ANMJ Featured Story

Engaging families: Maternal, Child and Family Health Nurses

Thursday 23rd November, 2017

Have you ever wondered what’s involved in practising as a maternal and child health nurse? Natalie Dragon investigates the different aspects of the role and the significant difference these nurses can make to the lives of young families.

“I enjoy the real life complexity. As much as our role is based around growth and development assessment, it’s also much more than that - it’s about family functioning,” says Victorian maternal and child health (MCH) nurse Fleur Turner.

Every day the maternal and child health service is accessible in Bayside, Melbourne through home visits, drop-in sessions and the 24-hour phone line.

“It can be daunting when parents go home from hospital with a newborn baby. I feel privileged to go into somebody’s home; it can be quite intimate with new parents looking at a baby only five to 10 days old in the first home visit,” says Fleur.

“You have to be mindful that you are in someone’s home. It’s a different shift to when someone comes in to see you in your office.”

Support and education for families is really important, says Fleur. “Baby cues, sleep and settling, skin care, growth and nutrition in the first few months then starting food. Then it becomes sleep and behaviour, toilet training, etcetera as they get older. It’s the changing milestones.

“I love doing what I do mostly because of the continuity of care. It’s such a privilege watching them grow from babies to pre-schoolers.”

Victorian MCH nurses follow 10 key growth and development assessments from birth to three and a half years.

“Our role also encumbers immunisation promotion and information, breastfeeding and lactation support and linkages to local services such as new parent groups, playgroups, playhouses and kindergarten services,” says Fleur.

“The other enhanced area is support for vulnerable and high risk families with complex needs, such as mental health issues, drug and alcohol use, child protection, and domestic violence.”

Victorian MCH nurses screen women for domestic violence at four weeks.

“I think because we directly ask a question. We are often the first person told, we refer on but we still need to handle that conversation which is why it’s so good to have that continuity of care,” she says.

Similarly, women are screened for postnatal depression at eight weeks post birth. “Sometimes a woman might be smiling at me and she’s scored very high for stress, anxiety and depression. Often if you don’t directly ask you wouldn’t know. Some people are really very open and other people feel shame and guilt,” says Fleur.

“It’s why communication skills are so important. It’s why I always ask ‘How are you?’ I stop looking at the baby and look at the mother. Some women will say ‘I’m having a bad day’.”

While not counsellors, Fleur says a key attribute of the role is the ability to listen and be sensitive, particularly when wanting to guide families towards referral.

“If there’s a developmental issue, for example there is no eye contact with a child, you have to be gentle in providing that message.

“Sometimes it’s about planting the seed and asking the question. Often it sits with someone and they may come back to you, such as smoking or domestic violence.”

Fleur says she gets immense satisfaction in making a difference to helping people. “It’s a satisfying job.”

Primary healthcare role

There are many different titles of the role both within Australia and overseas. In the Australian setting maternal, child and family health nurse (MCaFHN) is the term used to describe the specialty.

The role is embedded in the principles of primary healthcare under an umbrella of universal service delivery. MCaFHN work in community settings within the primary healthcare domain.

Many nurses have gained midwifery qualifications but it’s not required in all state and territories. Most will have a specialist child and family health postgraduate university qualification.

Previous research has highlighted that inconsistencies between jurisdictions in educational requirements, nomenclature and professional recognition of practice makes it difficult to define and work towards standards for best practice for the MCaFHN.

Former ANMF Federal Vice President and Victorian MCH nurse Maree Burgess says the specialty is a diverse group that provide a range of services to children and their families.

“Indeed, on a state by state and territory basis, the more we network, the commonalities in practice become very clear and the differences better understood.

“I believe that across Australia, maternal and child health nurses have a common vision for the provision of health services for families, however we acknowledge the very real differences between the states and territories in relation to educational preparation and service provision.

“It is paramount that in our deliberations, we respect difference, continue to build connections and look to develop standards of professional practice which acknowledge the breadth of practice in Australia.”

