Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation

Abstract

This service evaluation explored foster carers’ experiences of remotely accessing the children in care consultation model during the Covid-19 pandemic. The service evaluation utilised the Kirkpatrick evaluation model to collect data at four levels (reaction, learning, behaviour and results) and employed a mixed methodology. Participants were foster carers who had accessed remote consultations between June 2020 and June 2021. Thirteen participants completed questionnaires and eight consented to follow-up interviews. Questionnaires were analysed descriptively, and interviews were analysed thematically. Questionnaires demonstrated that most participants felt listened to, felt they could talk about what mattered to them and felt the consultations were the right length. However, some participants were unsure whether the pace and delivery were suitable for them. The thematic analysis highlighted four themes: (1) Reassurance and support: the consultations provided foster carers with reassurance and support that underpinned their current actions and aided their working relationships with other professionals; (2) Approach and understanding: the sessions provided foster carers with both specific and general approaches to challenges and enhanced their understanding; (3) Online consultation approval/disapproval: foster carers had mixed views regarding the remote delivery, but most valued this; (4) Behaviour change: following consultation, most foster carers experienced a change in behaviour within the household. Recommendations are discussed.

Plain language summary

It is recognised that foster carers play a unique role for children in care and that the nature of this role often requires specialised support. One format of specialised support for foster carers is the children in care consultation model. The consultation model allows for the exploration of the difficulties being experienced by the child in care and the needs of the foster carers supporting them. During the Covid-19 pandemic several services began administering these consultations remotely via videoconferencing communication platforms. This shift towards digital ways of working has also continued post-pandemic and many services continue to engage in remotely delivered practices. However, foster carers’ experiences of accessing these consultations remotely have not yet been investigated. Therefore, this evaluation aimed to explore foster carers’ experiences of remotely accessing the children in care consultation model. Participants were foster carers who accessed remote consultations between June 2020 and July 2021. Thirteen foster carers completed a questionnaire with eight of these volunteering to be interviewed. The questionnaire data revealed that foster carers predominantly felt listened to, felt that they could talk about what mattered to them and felt the consultations were an appropriate length. Most foster carers felt that the consultations covered enough material, were accessible and that they would recommend them to others. However, some foster carers were unsure whether the pace and delivery were suitable for them. The interview data produced four main themes: (1) Reassurance and support; (2) Carer approaches and understanding; (3) Online consultation approval/disapproval; and (4) Behaviour change. Overall, these responses were consistent with the interpretation that remote consultations appear to be predominantly feasible and acceptable to foster carers. Implications are discussed.

Keywords

Foster carers remote consultations service evaluation

Introduction

Population-level mitigation efforts which arose as a response to the novel coronavirus pandemic (Covid-19) in the UK required several support services to adapt to unprecedented changes in their routine practice. Recommendations for remote working (NHS England and NHS Improvement, 2020) and social distancing guidelines (Cabinet Office, 2021) reduced capacity for outpatient face-to-face appointments, which created a barrier to service provision. Services unable to overcome these barriers experienced long waiting lists and unpredictable referral rates (see Purrington and Beail, 2021). Therefore, several support services started to utilise online video communication platforms to maintain their standard practice.

Such adjustments were particularly important for foster carers who, due to the unique demands of their role, are recognised as a cohort who benefit from additional support and training (Adams, Hassett and Lumsden, 2018; McKeough et al., 2017; Randle et al., 2017). Accessing and engaging in such support and/or training increases the likelihood of a stable and high-quality placement, as foster carers are trained to cope with children who have increased needs (Osborne and Alfano, 2011; Redding, Fried and Britner, 2000). Recent research has also highlighted the heightened impact that population-level mitigation efforts have had on foster children (Wong et al., 2020). During the pandemic, social distancing increased physical isolation from peers and impacted contact arrangements with birth families, recommendations to work from home transformed the relationships foster children had with the professionals in their lives and school closures necessitated sudden increases in time spent with carers within the home environment (Galvin and Kaltner, 2020; Waite and Partap, 2020). The quantity of changes in the lives of foster children and the level of adjustment required to adapt to these changes resulted in certain literature suggesting that foster children warranted particular consideration during this time (Cohen and Bosk, 2020; Wong et al., 2020).

Equally, several of these adjustments have impacted foster carer wellbeing (Miller and Grise-Owens, 2021) and increased stress levels in foster carers (Miller, Cooley and Mihalec-Adkins, 2022). For example, social distancing guidelines resulted in fostering agency staff becoming less physically present to support foster carers (Galvin and Kaltner, 2020), staff absences within fostering agencies during the pandemic resulted in foster carers becoming more isolated (Miller and Grise-Owens, 2021) and the increase in acute psychosocial and emotional stress faced by foster children was likely to have a reciprocal impact on foster carers via their experiences within the carer–child relationship (Prime, Wade and Browne, 2020). Therefore, providing accessible support during the pandemic for foster carers became increasingly pertinent.

