Health visitors’ assessments of parent–child relationships: A focus group study

Increasing the psychosocial focus in child developmental assessments: a qualitative study

BACKGROUND

Previous studies have indicated a need for increased psychosocial focus on children and their families to improve children's wellbeing and mental health. Child developmental assessments could be a place to implement changes to achieve this. A standardised record might be helpful to clinicians trying to increase psychosocial focus. The aim of this study is to investigate clinical barriers and facilitators when introducing standardised child records with increased focus on psychosocial wellbeing and mental health into child developmental assessments.

METHODS

This is a qualitative study based on 12 semi-structured interviews with four midwives and nine doctors who carry out child developmental assessments in general practice. Data is analysed in the framework of Normalisation Process Theory.

RESULTS

General practice-based clinicians were positive towards increasing the psychosocial focus in child developmental assessments. The main barriers when clinicians used the standardised child records were: feeling forced to ask certain questions, in turn making the conversation rigid; leaving less room for parents to bring up other issues; making clinicians feel awkward when addressing problems that they cannot solve; the need for extended consultation time; and medico-legal concerns when registering findings. The experience of positive aspects when using the standardised child records facilitated continuous use of the records. Positive aspects included having a standardised approach to recording important findings, thereby uncovering psychosocial problems that could potentially be overlooked. Additionally, structured observation of parent-child interaction and gaining a new vocabulary to describe the findings were valued by clinicians. Balancing a standardised approach with clinicians' ability to steer the consultation and explore topics in depth while preserving the potential for patients to bring up other issues became an important theme.

CONCLUSION

Clinicians need to be well-equipped to handle psychosocial problems through coping strategies, referral options and communication techniques in the psychosocial domain. The parent-child-interaction assessment might expose potentially dysfunctional parenting behaviours and could improve communication between health professionals. Implementing standardised child development records with an increased psychosocial focus is feasible but improvements could optimise the use of the records. Parental views on an increased psychosocial focus during child developmental assessments should be investigated prior to further implementation.

TRIAL REGISTRATION

Trial registry number for the FamilieTrivsel (Family Wellbeing) trial: NCT04129359.

Parent-infant observation for prediction of later childhood psychopathology in community-based samples: A systematic review

BACKGROUND

Difficulties in parent-child interaction are easily observed and are a potential target for early intervention. This review aimed to assess the utility of current observational methods used to assess parent-child interactions-within the first year of life-and their ability to screen and identify children from low-risk samples most at risk of developing childhood psychopathology.

METHODS

Six bibliographic databases were searched, and reference lists screened. All peer reviewed papers studying the association between an independent observation of parent-child interaction and later childhood psychopathology in community-based samples were included. Included studies were those recruiting from population or community-based birth cohort data, which we define as 'low-risk'. Studies based on populations known to have a diagnosis of psychiatric illness or developmental disorder, or at high genetic or environmental risk of being diagnosed with such disorder, were excluded. Results were synthesised qualitatively due to high heterogeneity.

RESULTS

20,051 papers were identified, nine were included in this study. Childhood psychopathology was associated with fewer positive parent-infant interactions, lower parent vocalisation frequency and lower levels of adult speech and activity. Maternal sensitivity was inversely related to separation anxiety and oppositional defiant/conduct disorders were associated with lower shared look rates. Disruptive behaviour disorders were associated with higher frequency of child vocalisation.

CONCLUSION

Assessment of parent-child interactions, particularly the level of maternal activity, may be an early indicator of later childhood psychopathology in low-risk samples. Further longitudinal, population-based studies are required.

TRIAL REGISTRATION

PROSPERO review registration: CRD42020162917 https://www.google.com/search?client=firefox-b-d&q=CRD42020162917.

Assessing and promoting responsive interaction between parents and children - A qualitative study of the experiences of child health care nurses in Sweden

PURPOSE

One of the main tasks of a child health care nurse is to assess and promote a responsive interaction and secure connection between children and their parents for the future. This study aims to develop an understanding of Swedish child health care nurses´ experiences of assessing and promoting responsive interaction between parents and children.

DESIGN AND METHOD

A qualitative interview study using an inductive approach was implemented. Eleven nurses were interviewed (range: 30-58 min) during the period March to August 2016, and the transcripts were analysed using qualitative content analysis according to Graneheim and Lundman.

