritz, 2003). Supervision of NFP home visitors includes case

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conferences, team meetings, field supervision, one-to-one clinical supervision, and, most importantly, demonstrations of integrating theory into practice

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(http://nursefamilypartnership.org). The current study has three main objectives: (1) to identify similarities and differences in the home visitors’ initial readiness, (2) to explore home visitors’ perceptions of and experience with ongoing supervision and support, and (3) to examine the differences in job satisfaction reported by home visitors from the three home visitation programs.

ACCEPTED MANUSCRIPT 2. Materials and Methods 2.1 Study Participants Eighty-two home visitors from ten sites in a Northeastern state participated in this study: 54 home visitors from two EHS programs, 12 from three NFP programs, and 16 from five HFA

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programs. The HFA sites were clustered together in a large metropolitan area whereas the three

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a small urban area whereas the second operated in a rural setting.

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NFP sites were situated in three different counties. One of the EHS program sites was located in

Compared to NFP and HFA, the two EHS programs were engaged in program evaluation

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over a longer time period. Consequently, when new staff members were hired due to staff

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turnover, they were invited to participate in the study, resulting in a larger data pool of EHS respondents compared to the other two programs.

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2.2 Study Context

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Data were drawn from staff surveys and interviews during the first year of home visitor service delivery conducted between 1999 and 2004. Staff members entering these programs,

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who signed the consent form, were asked to complete a survey and participate in a face-to-face

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individual interview within the first year of program entry. Phone interviews were conducted when face-to-face contact could not be made, especially for NFP staff because the sites were

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geographically distant. All interviews were conducted by the same interviewer. The home visitors were asked identical questions regarding their educational background, prior work experience, and initial training. Follow-up open-ended questions were asked to supplement the numerical responses. This research was approved by the Pennsylvania State University Institutional Review Board. 2.3 Quantitative Measures

ACCEPTED MANUSCRIPT 2.3.1 Educational background, prior work experience, and initial training. Quantitative survey questions sought educational background and prior professional experience. 2.3.2 Commitment to the intervention model. Home visitors rated their commitment to the intervention model on one item using a 5-point Likert-type rating scale (1=lowest; 5=

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highest).

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2.3.3 Frequency and quality of supervision. Home visitors rated the frequency and

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quality of supervision on two 5-point Likert-type items (one each for frequency and quality of supervision; 1=lowest; 5= highest).

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2.3.4 Job Satisfaction. Overall Job Satisfaction scale (OJS; Gill et al., 2007), a 10-item

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Likert-type measure, was used to obtain data on home visitors’ overall job satisfaction (Cronbach’s alpha = .82). Higher scores indicated higher job satisfaction. Three subscales were

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created to elicit information about different aspects of job satisfaction. Three items comprised

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Salary and Benefits subscale (Cronbach’s alpha = .74); three items comprised Roles and Responsibilities subscale (Cronbach’s alpha = .66), whereas four items comprised the

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2.4 Qualitative Analysis

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Interpersonal Climate subscale (Cronbach’s alpha = .65).

Qualitative interviews were conducted with all home visitors to explore home visitor

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readiness, perceptions of support, and job satisfaction in greater depth. Home visitors were asked questions regarding areas for improvement in initial training, commitment to their intervention model, and perceptions of supervision. Interviews were transcribed verbatim and coded. This qualitative analysis was informed by grounded theory methods (Charmaz, 2014). Transcripts were initially coded using line-by-line coding. Codes were then compared and grouped into categories. The qualitative codes and quotes were used to confirm and illustrate the

ACCEPTED MANUSCRIPT quantitative analysis. 2.5 Data Analysis ANOVAs with Welch’s F tests and Games-Howell post-hoc comparisons were employed to test differences between the three home visiting programs on commitment to the intervention

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model, supervision, and job satisfaction characteristics. Welch’s ANOVA was employed

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because it is robust to unequal sample sizes and violations of homogeneity of variance (Field,

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2009). The Games-Howell post-hoc comparison was employed because it is also robust to unequal sample sizes and unequal variances (Toothaker, 1993).

