When opinions differ: the development of a reflection tool for youth professionals to support shared decision-making with parents

ABSTRACT

The importance of shared decision-making (SDM) in youth care is increasingly emphasised. Professional reflection on the decision-making process is an important means to improve the use of SDM in practice. In this study, we report on the development of a reflection tool for youth professionals primarily to use when they hold a different opinion then parents about referral to specialised youth care services. In co-creation with local youth professionals and parent representatives from the South of the Netherlands, the tool was developed and tested in practice. This process was guided by a three-stage cyclical research project. First, reflective group discussions provided an initial understanding of professionals’ needs, interests and experiences. This input then was analysed and documented into a draft tool with reflective questions. Next, this tool was tested on fictive and real life cases and adjusted with input from youth professionals and parents. This process resulted in an online reflection tool covering 16 overarching reflective questions to support youth professionals’ reflection on their shared decision-making in practice. The tool can be used and adapted by others in the field of youth care to improve the process of making shared decisions with parents in complex cases.

SAMENVATTING

Het belang van samen beslissen (SDM) in de jeugdhulp neemt toe. Het reflecteren op het proces van samen beslissen door jeugdprofessionals is een belangrijk middel om het gebruik van SDM in de praktijk te verbeteren. In deze studie doen we verslag van de ontwikkeling van een reflectie-instrument door en voor jeugdprofessionals voor situaties waarin zij een andere mening hebben dan ouders over verwijzing naar gespecialiseerde jeugdzorg. In co-creatie met lokale jeugdprofessionals en oudervertegenwoordigers uit het zuiden van Nederland werd het instrument ontwikkeld en getest in de praktijk. Dit proces is begeleid door een cyclisch onderzoeksproject in drie fasen. Eerst werd via reflectieve groepsgesprekken een eerste inzicht verkregen in de behoeften, interesses en ervaringen van de professionals voor een reflectie instrument. Deze input is vervolgens verwerkt in een concept-instrument met reflectieve vragen. Vervolgens is dit instrument getest op fictieve en reële casussen en aangepast op basis van de ervaringen van jeugdprofessionals en ouders. Op basis van hun feedback werd de definitieve versie gepresenteerd als een online reflectietool met 16 overkoepelende reflectievragen ter ondersteuning van de reflectie van jeugdprofessionals op het samen beslissen met ouders. De tool kan gebruikt en aangepast worden door anderen in het veld van jeugdzorg om het proces van samen beslissen met ouders in complexe casussen te verbeteren.

KEYWORDS:

• Youth work
• shared decision-making
• reflection
• professionals
• parents

TREFWOORDEN:

• jeugdhulp
• samen beslissen
• reflectie
• professionals
• ouders

1. Introduction

The decentralisation of social policy, including child welfare, is an international ongoing trend. (Carnochan et al., 2013; Léveillé & Chamberland, 2010; OECD, 2019).Since the Dutch Youth Act of 2015, local governments are responsible for providing all services for children and young people aged 0–18 and their families in the Netherlands . This involves care ranging from universal and preventive youth and parenting support to specialised voluntary and compulsory services such as youth mental health care and child protection services. Youth care providers, so-called generalists youth professionals, play a central role in this system. They make the initial assessment of children’s and families’ problems and needs, provide support themselves, direct clients to interventions of other providers to prevent problem from becoming more serve or refer to specialised services when needed. To this end, they must well be able to discuss and decide about care and support services options with families. To do so, these youth professionals are, among other things, supposed to work in a more evidence-based way and to involve parents and children/youth more explicitly in their decision-making – that is, to incorporate shared decision-making (SDM). The importance of SDM and evidence-based working in youth care is increasingly recognised yet both appear challenging to integrate into practice (Langer & Jensen-Doss, 2018; Liverpool et al., 2021; Nooteboom et al., 2020). In the Netherlands for instance, the Youth Act and the national working guideline on Shared Decision-Making (Bartelink et al., 2021) do not provide youth professionals with tools how to do so.

1.1. SDM in youth care and the added value of reflection

Research on decision-making in child welfare and social work shows a limited capacity of professionals to explain or make explicit their decision-making criteria (Bartelink et al., 2020; Heggdalsvik et al., 2018; Munro, 2011; Saltiel & Lakey, 2020; Taylor, 2012). Youth professionals rely on (evidence-based) guidelines in their work, but also on personal values, previous experiences and their intuition. Professional judgement to balance these elements in decision making is considered a core value yet complex aspect of social work (Helm & Roesch-Marsh, 2017; Ylvisaker & Rugkåsa, 2021). Heavy reliance on subjective experience has the risk of creating unwanted differences in decision-making and is therefore considered a potential problem (Roscoe et al., 2011; Whittaker, 2018).

