Child health nurses’ perceptions of the Family Community-based Assistance Resourcing and Education program in contemporary practice: a qualitative study

Developing strong therapeutic relationships with families to help identify and achieve family-determined goals was seen by participants as the cornerstone of the FCP, as reflected by these illustrative quotes:

Developing a relationship with the client … Finding out what their needs are, not necessarily what we are desperate for them to do. It’s not our agenda, its theirs … Offer them options.

…to facilitate them to identify how best they can support and reach, identify some goals for themselves through the program that they would decide to you know um, to be the parent that they wish to be.

Participant responses generally indicated the FCP program achieves its intention of providing support for families who may have limited access to health services for a variety of reasons:

I think another intention … of the program is that it is a family, that it’s a home visiting program, that we are going into people’s homes as their guests. And that was a way of accessing at-risk families that may not normally access health services.

CHNs identified that building rapport and trust, and developing a mutual respect were central elements of developing a therapeutic relationship to find solutions to family issues. Participants reflected:

There is a wonderful rapport you can develop with the client that they trust you and they listen to you, and you help them problem solve, you help them establish some of their goals.

I think too that it’s about establishing a trusting relationship … and to put us into that unique position of forming an incredible rapport with these families built on trust … again … so better outcomes for those families and children … we can facilitate their care in a, in quite a unique environment of their home …

Participant responses also suggested that the FCP family–nurse relationship presented a unique opportunity to actively demonstrate respect for individuals and their families, an experience not always common for families experiencing social challenges. This can impact their self-esteem and engagement with health and social support systems.

… some of these clients never have anyone turn up for them, the fact that we turn up, you know 90% of the time when we are supposed to … even that for someone can change, you know, their perception and how they feel about themselves … some people don’t think that they are worth turning up for, so their perception that we are going to turn up is that we are probably not going to. So even that, that’s something that is so minute for us, but for that person would be just humungous I would imagine.

In discussing the intentions of the FCP, participant responses highlighted that the family–nurse relationship was a partnership, working together to achieve goals prioritised by the family:

It’s more that partnership model rather than going in and doing a weight and things like that, so it’s more that relationship-based rather than you know the expert model.

Some CHNs raised that this family–nurse relationship can provide an opportunity for the family to reflect on their social relationships and how these may impact their interactions with their children:

[Families have more] complexity in their lives don’t they so it’s even about that relationship complexity. I am kind of the reflection of them [the family] on how they are being in [a] relationship.

CHN participants discussed opportunities for supporting families with vulnerabilities, particularly families at risk of poor maternal–infant attachment. Some CHNs mentioned that these opportunities may reduce involvement with child protection services. A considerable proportion of CHNs identified undertaking training in the Circle of Security attachment model (Hoffman et al. 2006) and the Together in Mind program (Queensland Centre for Perinatal and Infant Mental Health 2017). These professional development opportunities support this partnership work with families in supporting their goals that centred on developing secure attachment with their children.

… establishing the secure relationships as well as opportunities for children … you are strengthening relationships.

… [the intentions of the FCP] supporting vulnerable families … at risk of a poor attachment relationship between mother and child … attachment benefits through support and education … in the home you can see more about the attachment.

In summary, CHNs identified the FCP as a program that supported their ability to foster therapeutic relationships with families based on a partnership model, which aligned with original program intentions. Other beneficial aspects and strengths of the program from the perspectives of CHN program providers will now be explored.

Visiting a family in their home environment was regarded by CHNs as having multiple benefits. CHNs recognised that this environment provided for a more equal dynamic in the family–nurse relationship:

In their own home they have a sense of empowerment … we are a guest in their own home … you are more likely to gain that good relationship.

… environment that they feel comfortable in that we are not in a clinical environment. Different power base, isn’t it?

This environment was viewed by participants as providing a better understanding of the family’s functioning, as it facilitated growth in the trusting relationship and greater sharing of information to inform care assessments:

You get their true self in the home … I find that I have seen somebody in clinic, and in that one clinic appointment you have built that trust in you, and you go to that next visit and it’s in the home and they are different. They share a lot more with you … Because you get to go into their home and they invite you in and they are happy for you to come in, you get to see the true family life, the true person.