Research has explored the use of specific training and support for foster carers who are looking after children in care (CIC) and, notably, the consultation model appears to be most useful (Golding, 2003; 2004; Nissim, 1993; Osborne and Alfano, 2011; Sprince, 2000). The model allows for the exploration of the difficulties being presented by the CIC and explores the needs of the carer supporting them (Golding, 2003). In line with this, the National Institute for Health and Care Excellence (NICE) recommends that specialist services (such as Child and Adolescent Mental Health Services [CAMHS]) should provide consultations and/or training for carers of looked after children that focuses on fostering secure attachments (NICE, 2015).

Therefore, this service evaluation aims to explore the experiences of foster carers who remotely accessed the CIC consultation model during the Covid-19 pandemic. The findings and recommendations from the evaluation will then look to shape and inform service provision. The utilisation of remote consultations, provision of therapeutic support via videoconferencing platforms and move towards digital models of therapy have remained consistent features of routine practice for therapeutic services post-pandemic. Considering the lack of research in this area, it is hoped that this service evaluation will be useful for a wide range of services using remote consultation practices with foster carers.

Method

The service

The service is a CAMHS in the North of England that provides a variety of assessment and therapeutic interventions. One pathway within the service delivers support to carers and staff (foster carers, social workers, etc.) working with young people in the CIC system. A main component of this pathway involves the provision of consultation sessions delivered by a single clinical psychologist. To access consultations, referrals are either submitted by the carer or staff member or made on behalf of the carer or staff member (i.e., a social worker for a foster carer). If appropriate, one or more consultations (dependent on need) are then provided. Referrals typically request support for a range of difficulties, including behaviours that challenge (e.g., boundary difficulties, interpersonal difficulties, etc.), transitions (e.g., school changes or placement moves) and more. The consultations aim to help the attendee consider the needs of their young person, make sense of those needs and consider impactful changes. The clinical psychologist discusses these areas with reference to attachment theory (Bowlby, 1969), therapeutic parenting and other sources.

As a result of the recent Covid-19 pandemic, the service has been providing consultation sessions remotely. Prior to this, sessions were provided in a face-to-face format. Although other pathways are now using a combination of face-to-face and remote sessions, the CIC pathway has continued to work exclusively remotely. Such practices have continued due to the flexibility that remote sessions offer and the anecdotal success of these consultations. To maximise the ease of use of online sessions, the service provided telephone guidance from the administration team to service users accessing the consultations (if requested). Clinicians, however, were not provided with training on either setting up or providing support via online sessions. As no formal feedback has been gathered regarding the experiences of individuals accessing consultation sessions during the pandemic, this evaluation will aim to inform service management of their experiences to shape future service provision.

The consultation process

The consultations included meetings between the foster carers and the practitioner and meetings between foster carers, additional professionals (members of the child’s network such as school staff and social workers) and the practitioner. The majority of service users who completed the questionnaire within this study and all of those who were interviewed attended as single foster carers. In line with the original research by Golding (2003; 2004), the consultations broadly followed Caplan’s (1970) consultation model which is considered to be a consultee-centred case consultation model. Golding’s (2004) developments on this model outline a six-step consultation process, separate to setting the consultation scene and completing post-consultation tasks. The six steps include: (1) Exploration of the current situation; (2) Consideration of the child in different settings; (3) Exploration of background information; (4) Tentative formulation; (5) Solidification of formulation; and (6) Planning for further support. Due to the variety of support required by foster carers, the aims of the consultations varied, although common factors were apparent (e.g., reducing challenging behaviour, supporting difficulties with transitions and managing problems within educational settings). At times multiple aims emerged. For example, while certain service users commenced consultations seeking support with reducing the child’s challenging behaviour, an additional aim developed during the process to increase the child’s sense of safety, which would then likely, in turn, reduce instances of challenging behaviour.

Research approach

The Kirkpatrick evaluation model (1979) was used to organise the collection of data at four levels: reaction, learning, behaviour and results. Data for the reaction level was gathered using a novel questionnaire (see ‘Supplementary material 1’ online). Interviews were then conducted with willing participants who had completed the questionnaire to gather information for both the reaction level and the more complex levels (learning, behaviour and results). Braun and Clarke’s (2013) ‘six-phase approach’ method of thematic analysis was then employed to investigate the findings and analyse the emerging themes.

Sampling

For the purposes of coherence and transparency, sampling guidelines for interview-based qualitative research were utilised (Robinson, 2014). The process involves defining a sample universe (inclusion and exclusion criteria), deciding a sample size, devising a sample strategy and sourcing the sample.