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3. Results

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3.1 Home Visitor Readiness

3.1.1 Professional/Educational background. Educational backgrounds for EHS home

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visitors ranged from a Child Development Associate (CDA) certification to baccalaureate

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degrees in Child Development and Family Relations, Elementary Education, and Health and Physical Education to Criminal Justice. All of the NFP home visitors, except for one, held a

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bachelor’s or master’s degree in Nursing and were registered nurses. Home visitors in HFA

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demonstrated the greatest variation in professional training with no degree (one home visitor reported, ‘No degree, only trained by agency’) to a master’s degree in Social Work. Many

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participants had earned Associates degrees in diverse fields including biology/medical, human services, social work, and behavioral health. In addition to their educational background, respondents were asked about their prior professional experience. EHS home visitors’ prior experience involved human services (e.g., social services, Head Start, aide in childcare settings, and casework) and education-related fields (e.g., tutor in classrooms, therapeutic support staff, and teacher or teacher aide in kindergarten or

ACCEPTED MANUSCRIPT preschool classrooms). Home visitors in HFA reported prior work experience in a wide spectrum of human service positions (e.g., social services, protective services, childcare, case management, family advocacy, in-home counseling, maternity social work, and foster care). Home visitors within NFP exhibited the least diversity in previous work experience; all had

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worked in health-related fields, mostly in hospital, OB-GYN, and pediatric nursing.

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3.1.2 Initial training. Home visitors from all three programs reported receiving training

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before they started service delivery. In the interview, they were asked, ‘Would you like to see any changes in the initial training, e.g., in the way it is structured, its content, duration, timing,

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etc.?’ Two themes emerged regarding initial training: the overwhelming amount of information

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in initial trainings and the need to focus on specific issues and processes. Several EHS home visitors mentioned that they received too much information in their initial training and that

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spreading this material across a longer duration would have been helpful. One EHS home visitor

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characterized learning about all aspects of the job (caseload, paperwork, prepping for units, and getting organized) as ‘intimidating’; others noted that it was ‘too quick to absorb all the

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information.’ Some EHS staff expressed the need for a longer mentoring period which would

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include going on home visits with a mentor, more openness to sharing relevant information on policies and procedures, and some overlap with the outgoing home visitor. An EHS home visitor

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expressed the need to have, ‘more opportunities for someone to come out to shadow home visits.’ However, a few home visitors were satisfied and indicated that no change was required. HFA home visitors expressed a need for more, ‘training on specifics of issues,’ including such topics as mental health issues (recognizing symptoms, understanding diagnoses and medications), the process of reporting child abuse, dealing with teenage parents, interpretation of assessments, ways to get back in touch with ‘straying’ families, teambuilding, community

ACCEPTED MANUSCRIPT programs and resources, and paperwork. NFP home visitors also expressed a need to focus more on the home visitation process, infant/toddler training, and community resources. One participant expressed a need for greater understanding of the key elements of home visitation once she received her caseload (e.g., what occurs during home visits, how to organize time, what

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materials to organize, and how to work with the emotional aspects of home visitation).

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3.1.3 Commitment to the intervention model. There were statistically significant

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differences between the three groups on commitment to the intervention model, F(2, 28.70) = 6.05, p = .006. Games-Howell post-hoc analysis indicated significantly greater commitment to

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the intervention model from NFP home visitors (M = 4.92, p < .05) and HFA home visitors (M =

and NFP models (See Table 1 for details).

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4.77, p < .05) than from EHS home visitors (M = 4.42). There were no differences between HFA

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Qualitative quotes highlighted that home visitors viewed all three program models

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positively. When asked about the strengths of the intervention model, the EHS home visitors generally described support for the EHS program model, stating, ‘It is not perfect, but good’ and

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‘EHS is a good program’ or that home visitors ‘… believe in the importance of early

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intervention.’ An HFA home visitor noted that the model was, ‘good, especially for teens.’ Another noted that HFA, ‘goes the extra mile’ and ‘gives a personal touch.’ NFP home visitors

