Parentcraft Skills

The findings from the three studies indicated a general agreement that improving parenting capacity and self-efficacy is core business for CFH nursing and that, in line with CFH nursing professional guidelines (NSW Department of Health, 2011b), monitoring of infants’ growth and assessment of developmental milestones are key nursing functions. As expected, the three groups explored the nurses’ parentcraft competence from very different perspectives.

7.1.2.1 Expert panel

The participants in Study 1 referred to competencies in infants’ sleep and settling, feeding, crying, motor development and toddlers’ behaviour as CFH professional knowledge. They also identified as essential knowledge an understanding of the psychodynamics of family relationships, especially during the transition to parenthood, complemented by advanced communication skills to guide the family through those life changes.

7.1.2.2 Mothers

The mothers in Study 2 mainly focused on assessment and monitoring of their infant’s growth and development as the main role of CFH nurses. Most of them regularly attended the clinic where nurses wrote in the Blue Book, a child personal health record issued to all new mothers in NSW following the birth of their baby (NSW Kids and Families, 2013). The purpose of the Blue Book is to ensure that parents have an up-to-date record of their child’s progress, providing accurate information to various health professionals caring for the child throughout the preschool years. Most mothers commented on the importance of the information contained in the Blue Book and they trusted nurses to keep reliable data about their children:

The nurse completes it each time we go to the clinic. She ticks all the boxes (M7).

I went there just for the weekly and monthly check up, just to make sure baby was developing well, sleeping well, growing, he was thriving and later on to check that he was growing appropriately (M4).

Although first-time mothers regularly visited their local health clinic, their narratives indicated a sense of disconnection between the personal health record and the opportunity to discuss the information with the nurse or seek advice about related parenting issues. This finding was surprising but may have resulted from the study design, in which mothers were able to choose the particular experiences of nursing care that they wanted to talk about. Moreover, a number of mothers who believed that CFH

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nurses had the knowledge to support them with their parenting skills suggested that the nurses may not always have had the opportunity to help because of the structure of local health services. One mother, for instance, commented: “I get the feeling that they were doing the best that they could under the circumstances that they work under”. This issue, which is also raised in the literature (Kruske et al., 2006), is discussed in more detail in the next section.

The mothers reported that interactions with health professionals were more positive when the interventions took place at home. The practice of using routine baby checks strategically to engage with mothers and address parenting issues is well documented in the nursing literature (Browne et al., 2010; Marshall et al., 2012; Myors et al., 2014; Shepherd, 2011). One example of opportunistic teaching was reported by a mother of four children under the age of six. She was struggling with feeding distressed twins. The nurse, after seeking her permission, joined in the tasks of feeding, playing with and soothing the infants to sleep while they discussed the activities taking place. Some mothers had been referred to early intervention programs run by NGOs when antenatal psychosocial screening identified them as ‘vulnerable’. Although they received and appreciated intensive parenting support over an extended period of time (up to two years), it is important to point out that the home visitors were mostly volunteers and family workers. One mother described how the workers taught her to “bath, feed, put the babies to bed, how to handle them and hold them”. This clearly indicates that, while parents welcomed support and guidance with parenting, they did not necessarily expect nurses to be involved. Some of the mothers who did not access early intervention programs sought alternate sources of guidance, mainly from family members, neighbours and best friends who were parents themselves. Nevertheless, most of them conscientiously continued to attend the clinic for routine baby checks recorded in the Blue Book. This finding suggests that, although mothers’ attention is focused on the Blue Book, CFH nurses have the opportunity to build rapport and engage in important prevention and early intervention activities.

7.1.2.3 Nurses

The nurses in Study 3 identified a surveillance role, based on advanced observation skills, sound judgement and a robust knowledge of child developmental milestones, as a key element of their core practice. They reflected on their day-to-day work to illustrate how engagement with mothers allowed for transfer of essential information. They gave examples of how they used routine interactions with mothers about ‘baby stuff’ to develop trusting, respectful relationships. According to the nurses, this initial engagement encouraged mothers to ask questions, express doubts and seek reassurance about their parenting practices. One nurse, talking about her engagement with a depressed mother, described how she purposefully focused on an interactive dialogue to enhance the mother’s self-esteem and reduce her self-doubt:

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I don’t tell her it is better to do it that way I say: can you see the tired signs? What do you think baby is telling you? If you think he is ready to go to sleep then I can help you putting him down (N7).

One nurse, who was first employed in an early intervention team as a novice, spoke about her first experiences of telling mothers how to care for their baby. She described how years of experience combined with ongoing supervision and reflection transformed her task-oriented practice into a model of interaction in which she encouraged mothers to explore their parenting skills through the use of visual feedback. This approach, known as Steps Towards Effective Enjoyable Parenting (STEEP) (Erickson & Kurz-Riemer, 1999), has long been promoted as a means of assisting the development of child-carer attachment. It involves filming daily interactions between the mother and the child, usually in a home situation, followed by a mother-led discussion about the interaction. While STEEP is mostly used by infant mental health therapists, this particular CFH nurse was able to use it creatively to enhance parentcraft knowledge of mothers in a sensitive, respectful and inclusive way. The importance of nurses’ creativity in developing opportunistic interventions involving mothers’

participation and allowing for experimentation is well documented in the nursing literature ; (Moules et al., 2010; Shepherd, 2011). In its report on the future of nursing, the US Institute of Medicine (IOM, 2011) supports these findings, defining core nursing competencies as

Not task based proficiencies but higher level competencies that represent the ability to demonstrate mastery over care-management knowledge domains (p. 200).

Study 3’s findings provide evidence not only of the commitment of CFH nurses to parentcraft knowledge and skills as core elements of their practice, but also of their ability to integrate those elements within a broader, holistic approach to family care that was not reflected in the mothers’ experiences in Study 2. Nurses in Study 3 were convinced that the relational quality of their work with parents, combined with home-based interventions, allowed for engagement to be established and trusting relationships to be formed in order to support the enhancement of parenting capacity. For example:

You need an understanding of where people are at; you need to hear their stories, their pain, their background, and the transgenerational issues that have brought them where they are today. If you understand what they have been through….you develop rapport. Then you can move together forward…You are honest with parents, not judgemental, working on the issues that are important for them not for us as clinicians (N2).

It is about one step at a time and you learn to be paced by the family and gently raise the bar… and I think that you cannot do that if you don’t have a trusting, almost non- professional nurturing relationship (N3).

Those findings are consistent with those from other studies that explored CFH nurses’ practice (Fraser et al., 2014; Munns, Wynaden, Downie, & Hubble, 2003).

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