When defining the sample universe, the evaluation set about sourcing foster carers who had remotely accessed CIC consultations during the Covid-19 pandemic (between June 2020 and June 2021). Due to the variety of professionals who access consultations, the sample was made homogenous by concentrating solely on foster carers. Participants were not excluded for accessing more than one consultation session but must have accessed at least one session remotely during the aforementioned dates. Foster carers with a range of experience were included.

The sample size was selected in consideration of ‘information power’ and ‘data saturation’. For interview-based qualitative research, Malterud, Siersma and Guassora (2016) refer to information power, which proposes that the research aims, sample specificity, dialogue quality and analysis strategy are important, as fewer participants are needed if the sample provides more information relevant to the specific study. Alternatively, Guest, Bunce and Johnson (2006) suggest that 12 is a sufficient number of interviews to achieve data saturation for research that describes the experiences of a homogenous group. Thus, the researcher in this study aimed to complete around 12 interviews, whilst ensuring that the aforementioned information power elements were taken into consideration in case of reduced participant numbers.

Throughout the evaluation, a purposive sampling strategy was utilised. Initially, all foster carers from the service pathway database who met the inclusion criteria were contacted. From this, a number of participants volunteered to be interviewed.

Materials

In order to complete the evaluation, a novel questionnaire and semi-structured interviews were conducted. In relation to the Kirkpatrick model (1979), the questionnaire looked to accomplish the reaction evaluation level, with the follow-up interviews looking to achieve both reaction and complex (learning, behaviour and results) levels.

The questionnaire was developed according to the recommendations of Lietz (2010) concerning question length (16–20 words per question), grammar and simplicity, response numbers (five to seven Likert-scale options per question) and wording. The questionnaire aimed to collect sample demographic data, gather a sample for the follow-up interviews and achieve the reaction evaluation level. This level focuses on collecting individuals’ thoughts and feelings about the intervention (Dorri, Akbari and Sedeh, 2016). Two psychologists within the service with experience in the CIC field were also consulted on the questionnaire and adaptations were made where required.

The semi-structured follow-up interviews were developed based upon the guidelines of Kallio and colleagues (2016), which follow a five-stage process. The first stage – identifying the prerequisites for using a semi-structured interview format – was achieved as the researcher identified the need for qualitative data that would provide in-depth conclusions. Stage two was accomplished by utilising previous knowledge of the area (regarding CIC services and attachment-based interventions) as a basis for the interview guide. The next stage – formulating the preliminary semi-structured interview guide – was conducted along with the two aforementioned psychologists based within the service. They were able to consult on the suitability of the questions and to consider whether the interview provided foster carers with ample enough opportunity to share their experiences, whilst not leading them towards certain answers. The final two stages – testing the interview and presenting the complete guide – involved consulting another colleague and discussing the guide.

Procedure

After sampling eligible participants from the service database, a secure email was sent to 55 foster carers. The email included some evaluation information and a Qualtrics link should they wish to participate. The information stated that their participation was optional and that all information would be stored anonymously. The link included a confidentiality statement and information on the storage of data, as well as a consent statement for participants to agree to prior to completing the questionnaire. Once complete, participants were asked if they would be interested in follow-up telephone interviews to explore their remote consultation experiences further. For those who volunteered, an information sheet and consent script were read to them prior to the interview (see ‘Supplementary material 2’ online). For the purposes of continuity whilst also allowing pertinent points to be expanded upon, the interviews utilised a semi-structured format (see ‘Supplementary material 3’ online). In order to assist with data synthesis, all interviews were recorded with an audio recorder. Interview data were transcribed verbatim by the first author. Once all volunteer participants had been interviewed, data analysis began.

All questionnaire and interview responses were reported anonymously. All data were also stored securely in accordance with the National Health Service (NHS) Trust and the University of Sheffield guidelines. Once data gathering and data analysis processes were complete, the current report was written. Upon completion, the service lead agreed to make arrangements for the dissemination of the findings to the appropriate persons.

Data analysis

The qualitative evaluation component utilised a thematic synthesis method adhering to the ‘six-phase approach’ (Braun and Clark, 2013).The first author familiarised themselves with the data, annotating transcripts whilst reading them. Initial codes were then created, based closely on the participants’ language. Themes were then produced based upon the codes highlighted, recognising possible overlap. A secondary analyst then checked the coding and also produced themes from the codes. Final themes were then reviewed for their rigour, quality and meaningfulness, in consideration of both analysts’ conclusions. Themes were then named and the report was produced.