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noted several strengths of the NFP model such as, ‘It is well-organized,’ ‘Program has a good structure,’ ‘It allows a relationship to build between the mother and the home visitor,’ and that ‘Support is built into the model.’ Home visitors also indicated some weaknesses in program models, such as maintaining caseloads, paperwork, and delivery of curriculum. In one of the two EHS programs in the study, home visitors carried a mixed caseload of EHS and Head Start children; they noted managing

ACCEPTED MANUSCRIPT these caseloads at the same time as a challenge to appropriate delivery of the intervention model. HFA home visitors noted that, ‘paperwork makes time coordination cramped’ and ‘caseloads are too high.’ The service delivery structure of the program was criticized, as ‘some [families] may do better with every other week, don’t need to begin at Level 1.’ NFP home visitors mentioned

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that a weakness of the NFP model was the curriculum, which was, ‘too difficult for clients to

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follow.’ Difficulties in job functioning were also mentioned by NFP home visitors, including,

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‘low pay for staff,’ ‘minor adjustment in the paperwork,’ and, ‘caseloads are too large.’ 3.2 Supervisory Support

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Home visitors from all the three programs rated the frequency and quality of supervision

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positively. There were no significant differences in the frequency or quality of supervision received across the programs. However, qualitative interviews revealed more detailed

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information that indicated differences between the programs on issues including supervision

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frequency, supervision topics, and supervision administration. Home visitors were asked, ‘What can the program do to make the supervision better/more meaningful to you?’ EHS home visitors

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discussed a need for a change in supervision topics, i.e., ‘broader perspective’ rather than a

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strong focus only on child development, and to, ‘schedule formal supervision once a month, otherwise on an as needed basis.’ Several personal complaints with the supervisor were

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discussed, including, ‘things are not as simple as her answers are’ and ‘supervisor also tends to take questions or problems “personally”.’ Some HFA home visitors desired improvements in the structure of supervision, such as supervision style, content, and timing. One home visitor stated, ‘more consistency with scheduling, separate discussions of assessments from quality improvement. ’ Another home visitor remarked that for it to be more effective, ‘supervision [has to] be more clinical,

ACCEPTED MANUSCRIPT administrative, have more regular availability.’ Yet another noted, ‘change frequency to monthly, structure it to address 1-2 clients who have problems, don’t need to discuss all cases every week.’ Similar to EHS, an HFA home visitor stressed the need for mentorship: ‘Supervisor should shadow home visits.’

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An NFP home visitor stated that the supervisor ‘needs to be more focused on nurses’

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needs.’ Improvements in administration of supervision were also noted, such as, ‘NHVs [nurse

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home visitors] need more time to do supervision,’ and that the supervisor should, ‘be given more time for the program.’ Problems were mentioned with individual supervision: ‘Individual

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supervision can stagnate because the same person gives the same answers to the same

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questions/issues every week’ or, ‘. . . [supervision] might improve by [supervisors] filling out forms to give staff feedback (more frequently than yearly reviews).’

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3.3 Job Satisfaction

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There were several significant differences between the three programs on the OJS scale

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total score, F(2, 25.28) = 9.13, p = .001. The Games-Howell post-hoc tests indicated significantly lower scores for EHS as compared to HFA (M = 3.60, 4.09 respectively; p = .005)

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and NFP (M = 4.22; p = .009) home visitors (see Table 1). Additionally, OJS Roles and Responsibilities subscale scores differed significantly between the three home visiting programs,

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F(2, 24.64) = 7.66, p = .003. The Games-Howell post-hoc comparisons showed statistically significantly higher subscale scores for NFP than EHS (M = 4.52, 3.80 respectively; p = .004) but not HFA (M = 4.17, p = .292). Lastly, there were significant program differences on the OJS Interpersonal Climate subscale, F(2, 26.62) = 20.50, p < .001 with EHS respondents (M = 3.73) recording lower scores than both NFP (M = 4.60, p < .001) and HFA (M = 4.56, p < .001). There were no statistically significant between-program differences on the OJS Salary and Benefits