Several states, including Victoria and Tasmania recently celebrated 100 years of service provision. In the early days, prevention of transmission of infectious disease was the biggest issue, such as diarrhoeal diseases which were killers of infants, says Maternal, Child and Family Health Nurses Australia (MCaFHN) President Creina Mitchell.

“It was education on the importance of hygiene and sanitation. Now, it’s immunisation. In Victoria and NSW there have been recent outbreaks of measles and [MCaFHN] nurses are explaining the importance of immunisation.”

A health promotion focus now includes early onset of chronic diseases and risks such as obesity, with education on appropriate nutrition and child size serves.

“A lot is about education, such as cleaning teeth and dental caries. There are high rates of hospitalisation for under-fives to remove decayed teeth due to drinking sweet drinks where children are not taught to clean their teeth,” says Ms Mitchell.

Childhood health and wellbeing

Research increasingly shows the early years are vital: early exposures and experiences impact on the developmental trajectory, including health, across the lifespan.

The role of MCaFHN across Australia is to deliver services to enhance the growth and development of children in the early years, says Ms Mitchell.

“For MCaFHN in Australia the
workforce is involved largely in service delivery which is nurse led and at the forefront in primary and prevention for families with pre-school children.”

Health promotion and early intervention are key components of the role. After initial post-birth home visit, well baby checks are routinely conducted by MCaFHN in Australia. Not just to ‘weigh babies’ but to provide advice, education and support.

The role is comprehensive and diverse and differs to that of GPs who work from a different model, says Ms Mitchell.

“They [GPs] are the first port of call when families and children come in unwell or perform the child health checks. We provide another service – of education and support and assessment of child development. It’s not surprising that MCaFHN have a really broad scope of practice.”

It’s an area well known to the service users, largely women who have had children – who have a real understanding of what the service offers, says Ms Mitchell.

“Outside of this, the role is not that well known and nurses have not necessarily seen it as exciting as say the ED.”

Child and family nurses provide family centred nursing care, she says.

“MCaFHN build relationships and trust, they see that families can be complex; there are real issues and you need to start with what’s most important, not all at once. It’s about what’s a priority in partnership with that family ‘this is the biggest issue for me.”

“It’s about working with parents. We are really trying to upskill and support families at this time with a focus on positive parenting practices.”

Therapeutic relationships

Working in partnership with families and developing trusting relationships is crucial, says ACT’s Jill Pearson.

“I work with families in a partnership model; I work with them to their strengths. It’s so important to listen. What you think they want is often not what they might want. I often say ‘from my perspective if I referred you on to…will that help?’”

A large part of the role is often giving people support for unexpected outcomes, says Jill, a MCaFHN of nine years.

“The woman who has had a third degree tear after childbirth. We cannot answer all of people’s needs; there are community resources to refer people on to.

“We need to be able to assess in our home visits and glean enough of the history to ascertain the level of support needed. And ask: ‘How are you feeling?’ ‘I am feeling and doing ok.’ If not, we need to give the support early on so that parents do not flounder. The service is there for as often or as little as families need.”

Child health specialists

Maternal, child and family health nursing is a specialty, says Jill. “We have a fairly defined area of practice – zero to five years and so we do become specialists - child health nurse specialists.”

Nurses looking for a career path in the specialty should immerse themselves in the knowledge of normal child health and development, she says.

“The biggest thing is to have a really good knowledge of child development, to have that base knowledge of what’s normal: soak yourself in the normal.

“The role is to know the normal to be able to pick up the abnormal. To know what to expect at two, four, and six weeks to 12 and 18 months and then three and four years. To know what the normal is and systematically go through the process of growth and developmental check.”

It’s also important to question what you know, says Jill. “The more you know, the more you know you don’t know.”

Strengths based approach

The MCaFHN emphasises a strength based approach working with the strengths of the family and empowering them.

The nursing role is supporting that family whether that be a listening ear to initiating referrals for an identified need, says City of Whittlesea Maternal and Child Health Coordinator Karen Mainwaring.