RESULTS

Three categories emerged: Interpreting signals in parent and child behaviour, Reinforcing the parents in their role and Feeling inadequate as professional. Interpreting signals in parent and child behaviour was described fundamental when promoting responsive interaction. Further reinforcing the parents in their role was described central. The child health care nurses also described how they often felt inadequate in promoting responsive interaction.

CONCLUSIONS

Assessing and promoting responsive interaction is an important but challenging task which requires extensive knowledge and good communication skills. The child health care nurses express their insufficiency in that regard.

PRACTICE IMPLICATIONS

A targeted education and sufficient time for each visit at the child health care center should be allocated to facilitate the important work on parenting and child interaction and to enhance nurses' feelings of managing their work.

Promoting children’s health when a parent has a mental health problem: a mixed methods study of the experiences and views of health visitors and their co-workers

Background

Unrecognised and untreated parental mental illness is a major adverse childhood experience with potentially life-long consequences for health and wellbeing. In the United Kingdom (UK) health visitors provide a universal health promotion service to children aged 0–5 years, which includes safeguarding. This preventive work is highly relevant to policy aims of improving outcomes for children living with adverse childhood experiences, but is currently under researched. The aim of this study was to explore how health visitors promote young children’s wellbeing when a parent has a mental health problem, and to co-produce strategies to improve child health outcomes.

Methods

A mixed methods study was conducted, consisting of a cross-sectional survey and consensus workshops in Wales, UK. In phase 1 health visitors (n = 174) responded to an online questionnaire designed to explore the nature and scope of their preventive work with families experiencing mental ill health. For phase 2 providers of health and other support services (n = 38) took part in Nominal Group Technique workshops to co-produce strategies for better joint working to protect the wellbeing of children living with parental ill health.

Results

We identified that health visitors routinely provide support to families where parents have a range of mental health problems, including severe mental illness. Most practice is focused on mothers with depression, and fewer respondents were confident about working with fathers. Unmet training needs were identified in relation to adult mental illness, particularly the impact upon children. Solutions to working more effectively with professional and voluntary agencies included raising awareness of professional roles and responsibilities, timely two-way communication, taking a strengths-based approach and maintaining a focus on the child.

Conclusions

This study provided evidence on the range of parental mental ill health encountered by health visitors and the strategies they use to protect children’s wellbeing. Increasing the effectiveness of joint working is key to improving outcomes for babies and young children, including greater use of voluntary sector services. This study has implications for those who commission and provide health and welfare services for children, and adult mental health services.

Exploring health visiting professionals' evaluations of early parent-infant interactions

Objective: To examine the accuracy of Health Visitors (HVs) evaluations of the quality of parent-infant interactions. Background: HVs have been identified as key professionals in the early identification of difficulties in parent-infant interactions. Method: A sample of 56 HVs, 4 Family Health Nurses (FHNs) and 14 Community Nursery Nurses (CNNs) recruited from two National Health Service (NHS) Trusts, viewed video footage of six early parent-infant interactions which had been categorised as 'sensitive', 'mixed', and 'problematic' using the CARE-Index. Participants evaluated the quality of the parent-infant interactions shown in these videos using the Parent-Infant Interaction Rating Questionnaire (PIIRQ). Results: On average, participants correctly rated the problematic videos as lowest in quality, the mixed as higher in quality than the problematic videos, and the sensitive videos as highest in quality. Interestingly, within the problematic category participants rated the 'unresponsive' pattern of interaction as significantly lower in quality than the 'controlling' interaction. Conclusions: Findings suggest participants were relatively accurate in their evaluations of parent-infant interactions. However, they indicate that participants were more likely to be concerned about unresponsive, as opposed to controlling, interactive behaviours. Recommendations for further research include exploration of potential differences in how health-visiting professionals evaluate particular patterns of parent-infant interactions.

An exploratory study investigating perceptions, opinions and experiences of safeguarding education in pre-registration children's nursing curricula

AIM

To explore perceptions, opinions and experiences of safeguarding education within pre-registration children's nursing curricula.

METHODS

Using a qualitative research method, an online questionnaire was developed and disseminated to pre-registration children's nursing students to complete via a weblink added to their programme's virtual learning environment.

FINDINGS

This study highlighted the need to integrate other pedagogies in safeguarding education. These include implementing more practical-based workshops such as completing safeguarding referrals to social care and undertaking case vignettes from a multi-professional perspective.