The involvement of clients in decision-making is considered an effective strategy to improve the quality of social work assessment, and ensures that parents and young people get a voice in decisions that affect their lives (Nooteboom et al., 2020; Rap et al., 2019). For clients, SDM is linked to a higher satisfaction with services and positive outcomes (Langer & Jensen-Doss, 2018; Liverpool et al., 2021). For professionals, SDM relates to increased work satisfaction, and, in the long-term, to the development of a professional culture in which ‘deliberation and collaboration are regarded as guiding principles’ (Elwyn et al., 2015, p. 6; Wyatt et al., 2015). However, unlike in adult care, SDM has rarely been implemented in youth care (Abrines-Jaume et al., 2016; Boland et al., 2019; Bontje et al., 2021). The literature points out that in youth care, SDM is complicated by the potential complex relationships between young people, parents, and professionals (Liverpool et al., 2021; Wyatt et al., 2015). In particular disagreement concerning the form and intensity of support hinders SDM (Liverpool et al., 2021; Nooteboom et al., 2020). In addition, youth professionals experience difficulties in arranging family involvement, for instance due to a perceived lack of willingness, skills or support of clients and/or lack of skills, tools and time on the part of professionals (Nykänen et al., 2021; Rap et al., 2019; Van Bijleveld et al., 2013).

Case reflection related to shared decision-making is assumed to be a perquisite for the implementation of SDM (Munro, 2011; Sisk et al., 2017; Toros & LaSala, 2019). Reflection opens up ways for critical thinking: it helps to evaluate in-depth past situations, to identify what influences one’s own practice and to draw conclusions for future acting (Ferguson, 2018; Ylvisaker & Rugkåsa, 2021). Specifically in the case of differences of opinion, disagreement, or conflict between the professional and the parent(s)/child(ren), research suggests that it is ultimately important for youth professionals to engage in a reflective process supported by tools for reflection (Halloran, 2016; Sisk et al., 2017). With SDM, decisions should reflect both the professional and client view, and the professional should ensure that his/her view is not the primary or most important one, even when their perspectives differ. Reflection is considered essential to create conditions for professional development that ‘truly’ supports SDM (Boland et al., 2017; Elwyn et al., 2015; Munro, 2011; Sisk et al., 2017).

However, in the aforementioned Dutch ‘Shared Decision-Making guideline 2021’ (Bartelink et al., 2021) neither reflection nor the tools or instruments to do so are included. During a project to support youth professionals to go through the different phases of the decision-making process with parents properly, the professionals involved highlighted the need for a reflection tool to support their SDM process. They particularly felt the need for case reflection when they hold different opinions then parents about referral to specialised services. Therefore, in co-creation with youth professionals, parent-representatives, researchers, and social work students, a digital reflection tool was developed and tested. The process of co-creation shares with SDM that it ensures the input of all stakeholders (i.e. professionals, parents) involved in SDM in youth care. It also resonates with the principles of Evidence Based Practice that it is crucial to combine client perspectives, professional experiences, and evidence from research in advancing practice (Bergmark & Lundström, 2010; Drisko & Grady, 2015). Here, we report on the development and the content of this co-created reflection tool. By doing so, we aim to contribute to the knowledge about (the process of) developing a reflection tool by and for youth professionals to support reflecting on SDM in daily practice.

2. Theoretical background

As a starting point, it is important to consider the range of elements relevant for a tool aimed at supporting professionals to reflect on SDM. From a theoretical point of view, SDM relates to decision-making theories (e.g. the decision-making ecology) that emphasise that personal and organisational factors affect the decision-making process and its outcome, alongside characteristics of the case (Baumann et al., 2011, 2014; Dettlaff et al., 2015). This is underpinned by the more general emphasis on systemic approaches in social work, that stress that social workers should be considering both clients and themselves within their environmental contexts (Bastian et al., 2021; Helm & Roesch-Marsh, 2017) and highlights the need to consider factors at multiple levels when reflecting on SDM in youth care.