ACCEPTED MANUSCRIPT subscale, F(2, 22.94) = .34, p = .719. 4. Discussion This study explored similarities and differences in home visitor readiness (i.e., education, training, and commitment to the intervention model), supervisory support, and job satisfaction

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for NFP, HFA, and EHS home visiting programs. All three programs recognize the importance

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of parent-child interaction and effective parenting in securing healthy development of children

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during the early formative years. These programs acknowledge that environmental constraints negatively impact parenting capacity and that intervening with at-risk families is likely to

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promote young children’s health and well-being through an enhancement of parenting. Further,

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all three programs focus on understanding the home context, conceptualize parents as partners, and serve at-risk populations. However, the structure inherent in the way each program is

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organized may provide clearer guidance to home visitors regarding how to work with specific

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populations, possibly leading to greater job satisfaction and more commitment to the intervention model. Results of this study favored NFP and HFA as the most supportive in commitment to the

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intervention model and overall job satisfaction. Despite generally positive views of intervention

and supervision.

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models, home visitors across all three models mentioned challenges in receipt of initial training

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4.1 Home Visitor Readiness

Home visitor readiness was examined using the quantitative and qualitative results of professional and educational background, initial training, and commitment to the intervention model. Educational background and previous experience were diverse for HFA and EHS while less diversity was found for NFP with a majority of the home visitors having a bachelor’s degree or more and training in nursing. Results for initial training were reflective of previous literature

ACCEPTED MANUSCRIPT that highlighted the importance of preparation for special challenges home visitors encounter when working with families, such as depression and child abuse (Tandon et al., 2005). Home visitors in all three programs noted inadequate preparation in these areas. The findings suggest that in addition to greater institutional support, there is a need for improved training, particularly

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difficult issues can be improved through training (West et al., 2018).

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in specific topics. Home visitors’ knowledge, attitudes, confidence, and skills in working with

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Differences in articulation of the program model were evident in how well prepared the home visitors felt. NFP and HFA home visitors reported higher scores for commitment to the

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intervention model than did EHS home visitors. We attribute this difference to both the models’

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structure and targeted focus on specific, clearly defined outcomes and better alignment with the home visitors’ training and professional backgrounds. These differences were articulated in the

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qualitative responses of their diverse experiences of service delivery. For example, an EHS

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home visitor mentioned a lack of clear curriculum as a weakness of the service model, while an NFP home visitor stressed the benefits of the program’s structure. Although home visitors

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coming from diverse backgrounds and with a wide range of skills are likely to create a rich pool

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of service providers to meet unique needs of program participants, EHS likely faces a large challenge in meeting the training needs of staff from diverse professional backgrounds. These

readiness.

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factors might partly explain why EHS home visitors were less satisfied with their overall job

4.2 Supervisory Support Respondents from all the three programs reported similar and high levels of satisfaction with the frequency and quality of supervision. Qualitative data revealed home visitors’ endorsement of supervisory support but highlighted need for improvement. Home visitors either

ACCEPTED MANUSCRIPT wanted more or less supervision, yet all wanted to ensure that the most important challenges they experienced were adequately covered. Home visiting is a demanding job as every family on a home visitor’s caseload needs multiple supports, including case management, mental health support, and parenting skills. Juggling several responsibilities for multiple families can become

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highly stressful for home visitors (Finello, 2014). As such, home visitors need practical and

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emotional support from supervisors to effectively perform job responsibilities and experience job

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satisfaction.

Home visitors did not report any significant differences in the frequency of supervision in

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this study. In a previous study of home visitor supervision, Duggan et al. (2018) found that NFP

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required the greatest number of hours of group and individual supervision combined in comparison with HFA and EHS. However, HFA required the most hours of individual

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supervision. In contrast, EHS had no requirements for number of hours of group and individual

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supervision. Variation in perceptions of both group and individual supervision can be further understood through the comments of the home visitors.

