Chapter 7. Infants and their families
Jennifer Rowe and Margaret Barnes
Learning outcomes
Reading this chapter will help you to:
» define support and apply the concept to nursing support for early parenting
» critique early parenting support programs
» distinguish between universal and targeted health screening and surveillance services
» identify safe, supportive and health promoting practices related to infant feeding
» identify safe, supportive and health promoting practices related to infant settling and sleep
» understand the interactions among sociological, epidemiological and health promotion underpinnings of childhood immunisation
» locate nursing practice and programs in contemporary health service planning and delivery
» identify the knowledge, skills and processes necessary to engage in effective and nursing-proactive practice with families with infants
» critique the organisational role in facilitating responsive nursing-led services, and
Introduction
Infancy is both an exciting and a challenging time for families. In transition, as the result of the birth of a new child, families are shaped by the child, just as the child is shaped by the family into which they are born. A range of health services is available to support families during this important time. Nurses are at the frontline working in a range of government and private sector services, in institutions and community facilities. Service focus is predominantly on promoting good health for the infant and supporting parenting and families.
In this chapter, some of the challenges that face families during their child’s infancy are examined. The reader is provided with a clinical case study that situates the infant and family in the contemporary community. This case is then contextualised and discussed with reference made to central health and psychosocial issues, key nursing practices and innovative programs that are responsive to needs and are informed by current policy. Key topics of interest in nursing families with infants are addressed, including supporting parents, assessing infant growth and development, breastfeeding, settling and sleep, and immunisation.
Setting the scene: a clinical scenario
The nurse
It is 7.30 p.m. and you are the nurse on the 24-hour telephone support service. Frida has just called to talk about her 2-week-old baby girl. She tells you that the baby has been crying for much of the day. Frida says she has tried everything to settle her baby and does not know what else to do. She just does not know how to get through another night alone with her baby.
Frida
Imagine yourself as a late thirties woman, living in a major city, employed in a professional appointment. You have been on leave for just over 5 weeks, having left work 3 weeks prior to the birth of your baby girl, who is now 2 weeks old. You live alone, having split from your long-term partner 12 months ago because he did not want to have children. Following a private arrangement with a sperm donor, you fell pregnant and had a healthy term pregnancy and gave birth at the local hospital assisted by a girlfriend. You went home with your baby 2 days after her birth. You had read voraciously during your pregnancy, mostly about the birth, but also, later in the pregnancy, about breastfeeding and what to expect from the baby in the first year. You had attended five antenatal classes at the hospital. Your baby has been breastfeeding and you feel that you have mastered this skill quite well so far. The baby sleeps next to you in your bed.
This clinical scenario provides a starting point to consider the many healthcare needs of families during the first year of a child’s life. It is chosen in part because it helps to disrupt the traditional assumptions of the nuclear family and to draw attention to trends in childbirth and family. Embedded in this scenario are not only specific situational needs, but also universal issues, responses to which are central to the provision of effective family-centred nursing practice.
Families with young children: characteristics in Australia and New Zealand
Frida is one of many women who are having their first baby in their thirties, some of whom are managing alone for any number of reasons. Frida’s situation represents a growing family type—the one-parent family with dependent children. Chapter 1 provides a detailed description of the shape of contemporary families in Australia and New Zealand. To reiterate, one-parent families have stabilised in Australia at around 22% of families with dependent children (Australian Bureau of Statistics 2004), while in New Zealand the proportion is still increasing and most recently constituted 18% (Statistics New Zealand 2006).
Frida’s decision to go it alone makes her vulnerable, at least financially. The average income of one-parent families is less than that of couple families and a much greater proportion of lone parents receive a government pension (in Australia, 58% compared to 8% of couple families). Lone mothers earn less than lone fathers.
