Extended parenting education in an early parenting centre

Abstract

This article reports findings from a process and impact study of a residential early parenting centre programme in Australia. The programme supports parents with young children under the age of three, referred from health and child protection services. Multiple sources of data were used from interviews, focus groups, direct observations, observer notes and a parenting sense of competence questionnaire. Qualitative data were analysed using thematic analyses, and paired t-tests were used to test data from the questionnaire. Three themes emerged from thematic analysis of the qualitative data: engaging families, building parenting capacity and transitioning back to the community. Parents’ perceptions of parent competence improved significantly between admission and discharge for participating families. Detailed accounts of the way in which nurses work to achieve positive outcomes in relation to parenting confidence and satisfaction in the short term have provided useful insights into often taken-for-granted support processes in working with referred parents. The complexity of the nurses’ role and implications for nursing practice in residential parenting centres are discussed. Future research is warranted to determine longer-term benefits of this programme being delivered in a residential early parenting centre.

Keywords

Child protection children’s community nursing evaluation nurse–family relationships parenting support

Introduction

Parenting at the best of times can be stressful. Strong parenting skills and knowledge, confidence and good psychosocial and emotional health influence parenting and child development (Akai et al., 2008; Morawska et al., 2009). Programmes aiming to improve parenting practices include a range of home visiting and other, targeted community parenting programmes.

Early parenting centres (EPCs) are unique to Australia (Rowe and Fisher, 2010). Other countries employ primary health-care programmes such as outreach home visiting to support parents through early parenting (Phillips et al., 2010). EPCs were established to work with families experiencing complex parenting issues with children less than three years. They target adjustment to parenting, feeding and sleeping and issues related to children’s growth and development (Hauck et al., 2007). The goal of EPCs is to increase positive parenting behaviours through knowledge and confidence and developing safe, effective child-rearing practices (Rowe and Fisher, 2010). They exist within a broader system of child protection and family support services (Australian Health Ministers Advisory Council, 2009; Johnson et al., 2008).

EPCs use a multidisciplinary team framework, relying on collaboration and partnership between the health professions to support families with complex needs (Schmied et al., 2010). The EPC supports the use of the Family Partnership Model. This encourages a more facilitative role for the nurse (Keatinge, Fowler, & Briggs , 2007).

There is limited evidence for the ability of targeted residential parenting programmes to improve parenting capacity or indeed child outcomes (Nemeth and Phillips, 2006; Treyvaud et al., 2010). Previous research has focused on their influence to improve maternal mental health, maternal–child interaction and reduce unsettled infant behaviour, particularly sleep disruption and excessive crying (Eronen et al., 2007, Nemeth and Phillips, 2006; Rowe and Fisher, 2010).

Aim of the study and study method

This study aimed to (a) examine how nurses implemented an early parenting programme in an Australian EPC, (b) identify the facilitators and barriers to its implementation and (c) assess the programme’s influence on parenting capacity, parents’ perceptions of parental self-efficacy and satisfaction with the programme.

Study design

A mixed-methods concurrent triangulation design was used. The findings from each set of qualitative and quantitative data were integrated so that an overall interpretation could be drawn from the results (Creswell and Plano Clark, 2007).

Study setting

The EPC incorporated a multidisciplinary team approach to care. Nurses worked intensively with parents during the first week of the programme and gave less intensive support to parents during the second week of residence.

Recruitment and study sample

Parents were asked to consent to participate in the study at the time of the preadmission interview. Of the 14 eligible participants, 13 gave informed consent to participate in the study between August and November 2011. Twenty-five of 34 nurses invited gave written informed consent to participate in the study.

Ethics approval was gained from the Health Service District Human Research Ethics Committee (HREC/11/QRCH/81) and the University of Sydney HREC (Protocol No. 13965). Participation in the study was voluntary, and participants were made aware that they could withdraw without penalty. Participants were assured they could stay in the parenting programme even if they withdrew from the research.

Data collection

Interviews

Semi-structured interviews were conducted for 30 minutes with 11 parent participants at the end of the 2-week programme. Interview questions aimed to elicit parents’ views about the aims of the programme, their experience of participating in the programme and their perspectives of the nursing care they had received. Interviews were recorded and later transcribed verbatim.

Observations

An observational checklist was used to capture actions and interactions between nurses and parents. Lead author KB conducted all observations using the checklist. Observations of up to two hours were conducted twice with each parent and the nurse assigned to their care. A total of 22.5 hours were spent observing and describing the interactions. The first recorded observation was conducted in the first few days following admission when interaction between the nurse and family was intensive. The second recorded observation was conducted on weekends when there was reduced internal activity within the centre. A journal record was kept.