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The qualitative analysis of this study revealed a desire for improvement in the structure of

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supervision. In recent years, reflective supervision has been recognized as a strategy to support home visitors and facilitate a parallel process whereby they receive the same care as they are

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expected to provide to their clients (Lee et al., 2016), which, in turn, enhances parents’ reflective skills (Duggan et al., 2018). Reflective supervision is a form of support during which home visitors share frustrations, express feelings, and openly discuss personal effects of work (Alitz et al., 2018), which can improve home visitors’ problem solving and decision-making skills (Duggan et al., 2018). 4.3 Job Satisfaction

ACCEPTED MANUSCRIPT Quantitative and qualitative results overall suggested that NFP and HFA home visitors were most committed to the intervention model and most satisfied with their jobs. NFP and HFA home visitors scored higher on roles and responsibilities and interpersonal climate scales. These results can be explained by these programs’ alignment between commitment to the

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intervention model, professional and educational experience, and supervisory support. The NFP

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model has a well-articulated program theory in improving maternal and child health outcomes,

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which is backed by data from randomized trials (Olds, 2002). This alignment between theory, goals, and home visitor backgrounds is reflected in a well-defined curriculum, service delivery

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model, target population, supervision structure, and criteria for program participation and timing

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of program entry (Howard & Brooks-Gunn, 2009; Latimore et al., 2017; Zeanah et al., 2006). NFP home visitors are also more likely than EHS and HFA to receive training on topics relevant

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to their program’s model of change, including prenatal health and birth outcomes and

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breastfeeding and nutrition (Duggan et al., 2018). HFA also has a well-defined service delivery model and parenting curricula based on theory that child abuse can be prevented through

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development of positive parenting skills. NFP and HFA both have clearly defined target

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populations, with NFP focusing on pregnant first-time mothers and HFA focusing on parents with potential for child abuse. However, the HFA program allows greater flexibility than NFP in

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supervision, local programs’ selection of parenting curricula, local supplementation of curricula, and qualifications of home visitors (Duggan et al., 2018). The EHS program model seeks to offer comprehensive services to support children, parents, and families as a unit where families may enter the program at any time between pregnancy and age 3. The program theory and processes of intervention are well articulated, whereas there is substantial variation in timing of program entry, curriculum, models of service delivery, supervision, and home visitor

ACCEPTED MANUSCRIPT qualifications and professional backgrounds (Olson & DeBoise, 2007). EHS has greater flexibility in criteria for program entry than NFP and HFA. NFP requires entry during pregnancy, and HFA has criteria for different levels that families may enter at. The similarities and differences between NFP and HFA in their alignment between program theory and program

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goals and curricula, clearly defined target populations, and criteria for program entry can explain

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the results in greater job satisfaction and commitment to the intervention model for the NFP and

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HFA programs. 4.4 Limitations

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Two limitations of the study warrant attention. First, the number of home visitors in each

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of the programs was small. As a result, it was not possible to explore within model variations in home visitor reports in the selected domains. Small sample size could also have limited the

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power to detect differences in the three programs and may have led to an underestimation of the

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findings. Second, the data comes from an earlier period of program implementation for all of these programs. In recent years, professional development of home visitation staff has received

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more attention (Harden et al., 2010), which is likely to have addressed some of these concerns.

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Despite these limitations, the contribution of this study lies in presenting a baseline of staff development needs in three of the most widely implemented home visitation programs (Duggan

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et al., 2018). The study also highlights the value of aligning the key ingredients of the service delivery model to inform and bolster professional development. 4.5 Implications for Practice Home visitors provide unique early intervention services to families and children who are vulnerable, hard to reach, often experience multiple challenges, and may be geographically isolated (Bhavnagri & Krolikowski, 2000). Although families are enrolled to receive a specific

ACCEPTED MANUSCRIPT set of services, these services need to be individualized in response to goals and challenges and thus require home visitors to be creative, well-trained and well-supported to attain high quality implementation in diverse family contexts. The above findings suggest the need for greater attention to issues of home visitors’

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institutional support and professional development. First, there is a need to consider the nature

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and content of supervision beyond monitoring and accountability. Supervision needs to be

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tailored to the challenging situations home visitors address in their everyday work. Flexible, need-based supervision that meets home visitors’ needs through adequate individual mentoring,

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group supervision, and support when home visitors are experiencing specific case-related