In this study, therefore, three factors (i.e. case-related, organisational, and personal) serve as a theoretical starting point in the development of the reflection tool. First, for case-related factors, the Framework for the Assessment of Children in Need and their Families (FACNF) is relevant (Department of Health, 2000; Horwath, 2011; Léveillé & Chamberland, 2010). The FACNF consists of three sides or ‘domains’, representing (a) the developmental needs of the child, (b) parenting capacity, and (c) the family’s environmental or contextual factors. For example, the child's developmental needs (a) include the child’s physical and mental health, the quality of (early) attachments, the child’s adaptation to change, response to stress, and degree of self-control. Parenting capacity (b) refers to providing basic needs such as housing, food, and safety, whether parents can offer a stable and affectionate relationship (emotional warmth); stimulate cognitive development and the child’s self-regulation of emotions and behaviour. Finally, family context or environmental factors (c) compromise (wider) family functioning such as (changes in) family/household composition, childhood experiences of parents and significant life events, (the absence of) paid work by family members, economic hardship, and family integration in the neighbourhood and local community.

Second, following the decision ecology, organisational factors are important to take into consideration as part of a reflection tool (Baumann et al., 2014; Hayes et al., 2019). Youth care is practiced in various organisational contexts, often characterised by competing demands, high workloads, a specific team culture, services that are (not) available in the local context et cetera. For youth workers, it may be difficult to balance organisational requirements with the ethics of representing the voice of the child (Van Bijleveld et al., 2013). Therefore, it is important to reflect upon the organisational context and processes in which SDM occurs. For instance, a lack of a supportive (cultural) infrastructure will make the implementation and take up of SDM much more challenging and will hinder the development of an SDM culture, including being critical about and reflecting on one’s own functioning. Conversely, strong leadership and an adaptive organisational culture are important facilitators for SDM (Allaire et al., 2012; Munro et al., 2019; Nykänen et al., 2021). Which organisation factors exactly influence SDM, and how, has received much less theorisation and study (Scholl et al., 2018). As a starting point in this study, we rely on the recent review by Scholl et al. (2018). They describe six main organisational-level characteristics that are likely to influence SDM: organisational leadership (e.g. encouragement for and degree to which leaders in organisation proactively support SDM); culture (autonomy, shared views, and goals); teamwork (communication and coordination); resources (i.e. time, financial, and space); priorities; and workflows.

Third, personal factors of the decision-maker affect shared decision-making and are therefore eligible for reflection. These factors relate to the personal traits of the professional such as the individual's background, education, professional experience, expertise and norms, values, attitudes, and beliefs. The literature also points to the professional’s preference for a particular form of decision-making varying from more ‘technocratic’ (i.e. rational, standardised, using instruments and tools) to more cognitive intuitive processes (Baumann et al., 2011; Gillingham et al., 2017; Saltiel & Lakey, 2020; Whittaker, 2018). With respect to the length of professional experience, ‘early career’ professionals tend to be more risk averse or more cautious (Baumann et al., 2014), make higher risk assessments (Davidson-Arad & Benbenishty, 2010), and show more positive attitudes towards intrusive interventions compared to more experienced professionals. In addition, professionals could view SDM itself as either intrinsically rewarding and positive, or burdensome and impractical, with an accompanying impact on their practice (Elwyn et al., 2015).

To sum, the case-related, organisational, and personal factors as outlined in this section form the multi-layered starting point that assisted in providing a structure for the development of the reflection tool.

3. Materials and methods

The research project on the development of the reflection tool is based on a qualitative research design characterised by co – creation with diverse stakeholders in a three-year study (2016–2019).

A group of 20 youth professionals (generalists youth care providers) from four different local governments were involved. Together with five youth specialists/behavioural scientists, five clients (parent) representatives, four researchers (i.e. two main researchers/social work educators of a local University of Applied Sciences and two researchers of the School of Social and Behavioral Sciences of Tilburg University), and over 10 social work students from the University of Applied Sciences they collaborated in slightly different compositions throughout the stages of the project. The participating youth professionals and youth specialists were recruited from four different local governments (middle-sized municipalities in the South of the Netherlands: Breda, Oosterhout, Roosendaal, and Woensdrecht) by their team managers. Parent representatives were involved through a professional network-organisation of parents with experience with youth care.

Approval for the project was obtained from by the Ethics Review Board of the school of Social and Behavioral Sciences at Tilburg University (EC-2016.16). All participants were informed about the study, including the right to withdraw, and signed a written consent.