Home visiting was also valued, as it was perceived to facilitate family awareness of, and access to, information and sources of support, including primary medical care and other referral pathways, for families who may not access clinic-based services, for a variety of reasons:

… that it’s a home visiting program, that we are going into people’s homes as their guests … accessing at-risk families that may not normally access health services … in a centre.

Several participants highlighted their FCP role as a family’s primary source of information during the first year of the child’s life:

I think one of the key elements is that we are their source of information, that we are their source of truth … we are their avenue to seek information about growth and development and to give them that sense of the health professional as primary resource.

Participants also recognised that for some families with social vulnerabilities, the home visiting program provided an avenue for the family to receive social support, which they may not have been able to otherwise access, despite referral systems in place for these supports (e.g. community play groups).

… some families are so isolated, they don’t have the resources to get the social contacts … sometimes we are just the person that comes through the door, its sometimes … as simple as that … and not only a person, a non-judgemental person that’s not involved; ‘cause [people] in their limited social networks they are invested in their lives emotionally and we can come in and listen to their story and not go, ‘you shouldn’t do it that way’.

Home visiting was also viewed as a practical solution for families already burdened with complex health and social circumstances. Care is provided in a familiar comfortable environment within the family’s resources to access.

… reduction of stress, how many parents get stressed loading the child up into the car … they have had a bad day and they’ve got to go into the clinic or whatever. So knowing that that person is coming out to your house does reduce those stress levels.

CHNs also shared how the flexibility of the FCP home visiting model facilitated options in program content to support family goals. This flexibility was regarded as an important element:

… the advantage to the program is its flexibility … Around the process as well as when we visit … And how often we visit, you know there is the suggested visits and we can have flexibility around that as well.

It gives flexibility, because you can go in to do a 6-week check, but the baby’s screaming, there is a lot of distress in the house and the mother doesn’t want to focus on the developmental review, she wants to get help with her unsettled baby. So you can use that visit to do that and then come back. Because it’s the FCP, you can go back the following week and catch up.

The structure of the FCP – providing more visits early in the transition to parenthood, with reduced frequency in the latter half of the first year – was regarded by participants as a strength of the model, supporting the family to develop skills and confidence over time:

I think that another element is the fact that it’s staggering home visits, so intensive in the beginning and then we get decreasing amount of visits, so we kind of, I think by the end there is a purpose behind about that, about this empowerment … it enables them to build up their own skills with that reassurance from you as the helping professional and to gain, they obviously gain confidence as we move through the program.

The ability for CHNs to access case conferencing (reflective supervision to confidentially discuss family goals and care plans within a multidisciplinary child health team) was regarded as a strength and support mechanism for staff. These forums enabled nurses to reflect on practice decisions and receive support in managing care of complex families, within a professional environment.

… [Case conference] it’s having those other pair of eyes on it, especially when you have a really complex family, you can get so sucked in to their own dramas, as much as you try to stay outside of it, it can block your view of what to do sometimes, you can’t see the wood for the trees and you are not sure where else to go with it. Or sometimes just to be told … I wouldn’t have done anything else … that can be really reassuring as well. We are all really good at reflective practice and offloading to each other informally, but having a formal structure is really valuable. It’s also quite protective for the clients and for us.

Some participants reflected on the value and meaning of their role as CHNs working with families with complex needs, which they took forward in establishing new relationships:

Tackling the inequalities of health, targeting resources at families that are more vulnerable … [the] most needy, the most complex, the most vulnerable.

You home visit someone for 12 months and you run into them two years down the track and they have had another baby and they are saying that things are going really well … We have been able to keep a job or we have been able to keep our house… [the] previous work … helped build that … I think that you go in with that intention of giving them the best that you can.

While multiple advantages to the FCP were identified by participants, they also shared their perceptions of several limitations, which identified areas for improvement.

Participants identified that the FCP eligibility criteria was too narrow and did not account for contemporary families with vulnerabilities:

We are not meeting all of those needs for the criteria … in family care at the moment, it doesn’t fit really with what is happening socially for the increased drugs and alcohol. They don’t automatically fit into those criteria anymore.

