The role of child health nurses in supporting parents of young infants

Article Outline

• Summary
• Introduction
• Methods
  • The questionnaire
  • Ethical considerations
  • Data analysis
• Results
  • Parents views of overall support received from child health nurses
  • What aspects of support predicted parents’ views of overall child health nurse support
• Discussion
  • Practice implications
  • Limitations
• Conclusion
• Acknowledgements
• References
• Copyright

Summary 

Objective

As a part of an action research project to determine a model of service to meet the needs of parents, this non-experimental study explored the role of child health nurses in supporting parents of young infants. It also examined whether changes to the service altered parents’ views of that support.

Methods

Two surveys were conducted at eight month interval during which changes had been implemented in the child health service. The participants, recruited from well child health clinics, comprised 413 parents of infants younger than 12 months of age (206 in the first survey and 207 in the second survey). Data were collected by self-report questionnaires developed for the study, and analysed using descriptive and inferential statistics, factor analysis and linear regression.

Results

The results showed the majority of parents (n=328, 79%) had valued the professional support from child health nurses, but there was no significant difference between the two surveys in the parents’ views of overall support they had received. Although parents reported improvement in accessibility and availability of the services, no improvement had occurred in the aspects of care most important for them. These were to be respected as a parent, have their parenting skills validated and be supported to make their own infant care choices.

Conclusion

Empowering parents to make their own decisions about infant care is imperative for child health nurses in order for them to support parents effectively. The child health nurses need to build the parents’ capacity to make their own decisions through giving relevant information about care options and supporting parents in their decisions.

Keywords: Child health nursing, Parents, Support

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Introduction 

The first few months after the birth of an infant can be very stressful for parents and they often need support (Eronen, Pincombe, & Calabretto, 2007). Child health nurses are in a key position to provide professional support for parents at that time. International research has shown that parents turn to child health nurses for professional information, particularly if they face problems or have concerns about infant feeding or settling (Börjesson et al., 2004, Fägerskiöld and Ek, 2003, Rowe and Barnes, 2006). Parents also expect to receive emotional support from child health nurses (Fägerskiöld & Ek, 2003). Studies have shown parents value when child health nurses show genuine interest in their wellbeing and listen to their concerns, and they feel unsupported if the nurses do not take their concerns seriously (Arborelius and Bremberg, 2003, Fägerskiöld et al., 2003). Parents want to gain a sense of confidence in their parenting ability (Roche et al., 2005) and expect the child health nurses to confirm what they are doing well (Fägerskiöld, Wahlberg, & Ek, 2001). That kind of reassurance has been demonstrated to have a positive relationship with mothers’ confidence in caring for the infant (Warren, 2005). Parents also value assessment of the infant’ growth and development, and confirmation that their child is growing and developing normally (Fägerskiöld and Ek, 2003, Hallberg et al., 2001).

The traditional role of maternal and child health nurses originated from the early 1900s Infant Welfare Clinics in France and England, and was based on a medical model of care and followed rigid rules (Lewis, 1980). The role of child health nursing has since expanded and the focus has changed from the child's growth and development to the psychosocial health of the whole family (Briggs, 2006). There has also been a move away from directly advising parents on aspects of infant care to working in partnership with families to find solutions to their problems (Briggs, 2006).

The nomenclature of registered nurses who care for infants, children and their families in a primary health care settings includes different combinations of child, family and youth health nurse; public health nurse; Plunkett nurse; and health visitor; depending on the country or a state in which the nurses practice. In this paper the term ‘child health nurse’ will be used for all contexts.

This study took place in the Australian Capital Territory (ACT), where child health nursing service, based on primary health care principles is universally available for all parents. All new parents receive an initial phone contact and a home visit from a child health nurse and they are invited to attend child health checks at regular intervals. Parents can also attend the child health clinic at other times if they face problems or need further support. The service needed reviewing because the child health nurses’ time had been taken up by providing childhood immunisations; thus not leaving enough time for other primary health care activities such as supporting parents. A project was set up as an action research to determine a model of child health nursing service that would be responsive to the needs of parents of young infants.