Focus groups

Nurse participants attended two facilitated focus groups (n = 15). Focus group discussions were held before and then again after the two-week Extended Parenting Education Program (EPEP). Discussions lasted between one and a half to two hours and were audio recorded and transcribed by a research assistant. The discussions were conducted to: (a) gain insight into nurses’ experiences of working with parents admitted to the centre during the data collection period; (b) explore nurses’ confidence in their ability to improve parenting capacity, parenting self-efficacy and parenting satisfaction; and (c) explore facilitators and barriers to the implementation of the EPEP.

Questionnaire

The Parenting Sense of Competence Scale (PSOC) was completed before commencing the two-week programme and repeated on discharge. The PSOC has tested reliability and validity for use in measuring parent satisfaction in the parenting role and provides insight into how effective parents perceive themselves to be (Ohan et al., 2000). Replication of the scale’s factor structure support its ability to measure parenting self-esteem (Ohan et al., 2000).

Data analysis

Transcriptions were coded, codes were checked through inter-coder agreement, codes were developed into themes and analysed using thematic analysis, assisted with NVivo 9. Respondent validation was conducted using two group discussions with nurses (Barbour, 2001; Kitto et al., 2008 ).

PSOC scores were transcribed onto a PSOC scoring sheet and screened for accuracy and normality using SPSS 20.0. The statistical tests used by Johnston and Mash (1989) were replicated. Firstly, pretest and post-test scores were tested using a paired t-test, and the p value and confidence intervals calculated. Effect sizes for each element had been determined from previous studies (Gibaud-Wallston, 1978; Gilmore and Cuskelly, 2008, Johnston and Mash, 1989; Ohan et al., 2000), each of which used Cohen’s d adjustments in the determination of the effect sizes. Then, to compare the results in the present study with those in the Johnston and Mash (1989) study, a one-sample t-test was applied to both satisfaction and efficacy scales.

Results

Three overall themes emerged from the qualitative data: (a) engaging parents, (b) building parenting capacity and (c) ensuring transition back to the community. Facilitators and barriers to programme implementation were also identified (see Table 1).

Table 1.

Summary of findings (qualitative data).

Finding	Descriptor of finding
Engaging parents	Nurses engaged with the families by showing genuine interest, building a trusting relationship and having positive regard and respect for the family.
Building parenting capacity	Parenting capacity refers to the parent being able to identify and prioritize the child’s needs over their own.
Transition to community	Providing the referring agent with comprehensive accounts of education, support and a detailed assessment of their parenting strengths and limitations.

Engaging with parents with complex vulnerabilities

Nurses initially engaged with the parents using a range of sophisticated interpersonal qualities including ‘showing genuine interest in the family’, ‘building a trusting relationship’ and ‘having positive regard and respect’. Nurses recognized that they needed to use a gentle approach.

Certainly an important component too is building a therapeutic relationship with them in those first few days. Umm, not being overly critical about their skills or anything else but really nurturing that relationship. (Nurse focus group Two)

On observation, this approach featured nurses demonstrating active listening and the use of reflective strategies. Interpersonal skills such as eye contact, active listening, positive regard and empathy were observed projecting this warmth towards the parents. An environment was created where parents could express their needs without feeling judged or criticized. Taking this approach led parents to believe that the nurses were genuinely interested in them. This was seen by parents to be an important part of the relationship with the nurse.

I saw them (nurses) being able to bond with him as well and they actually cared about him and were excited when I told them things about him and um they you know they talked to him and developed a relationship with him and just not just me. (Parent interview 4)

Building parenting capacity

Nurses used the relationship to build parenting capacity. A number of key strategies were identified including ‘assessing parenting capacity’, role modelling’, ‘providing opportunistic and targeted teaching’, ‘putting child safety first’ and ‘surveillance’.

Parenting capacity in this context required the parent to identify and prioritize the child’s needs over their own and provide a safe and more nurturing environment. Nurses also needed to make an assessment of parenting capacity. This was achieved through observation of parent-to-child interactions such as how parents interpreted infant cues, feeding and nutritional practices, sleeping, hygiene and child safety. Nurses would role model and reinforce parenting behaviours by coaching the parent through tasks. For example, nurses would get down to the child’s level, look the child in the eyes, and communicate using a quiet calm voice and positive language. This was often in response to infant cues that were not being responded to by parents. Parents would observe how the infant responded to the nurse and were encouraged to replicate what the nurse had done.

The process of engagement and building parenting capacity was overlaid by the imperative of maintaining the child’s safety. Nurses used every opportunity to raise the parent’s awareness of child safety issues.

‘I’d like to think that every parent goes home having done this programme has the capacity to keep their babies safer’. (Nurse focus group One)

At the same time, nurses needed to make an assessment of whether the parent was able to assimilate the new knowledge and skills into everyday parenting practice. This required surveillance.