“It’s a big transition period for families with newborn babies. The MCH nurse role is empowering families in making that transition, providing them with education on new baby forming attachment, growth and development; linking them into any other supports or services they might need; and being supportive with decision making.”

Whittlesea Council is one of 10 organisations across Victoria to have just received additional funding to deliver improved maternal and child health services to Aboriginal families and children.

The Whittlesea catchment, north of Melbourne is a significant growth area. There were 3,400 births in the past financial year, with a significant Aboriginal population in the 0-5 age group.

While many engaged with the maternal and child health service there were a number who had disengaged for various reasons, says Ms Mainwaring.

“We identified the need to strengthen our partnerships in providing care to women and babies in the antenatal to postnatal period and beyond. It’s the whole gamut of maternal and child health services and to look at families who are disengaging - to give families a choice of the care they want, the universal maternal and child health service or alternate pathways to bridge the gap.

“With the Aboriginal service, it’s individual and it’s about choice. Many families are happy to engage with the universal service. Other families have specific needs.”

City of Whittlesea have a MOU with the Northern Hospital and the Koori Maternity Service. Whittlesea Aboriginal MCH nurse Teagen Cornelissens attends antenatal appointments with a midwife at the Northern Hospital where appropriate to make the bridge from the hospital to the community.

“I make face to face contact and get to know them [clients] in addition to the midwife. This is a significant approach to work closely with Aboriginal women, to engage them and have continuity of care.”

A proud descendant of the Badimia People in Geraldton, Western Australia, Teagen says trust builds over time with Aboriginal families and children.

“We know from the broader picture that this group has significant health risks, not just necessarily in Whittlesea and there is risk of disengagement because of past experiences.”

Trust is crucial for these families, says Ms Mainwaring. “It’s a journey alongside families to support them in their journey of parenthood. The service is voluntary. Families choose to come to us – it’s their choice. If they aren’t happy or comfortable they won’t come back. We have to recognise what’s the most important thing for a family at that time.”

The service also offers a Universal Family Engagement Program which seeks to engage families who are unaware of the service or have disengaged for some reason. It is a range of ways of engaging including pop-ups at play centres and play groups where families meet.

“We set the scales up and let families know we are available. We have had to be flexible and creative to meet the needs of families in the community,” says Teagen.

Each municipality looks at what they need; there is no one size fits all, says Ms Mainwaring. “We change to meet the needs of families, we need to continually review – it’s about being proactive not reactive.”

Engagement

The Child Health and Parenting Service (CHaPS) was recently awarded for its work by the ANMF Tasmanian Branch. CHaPS is a state-wide service for children 0-5 years, in two regions North-North West and South of Tasmania.

CHaPS Assistant Director of Nursing South Kim Parker said historically it had been difficult to engage and keep the community engaged in the region.

“We have been able to think outside the square and work in partnership with the community, to better meet their needs, and build on their strengths rather than focus on the negative. Now our rate of engagement in the first year of life of that child we have close to 100% and even into the second year.”

CHaPS CFHN Wendy Spinks says the service needed to come up with sensible engagement and sometimes think outside the box.

“We have some extraordinarily complex families - we have a disproportionate amount of congenital defects, complex medical conditions, drug and alcohol use, complex mental health issues - and it really guides our practice.

“We had to go in and acknowledge
where there was disrespect we fostered respect; where there was miscommunication we developed excellent communication; where there was equity issues we provided honesty about what we could do. Getting to the core is respect, communication and client-centred goals.”

Wendy says CHaPS practice nursing based on a primary nursing model for the family.

“We make a five-year commitment and get to know our families - it might take two to five years to reach our outcomes.”

Nurse Unit Manager Liz Jayatunge said routine growth and developmental checks were really important to reach the next level for clients.

“They open the door for families to come back when they have a need – when they need that extra support and realise that you are there. Where we have needed to make some changes, we demonstrated real partnerships with vulnerable families to achieve good outcomes.”

CFHN Gwyneth Delpero said honesty with clients also helped foster engagement. “Honesty from day one really helps, particularly for when you are delivering distressing news. We do deal with vicarious trauma and that is quite confronting. We keep clients in the loop and have an open conversation.”