It is important to keep in mind that the single-family household (rather than extended family) is the dominant social grouping in Australian and New Zealand society. Thus, most mothers, whether alone or part of a couple, will experience some degree of isolation as they engage in parenting their young babies. They may find themselves isolated from family and friends at a time when social support is most needed. As parents, they need support so that they are able to find the balance between self and other—that is, to manage their own desires and needs while also providing nurturing care (Rowe 2003) that provides infants with continuity and stability, within a dynamic process of relatedness (Bowden 1997).
Supporting parents and families
Supporting parents in the first months of their new baby’s life is a significant practice responsibility for health professionals. This need reflects societal trends where extended family is a minority grouping, and where, for decades, childrearing has been relegated to the invisible space of the domestic frontier, while at the same time, perhaps ironically, subjected to increasing public sector scrutiny and surveillance.
What is support?
Support is an essential aspect of strengths-based and family-centred practice. One of the fundamental tenets of these approaches is to enable families to make informed decisions and choose actions that are informed about things that matter to them (Department of Human Services 2004b). Accepting this assumption is important to the development of services that support families.
Support is conceptualised in different ways in nursing and social science disciplines. Three types appear frequently: informational, tangible or instrumental, and emotional (Heath 2004). Informational support has two important characteristics: accuracy and relevance (House 1981). Emotional support is a complex set of interactions, focused on supporting a person’s sense of self or value (Heath 2004, House 1981), or alleviating emotional responses to stressors (Finfgeld-Connett 2005). Tangible or instrumental support includes a wide range of concrete actions—those providing goods and services (Finfgeld-Connett 2005).
An important aspect of an enabling approach is that regardless of the type, or types, of support appropriate to a situation, the central concern is how parents appraise their situation and define it (Finfgeld-Connett 2005, McCubbin & McCubbin 1993). In addition, it is important to understand the coping styles, strategies and resources used by, or available to, parents.
Supporting parenting on the basis of these assumptions requires more than providing information or educating parents in parentcraft topics. Based on the assumption that parents are the constant in a young child’s life negotiating knowledge and experience and needs (Barclay et al. 1997, Rogan et al. 1997, Rowe 2003), it requires practice that places authority in the hands of parents and accepts that parents bring knowledge and are able to be ‘the expert’. It infers practising in such a way as to build the capacity of parents to make decisions and, where able, look after their infants, or participate in their infant’s care as partners (Rowe & Barnes 2006). The traditional expert (i.e. the nurse as teacher and authority) is thus replaced by a nurse who is an expert in a number of other practices, including helping parents to:
» identify and frame their needs and also their strengths
» reframe their situations, and
» access and utilise a range of resources and thus increase adjustment to parenting (e.g. personal/family community resources).
Priorities for early parenting support
These underpinnings can be applied to supporting early parenting. Some common stressors or challenges have been extensively investigated for men and women, as they negotiate the changing demands, needs, priorities and relationships associated with parenting. Parenting is theorised to involve challenges to both identity and skills in parentcraft or caregiving. These challenges, interweaving ones, may give rise to a range of needs and stressors for both mothers and fathers. Thus, for women, skill in practical caregiving such as breastfeeding and settling an infant can affirm and confirm a maternal role and a narrative of self as mother.
Like women, the transition for men to fatherhood is ongoing and dynamic. The dynamics are similarly complex and involve negotiation and renegotiation of the ideals and realities of care, relationships and other work. Men’s transition has not received intense scrutiny, and so specific interactions between beliefs, social discourses and personality are less clearly mapped as they relate to fatherhood and fathering (Dowd 2000, Kaila-Behm & Vehviläinen-Julkunen 2000). For both men and women, successful parenting, marked by acceptance of self and confidence in caregiving, is a keystone in family adjustment and thus family strength.
Programs to support parenting
In both Australia and New Zealand there is a long history of community child health services, reaching out to large proportions of families with babies and young children. Today such services continue to play a role in promoting health and wellbeing for infants and young children, and now incorporate parenting programs to support parents during early childrearing (Barnes et al. 2003, Rowe & Barnes 2006). The need to support parents, as a vital key to strengthening families, is constant whether health services focus on universal or targeted population groups. In Australia, state health departments manage the vast majority of services and so a diverse range of services is offered. See Box 7.1 for an example.