To enable the delivery of parenting support and an accurate judgement of parenting capacity, nurses needed to consider their own biases about parenting. This reflection sometimes resulted in distress.

So it’s a fairly large emotional load where you’re trying to advocate for the child, the child’s needs are being met to a degree but maybe not met to the point that they could be, so you’re having to try and find that, what other things in the world, in the child’s life can all… (Nurse focus group Two)

Ensuring transition back to the community

Another important aspect of the nurses’ work was assisting the parents to return to their community. This began at the initial contact with the referring agent and continued throughout the admission.

Nurses worked to ensure that referring agents were included in planning for the family admission as well as the transfer of the family at the conclusion of the programme. Other multidisciplinary team members, including a social worker and a psychologist, undertook the role of case manager from the time of referral. Nurses identified issues in the parent–child relationship, intervened, challenged and set goals with parents. In this team, the nurses undertook the majority of the contact work, and it was a compilation of their observation and interactions with the family that were documented to form the basis of the discharge summary to the referring agents.

… over the two-week period we get to see a pattern whether they’re consistently providing those [parenting] needs in the manner we would hope they would or not, and if they’re not providing that then we generally comment in the nursing progress notes what the situation was around that. So by the end of the two week stay we’ve got a fairly good, picture of what’s happening so we can let the referring agent know. (Nurse focus group Two)

Facilitators and barriers to programme implementation

A number of factors were identified as having a critical influence on the ultimate success or failure of the programme. These were nurses’ attitudes and feelings about working in the programme. Others were system issues, such as policies and procedures that affected continuity of care. Despite the nurses’ best efforts, parents were not always willing participants in the process.

Well, they [parents] disappear at eight o’clock in the morning and they might be home for lunch and then they might disappear at two in the afternoon and they might be home at five o’clock. (Nurse focus group One)

Parents were observed to roll their eyes, cross their arms, raise their voices or use a rude abrupt tone of voice towards the nurse at times. Where appropriate, parents were gently confronted by the nurses, using a range of strategies to defuse the situation.

Nurses’ personal belief systems effected how they engaged with families and expressed their need to feel appreciated and respected by the parents.

The passion and the commitment and the belief in it has to have some impact …. (Nurse focus group One)

Nurses felt a sense of reward when parents were appreciative, when parents implemented parenting strategies and when parents received positive infant responses. Nurses were distressed when their value systems were challenged. Despite these issues, parents expressed appreciation for the nurses’ support and identified their progress as parents.

Just that everyone has been lovely and supportive and that is great and I am definitely happy about being here and having been in the programme. (Parent [mother])

Parenting capacity, self-efficacy and satisfaction

The clinical and statistical significance of each subscale of parenting satisfaction, parenting efficacy and interest are presented in Table 2.

Table 2.

t-Test results for total scores (n = 14) compared to normative data from Johnston and Mash (1989).

Variable	Mean (SD) for study herein; (n = 14)	Mean (SD) reported in literature (Mothers: n = 297; Fathers: n = 215)	p Value^a
Satisfaction with the parenting role	39.36 (6.88)	Mothers: younger: boys 37.40 (6.60)	.306
		Mothers: younger: girls 38.76 (5.87)	.751
		Mothers: older: boys 37.69 (6.13)	.381
		Mothers: older: girls 38.50 (6.34)	.649
		Fathers: younger: boys 39.77 (5.44)	.826
		Fathers: younger: girls 39.42 (6.28)	.973
		Fathers: older: boys 40.47 (5.72)	.555
		Fathers: older: girls 39.20 (5.62)	.933
Parenting efficacy	34.43 (3.76)	Mothers: younger: boys 25.52 (5.29)	<.001
		Mothers: younger: girls 25.08 (5.97)	<.001
		Mothers: older: boys 24.79 (5.79)	<.001
		Mothers: older: girls 25.69 (6.61)	<.001
		Fathers: younger: boys 24.95 (4.99)	<.001
		Fathers: younger: girls 25.77 (5.29)	<.001
		Fathers: older: boys 25.43 (6.21)	<.001
		Fathers: older: girls 25.42 (5.43)	<.001

Parenting satisfaction

Interviews revealed parenting not only stressed the parents but that they were frustrated before undertaking the programme. Normal infant and child behaviours were misconstrued as naughtiness and a deliberate attempt to upset and frustrate them. Analysis of the satisfaction PSOC subscale showed a large effect size (d = 1.09) and a p value of .001 for the intervention. Parents felt more satisfied following the intervention, indicating they were less frustrated and less anxious in their parenting role.

Parenting efficacy

Parents could see that the nurses demonstrated, educated and worked alongside them to increase their ability to recognize normal childhood development and infant cues. Analysis of the efficacy PSOC subscale resulted in a medium effect size (d = 0.61) and a p value of .048.