Reflexivity

Both authors were male trainee clinical psychologists in their late 20s at the time of the study. Neither author has experienced the foster care system, been a foster carer or worked as a qualified psychologist in the consultation pathway. This lack of experience may have influenced interpretations of the data and the ways in which the data were gathered. To minimise the risk of bias, the evaluation fulfilled various guidelines outlined by Elliott, Fischer and Rennie (1999) which ensure the successful administration of qualitative and quantitative research. Namely, a secondary analyst was utilised, general and specific research tasks were conducted, participant data were accurately reported, research implications were discussed and themes were paired with examples. Thus, the evaluation appears to have fulfilled several guidelines which are identified in good quality research. Additionally, supervision was accessed throughout to discuss the authors’ responses and consider their reflexivity in more depth.

Ethical considerations

This project was classified as a service evaluation and is being written up retrospectively. As such, it did not require ethical approval. The service evaluation was commissioned by the service lead and registered with and approved by the Trust’s Quality Improvement and Assurance Team, who were consulted throughout. Prior to the collection of data all participants were provided with consent forms and consented to their involvement in the service evaluation. The authors confirm that all procedures contributing to this work complied with the American Psychological Association ethical standards in the treatment of participants, the British Psychological Society code of ethics and conduct and the Health and Care Professionals Council standards of conduct, performance and ethics.

Results

Overall, 55 foster carers were sent an online link to the questionnaire, with 13 completing it. From this sample, seven foster carers had accessed either one or two consultations, with six having accessed either four or more than five. Ten foster carers had not accessed face-to-face consultations prior to accessing remote consultations. The foster carers’ level of experience in the role varied, with seven having had nought to three years or three to six years and six having nine to 12 years or over 12 years of experience. Twelve participants felt the consultations were about the right length. Eight participants were ‘Very much’ satisfied with the consultations overall, with three being ‘Somewhat’ satisfied, one ‘Unsure’ and one ‘Not really’ satisfied. Ten felt that they were ‘Very much’ listened to. In addition, 11 felt that they were given a chance to talk about what mattered to them. Nine participants felt that the consultations ‘Very much’ covered enough material and eight felt the pace and delivery ‘Very much’ worked for them (with five selecting either ‘Somewhat’ or ‘Unsure’). Ten participants were extremely satisfied with accessing video consultations and nine felt they were ‘Extremely accessible’ (with four others feeling they were ‘Somewhat accessible’). Nine participants selected that they would ‘Very much’ recommend the sessions. Figure 1 illustrates the distribution of responses to questions 5, 6, 7, 8, 9 and 12 of the questionnaire, indicating participants’ perceptions of the consultations. (To view tables outlining the distribution of responses to all questions, see ‘Supplementary material 4’ online.)

Figure 1.

Views on the remote delivery of the children in care (CIC) consultation model: distribution of questionnaire answers.

Of the 13 participants who completed the questionnaire, eight volunteered to be interviewed. From the transcripts, the thematic analysis resulted in the identification of four main themes, which will be discussed below: (1) Reassurance and support; (2) Carer approaches and understanding; (3) Online consultation approval/disapproval; and (4) Behaviour change.

Theme 1: Reassurance and support

Four of the participants felt that the remote CIC consultations were useful as they provided them with reassurance and/or resulted in them feeling more supported. Overall, five participants detailed feeling this way, with some examples of their comments below:

[I found] that permission and agreeing with the way I thought things should have been anyway [helpful] … what [the psychologist] said to me in that meeting was backing up what I was thinking, that’s why I use the word ‘permission’, because I had that backing. (Participant 1)

… it was about getting the reassurance that I’m doing the right thing. (Participant 3)

… just being reassured that we’re on the right track [was useful]. (Participant 7)

Importantly, three participants also felt that the consultations aided their working relationships with other professionals who were supporting them and provided them with the backing they wanted:

So he understood, so it was like setting that stall. That all came from [the psychologist] saying that is fine to do that as I felt pressured from social workers to not do that. I felt like I could always say ‘[The psychologist] said that’. (Participant 1)

I learnt that what I was thinking was right. [The psychologist] helped me to get it out and supported me in saying what I needed to say to other staff in the consultation … I’d been thinking, why can’t they see what I’m seeing? It’s absolutely helped no end. He could relate to what I was saying. (Participant 5)

Theme 2: Carer approaches and understanding

Five participants shared that the consultations provided them with specific and general approaches in relation to their dilemma:

[The psychologist] said she [the foster child]’s not had the experiences a six-year-old would normally have and so maybe my expectations were too high. That made us discuss how I approach things with her and what to expect. (Participant 2)

[The psychologist] suggested it was about how I say things so he [the foster child] doesn’t take it the wrong way. Also, I was told how important structure is, for example during the six-week holidays. (Participant 6)

Whilst reflecting on the different carer approaches that were suggested from the consultations, three participants shared a flexible attitude to trying out new methods as a foster carer:

You may see great progress and then she [the foster child] might go backwards. She’s got a new adoption order now so she’s bound to regress so we’ve got to help her manage as best as she can. (Participant 2)