CONCLUSION

The recommendations from this study for future safeguarding education in pre-registration children's nursing curricula include incorporating a hybrid experiential learning approach, through problem-solving and simulation-based learning, to bridge the theory-to-practice divide and ensure practitioners are fit for practice.

Integrative review: nurses' roles and experiences in keeping children safe

AIM

To identify nurses' role and experiences of keeping children safe.

BACKGROUND

Approaches to preventing, identifying and responding to child abuse and neglect have moved towards a multidisciplinary approach where all professionals are expected to contribute to the goal of keeping children safe. Frequently in contact with children and families, nurses well positioned to contribute to keeping children safe from abuse and neglect. Much has been published around nurses' experiences of their role in keeping children safe, but this literature has not yet been synthesized to determine the challenges and potential scope of this role.

DESIGN

Integrative review following an Integrative Review framework.

DATA SOURCES

Studies were identified through a search of the electronic databases CINAHL, Medline, Web of Science, Scopus and Informit to identify literature published between 2005-2015.

REVIEW METHODS

All the studies were critically appraised for methodological quality using the Critical Skills Appraisal Programme. Data from each study were extracted and categorized according to the review aims and the study's major findings.

RESULTS

Inclusion criteria were met in 60 studies. Three main findings were identified including nurses' insufficient knowledge, need for validation and improved communication and balancing surveillance and support for vulnerable families.

CONCLUSIONS

Nurses have many roles and experiences in keeping children safe but often felt they did not have the knowledge, skills and support to take action in this area. Further research is needed to understand why nurses feel inadequate and disempowered to advocate and intervene on the behalf of children at risk of abuse or neglect.

Health visitor education for today's Britain: Messages from a narrative review of the health visitor literature

OBJECTIVES

This paper draws on a narrative review of the literature, commissioned to support the Health Visitor Implementation Plan, and aimed at identifying messages about the knowledge, skills, and abilities needed by health visitors to work within the current system of health care provision.

DESIGN

The scoping study and narrative review used three complementary approaches: a broad search, a structured search, and a seminal paper search to identify empirical papers from the health visitor literature for review. The key inclusion criteria were messages of relevance for practice.

DATA SOURCES

378 papers were reviewed. These included empirical papers from the United Kingdom (UK) from 2004 to February 2012, older research identified in the seminal paper search and international literature from 2000 to January 2016.

REVIEW METHODS

The review papers were read by members of the multidisciplinary research team which included health visitor academics, social scientists, and a clinical psychologist managed the international literature. Thematic content analysis was used to identify main messages. These were tabulated and shared between researchers in order to compare emergent findings and to confirm dominant themes.

RESULTS

The analysis identified an 'orientation to practice' based on salutogenesis (health creation), human valuing (person-centred care), and viewing the person in situation (human ecology) as the aspirational core of health visitors' work. This was realised through home visiting, needs assessment, and relationship formation at different levels of service provision. A wide range of knowledge, skills, and abilities were required, including knowledge of health as a process and skills in engagement, building trust, and making professional judgments. These are currently difficult to impart within a 45week health visitor programme and are facilitated through ad hoc post-registration education and training. The international literature reported both similarities and differences between the working practices of health visitors in the UK and public health nurses worldwide. Challenges related to the education of each were identified.

CONCLUSIONS

The breadth and scope of knowledge, skills, and abilities required by health visitors make a review of current educational provision desirable. Three potential models for health visitor education are described.

Why health visiting? Examining the potential public health benefits from health visiting practice within a universal service: a narrative review of the literature

INTRODUCTION

There is increasing international interest in universal, health promoting services for pregnancy and the first three years of life and the concept of proportionate universalism. Drawing on a narrative review of literature, this paper explores mechanisms by which such services might contribute to health improvement and reducing health inequalities.

OBJECTIVES

Through a narrative review of empirical literature, to identify: (1) What are the key components of health visiting practice? (2) How are they reflected in implementing the universal service/provision envisaged in the English Health Visitor Implementation Plan (HVIP)?

DESIGN

The paper draws upon a scoping study and narrative review.

REVIEW METHODS

We used three complementary approaches to search the widely dispersed literature: (1) broad, general search, (2) structured search, using topic-specific search terms, (3) seminal paper search. Our key inclusion criterion was information about health visiting practice. We included empirical papers from United Kingdom (UK) from 2004 to February 2012 and older seminal papers identified in search (3), identifying a total of 348 papers for inclusion. A thematic content analysis compared the older (up to 2003) with more recent research (2004 onwards).