Parent interest

Analysis of the interest PSOC subscale resulted in a small effect size (d = 0.13) and a p value of .538. That is, interest in parenting did not improve. Parent observations revealed that parents often left the centre, perhaps to avoid demanding periods of child-rearing such as mealtimes.

Discussion

The study provides further insight into an approach that seeks to engage parents as partners in care with community child and family nurses and move away from an ‘expert’ model of care (Fowler et al., 2012; Kruske et al., 2006; Schmied et al., 2010). The complexity of this work in the context of a community residential centre is highlighted.

A definition of parenting capacity has been found as that of the parent’s ability to identify and prioritize children’s needs over their own and to provide a safe and more nurturing environment. It is important because the parent needs to demonstrate that they can understand new knowledge about parenting and accomplish skills in everyday parenting tasks. This definition has the added component of accepting and demonstrating the use of new parenting knowledge and skills (Donald and Jureidini, 2004; Goodwin and Sandall, 1988; Taylor et al., 2009). It is clear from the findings that the EPC nurses undertook a number of complicated tasks simultaneously. The role of surveillance may be seen as contradictory to the therapeutic relationship in that it was aimed at providing assessment and judgement of the parent rather than relationship building. Assessing parenting capacity is contentious, and there is argument about what comprises ‘good enough’ parenting and what this means in the context of families with multiple or complex needs (Crawford, 2011; Donald and Jureidini, 2004; Harnett, 2007). The unique EPC environment allows for the collection of multiple sources of data and the nature of the work enables goal setting and close observation of parent–child interactions. Nurses are supported by the multidisciplinary team to engage and challenge parents using elements of the family partnership model as a tool to facilitate their work (Fowler et al., 2012, Hauck et al., 2007; Schmied et al., 2010).

Despite literature suggesting that parents don’t always see role modelling and parenting education as supporting their learning (Hebbeler and Gerlach-Downie, 2002), parents in this study acknowledged not only the help and support that the nurses gave them but also that they had learnt a lot about parenting. They felt their parenting skills had improved. In many ways, both the parent and nurse factors found in this study are consistent with previous studies. For example, other studies have indicated that parents may be resistant because they were being closely observed and were dependent on nurses for support and education (Sandberg, 2011, Scanlon and Adlam, 2011). Through reciprocity, and the parents making some positive parenting changes, nurses in this study felt a sense of achievement and reward. Identification of the parent’s strengths and weakness allowed the nurse to scaffold education enabling the parents to develop and use new parenting knowledge and skills (Bibok et al., 2009; Landry et al., 2001).

Clinical and statistical improvement in parenting satisfaction and perceptions of parental efficacy over the course of the programme was an important finding. Effect sizes for PSOC in this complex sample of parents were calculated. This appears to be the first Australian study that has attempted to assess whether the programme in an EPC has made a clinical difference for parents following the intervention (Nemeth and Phillips, 2006; Treyvaud et al., 2010).

Limitations of the study

Given the small, purposive sample, the study attempted to be comprehensive, and the results may apply to this particular setting alone. Participating parents were in an unfamiliar environment, had limited parenting experience, low levels of education, and poor mental health. Interviews were challenging at times when parents struggled to find the best words to explain and describe their experiences. This may have influenced the results of the study. Nevertheless, the quotes provide us with a deeper understanding of their experiences.

Implications for clinical practice

The findings provide a novel and important contribution to improving practice and policy when working in partnership with parents, undertaking surveillance and scaffolding education and support for parents. A longer term study is warranted to examine whether these results are sustained over time. A cost–benefit analysis to determine whether longer term outcomes made this resource-intensive programme economically sustainable would be valuable.

Conclusion

The EPC’s multidisciplinary approach to care and the complexity of the nurses’ role in a residential parenting centre has been highlighted. Nurses do rely on their clinical expertise in relation with parenting to convey child health knowledge and provide adequate surveillance of parenting capabilities.

Footnotes

Acknowledgements

We thank the parents and staff at the participating residential centre for supporting the study so generously.

Author Contribution

KB posed the research problem and formulated the research questions; KB, JF, YHJ and KF conceived the study design, KB collected the data and KB, JF, YH J and KF wrote and edited the article from the first draft written by KB. This research was completed as partial fulfilment of a Master of Philosophy award to KB at the University of Sydney. JF was principal supervisor, YHJ, and KF were associate supervisors of the study.

Ethical approval

Queensland Children’s Health Services (RCH) Human Research Ethics Committee in June 2011. Approval was granted on 20 of June 2011 (HREC/11/QRCH/81). Approval was sought from the Human Research Ethics Committee University of Sydney in July 2011 and granted on 21 July 2011 (Protocol No. 13965).

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author KB was awarded a Queensland Nurses’ Union Registered Nurse Scholarship of 1000AUD for research assistant support.

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