Early in the project we conducted five parent focus groups, at which a total number of 25 first-time parents of infants aged between 6 and 21 weeks participated. The findings, published elsewhere, suggested that parents valued receiving support from the child health nurses. They expected child health nurses to listen to their concerns; provide validation of their parenting skills; give information about infant growth and development; and provide options from which to make their choices of infant care. The focus group parents had faced problems with lack of continuity of care; conflicting advice; long waiting times; accessing a nurse when faced with concerns; and limited knowledge about services (Eronen et al., 2007). Following the focus groups, changes were implemented in the child health nursing practice including increasing the number of parenting groups for first-time parents, reorganising child health nursing teams to improve continuity of care and changing the focus of child health assessments to include more parenting support.

The aim of this non-experimental study was to determine whether there had been any change in parents’ views of child health nurse support in the eight month period, during which the changes had been implemented. We also explored what aspects of care were most important to parents.

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Methods 

Surveys were used to collect data in May 2006 and late January and early February 2007 from two independent samples of parents. The study population consisted of parents who were clients of the child health service and had an infant aged six months or less, or came for the immunisation or child health assessment scheduled for a six-month old infant. In these cases the infants’ ages exceeded six months. All parents who fulfilled the selection criteria and who visited a child health clinic during the specified, two and a half-week recruitment period, were invited to take part in the surveys during their clinic visit.

The samples from both surveys exceeded the required sample size calculations. Using nQueryadvisor 4.0 the calculations indicated that the sample size of 86 ensured 90% statistical power to detect a difference of 0.5 in the group means with significance of p=0.05 on a two-sided t-test, assuming that the standard deviation was 1.00. The larger sample sizes allowed for data analysis of subgroups of the population.

The questionnaire 

A written questionnaire was designed for the study based on the findings from the previously conducted parent focus groups. Some concepts raised by the focus groups were measured by two existing instruments: an instrument of social support provided by public health nurses developed by Tarkka, Paunonen and Laippala (1999) and Fraser's (2000) tool of satisfaction with community child health services.

The tool by Tarkka et al. (1999), based on Kahn's (1979) theory of social support, is an 18-item Likert-type scale, and comprises questions to measure emotional support, decision making support (affirmation) and practical support. These scales had very good internal consistency values in the study by Tarkka et al. (1999) (emotional support: Cronbach α=0.90, affirmation α=0.89 and practical support α=0.74). Fraser's tool is a 10-item Likert-type scale and measures general satisfaction with the service, and the health professional's interpersonal manner, communication, time spent, accessibility and convenience. Internal consistency of the scale in Fraser's study was good (Cronbach α=0.84) (Armstrong et al., 2000, Fraser, 2000). With the permission of the authors the tools were adapted for the current study. Tarkka's tool was first translated from Finnish to English using one-way translation with two independent translators. Further questions were designed for the concepts these two instruments did not measure.

The content validity of the questionnaire was determined by a group of expert child health nurses, who assessed readability and clarity of the questions, and their ability to measure what was intended to be measured. The questionnaire was pilot tested, and stability of the instrument was determined using test–retest method through administering it to a group of 23 parents twice at one week's interval. Intraclass correlation coefficients (ICC) were calculated to compare the responses at the two times. Three items with weak ICC values were removed from the questionnaire. Parents’ responses to an open-ended question in the first survey indicated that parents expected to receive emotional support from the child health nurses. As a result, four questions about emotional support were added to the questionnaire before the second survey. Wording for these questions was informed by the questionnaire developed by Young et al. (1996) for a nation-wide survey of parents in United States of America. The final questionnaire consisted of 62 questions: 13 socio-demographic questions, 11 questions about parent groups, 37 opinion questions about the child health service and child health nurse support, and one open-ended question for additional comments. All opinion questions were in 5-point Likert-style format. Their response options are displayed in Table 1.

Table 1. Response options of the opinion items in the questionnaire.

Ethical considerations 

Ethics approval was obtained from both the university and the local health authority ethics committees. All participants received information explaining the purpose of the study. Pilot study participants completed informed consent forms. Consent to participate in the surveys was assumed by return of the anonymous questionnaires.