RESULTS

The analysis revealed health visiting practice as potentially characterized by a particular 'orientation to practice.' This embodied the values, skills and attitudes needed to deliver universal health visiting services through salutogenesis (health creation), person-centredness (human valuing) and viewing the person in situation (human ecology). Research about health visiting actions focuses on home visiting, needs assessment and parent-health visitor relationships. The detailed description of health visitors' skills, attitudes, values, and their application in practice, provides an explanation of how universal provision can potentially help to promote health and shift the social gradient of health inequalities.

CONCLUSIONS

Identification of needs across an undifferentiated, universal caseload, combined with an outreach style that enhances uptake of needed services and appropriate health or parenting information, creates opportunities for parents who may otherwise have remained unaware of, or unwilling to engage with such provision. There is a lack of evaluative research about health visiting practice, service organization or universal health visiting as potential mechanisms for promoting health and reducing health inequalities. This paper offers a potential foundation for such research in future.

Patterns of primary care service use by families with young children

BACKGROUND

In the UK, early years policy emphasizes that all families should have access to support tailored to their individual needs. Knowledge of the determinants of health service use should help to inform rational and equitable planning and delivery of services to parents.

OBJECTIVES

We seek to investigate the determinants of primary care service use in families with preschool children.

METHODS

Determinants of service use in two population cohorts (families with children aged 0-1 and 2-3 years) from the Growing Up in Scotland study are presented. Services related to use of the family doctor or health visitor for information on the child's health or behaviour in the last year.

RESULTS

A range of socio-demographic determinants were significant predictors of service use on multivariate analysis. Determinants of service use differed between the health visitor and family doctor.

CONCLUSIONS

The analysis provides an insight into the determinants and patterns of health service use by families with young children at two stages of development. While some of our findings are expected or supported by previous research, others highlight areas that require further investigation.

Negotiating policy in practice: child and family health nurses' approach to the process of postnatal psychosocial assessment

Background

There is growing recognition internationally of the need to identify women with risk factors for poor perinatal mental health in pregnancy and following birth. In the state of New South Wales, Australia the Supporting Families Early policy provides a framework of assessment and support for women and families and includes routine psychosocial assessment and depression screening. This study investigated the approach taken by Child and Family Health Nurses (CFHNs) following birth to assessment and screening as recommended by state policy. This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Methods

This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Results

CFHNs demonstrated a range of approaches to assessment and screening. Psychosocial assessment was conducted in 50% (10 out of the 20) of the interactions observed; however, all the women were screened using the Edinburgh Depression Scale. Four major themes that represent the approach taken to the assessment process were identified: ‘Engagement: getting that first bit right’, ‘Doing some paperwork’, ‘Creating comfort’ and ‘Psychosocial assessment: doing it another way’. Nurses utilised other skills such as observing the women interacting with their baby, taking note of non verbal communication and using intuition to develop a clinical decision.

Conclusion

Overall, nurses’ took a sensitive and caring approach to assessment and screening, however, there were differences in interpretations of the policy recommendations across the two sites. Nurses adopt a flexible, relationship-based approach to the assessment process; however, they experience tension when required to incorporate structured psychosocial assessment processes. To undertake assessment and screening effectively, CFHNs require ongoing support, training and supervision to maintain this sensitive and emotionally challenging work.

Can psychopathology at age 7 be predicted from clinical observation at one year? Evidence from the ALSPAC cohort

One of the challenges of developmental psychopathology is to determine whether identifiable pathways to developmental disorders exist in the first months or years of life. Early identification of such disorders poses a similar challenge for clinical services. Using data from a large contemporary birth cohort, we examined whether psychopathology at age seven can be predicted from clinician observation at one year. Two groups of clinical raters observed videos of caregiver-infant interaction. Neither group of raters could reliably identify any precursors of later development of psychopathology in the one-year-old infants in this setting.

Matching parenting support needs to service provision in a universal 13-month child health surveillance visit

BACKGROUND

The Glasgow Parenting Support Framework is an intervention to support families with preschool children. It provides structured support through universal and targeted interventions. Two routine family visits by health visitors have been piloted, one involving a home assessment when the child is 13 months old.