Similarly, Derbarl Yerrigan Health Services in WA has seen positive results in engagement and uptake of maternal and child health services.

Maternal Child Health Coordinator and Eligible Midwife and RN Liesl Baxter said maternity services were welcoming, culturally safe, responsive and respectful. The underpinning Maternal and Child Health Model of Care in the Aboriginal Community Controlled Health Sector was an accepted and community informed model of care in the Indigenous demographic.

A big part of the organisation’s success is the Aboriginal health workers first policy with key role models engaged in service delivery, strong community advisory and evidence based practice, Liesl says.

“Essentially what we deliver is the same as mainstream services.  It’s the way we deliver it – the HOW we do it that is different and that’s really important.”

It’s about development of therapeutic relationships and the development of trust, she says. “We provide longer appointments and we really focus on continuity of care to keep that engagement strong. We have had strong successes such as increased immunisation and Pap smear screening rates.

“Every Aboriginal woman wants what other women want and that’s continuity of care and even more than other women they need longer appointment times in terms of the cultural context. The midwife is often working with concepts of care that a client has not grown up with and it’s not necessarily something a client may understand. You may not be scared of a stethoscope because you’ve grown up knowing it but an Aboriginal woman may view it with suspicion and may need to know it doesn’t extract or give spirits. Similarly sometimes health decisions may involve a family, not an individual. Empowering clients with knowledge and understanding and ensuring informed consent for health care is integral for all clients. Ensuring foreign concepts are understood takes development of trust and extra time to ensure understanding cross culturally.”

As a practitioner, Liesl acknowledges she is in a unique position of advocacy.

“My job is to maximise opportunity to provide a holistic patient journey that is protective of the client. I need to ensure as much as possible that people come out the other end feeling better not worse for the experience. We need to facilitate a safe experience for them and as practitioners really understand the Equal Opportunities adage “In order to treat me fairly you may have to treat me differently.”

“I ask myself often ‘Why do we do what we do? The reason is that I want to make a difference. I wake up every day and know that I have the capacity and the honour to make a difference with every patient interaction I have.”

Vulnerable families

Research has identified the need for nurses to develop trusting relationships with ‘at risk’ families. Churchill Fellowship recipient Catina Adams is currently studying enhanced programs offered by maternal and child health services in Victoria.

“The intention is to support vulnerable families. Any family can become vulnerable; changes in their circumstances can make them vulnerable.

“This may include losing a job, the mother losing someone important to her, or having a child with an illness.

You have to be respectful of priorities, says Ms Adams who works with vulnerable families in Broadmeadows, Melbourne.

“My priority as a maternal and child health nurse might be to get a child weaned off a bottle at two years to protect their teeth and for better nutrition. As I work through this with the woman, I realise that the bottle is protective because when the baby cries, her husband becomes angry. Women are very good at working out what they need to do. You need to let her tell you, she’s not worried about the bottle at all - she actually needs support with a safety plan.”

Ms Adams’ research is also looking at patterns of disclosure. “It’s about having conversations. And it’s done in the client’s home, on her turf, you’re her guest. Not in the clinic where she is less likely to disclose to you.

“We receive a referral ‘my baby won’t stop crying’ or ‘my toddler is out of control’. The nurse gets to the home and it’s not about the baby at all. In two to three visits it might be significant mental health issues where the woman is really depressed and anxious, or undisclosed family violence. You build that relationship – that is the essence of maternal and child health nursing.”

Ms Adams says it is about developing the therapeutic relationship. “When you have a therapeutic relationship it doesn’t matter what we are saying whether it’s about healthy food and nutrition, safe sleeping, whatever you are talking about, it’s the relationship. It’s having the support from a non-judgemental caregiver that is important to women.”

You have to keep the big picture in mind, but it’s also about the individual interaction, Ms Adams says. “I know that every single word, every single exchange with a woman has the potential to change her life. I know that we make a difference every single day, one woman at a time.”

To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_dec_jan_18_book_issuu