Data analysis 

The statistical analysis was performed using the SPSS Graduate Pack 15.0 for Windows (Arbuckle, 2006). The missing cases were excluded pairwise. Socio-demographic information was summarised by using descriptive statistics. The groups were compared for demographic indicators using independent samples t-test for continuous variables and Chi-squared test for categorical variables. Exploratory principal components analysis (PCA) was computed on the data from the first parent survey (206 responses) to reduce the number of variables for further analysis. Suitability of data for factor analysis was assessed by, as Pallant (2005) suggests, considering adequacy of sample size and strength of relationships between variables. The Kaiser–Meyer–Olkin Measure of Sampling Adequacy was 0.883 and Bartlett's Test of Sphericity reached statistical significance (p<0.001). The solution was computed using oblique (direct oblimin) rotation of the factors because correlations between the factors existed.

Simple linear regression and multiple regression analyses were performed on the data from both surveys to determine which factors (predictor variables) were important to parents when considering overall support they received from the child health nurses (outcome variable). Several techniques were used to examine the data for violation of assumptions, as proposed by Tabachnick and Fidell (2007, p. 123).

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Results 

After excluding from the analysis incomplete questionnaires and those completed by parents of infants older than 12 months (ten in the first survey: 5%, and nine in the second survey: 4%), there were 206 participants in the first survey and 207 in the second. The socio-demographic data from both surveys are presented in Table 2. In both surveys the majority of parents were mothers (n₁=195, 95%; n₂=200, 97%), older than 24 years (n₁=190, 92%; n₂=182, 88%), married or living with a partner (n₁=195, 95%; n₂=187, 95%), and employed or on maternity leave (n₁=155, 75%; n₂=142, 69%). High proportion of mothers held university degrees (n₁=110, 53%; n₂=102, 49%). There were no statistically significant differences between the first and the second survey in respondents’ ages; marital status; cultural background; education; weekly income; whether they were first time parents; their relationship with the infant; and the location of their address. However, there was a statistically significant difference in the ages of the infant (p<0.05), as in the second survey the parents had older infants. The mean difference in the infants’ ages of three weeks, however, was unlikely to make a difference to how the parents viewed the support they received from the child health nurses.

Table 2. Participants’ socio-demographic characteristics in both surveys.

Participant characteristics	Category	Survey 1 (N=206)		Survey 2 (N=207)		Sig.
		No.	%	No.	%
Age	Less than 20 years	0	0.0	4	1.9	χ2=5.75, df=3, p=0.33
	20–24 years	16	7.8	21	10.2
	25–29 years	52	25.2	54	26.1
	30–34 years	85	41.3	80	38.6
	35–39 years	48	23.3	41	19.8
	>40 years	5	2.4	7	3.4
Marital status	Married or living with a partner	195	94.7	197	95.2	χ2=0.493, df=3, p=0.92
	Separated, divorced	3	1.4	4	1.9
	Never married	8	3.9	6	2.9
Birth continent	Australia	163	79.1	158	76.3	χ2=3.651, df=6, p=.72
	Other Oceania	5	2.4	7	3.4
	Europe	13	6.3	13	6.3
	Africa incl. Middle East	3	1.5	7	3.4
	Asia	17	8.2	16	7.7
	America	2	1.0	5	2.4
	Not stated	3	1.5	1	0.5
Aboriginal or Torres Strait Islander	Yes	2	1.0	2	1.0	χ2=0.000, df=1, p=0.996
	No	204	99.0	205	99.0
Highest education level achieved	High school (>10)	4	1.9	5	2.4	χ2=9.37, df=5, p=0.095
	Completed year 10	9	4.4	15	7.2
	Completed year 12	25	12.1	43	20.8
	Technical/vocational	58	28.2	42	20.3
	University diploma/degree	74	35.9	71	34.3
	Postgraduate degree	36	17.5	31	15.0
Employment status	Maternity leave	129	62.6	111	53.6	χ2=4.09, df=3, p=0.25
	Employed P/T	15	7.3	19	9.2
	Employed F/T	11	5.3	12	5.8
	Not employed	49	23.8	65	31.4
	Missing System	2	1.0	0
Weekly family income	<US$ 499	14	6.8	15	7.2	χ2=8.86, df=11, p=0.66
	$US$ 00–US$ 999	33	16.0	40	19.3
	A US$ 1000–US$ 1499	56	27.2	55	26.6
	A US$ 1500–US$ 1999	50	24.3	42	20.3
	A US$ >2000	46	22.3	49	23.7
	Missing	7	3.4	6	2.9
Infant age	Continuous	μ=16 wk SD 8.2		μ=19 wk SD 8.3		t=−4.64, df=410, p<0.001*
Respondent's relationship to the infant	Mother	195	94.7	200	96.6	χ2=0.95, df=1, p=0.33
	Father	11	5.3	7	3.4
First-time parent?	First-time	116	56.3	124	59.9	χ2=0.547, df=1, p=0.46
	Subsequent	90	43.7	83	40.1