Anything [the psychologist] suggested I tried. Some things work, some things don’t. I think I’ll always be changing things and always be learning as one day to the next this little lad is different. (Participant 6)

What I got out of the sessions, talking about what happened, things were highlighted, then suggestions [were given]. ‘What about trying this?’ Sometimes they work and sometimes they don’t but you have to keep trying. (Participant 7)

When discussing carer approaches, four foster carers expressed the development of their knowledge around theoretical concepts and approaches (i.e., therapeutic parenting, attachment and child brain development):

[Something I found helpful was the psychologist] pointing out that I must use a therapeutic parenting approach back to her [the foster child], rather than saying ‘I can’t believe you’ve told lies’. (Participant 2)

The sessions gave me confidence with therapeutic parenting. (Participant 5)

We talked about attachment and obviously he needs more therapeutic parenting. (Participant 6)

[I] … had to take myself back to her experiences and what she’s missed and what we need to build on. We talked about how the brain works from the base. If the bricks aren’t laid down initially, they’re missing and that will affect the bricks later. (Participant 8)

Theme 3: Online consultation approval/disapproval

Five participants outlined their approval of online consultations. These participants shared their approval based upon the increased accessibility of sessions and the fact they have become accustomed to working in this way:

The online thing was a bit less daunting than going in [in person]. (Participant 1)

I would do online Teams again, because it’s not interrupting anyone’s day. For convenience Teams is the way forward. We’re all used to it now, it’s just become part of life. (Participant 3)

I’ve found it’s great, you can get through more, it’s time effective and it’s more convenient as you don’t have to drive there. It’s fantastic really. (Participant 7)

On the other hand, three participants disapproved of online consultations, reflecting that they either experienced technical issues or had difficulties with them due to personal reasons:

It was more the technical side of things that [was] challenging. We had to mute when the other person was speaking. (Participant 2)

On the negative side, one of the professionals was quite distracted. He was listening, but he said he couldn’t get it to work properly. (Participant 4)

I hated them. I found them very stressful, I am dyslexic. I struggle with things like that … I felt uncomfortable, felt like I was interrupting when I wanted to speak. I prefer face to face. (Participant 6)

Theme 4: Behaviour change

Four participants felt that changes in behaviour had occurred for their foster child and/or within their household following consultations:

… everybody knew where we were. In this house between us, things worked a lot better because he couldn’t get away with saying ‘That’s not fair’. (Participant 1)

She’s just being herself now, bubbly, happy, settled, [it has] made a massive difference to her health. (Participant 5)

She’s made great progress and to have somebody to say ‘You’re doing well’ and ‘Keep going’ and to talk about the finer details of challenging issues was good. (Participant 8)

Discussion

Through the utilisation of a mixed methods approach, the service evaluation gathered foster carers’ experiences of accessing CIC consultations remotely.

In reference to the Kirkpatrick (1979) model, the questionnaire initially gathered data from the reaction level. It found that most foster carers felt consultations were an appropriate length, covered suitable levels of material and provided a chance to talk about what mattered to them. A large proportion of foster carers were extremely satisfied with remote consultations and felt they were accessible. Furthermore, a majority were satisfied overall and stated that they would recommend these remote sessions to other foster carers. Some foster carers felt less sure about the pace and delivery of consultations.

However, equally of note is the presence of some significantly negative comments about working online. It is possible that the unique circumstances of the pandemic may have created an environment in which practitioner preparation, in terms of orientation to remote delivery, was limited. For example, the psychologist providing the consultations may not have received formal training regarding the remote delivery of consultations and psychological therapies. It could be suggested, therefore, that some of the more negative experiences of those receiving consultations may have been alleviated with the provision of enhanced support and staff training.

The qualitative component of the evaluation highlighted four key themes – ‘Reassurance and support’, ‘Carer approaches and understanding’, ‘Online consultation approval/disapproval’ and ‘Behaviour change’ – that achieved the more complex Kirkpatrick levels (learning, behaviour and results). In particular, the learning component of the model was heavily present for one theme (‘Carer approaches and understanding’), which evidenced foster carers learning new approaches and expanding their understanding. Further fulfilment of this level was evident within the theme of ‘Reassurance and Support’, where foster carers appeared to learn to trust themselves and their own judgement. Fulfilment of the behaviour level was also apparent within the theme of ‘Behaviour change’, with foster carers reflecting on either changes in their child’s behaviour and/or changes in their own approaches. Facets of the uppermost level (results) were also evident in the theme of ‘Behaviour change’. However, as such results are not supported by measurable outcomes, it is not possible to make conclusions regarding effectiveness. Rather, the themes and the findings underpinning them indicate a high level of acceptability and feasibility for the remote consultations.