3.1. Strategy: developing and testing of the reflection tool

The actual development and testing of the reflection tool contained three stages. The first stage consisted of ten reflective group discussions.(two in Oosterhout, two in Roosendaal, three in Breda, and three in Woensdrecht), with three to six youth professionals from each municipality. One of the main researchers hosted the meetings that each lasted 1.5–2 h. Generally, participants (professionals, parents and students) were familiar with SDM. Yet for the overall understanding of the concept, the main researcher further introduced SDM at the start of each meeting. This also held for the general goal of the meeting: to obtain initial understanding of relevant topics for a reflection tool on SDM for professionals and the theoretic central concepts of case, organisational and personal factors. During each discussion, one or two professionals presented a deidentified case to the rest of the group. The students and parents observed the group discussions. They, together with the researchers, evaluated the process, but were not substantively involved in the group discussions f. Recordings from each group discussion were transcribed verbatim.

In the second stage, two main researchers transformed the reports of the group discussions into a total inventory of factors. They did so using a flexible approach for content analysis of qualitative data, closely related to thematic analysis (Braun & Clarke, 2006; Hayes et al., 2019). This is a deductive method in which already existing (theoretical) constructs of interest are the starting point for identifying, classifying, analysing and reporting the data. Informed by Braun and Clarke (2006), the researchers followed six steps as part of the thematic analysis: familiarising oneself with the data, generating codes, searching for themes, reviewing themes, defining and naming themes, and producing an end report. To verify the validity (consensus about the coding) and the results of this approach, the four researchers discussed the process and results of the analysis in a joint session. During follow-up group discussions with the professionals and parents, the analysis and key findings were presented and it was collaboratively decided to include them as input for the first draft of the tool. Subsequently, together with a developer (agency specialised in the creation of online tools), the researchers built an initial concept for the reflection tool. This tool was then discussed with the professionals and parents, put online on a protected website and presented at a meeting for all project participants in August 2018.

The third, final stage consisted of testing and adjusting the tool in practice. This was done in self-organized meetings of the participating youth professionals with colleagues in their own local work setting and additional group discussions with professionals and parents. Based on real life or fictitious cases (depending on the professional’s preferences), the professionals tested the tool and provided feedback to the researchers on its content, practical usability and its face validity (i.e. does the tool seem to cover all the relevant questions) for reflection on their shared decision-making in these cases.

4. Results

We present the results in accordance with the three phases of the process of developing the tool: 1. Reflective group discussions for initial input; 2. Preliminary design and first testing of the tool 3. Testing and adjusting the tool in practice.

4.1. Reflective group discussions

The ten reflective group discussions to collect initial input for the reflection tool covered a total of eighteen real-life example cases characterised by a difference of opinion about referral to specialised services with parents. A case example is provided below. After the youth professional who introduced the case discussed and reflected on the factors that he/she felt influenced the SDM in that specific case, other participants added more depth on the factors already mentioned, factors they missed, and factors that were relevant in their own more or less similar cases. In addition, they elaborated on the importance of the factors.

In general, the group discussions demonstrated that the professionals were able to express their experiences, knowledge and dilemma’s that came across when going through a shared decision-making process with parents. In short, they talked about the benefits of shared decision-making and spoke about what they felt challenged them in the example cases. They acknowledged that mainly their assessment of parenting capacity and the parents’ willingness to change implicitly influenced their decision-making process. Personal experiences and values concerning standards of care and own expertise to provide support to the family generally mostly hindered the consideration of alternative actions according to the youth professionals.

Textbox

Case example: arguments for and against referral to specialised services

M. is a 14 year old girl; she is in the third year of pre-vocational secondary education. Her parents have been involved in a custody battle for more than a year. Before that, domestic violence occurred regularly, and M. took care of her younger sister.

It was not possible for the professional to talk to the parents together. Although the mother was inclined to agree to a joint consultation, the father did not. He was afraid of losing his temper. The professional did speak to both parents separately, explaining how their behaviour affects the children. The parents understand their influence, but do not seem able to change the situation. They do not feel the desire for further treatment for M.

Dilemma

Referral to specialised care is not necessary. According to the professional, the parents harm the child(ren) by their constant arguing and violence. The parents should together take responsibility for shaping their parenthood and make agreements with each other about raising and caring for the children. The parents should probably follow a parenting support intervention. The professional has regularly spoken to M. and encouraged her as much as possible to make her own choices, to express her displeasure to her parents, and to work on strengthening herself. M. always indicates that she likes to speak to the professional.