Parents views of overall support received from child health nurses 

A majority of parents in both surveys reported that they had received either ‘very much’ or ‘quite a lot’ of support (78% of parents, n₁=155 in the first survey; and 84% of parents, n₂=173 second survey) from the child health nurses, as illustrated by Fig. 1. None of the participants reported to have had received ‘no support at all’.

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• Figure 1. 

  Parents’ views of overall support received from child health nurses.

Data from the open-ended question supported these results and added further understanding about the parents’ views of overall child health nurse support. Forty-five parents in the first survey and 93 in the second survey made positive remarks about the child health nursing service, as illustrated by the following examples of parents’ comments:

Overall I have been very satisfied with the services of the child health nurses. As I live away from family any support/advice is greatly appreciated. All members of staff have been friendly and easily approachable—you are not made to feel inadequate as a first time parent when it comes to parenting and the skills required. I generally have been reassured that my child is developing the way she should be. Keep up the wonderful work! (First-time mother, survey 1)

I’ve always been very impressed with the child health nurses. They have always been very professional and very helpful. My children have never required any extra care besides immunisations & routine health checks but I have always felt confident that help was available if needed from the child health nurses (Mother of a subsequent child, survey 2).

The child health service is fantastic. As a new parent for all aspects we wouldn’t have survived those first few weeks without it! (First-time father, survey 2).

However, no significant difference was found in parents views of overall child health nurse support between the scores of the first survey (M=1.95, SD=0.062) and the second survey (M=1.83, SD=0.056; t (404)=1.38, p=0.17).

What aspects of support predicted parents’ views of overall child health nurse support 

We then explored which aspects of support were most important for the parents. The principal components analysis revealed seven components with eigenvalues exceeding 1; explaining 61.8% of the variance. For clarity the term ‘factor’ will be used in the following discussion instead of ‘component’. Four factors were retained for further analysis following examination of the scree plot and using Parallel Analysis technique. Oblimin factor rotation revealed an interpretable structure with factors showing several strong loadings. The four-factor solution explained 49.8% of the variance. Examination of the Structure Matrix revealed that three variables loaded highly on two factors. These were ‘good explanations of baby care’, ‘created sense of security’ and ‘satisfied with all aspects of care’. Therefore these three variables were removed and oblimin rotation was repeated to derive a new factor solution. The new four-factor solution explained 49.4% of the variance. The pattern matrix for factor loadings is displayed in Table 3. Only items with loadings greater than 0.5 were included in the interpretation.

Table 3. Pattern matrix for factor loadings from oblimin rotation of four factor solution for CHN support items.

The first factor was labelled ‘respect and empowerment’ and explained 29.5% of the variance. It contained 9 items that related to the child health nurses showing respect to the parents and their parenting ability, as well as supporting parents to make their own decisions through providing information about the care of their infant. The second factor included 4 items about parents’ satisfaction with the timing of services and their knowledge about services available for parents with a young infant. It was labelled ‘timing and accessibility’ and explained 7.4% of the variance. The third factor, named ‘information about child development’, included 3 items about discussing information and promoting child development. It accounted for 6.6% of the variance. The fourth factor, titled ‘availability’, included 4 items about availability of assistance, and nurses having enough time to give to the parents. It explained 5.9% of the variance. The totals for all items in the factors were calculated to form the scores of the new factor variables.

Simple linear regression analyses revealed that 21% of variation in the overall child health nurse support could be explained by ‘respect and empowerment’, 13% by ‘information about child development’, 12% by ‘timeliness and accessibility’ and 10% by ‘availability’ (see Table 4). Further simple linear regressions were performed on the four items that were added into the second survey as they were not included in the factor analysis (see Table 4). These were ‘nurses asked about parents’ feelings’ (14% of the variance in parents’ opinion of overall child health nurse support), ‘nurses discussed meeting parents’ own needs’ (14%), ‘nurses talked about stressful events’ (8%) and ‘nurses asked about emotional support’ (10%).