Sekhon, Cartwright and Francis (2017) propose that the acceptability of a healthcare intervention is a complex construct which includes seven components:

Affective attitude: how recipient/deliverer feels about the intervention;

Burden: the perceived effort required to receive/deliver the intervention;

Ethicality: how well the intervention fits into the recipient/deliverer’s value system;

Intervention coherence: how well the recipient/deliverer understands the intervention;

Opportunity costs: how much must be sacrificed in order to receive/deliver the intervention;

Perceived effectiveness: whether recipient/deliverer believes the intervention achieves its goals;

Self-efficacy: how confident the recipient/deliverer is in their ability to carry out the behaviours necessary to engage in the intervention.

These seven components indicate the extent to which individuals delivering or receiving an intervention consider it appropriate for them.

Several of the statements made in the interviews can be regarded as service users expressing high levels of retrospective acceptability for the online consultations. Most notably, statements coded into the theme of ‘Online consultation approval/disapproval’ indicated that, largely, service users maintained a positive affective attitude, experienced low levels of burden, reported a positive balance of opportunity/costs and exhibited high levels of self-efficacy in relation to engaging with the online consultations. Statements coded into the themes of ‘Reassurance and support’ and ‘Carer approaches and understanding’ once again indicate high levels of affective attitude alongside a positive sense of intervention coherence. Finally, the theme of ‘Behaviour change’ highlights that service users reported high levels of perceived effectiveness regarding online consultations.

Moreover, Weiner and colleagues (2017) suggest that the feasibility of a healthcare intervention should be assessed by considering the extent to which the intervention appears simple and easy to engage with, whether the intervention is practicable and whether it can be implemented in routine clinical practice. The responses obtained from the dataset are consistent with the interpretation that remote consultations are indeed feasible.

Despite the predominance of positive findings relating to feasibility and acceptability, certain service users reported feeling uncomfortable with remote consultations and perceiving that the professionals with whom they were meeting appeared distracted. Therefore, there may be ways to improve the experience of remotely delivered consultations to enhance outcomes for a greater number of service users. For example, if carers develop a relationship with practitioners prior to receiving remote consultation support it may be possible that feelings of discomfort and breaks in attunement between practitioner and carer could be easier to navigate within the therapeutic relationship. Martin, Garske and Davis (2000) and Norcross and Lambert (2011) suggest that the development of a meaningful working alliance is associated with better therapeutic outcomes. In this way, the nature of the practitioner–carer relationship before the consultation has a great influence on the consultation experience. As no data relating to the nature of the pre-consultation practitioner–carer relationship were collected within this service evaluation, it is unknown whether this relationship impacted on the synthesis of the findings.

The presence of self-selection bias, which can introduce an inherent bias into the traits of the sample collated (Sharma, 2017), may have also impacted the findings. Foster carers who volunteered to be involved may have done so due to their positive experiences, as favourable involvement with services may be more pleasant to share. On the other hand, foster carers who had a less favourable experience may have abstained to avoid the discomfort induced by exploring negative experiences. Despite these suggestions, evaluating self-selection bias is difficult due to the lack of access to those who did not take part (Costigan and Cox, 2001). Proposals regarding the influence of this phenomenon are therefore speculative but remain worthy of consideration.

A further influence on these findings may have been the foster carers’ prior experience of consultations. There is a need to explore the satisfaction levels of consultations with service users who have only experienced remote consultations, those who have only experienced face-to-face consultations and those who have experienced both. This would allow for an exploration of the similarities and differences in findings between these two experiences. This is particularly important due to the convenience associated with virtual consultations. There may be a risk that the benefits to both time and cost of virtual consultations will limit the provision of face-to-face approaches. Certain literature proposes that during face-to-face therapeutic interventions therapists report exhibiting a greater number of therapeutic attributes compared to during remote consultations (Lin et al., 2021). Lin and colleagues (2021) found that during face-to-face therapeutic interactions, therapists perceived themselves to exhibit greater aptitude in 19 therapeutic skills including alliance rupture repair, empathy, conversational tone, emotional expression and warmth. There are, therefore, questions regarding whether remote consultations can provide similar levels of relational depth as face-to-face consultations and whether this mediates the impact of the consultations. Further research is required to compare the strengths and weaknesses of each consultation delivery format to establish whether there is indeed a trade-off between time and cost for relational depth and openness.

More broadly, it is important to consider the wider implications of remote consultations for the network around the child and to compare these with telephone and face-to-face consultations. Foremost, the convenience and affordability of remote consultations will impact the use and effectiveness of including members of the child’s network in the consultations. Snoswell and Comans (2021) found that failure-to-attend rates were almost 50% lower for patients accessing remote appointments compared to face-to-face appointments. It is therefore anticipated that social workers, teachers and other caring professionals will be more likely to attend remote consultations on a consistent basis and that this will have a number of benefits. However, similar challenges relating to the application of therapeutic skill may present themselves if the team around the family fail to meet face to face (Lin et al., 2021). There is also a risk that familiarity with remote working may lead to a prolonged and consistent rise in telephone and video consultations alongside a decline in face-to-face consultations in routine practice. This may have a persistent and pervasive impact on the quality and consistency of care provided during consultations. However, it is important to note that, at present, these considerations are speculative and further research is required to appropriately ascertain the similarities and differences in the format of consultation delivery.