Box 7.1
The service
The Tresillian Family Care Centres or, more formally, the Royal Society for the Welfare of Mothers and Babies, is an organisation with a long and rich history in providing support to families with young children in Sydney. Its beginnings date back to the early twentieth century. From its first baby health clinics established in inner Sydney at that time, the service has maintained a continual presence, known by professionals and families across generations simply as Tresillian. Today, it provides a range of targeted services staffed by nurses, psychologists, social workers and medical officers.
Programs
Parents can contact a 24-hour telephone help line if they need advice or assurance, or go online to consult with a nurse, as part of the innovative Messenger Mum strategy. Families who may be struggling with parenting or having difficulties can have a home visit or attend a day-stay clinic for some one-on-one support. For women who may not be coping, or are exhausted or depressed, a tertiary residential service is available.
Developing service and practice
Tresillian has strong links with tertiary education providers to enhance the education and professional development of nurses and is active in research, evaluating outcomes and seeking ways of further developing practice that is responsive to targeted populations (see www.cs.nsw.gov.au/tresillian/default.cfm).
The Royal New Zealand Plunket Society (RNZPS), known as Plunket, is the major New Zealand organisation providing community parenting support services. In Australia, between 75% and well over 90% of new mothers engage with community child health services (Comino & Harris 2003, Department of Human Services 2004a). Plunket sees well over 90% of New Zealand’s new mothers (Royal New Zealand Plunket Society n.d.). Because of the vulnerability of disadvantaged groups, targeted services are increasing in an effort to minimise longer term health and social problems.
Traditionally, Well Baby clinics were structured around individual consultations, conducted at health centres, between nurse and parent, usually the mother. Three types of programs have emerged in recent decades that provide support for mothers and, to some extent, fathers, in very different ways. The programs are telephone support lines, parent support groups and home-visiting programs.
Telephone support lines
Recall the scenario at the beginning of the chapter. Frida had picked up the telephone, seeking help. The availability of community and professional support services can be very important for new parents. Telephone support services are used in a wide variety of health settings, and in the context of new parenting are organised by both state government health services and community organisations. Assessment of and support for immediate needs, and referral to other services, are thought to be significant functions of such services, as well as the 24-hour availability (Lattimer et al. 1998, Sheehan & Barclay 1999).
Telephone contact may be able to be used not only as a response mechanism to parent-identified issues, but also as a contact point for preventive intervention at recognised difficult stages in early parenting. For example, for breastfeeding, if there is contact after discharge from maternity services, during the first week, and again at 8–12 weeks, this may be effective in encouraging breastfeeding maintenance (Department of Health and Human Services Tasmania 2005).
While telephone services are helpful, it is important to keep in mind that evaluation of the standards and effect of these services is limited. Those evaluations that are available suggest that appropriate and specific skills and adequate education on the part of the health professional conducting the telephone service are necessary to ensure accuracy of information provided over the telephone (Andrews et al. 2002). The nurse, as a knowledge worker, must be skilled, not only in the practice area but also in the communication skills needed to consult and counsel on the phone. See Chapter 5 for further information on communication and therapeutic relationships. Given these parameters, effective support for Frida is quite possible.
For Frida, ringing for assistance may have been a last resort; she may be in crisis. Because of this possibility, the nurse in this situation needs, first, to assess her degree of distress and, as far as possible, assess the infant’s current wellbeing. The nurse needs to establish that Frida is neither at risk herself, nor of placing her infant at risk, and has the capacity at this time to regroup and continue without seeking assistance as a matter of urgency.