Table 4. Results from simple regression analyses.

Standard multiple regression analyses were computed to determine which of the factor variables best predicted parents’ opinion of overall support provided by the child health nurses. These were calculated first without the emotional aspects of care and then with them. The multiple regression model without the emotional aspects of care explained 28.1% of the variance (see Table 5). The model (F ratio) was statistically significant (p<0.05). All factors made a statistically significant independent contribution to the variance in the overall child health nurse support (p<0.05). ‘Respect and empowerment’ made the largest unique contribution to the variance. Addition of emotional aspects of support did not add to the explanation and therefore the results are not included in this report.

Table 5. Regression of parents’ views of overall CHN support onto the factor variables.

Summary statistics. Multiple R=0.530, R²=0.281, Adjusted R²=0.273, Standard error=0.718. F=35.676, p<0.001. ^*p<0.05.

Subsequently, independent-samples t-test was performed to determine the degree of change in the factor variables from survey 1 to survey 2. As Table 6 illustrates, there was statistically significant although small difference in the ‘timeliness and accessibility’ and ‘availability’ between the first survey and the second survey. There was no statistically significant difference in the ‘respect and empowerment’ and ‘information about child development’ between the two surveys.

Table 6. Comparison of the mean scores of the factor variables in surveys 1 and 2.

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Discussion 

The majority of respondents in this study were well educated mothers either married or living with a partner, which may be indicative of clients who access the universal child health service in the ACT. Although the service is inclusive of fathers and its focus is the whole family, it is still predominantly mothers who visit the clinics with their children. Compared to ACT perinatal statistics (Population Health Research Centre, 2007), the sample was representative of ACT birthing population in marital status, mother's birth continent and in maternal age except for the below 20 age group. The high educational status of the respondents could be partly due to the high school retention rates in the ACT. Eighty-nine percent of students stayed at school to Year 12 in 2006 according to Australian Bureau of Statistics (2007). It may also indicate that families with lower educational background were less likely to respond to written surveys or are less likely to visit child health clinics. These aspects could be further explored in future studies.

This study confirmed that parents valued the support they received from child health nurses, which is similar to findings from other studies (Bowns et al., 2000, Orima Research, 2003). Most mothers in surveys by Bowns et al. (2000) in the UK and Orima Research (2003) in Victoria, Australia were satisfied or very satisfied with the support they received from the child health nurses. Child health nurse support is viewed especially important, when other support is not readily available (Worth & Hogg, 2002).

However, no significant change had occurred during the eight month period in the parents’ views of overall child health nurse support in spite of the changes implemented in the aspects of the service as identified by the earlier conducted focus groups. The slowness of the change process may partly provide an explanation for lack of improvement. Although several changes were implemented at this time, the interval between the two surveys may not have been long enough for some changes to have taken full effect. Some aspects of the change were also slow in gaining acceptance due to inadequate educational and organisational support during the change process. More focus should have been placed on continuing educational support (Rock & Schwartz, 2006) and on providing an organisational climate that supports change (Kilbride, Meyer, Flatley, & Perry, 2005).

Another explanation could be provided by the fact that the areas of care in which statistically significant change had been achieved – availability and accessibility of services – were not rated as important by the parents as respect and empowerment, an area were no improvement was demonstrated. The results from the regression analyses showed that when parents felt that the child health nurses respected them and their parenting ability and empowered them to make decisions about the care of their infant, they reported having received more overall support from the nurses. Parents need reassurance and support from the child health nurses while lacking confidence in parenting (Roche et al., 2005, Tucci et al., 2004) but they do not like to receive unsolicited advice (Fägerskiöld & Ek, 2003) or to be pressured to adopt the nurses’ ways of caring for the infant (Arborelius & Bremberg, 2003). Some of the responses to the question in the first survey on what parents expected from the clinic also reflected parents’ wish for nurses to support their decisions rather than give expert advice.

Support my decisions without judgment (Mother of a subsequent child, survey 1)

Encouragement/support for breastfeeding, but acceptance of decision to bottle feed if applicable; constructive advice but only if necessary (i.e. not acting like ‘the expert’ if not necessary for baby's well-being) (First-time mother, survey 1).