Referral to specialised care is necessary. M. is a strong girl, but she is very damaged by the long period of domestic violence and by the lack of communication between and with her parents. She is stuck between them and constantly feels a strong responsibility to take care of her younger sister. Moreover, there are concerns about M.'s weight. The professional is afraid the girl is developing or already has developed an eating disorder.

All the factors mentioned during the group discussion were written down on a flip chart, scored and divided into the three main themes (i.e. case-related, organisational, and personal factors). This resulted in an-overview of 213 factors, including the number of times a factor was mentioned (scores per factor) and the importance attached by the professionals for each factor.

4.2. Preliminary design and first testing of the tool

In phase two, the main researchers categorised the total inventory of the 213 factors from the group discussions. This resulted in a division of 89 case-related factors (32 factors related to the child’s developmental needs, 36 to parenting capacity, 21 to family and context), 29 factors related to the organisational context, and 95 personal factors. As mentioned, concerns about ‘the perceived extent to which parents show insight in the needs of their child(ren)’ and the question, ‘are you convinced that as a youth professional, you can offer sufficient guidance for this family?’ are important case and personal-linked element for reflection according to the youth professionals involved. In practice, this means that if a professional thinks he/she cannot provide sufficient support, he/she should reflect on how this has affected the process of shared decision-making and the difference of opinion with parents.

The researchers further reduced the inventory to 50 factors to 16 overarching themes, after consultation and in accordance with the participants. This was done to summarise the key factors, reduce overlap between the factors and to attain a manageable set of factors for use by professionals. For a complete overview of these themes, see Table 1. Examples include evaluation of self-insight and ‘teachability’ of parents, child functioning, colleagues’ expertise, organisational challenges and the professional’s perception of own competence, expertise, ability, affinity, time and resources. These 16 themes were rephrased and formulated as reflective topics/themes for the first draft of the tool. The 50 underlying factors serve as sub-questions to the specific main overarching themes – that is, narrower questions that do not need to be answered per se but can serve as example or supportive questions related to the overarching theme. Table 1 provides an overview of the 16 overarching themes and some examples of sub-questions for each theme.

Table 1. Case, organisational and personal factors translated into 16 overarching themes/questions for the reflection tool and sub-questions for each theme.

A. Case-related factors

Parenting capacity

1. Evaluation of self-insight and ‘teachability’ of parents in raising their child(ren). To what extent do parents show insight into their situation and parenting skills? Do parents show insight into the needs of their child? Are parents able to formulate questions concerning their own care and support needs?

2. Evaluation of the motivation for and acceptance of support/help by parents. To what extent do parents seek and/or accept help for their child and for themselves? Do they agree on the request for support for their child and/or themselves?

3. Evaluation of parents’ perception of family functioning/problems and hesitancy to act. To what extent do parents experience feelings of competence and self-efficacy in raising their child? Do they have positive perceptions of the parenting process, the child-parent relationship? To what extent do parents show hesitancy/willingness to actively seek help for their child?

Developmental needs of the child

4. Evaluation of child functioning. To what extent does the child experience mild intellectual disability, mental, emotional and/or behavioural difficulties? To what extent does the child show age-appropriate general child development, expression and regulation of emotions, resiliency, social functioning, and peer relationships?

5. Evaluation of child’s voice and preferences for help. To what extent are the child’s opinions and preferences taken into consideration? To what extent is the child asking for and open to help?

Family and contextual factors

6. Evaluation of empowerment at the level of the family. To what extent is the family sufficiently/well empowered (i.e. possesses competencies and resources to control and improve their situation)? To what extent can this family rely on a supportive social network for emotional and practical support? c. What sources of formal and informal help are available from family, friends, neighbours, volunteers, and professionals?

7. Evaluation of the understanding of family life (systems approach to family-level characteristics). To what extent are problems approached from the perspective of the family or system, rather than just the individual child/young person? To what extent does genetic vulnerability for emotional, social, and psychiatric problems in the child and siblings play a role and to what extent do risk factors accumulate for this family? Is there a strong, loving, positive relationship between parents and child?

8. Evaluation of active engagement of school and (mental) health care providers with the family. To what extent is there already active engagement of the school and youth (mental) health care providers? To what extent is school involved for emotional/behavioural problems?

B. Organisational factors

9. Colleagues’ expertise. To what extent can you rely on the expertise of colleagues in your team? To what extent can you fall back on the expertise of behavioural specialists outside your own team/organisation?