AIMS

To establish the need for parenting support in the population at 13 months and whether or not the home assessment improved the match of service provision to need.

METHODS

Health visitors were asked to collect data on existing problems and service provision to families, the mental state of the child's principal carer, an observation of the parent-child relationship and details of management plans. Data from the Child Health Surveillance System were also used.

RESULTS

Data were obtained for 549 families. Nine families were noted to have problems in the parent-child relationship. Carers in these families had poorer mental health. In all, 20% of families had a revisit scheduled: they were also more likely to have poor mental health. All families with possible problems in the relationship had a revisit scheduled. Depression scores measured during the pilot were a significant predictor of revisiting and referral, with an odds ratio of 1.37 for every one point increase in score on the Adult Wellbeing Scale depression subscale.

CONCLUSIONS

Current service provision matches need to some extent but routine visits focused on parenting difficulties at 13 months, particularly parental depression, may help to identify families needing support who would not otherwise have received it.

Evaluation of the clinical effect of an on-line course for community nurses on post-partum emotional distress: a community-based longitudinal time-series quasi-experiment

About 14% of Icelandic women suffer post-partum from frequent depressive symptoms, and of those, 12% also report a high degree of parenting stress. Education of nurses and midwives on post-partum distress is crucial in reducing its degree. The purpose of the study is to evaluate the clinical effect of an on-line course for community nurses on post-partum emotional distress. A community-based, longitudinal, time-series quasi-experiment was conducted in four stages from 2001 to 2005. Mothers attending 16 health centres throughout Iceland and scoring ≥ 12 on the Edinburgh Postnatal Depression Scale (EPDS) at the 9th week post-partum were eligible to participate. Health centres were divided into experimental (EHC) and control centres (CHC), and control centres were crossed over to experimental centres the following year and new control centres recruited. Nurses at EHC attended an on-line course on post-partum emotional distress. Participating mothers answered the EPDS; the Parenting Stress Index/Short form and the Fatigue Scale. Nursing diagnoses and interventions were recorded at all study centres. Of the women who were eligible (n = 163), 57% (n = 93) participated. At baseline, 9 weeks post-partum, there were no significant differences between groups of women in the rate of depressive symptoms, fatigue or parenting stress. Women in all groups improved on all distress indicators over time; however, those from the EHC improved statistically and clinically significantly more on depressive symptoms than those from the CHC. Documentation of particular nursing diagnoses and interventions was significantly more frequent at the EHC, but referrals to specialists were significantly less frequent. On-line education for nurses on post-partum emotional distress is feasible and is related to improvement in post-partum depressive symptoms.

Psychometric properties of the Chinese version of the Parental Bonding Instrument

BACKGROUND

The Parental Bonding Instrument (PBI) is a widely used assessment tool for measuring parental characteristics that affect parent-child bonds. The measure was developed for and has been most administered in Western populations. Psychometric analyses have yielded discrepant results as to whether the PBI is best represented by a two-factor model (care and overprotection) or a three-factor model (care, overprotection, and autonomy).

OBJECTIVES

Little is known about how the PBI performs in Chinese samples, and there is limited data from Eastern populations as a whole. The purpose of this study is to: (1) explore the data and identify the underlying structural model that best fits the Chinese culture, and (2) to further compare the factor structure that emerges in a Chinese sample with that which has emerged in other Eastern cultures (i.e., Japanese) and Western countries.

METHODS

The present study investigated the psychometric properties of a Chinese translation of the PBI among a sample (N=1417) of mothers of kindergarten children. Confirmatory factor analysis was used to identify the most adequate model.

RESULTS

Results supported a four-factor model that included an indifference factor (χ(2)/df<3.0; RMSEA<0.06; SRMR<0.08). Both the two-factor and three-factor models performed poorly (χ(2)/df>5.0; RMSEA>0.08; SRMR>1.0; CFI<0.90 for both). In this sample, use of a Chinese translated version of the PBI was successful. Support for the four-factor model is consistent with findings from previous studies of Eastern populations and discrepant from those among Western samples.

CONCLUSIONS

The indifference factor may reflect aspects of parenting specific to Eastern cultures, which tend to value group cohesion over individualization and independence. More research is needed to determine whether these findings are generalizable to all Eastern countries and whether aspects of Chinese culture (e.g., the single-child law) produce unique effects that may impact PBI administration in China.