Implications for practice

The findings of this service evaluation indicate that the remote delivery of the consultation model: implemented the most important components of the consultation framework; was both feasible and acceptable to consultation recipients; and delivered impactful support which was well-received by foster carers. In light of these findings, numerous recommendations are proposed for services offering remote consultations:

Offer both online and face-to-face consultations. Some participants felt online consultations were better, whilst others preferred face-to-face consultations. Consequently, it would be beneficial for services offering online consultations to continue this practice alongside offering face-to-face consultations in certain circumstances.

Consider the pace and delivery of sessions. Some foster carers felt that the pace and delivery of sessions may not have been right for them. Practitioners delivering remote consultations should consider the utility of talking about the process or experience of consultations with foster carers to check whether the focus, content and pace are appropriate for them. These should then be altered accordingly.

Validate and advise foster carers. Foster carers noted the positive impact of being reassured. This highlighted the importance of normalising and validating their current strategies/thinking alongside advising on new approaches within consultations.

Pathway addition. In order to ensure that foster carers can receive the reassurance and validation they noted as useful for them, services might consider creating new ways this can be successfully offered more flexibly outside of the consultation framework.

Make foster carer session impact explicit. To assess consultation impact, it would be useful to set foster carers goal-based outcomes and rate these at the start and end of sessions. Services offering remote consultations should also consider creating novel measures that consider various foster carer impact indicators, such as theoretical understanding, confidence levels and evaluations of other idiosyncratic importance.

Ensure consistency through integrated working. Some foster carers felt consultations were required to oppose contradictory information from other professionals. Therefore, it might be useful for services to incorporate additional joined-up working with other services to ensure consistent messages to foster carers from professionals.

Ensure adequate training and support. Providing brief telephone coaching prior to people accessing online consultations could reduce the likelihood of encountering negative experiences. Furthermore, the provision of training for staff around providing consultations/psychological input via remote media could also be beneficial.

Implications for future research

The findings suggest that remotely delivered consultations are both feasible and acceptable to service users in routine practice. Future research should therefore seek to examine the preliminary efficacy of remote consultations across a range of quantitative outcome measures.

One concern with virtual consultations is that the delivery format may modify the balance of reflective/affective support towards the reflective end of the spectrum. For example, remote consultations may shift the focus towards providing advice about caregiving, compared to providing the opportunity to explore the emotional impact of caring for the child. Further research is needed to consider the presence, nature and form of this phenomenon. A qualitative exploration of the experiences of emotional support, changes in emotional wellbeing and feelings of efficacy following remote consultations is warranted.

Further research should consider exploring satisfaction with consultations for those who have only experienced remote consultations and those who have only experienced face-to-face consultations. A comparative study is required to examine the similarities and differences in outcomes between video-, telephone-based and face-to-face consultations.

Limitations

Despite the useful findings of the service evaluation, it should be recognised that some limitations were evident. Principally, this was apparent when interviewing the foster carers, as a large proportion had accessed the Fostering Lasting Attachments Group (FLAG; Golding, 2006), with only some having attended additional or alternative training (all of which had occurred in person). As a consequence, some participants found it difficult to recall the exact content of consultations, which may have affected the answers they were able to give. Due to this, it is important to note the differences and similarities between the FLAG training and the consultations provided. The FLAG content is theoretically underpinned by both attachment theory and social learning theory and covers three main modules: (1) Providing an understanding of attachment theory; (2) An introduction to the ‘House Model of Parenting’; and (3) A continued exploration of the ‘House Model of Parenting’. Alternatively, although the consultations utilise knowledge and theory underpinning the FLAG, they provide a more open space to explore idiosyncratic situations, resulting in the tailoring of content based upon the six-step consultation model (Caplan, 1970). In practice, this means that alternative formulations were utilised, along with the discussion of concepts relating to other intervention frameworks, such as Dyadic Developmental Psychotherapy (DDP) including the PACE (playfulness, acceptance, curiosity and empathy) parenting principles (Hughes, Golding and Hudson, 2015). Overall, the FLAG and the consultations cover overlapping content (especially with regards to attachment theory, attachment styles and attunement). However, the consultations are more varied and flexible in their nature. Despite this clarification regarding the similarities and differences of the interventions, it is still difficult to separate the impact of the consultations from the training the foster carers may also have accessed. When gathering data, to facilitate service user memory and recall of their consultations additional time was provided to those who had also recently participated in the FLAG intervention, and the interviewer made it explicitly clear that any reflections must be about the online consultations. In the future, this could be safeguarded against by interviewing foster carers after they had completed consultations but prior to undertaking further training.