10. Organisational challenges. To what extent do you experience high workload/caseload? To what extent do you experience professional autonomy in the local municipality’s youth work setting? To what extent do you experience enough time and resources necessary to spend with families and support for long-term involvement?

11. Collaboration within the care chain/ between services To what extent do you have insight into suitable and available preventive interventions? To what extent are there (un)acceptable waiting lists for specific specialised youth care providers? To what extent is there efficient, effective, and pleasant interdisciplinary and inter-organisational collaboration with relevant parties involved in working with youth and the family? To what extent do you agree on the assessment criteria and diagnosis of relevant parties (e.g. Youth Health Care, specialised professionals, and child protection services)?

C. Personal factors

12. Perceived progress/assessment of opportunities and risks. To what extent do you perceive that prior guidance/interventions lead to improvements? To what extent do you see opportunities for positive development or risks induced by an accumulation/combination of problems? Do you feel you established a close working relationship with the parents/child?

13. Personal beliefs about help. Do you believe that a request for help must come from parents first and that they determine the course and pace of care? Do you always adopt a Systems Approach (i.e. targeting different domains and contexts) irrespective of the specific problem at hand? Do you believe that a thorough, unambiguous, and shared analysis, including exploration of the professional and family network, is necessary to make a good decision? Do you work from the idea that clients are entitled to appropriate help, time, and attention at all times?

14. Perception of own competence, expertise, ability, affinity, time, and resources regarding the child’s and family’s needs. Are you convinced that, as a youth professional, you can offer sufficient guidance for this family? To what extent do you have confidence in your own expertise and experience for this case?

15. Consensus with other professionals involved. To what extent do you share the diagnosis/vision of the other professional(s) involved? To what extent do you experience parent-centred attitudes in yourself and other professionals?

16. Knowledge about the severity of the problems. To what extent do you suspect psychiatric/traumatic problems in (one of) the parent(s)? To what extent do you feel capable to provide culturally sensitive support?

Each substantive levels of content – that is, case-related, organisational, and personal factors – in the tool covers key questions for the professional. Answers to the questions can be scored on a coloured bar varying from sufficient (green), to doubtful (orange) to worrisome (red) – and provides an extra option ‘not enough knowledge to make a judgement’ (yellow). After answering the questions, the tool provides room for a summary of the key findings concerning the particular case. This helps the youth professional to identify potential pitfalls and indicates which important case-, organisational-, and/or professional-level factors to take into account prior to or in the (next) conversations with colleagues and/or clients.

4.3. Testing and adjusting the reflection tool in practice

After presentation at an official kick-off event in August 2018, the first draft of the tool became available on a protected online environment for youth professionals to use alone/independently or together with colleagues for case reflection. The youth professionals worked with the tool and provided feedback based on their experiences. This feedback resulted in only minor adjustments. For instance, it was clarified in the introduction of the tool that not all questions necessarily needed to be answered for the tool to be useful. No adjustments resulted from this round in terms of content.

As a last step, in October and November 2018, the reflection tool became available for all youth professionals in the participating municipalities to test in practice. In addition, in a final consulting round in March 2019, 11 of the initial 20 involved youth professionals and four parent representatives gave mostly individual (face-to-face or via telephone app) feedback. By navigating through the tool and answering the questions, the professionals indicated that the tool supported them in clarifying their SDM process, helped them to increase awareness of their own implicit considerations, and provided valuable insights to justify and accept responsibility for their own role in the SDM process with parents. They also indicated that the tool supported the recognition of blind spots and shortcomings and promoted the incorporation of new insights. In addition, the professionals perceived the results as relevant for conversations with clients (parents, children/youth) and other professionals. Although the professionals were positive and (plan to) use the tool for reflection as an integral part of their work (e.g. in a number of team reflection meetings per year) some (practical) barriers were also mentioned. The length and time investment to work with the tool were such barriers. Some professionals also perceived the tool as particularly suitable for early-career professionals, but not necessarily for more experienced ones.

Some final practical adjustments were made in this stage, such as adding links in the tool to other guidelines (e.g. the guideline on multi-problem families) and the parents’ suggestions on equality between parents and professionals in the formulation of the questions. For example: I as a professional think differently – was changed into: We think differently about … referring to both parents and the professional. Finally, professionals came up with innovative ideas, such as developing an app, making the tool more applicable for cases of conflict between parents and for use with non-Western migrant families. As the end of the project was approaching, these suggestions will be kept in mind for the further development of the tool. Parents shared no substantive comments in this final stage. In May 2020, the tool came online and is accessible since then for youth professionals in general to use after requesting a password (free of charge) via the Bramtool website (https://bramtool.nl/). Between May 2020 and December 2021, a personal password to gain access had been requested 200 times.