Frida’s actions indicate that she is aware of community resources available to her, and this may be the first kernel available to the nurse to provide emotional support—that is, to acknowledge her resourcefulness in seeking assistance. With this key, in a situation that is not ideal, there is opportunity for the nurse to provide Frida with informational and emotional support to address her immediate needs, and also to initiate a discussion that focuses on what she is doing well, and help her recognise her resources at hand. It will be important for the nurse to attempt to gain a picture of Frida and her baby. This is achieved by asking Frida to describe her baby, her baby’s behaviour, and her caregiving actions. This process may be quite settling for Frida, as it focuses on concrete things in her world, and provides the nurse with information as a basis for supportive feedback and encouragement.
Encouraging exploration of ways to connect with other supports in the community will assist Frida in identifying resources in the longer term. Providing suggestions may be the most appropriate first start when speaking to Frida, but also taking the time to ask about the times when the baby is settled will highlight to Frida that she has managed well previously. Discussing the wide range of ‘normal’ infant behaviour and providing information about developmental milestones and changes in infant behaviour and infant care requirements, particularly with regard to feeding, settling and awake period interactions, may address Frida’s immediate needs. It is important at this time to ensure that Frida is able to access ongoing support through health services, support groups or family.
Parent support groups
Sometimes known as facilitated peer networking (Barnes et al. 2004, Scott et al. 2001), the parenting group takes many forms. It refers to a small group of peers—new parents, usually facilitated by a nurse, at least in the first instance. The immediate advantage is that this service puts parents, most usually mothers, in touch with each other, a process that is increasingly difficult for mothers to do informally via family and friendship networks. Women such as Frida can be put in touch with other women, and young children. See Box 7.2 for an example of a parent support service.
Box 7.2
This service was established in the late 1990s for parents of babies up to 2 months of age. Based on principles of enabling parents through partnership and peer support, it aims to promote parents’ exchange of expertise, and their confidence with decision making, and satisfaction with parenting. Recruiting parents as soon after a baby’s birth as possible, the program involves the use of a series of facilitated support group meetings for parents, most usually mothers.
It is anticipated that groups, or some members of groups, will develop ongoing relationships and this is encouraged by the facilitating nurse. It also assumes a partnership between the parent and the facilitating nurse, who brings expertise on a range of topics. Parents continue to have access to individual consultation with nurses if they require it and also for ongoing child health assessment.
Practice development
This program is an interesting example of parenting support groups, and also of principles of practice development. It is nurse-initiated and led, established as a result of a local service review and developed with involvement of nurse/midwifery researchers and clinicians. It includes key structural elements and strategies for clinical nurses to use in its implementation. This has been achieved through the production and wide distribution of a user’s manual for nurses, which contains information about running groups, communication strategies, challenges nurse facilitators may face, and proforma and standardised evaluation tools to use with groups. Thus, it equips nurses with the tools they need in a range of settings to implement and evaluate the program. It recognises the need to include education and professional development for clinicians.
With an evaluation mechanism built into the program, ongoing responsiveness in the program is enhanced. Further, evaluation has been more widely disseminated through publication of evaluation data in the peer-reviewed literature (see Kruske et al. 2004).
The scene is then set for women to share experiences, knowledge and ideas with each other. This sharing attends to both emotional and informational support needs. Women have a space to share the important stories of caregiving minutiae, relationship and family dynamics, and reflections on the maternal role. From these interactions, women continue negotiating and confirming their role (Börjesson et al. 2004), and testing the information they glean in their own context (Rowe 2003, Rowe & Barnes 2006). In addition, it provides the opportunity for anticipatory guidance on caregiving topics such as breastfeeding, settling and sleep, immunisation and important developmental steps for the infants.
Evaluations demonstrate the effectiveness of peer support to help parents build confidence and increase breastfeeding maintenance (Kruske et al. 2004). They also generate longer term social networks for parents and families (Scott et al. 2001). One evaluation study found that women appreciated becoming involved in a support program as soon after the birth of their baby as possible (Kruske et al. 2004). Evaluations also raise a debate about whether these are mothering or parenting groups, due to the small involvement of fathers in these initiatives (Scott et al. 2001).
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