Empowering Families with the FRAIT: A Transformative Healthcare Tool
Families can be confronted with a multitude of challenges at any time, and those with newborn babies and young children are particularly vulnerable to stress. In the face of economic hardship, health crises, and other unforeseen adversities, it is remarkable to see families harnessing their resilience. Professor Carolyn Wallace, Emeritus Professor David Pontin, and Dr Michelle Thomas from the University of South Wales focus on understanding the social and environmental factors that enable families to navigate challenges successfully. Their vital work has led to the development of the Family Resilience Assessment Instrument and Tool (FRAIT).
The Family Resilience Assessment Instrument and Tool
The Family Resilience Assessment Instrument and Tool (FRAIT) is now invaluable in health visiting assessments of the family. It provides a structured approach to measure the strengths and vulnerabilities of family units as they navigate through ups and downs in life. Professor Carolyn Wallace, Emeritus Professor David Pontin and Dr Michelle Thomas from the University of South Wales have dedicated years to developing this systematic framework.
The FRAIT measures and evaluates family resilience by gathering information from families through a structured assessment on multiple dimensions, including family cohesion, communication, adaptability, family belief system, social support, and more. Together, these dimensions provide a holistic view of family resilience, allowing professionals and families themselves to identify strengths and areas where support might be needed.
Once the assessment has been completed and analysed, Health Visitors can ascertain a score indicating levels of family resilience. Interpreting the results is crucial because it creates a comprehensive picture of a family’s resilience profile. Based on the interpretation, FRAIT supports the provision of feedback to families and professional judgement as to whether and what type of support is required to strengthen family resilience. Ongoing review of the family’s FRAIT enables Health Visitors to track family resilience and adapt their support strategies.
The Process of Development
The need for an evidence-based tool came from Health Visitors looking to address health inequalities through early prevention and intervention with direction from the Welsh Government. Within the Welsh healthcare system, Health Visitors – public health nurses working with all families of children under 5 years of age – play a critical role. In the work of promoting, protecting, and safeguarding family health in partnership with families, communities, and other agencies, FRAIT offers a practical guide to assess how well families adapt and recover from hardships.
Assessing and analysing family resilience is part of the daily practice of Health Visitors. This is integral in supporting families, promoting positive lifestyle choices, and improving child health and development. However, integrating FRAIT into Health Visitors’ practice required initial research. In 2014–2015, Professor Wallace, Dr Thomas, Emeritus Professor Pontin, and Health Visitor colleagues across Wales, conducted a study to explore the concept of family resilience as understood by Health Visitors. This work was fundamental in developing the FRAIT, which was tested in simulation and health visiting practice to ensure it could be used across Wales successfully.
In 2018, a Health visiting Community of Practice for FRAIT was established, bringing together Health Visitor representation from every health board in Wales to offer a solution-focused forum supporting the correct use of FRAIT. Currently, the community of practice meets regularly to contribute feedback about the usability of FRAIT but also to discuss specific life situations that might make using the FRAIT assessment more challenging, such as when working with children in foster care.
Training Health Visitors
The process that brought FRAIT to its status as an invaluable, everyday tool in Welsh healthcare practice consisted of multiple steps, with the systematic appraisal of its usefulness at the core. Dr Thomas, with the support of Professor Wallace and other colleagues, adopted a cascade training approach with great success, as every Health Visitor and student Health Visitor must complete the training before using the FRAIT.
Cascade training entails Health Visitors first receiving comprehensive training in the proper administration of FRAIT and its nuanced interpretation. These initially trained Health Visitors then become trainers, passing their knowledge and skills to their colleagues, creating a cascade of training.
The success of cascade training can be attributed to several key elements. First, it provides the Health Visitors with a safe space to obtain training materials among their peers. Second, it helps them anticipate the specific training requirements needed for their community environments. Lastly, it increases their competencies in using it and confidence to pass the knowledge further.
The Health Visitors expressed their positive experience in delivering training programmes and their motivation to support the development of this programme further. Overall, using cascade training helped progress the initial stages of the implementation of FRAIT in the practice of Health Visitors, as well as proving to be an effective form of professional education. The provision of self-paced eLearning modules for both student Health Visitors and practising Health Visitors allows additional flexibility in the training process.
Other Forms of Health Professional Education
There has been a general criticism of health professional education for not integrating patient expertise and experience into professional curricula. Professor Wallace and Emeritus Professor Pontin recognised these limitations and sought to develop a new expert patient-centred model for teaching patient empowerment. In their international project with colleagues and participants from Finland, Ireland, Bulgaria, and Wales, patients, healthcare students, and lecturers, they established a new pilot intensive educational training programme.
Within this model, elements of empowerment were categorised into four subthemes: 1) life stories, 2) compassionate care, 3) expert identity by experience, and 4) learning through action. For example, patients often felt more empowered by telling their personal life stories to students. One patient recalled: ‘It was a very positive experience. The entire day I felt that I had been in my past and I was amazed how many good things we had found from there. And in the everyday life you fight with those small negative things. In fact, the meetings were very empowering because I had to speak out the things that empower me’.
These four themes were recognised not in isolation but as interconnected components. The results emphasised the significance of collaborative learning, focusing on the mutual growth of the professionals and patients. The findings of this study showed that patients felt more in control, which further empowered them in this patient-professional dynamic. The healthcare students appreciated that they would grow both professionally and personally, which gave them a heightened appreciation for their service and an understanding of what needed to change to empower their patients.