Another limitation relates to the use of the purposive sampling strategy. When using this strategy, self-selection bias is often present, as the participants independently decide to participate in the research. Sharma (2017) postulates that this may introduce an inherent bias into the traits of the participants, which could lead to the sample being unrepresentative of the studied population. Bethlehem (2010) also suggests that self-selection bias can be more prevalent with online questionnaires due to participant inaccessibility. Although some disadvantages are present when utilising purposive sampling, the strategy is recognised for being less time-consuming and guaranteeing a particular sample type (Rai and Thapa, 2015). Additionally, self-selection bias can ensure that participants are more likely to be committed, which may result in an improvement in the participants’ willingness to provide more insights (Sharma, 2017).

Some may also feel that the evaluation was limited due to its sample size. As outlined, Guest, Bunce and Johnson (2006) recommend a sample size of 12 as this achieves data saturation and accounts for variability. Unfortunately, due to difficulties recruiting willing participants, only eight attended follow-up interviews, which could mean the sample is less representative than desired. However, in relation to the informational power principles outlined by Malterud, Siersma and Guassora (2016), as the evaluation had a focused question and aims, used a homogeneous sample and involved comprehensive interviews, a smaller sample size can be valid. However, the fact that consultations were only provided by a single clinical psychologist during the service evaluation may have also impacted the sample collated. Despite all participants being provided with information about data collection, storage and confidentiality, it is possible that service users’ feared their data being identifiable during the project, which may have increased concerns that their participation might impact upon their future service provision. This may have introduced a positive response-rate bias. Moreover, it is noted that generalising from an individual practitioner may influence the external validity of the findings, due to factors such as the practitioner’s idiosyncratic delivery. Results and recommendations should be interpreted with this context in mind.

Finally, the interview topic guide focused on learning, behaviour and results, which mainly attracted responses relating to cognitive outcomes. This may have impacted the overall conclusions reached due to an absence of data regarding the level of emotional support the service users received during the remote consultations. For example, it is unknown whether these remote consultations successfully contributed to emotional developments such as increases in emotional wellbeing and feelings of efficacy.

Conclusion

This mixed-methods service evaluation aimed to explore the experiences of foster carers remotely accessing the CIC consultation model during the Covid-19 pandemic. A total of 13 foster carers completed a quantitative questionnaire which revealed that, overall, the foster carers felt the remote consultations were an appropriate length, covered a suitable amount of material and provided them with an opportunity to discuss what was important to them. Most foster carers felt extremely satisfied with the remote consultations and would recommend them to other foster carers. However, some foster carers were less pleased with the pace and delivery of the consultations. Additionally, eight foster carers were subsequently interviewed with four major themes emerging: the consultations provided the foster carers with reassurance and support; the consultations provided the carers with specific and general approaches and an increased understanding relating to their dilemma; online consultations were met with a mixture of approval and disapproval; and the consultations resulted in behaviour changes within the household. Going forward, services currently delivering remote consultations for foster carers should consider offering both online and face-to-face consultations where possible, consider the pace and delivery of the sessions, seek to validate and advise foster carers and potentially add new service pathways to sensitively respond to foster carers’ needs, begin to incorporate goal-based outcomes during consultations and seek to ensure consistency through integrated working.

Supplemental Material

sj-pdf-1-aaf-10.1177_03085759231178315 - Supplemental material for Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation

Supplemental material, sj-pdf-1-aaf-10.1177_03085759231178315 for Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation by Jonah Gosling and Jack Purrington in Adoption & Fostering

Supplemental Material

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Supplemental material, sj-pdf-2-aaf-10.1177_03085759231178315 for Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation by Jonah Gosling and Jack Purrington in Adoption & Fostering

Supplemental Material

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Supplemental material, sj-pdf-3-aaf-10.1177_03085759231178315 for Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation by Jonah Gosling and Jack Purrington in Adoption & Fostering

Supplemental Material

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Supplemental material, sj-pdf-4-aaf-10.1177_03085759231178315 for Experiences of foster carers remotely accessing the children in care (CIC) consultation model during the Covid-19 pandemic: A service evaluation by Jonah Gosling and Jack Purrington in Adoption & Fostering

Footnotes

Acknowledgements

The authors would like to thank both the service and the service users for their support and engagement throughout this project.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The first author undertook a clinical training placement in the service in which the evaluation is based, however, both authors are now employed elsewhere.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Jonah Gosling is a clinical psychologist in the East Cheshire Community Learning Disability Team, UK.

Jack Purrington is a clinical psychologist at Chrysalis Associates, UK, working in the field of developmental trauma and attachment difficulties.

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