5. Discussion

In this study, we described the co-creative process of developing a reflection tool for and by youth professionals that supports them to explore, make explicit, and improve their SDM in cases when they hold a different opinion than parents about referral to specialised youth care services. Starting from the policy and theoretical rationale behind SDM, we collaborated extensively with professionals and parents in the actual development of the tool to ensure that the tool is both scientifically sound and relevant for practice. Youth professionals can either use the tool alone/independently or together with colleagues for case reflection. In addition, they can share the results for discussion with colleagues, youth specialists or in conversation with clients. In youth care, decisions on whether or not to intervene in a case are not always clear-cut, yet can have a significant impact on the lives and well-being of young people. Reflecting on how to make real shared decisions can help youth professionals to handle the complexity of their work.

In the project, we started from the notion that targeting multiple domains is critical for a reflection tool on SDM. Consequently, the tool gives explicit and more or less equal weight to case, organisational, and personal factors. We believe that it is relevant to differentiate between these factors; the Decision Making Ecology model of Baumann et al. (2011, 2014), for instance, highlights that case-related factors have a strong influence on the assessment process, whereas factors at the professional and organisational level have a stronger influence on the decision process and outcome. We suggest that our approach to reflect on SDM – that is, beyond case-related factors – provides a strong substantive base to guide the reflection on SDM in the field of youth care.

In our approach, different stakeholders from practice, i.e. professionals and parents, research and education collaboratively worked on the development of the tool. Persons directly involved in the shared decision-making shared their input and insights, and tested and evaluated the tool. Stakeholders perceived an added value of this way of working together and were highly motivated to take part in the project. Study participants also unanimously perceived an added value of the tool. In their view, it enhanced meaningful case reflection, increased the recognition and incorporation of alternative views in SDM, and improved the interaction and transparency on SDM between professionals and with families. Overall, the tool increased the professionals believe that SDM is ‘the right’ thing to do and provided support to realise SDM in practice. However, the study is based on one modest-sized sample case study in the Netherlands, with its particular policy context. It is important to note that national and local differences in the context of youth care might require adaptations to the tool and its use.

Finally we collaborated with parents in the development of the tool, not directly with children and youth. We did so because the parental perspective on decision-making processes in youth work is mostly missing, while parents do play a crucial role in the contacts with professionals and in young people’s lives (Boland et al., 2019; Bontje et al., 2021). Moreover, despite some promising examples, involving children and youth in social work decision-making is complicated by conflicting opinions and concerns (Van Bijleveld et al., 2013; Rap et al., 2019). As we do emphasise their rights to participate, the next step would be to involve youth directly and to contribute to a more child-centred approach in SDM in youth care (Bastian et al., 2021).

Acknowledgements

We wish to acknowledge Monique Cornelisse MSc as one of the main researcher on the project at Avans University of Applied Sciences.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by The Netherlands Organisation for Health Research and Development (ZonMw) [grant number 737.200.008].

Notes on contributors

Mariëlle Cloin

Mariëlle Cloin, Ph.D., is a sociologist and works as a senior researcher at Tranzo, the scientific centre for care and wellbeing, a department of the Tilburg School of Social and Behavioral Sciences (TSB) of Tilburg University in the Netherlands. Her research focusses on families in vulnerable circumstances, vulnerable pregnant women, preventive services for families and youth and on youth’s and parents’ own capacities and resilience.

Jolanda Mathijssen

Jolanda Mathijssen, Ph.D. studied pedagogical sciences and epidemiology and did research on the relationship of family functioning on changes in problem behaviour in children. Since 2009, she is associated with Tranzo as a research coordinator at the Academic Collaborative Centre Youth. She supervises several PhD students/researchers on various topics related to youth (health) care, and the Dutch transformation of youth care.

Eva Blaauw

Eva Blaauw, MSc is a lecturer in Social Studies at Avans University of Applied Sciences with a specialisation in youth. She is educated and trained as an organisational scientist and social pedagogue and was an advisor at the Dutch Youth Institute. In addition to teaching and developing educational programmes, she has ample experiences with performing action research.