The endeavour to integrate patient empowerment into professional education resonates deeply with the principles of FRAIT, where the emphasis lies on active participation and collaborative assessment with families. Professor Wallace and Emeritus Professor Pontin’s experience from this study further contributed to the development of FRAIT and understanding of the importance of conversational assessment and actively listening to the family.
The Welsh Government Healthcare Initiatives
While the impact of the FRAIT on individual and family levels is undoubtable, its use also has significant implications for Welsh Government policy and practice. The FRAIT provides valuable data and insights into families’ resilience levels on the national level, and also details how families operate and cope. The FRAIT team provides Welsh Government representatives with the necessary information on request.
FRAIT also helps to identify areas for improvement. The Welsh Government can use this information to develop programmes tailored to the unique requirements of families. For example, if FRAIT reveals that families in certain regions are experiencing high levels of economic stress, the Government can use this as evidence to allocate resources, such as financial counselling, in those specific areas. Importantly, understanding FRAIT scores can help to identify the most appropriate sources of early intervention to support families facing significant challenges. Emerging evidence suggests that FRAIT scores can effectively predict school readiness and further investigations are exploring this. If successful, this would provide evidence for the Government to ensure that measures are put in place to support children and families before they reach school age.
From Research to Real-Life Impact: Revolutionising Health Care
The impact of the FRAIT developed by Professor Wallace, Emeritus Professor Pontin, Dr Thomas, and the rest of the team has been assessed as internationally excellent by the Research Excellence Framework. Their research work has been translated into the everyday practice of healthcare professionals. Professor Wallace and Emeritus Professor Pontin have proposed and tested multiple models and frameworks for improving healthcare professionals’ education and their practice in their communities. The FRAIT team have also contributed to a significant change in how the Welsh Government operates their health care system for families, addressing protective factors rather than risk assessment. The FRAIT is now a standardised assessment tool used by every Health Visitor in Wales to assess and monitor families, their resilience, problem-solving, and recovery from hardships. The FRAIT enables Health Visitors to identify the support that families need to give their children the best start in life. In doing so, this work helps families but also promotes social learning within Health Visitors’ professional identity.
The next evolution of the FRAIT – the E-FRAIT – has recently been developed. This will allow Health Visitors to fill in the FRAIT electronically and calculate the score automatically. A major advantage of this is that all records can be kept electronically and integrated into the IT systems of health boards. Ongoing work has led to international interest in the development of the self-assessment of family resilience and developing the concept of family resilience in India.
The tireless efforts of Professor Wallace, Emeritus Professor Pontin, Dr Thomas, and their dedicated team have left a permanent mark on healthcare in Wales. Their pioneering work culminating in the creation and cross-country adoption of FRAIT has not only empowered Health Visitors to identify the gaps in the support that families receive but has also transformed nationwide healthcare practice and policy starting on a community level.
MEET THE RESEARCHERS
Professor Carolyn Wallace, PhD, MSc, PGCE, BSc, FHEA, RGN
Faculty of Life Science and Education
University of South Wales
Professor Carolyn Wallace has pioneered the development of the Family Resilience Assessment Instrument and Tool from conceptual development to practical implementation. She has extensive nursing experience in the National Health Service as both practitioner and manager, working in hospital and community settings, particularly in integrated care. She is currently a Professor in Community Health and Care Services at the University of South Wales, where she has been developing expertise in qualitative methodologies and applied mixed methods research since 2004. Professor Wallace is also an Associate Director of the PRIME Centre Wales, launched in 2015, and a founding member and the Director of the Wales School for Social Prescribing Research, launched in April 2020.
Dr Michelle Thomas, RGN, SCPHN-HV, V100, MSc, PGCed, FHEA, PhD
Faculty of Life Science and Education
University of South Wales
Dr Michelle Thomas is a specialist community public nurse and a senior lecturer at the Faculty of Life Science and Education at the University of South Wales. In 2022, she completed her PhD focused on Health Visiting Communities of Practice. Working with Professor Wallace, Dr Thomas played an important role in the development of the Family Resilience Assessment Instrument and Tool (FRAIT) and is the Lead for the FRAIT Wales Community of Practice for Health Visitors. She is particularly interested in participatory and action research.
M Thomas, C Wallace, G Jones, et al., Using an integrated competence model to evaluate a health visitor cascade training programme for the Family Resilience Assessment Instrument and Tool (FRAIT), Nurse Education in Practice, 2022, 62, 103336. DOI: https://doi.org/10.1016/j.nepr.2022.103336
D Pontin, M Thomas, G Jones, et al., Developing a family resilience assessment tool for health visiting/public health nursing practice using virtual commissioning, high-fidelity simulation and focus groups, Journal of Child Health Care, 2020, 24(2), 195–206. DOI: https://doi.org/10.1177/1367493519864743
CA Wallace, D Pontin, K Dokova, et al., Developing and Translating a New Model for Teaching Empowerment Into Routine Chronic Care Management: An International Patient-Centered Project, Journal of Patient Experience, 2018, 5(1), 34–42. DOI: https://doi.org/10.1177/2374373517721516
C Wallace, F Dale, G Jones, et al., Developing the health visitor concept of family resilience in Wales using Group Concept Mapping, Rural and Remote Health, 2018, 18, 4604. DOI: https://doi.org/10.22605/RRH4604
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