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difficulties is likely to boost morale. Second, institutional support must go beyond supervision to include balanced initial and ongoing training. In this regard, Martinez-Beck, Cabrera, and

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Zaslow (2009) suggest that across the course of the home visitor’s career, professional

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development must become increasingly more of an “inside-out” process, in that professional development efforts should be in response to home visitors’ perceived needs. This suggests that

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home visitors should be empowered to take more of a leadership role in directing their own

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education in best practice, including taking part in professional development opportunities. Initial training might be improved by dispersing presentation of material over longer periods of

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time, greater initial mentoring, and more frequent shadowing. Home visitors may need additional support to become more reflective to assess their own work and capacity to meet program goals. Training should also prepare home visitors to meet varied job demands that may not have been learned through their educational training, including dealing with abusive situations or mentally ill parents. Duggan et al. (2018) found that home visitor training is a challenge for local programs because it does not cover all areas relevant to positive program

ACCEPTED MANUSCRIPT outcomes. Home visitors felt unprepared to address these topics despite a majority of EHS, HFA, and NFP home visitors’ receipt of training addressing mental health and stress, positive parenting behavior, child maltreatment, child preventive care, and child development. Home visitors can be successfully trained to address such issues. For example, participation in a day-

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long training on intimate partner violence (IPV) for home visitors increased their confidence in

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performing IPV screening and developing safety plans (Abildso et al., 2018).

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Home visitors may need increased supervisory support to handle the challenges of feeling overwhelmed by both the size of their caseloads and the amount of required paperwork.

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Guidance regarding how to manage and organize job responsibilities, paperwork, data entry, and

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management of caseloads can impact home visitors’ ability to engage with families (Alitz et al., 2018). Finally, program leaders’ attention to provision of training that more clearly illustrates

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strengthen home visitor competence.

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concrete linkages between theory of intervention and program implementation is likely to

4.6 Conclusions

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In conclusion, the need to attend to training, supervision, and the commitment to the

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intervention model is important to strengthen the service delivery of home visitors. Attention to these factors can lead to better job satisfaction. This research contributes to the literature that

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emphasizes the need for continued comprehensive evaluations of home visiting programs and home visitor experiences in order to improve the impact of home visiting for child and family outcomes (Azzi-Lessing, 2011).

Conflict of interest statement The authors have no conflicts of interest in publishing this paper.

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SD

54 52 49

4.01 4.05 3.60

1.02 .89 .57

49 49 49

3.80 3.22 3.73

.63 .79 .61

36

4.42

.69

16 15 16

4.25 4.53 4.09

16 16 16

4.17 3.38 4.56

AN

US

1.13 .74 .47 .64 .71 .54 .60

4.50 4.33 4.22

.90 .78 .57

12 12 12

4.52 3.39 4.60

.59 1.17 .49

12

4.92

.29

PT

ED

M

4.77

12 12 12

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Mean

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N

13

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Variable EHS Supervision Frequency Supervision Quality OJS Mean OJS Roles and Responsibilities OJS Salary and Benefits OJS Interpersonal Commitment to Intervention model HFA Supervision Frequency Supervision Quality OJS Mean OJS Roles and Responsibilities OJS Salary and Benefits OJS Interpersonal Commitment to Intervention model NFP Supervision Frequency Supervision Quality OJS Mean OJS Roles and Responsibilities OJS Salary and Benefits OJS Interpersonal Commitment to Intervention model

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Table 1. Descriptive statistics for quantitative analyses

ACCEPTED MANUSCRIPT Highlights

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

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

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

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

Nurse-Family Partnership and Healthy Families America have higher job satisfaction than Early Head Start – Home-Based option due to standardized protocols, target populations, and entry levels There is a need for more home visitor training on challenging topics, such as substance abuse, mental health issues, and intimate partner violence. Home visitors from all three intervention models (EHS-HBO, NFP, and HFA) are equally committed to their intervention model despite some reported weaknesses. There were no differences between the three intervention models in satisfaction with frequency or quality of supervision. Home visitors reported a need for support through supervision for their most important challenges.

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