… there are more criteria that we could open up to meet more vulnerable people.

Participants highlighted the limitations of the Edinburgh Postnatal Depression Scale screening tool. Although useful for screening depression, participants suggested it did not always effectively assess mothers experiencing perinatal anxiety whom they felt would potentially benefit greatly from FCP.

Even the antenatal screening bit, with just doing an EPDS [Edinburgh Postnatal Depression Scale] for depression, obviously we are seeing so much more anxiety … which doesn’t score, and half of these women would really benefit from the program, PTSD all of those sort of things. So we change how we are assessing that so we meet those famil[ies] needs a bit more.

A counterargument to broadening the eligibility criteria is that the CHNs have a particular skillset, enabling them to specialise in assisting families with specific risk factors.

I would be a little reluctant to open up the [eligibility] criteria too much, just because of our skill level … we are looking at a lot of significant mental health illness … I think there is a safety in the criteria currently, that is there for us.

Despite this conjecture, there was a consensus within and across both focus groups that ensuring services were targeted towards those families most likely to receive benefit would assist in achieving program outcomes.

But then it is also where we can make a difference … the people who are not critically unwell with something like psychosis, I mean we do address that and support them, but we have got to get beyond our own service to support them, so it’s about where we can make a difference.

Several CHNs suggested that program structure was useful, and that a lack of structure can make working with families experiencing adversity difficult.

Sometimes I think we need a bit of structure but, I feel sometimes we might get a little bit lost and if you look at other types of programs … they do have structure and [families] enter the program knowing that there is going to be an education model so I think that sometimes [helps] with these chaotic families.

In contrast, others perceived the program structure to represent a lack of flexibility, particularly with respect to the timing of visits and allocation of resources to families with greater needs:

… talking about the structure for me, the thing I struggle with is when we go two-monthly. ‘Cause I would argue that if most people can go two-monthly they probably don’t need us.

I think [if] we had more flexibility in our model we could access more people that needed it and not spend so much time on people that perhaps don’t.

Many CHNs also identified that antenatal contact, although not mandatory to the program, would be ideal to support the establishment of the relationship with the family:

… I would actually like to see two or three antenatal visits, so we have really established the relationship with the mother before the baby is in the picture, and you have talked about goals with parenting and all those expectations.

The 1-year duration of the program was seen as a limitation by some CHNs:

I think one of the other limitations for me is that it does only go on for a year … I’m wondering if it would be more effective in a sense of being involved in that family a little down the track.

… these people are so vulnerable, but then we visit them at home and expect them at a year [to be] fixed.

Home visiting was recognised as time and resource intensive in terms of staff and transport required, with a lack of service resourcing affecting the availability of the FCP for all families who may benefit.

Resources never matched what we need to do, you end up doing a lot of home visits, and you can have this wonderful program, but still have lack of resources in time and cars.

Having the FCP embedded within the universal child health service created tensions related to resourcing. CHNs reported that when resources were strained, families with the greater perceived vulnerabilities were often prioritised last.

Resources, staff … our biggest struggle is annual leave … our universal program gets the priority … so if someone is off sick where straight away our family care get knocked off and the universal gets taken over.

Participants highlighted the lack of understanding of the CHN role in the FCP, both by the public and other health care professionals.

We are not promoted enough. We don’t have universal promotion in the community, we are not part of health forums, we are not a part of generalised community support, you know we are just a little part of child health, community health, that even now some people don’t even have a clue what we are.

CHNs expressed the view that families may confuse the role of the CHN and statutory child protection services, a misunderstanding which could affect the family’s level of engagement with the FCP.

I think our name child health is a misinterpretation … that we don’t really see the absolute vulnerable people, because they think that we are a part of … child safety.

Respondents also identified there was a lack of clarity around how or what outcomes of the FCP were measured, as evaluation was not clearly embedded into program delivery and quality control measures to monitor program fidelity are lacking. Poor evaluation of programs provided staff with little objective evidence of what, if anything, a family’s involvement in FCP achieves, as suggested by this response:

… it’s not measured, we don’t know how family care meets it, no one is measuring it … we have no questionnaires, you know we don’t even gain feedback.