Child health nurses can encourage a sense of independence and inspire self-belief in parents by showing confidence in their ability to parent (Leap, 2000). A study using grounded theory by Hauck and Irurita (2003) demonstrated that it is important for mothers’ self-concept and self-esteem that they do well in their parenting role. Comments by health professionals had a significant impact on how mothers viewed their success in the role. Their study revealed that mothers expected health professionals to support them in their decisions, but instead sometimes they had received information that was based on the health professional's values and expectations (Hauck & Irurita, 2003). Women also felt unsupported when health professionals were directive and undermined their decisions (Hall & Hauck, 2007).

In order to empower parents to make decisions about the care of their child, child health nurses need to provide parents with adequate information and respect their wishes (Hallström, Runeson, & Elander, 2002). Thus nurses control the degree of parent participation in care through controlling the information they give and the support they provide to the parents in the decision-making process (Corlett & Twycross, 2006). Child health nurses also need to understand how to assist parents in decision-making when it seems the parents are not able to make their own decisions because of fatigue or some other reason. They need to build the parents’ ability to make decisions, as revealed by a narrative inquiry in Brisbane, Australia by Rowe and Barnes (2006) into the child health nurses’ role to support mothers. To feel supported parents need to be given options from which they choose how to care for their infant. Thus, the expertise in child health nursing would encompass not only expert knowledge in the field but also expert skills to be a ‘facilitator to promote parent expertise, wisdom and confidence’ (Rowe & Barnes, 2008, p.124). To do that effectively, the nurses have to become non-judgemental and have an attitude of respect. They also have to value parents’ expertise and work from their perceived needs rather than the nurses’ agenda (Bidmead & Cowley, 2005).

Practice implications 

This research has confirmed that many parents need and value professional support from child health nurses during the early months of parenting a new infant. Therefore child health nurses should feel proud of their work and the potential to impact on a person's life-long health and wellbeing through supporting parents.

Yet, this study has highlighted areas where child health nurses can improve in providing support for the families. The child health nurses need to reflect more as individual practitioners and collectively on whether they are meeting the needs of the families they support. Instead of giving expert advice on infant care, it is more helpful to provide information, resources and support for parents to make their own decisions. The child health nurses need to enable parents to make their own choices from various infant care options. This type of information-giving should reduce the likelihood of parents’ reports of receiving conflicting advice.

It is important that postgraduate nursing programs not only provide specialised knowledge in the child health field, but also prepare nurses for the client-centred empowering approach of care. This requires reinforcing the need to reflect on one's own practice, and providing skills and tools to help child health nurses to be more reflective of whether they are meeting the needs of the families. In addition, the preparation of child health nurses should provide facilitation skills that help them to explore choices and assist parents in decision-making. Ongoing professional development programs should also provide opportunities for current child health nurses to have peer reviews and clinical case discussions as strategies to facilitate reflection on child health nursing practice and learning from each other.

Limitations 

This study measured overall change in the parents’ opinion of the support they had received from the child health nurses. The relatively short time between the two surveys may have provided insufficient time to implement changes in the service to produce detectable change in parents’ views of the support they had received. The sample did not include many younger age-group parents or fathers; therefore the results may not fully reflect their views about the child health nurse support. Neither may the result represent the views of those parents who do not attend a child health clinic and those who do not have adequate English language skills to complete written questionnaires.

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Conclusion 

The child health nurse role has expanded since it first began in the early 1900s. Its focus has changed from the child and the child's physical health to the whole family and wider psychosocial aspects of health. The role has become a lot more complex requiring nurses to work in partnership with parents rather than giving directive advice. While parents value the support they receive from child health nurses, empowering parents to make their own decisions about infant care is imperative for child health nurses in order to support parents effectively. The empowerment of parents requires that child health nurses respect the parents and trust their capacity to make their own decisions.

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Acknowledgements 

We would like to thank Professor Adrian Esterman, Biostatistician at the School of Nursing and Midwifery, UniSA, for his assistance with statistical procedures. We also would like to thank all parents and nurses who took part in the study. The study was supported by a research grant from ACT Nursing and Midwifery Board.

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