Public health nurses’ assessment of early interaction between infants and parents

Research shows that children’s positive development depends on a secure attachment to their care-givers. Children’s experiences of interaction with their care-givers form the foundation for the style of attachment they develop: secure or insecure attachment. Their attachment style will influence their development as well as their health (1-3).

Recent brain research has revealed the importance of childhood experiences to the development of the brain, and knowledge about the cerebral consequences of traumas has received greater significance (1, 4, 5). Children develop their attachment to their care-givers during the first year of their life (1–3). Early efforts are therefore important in order to identify challenges with respect to interaction and non-standard development of attachment. If the challenges are identified at an early stage, there is a greater chance that any negative impact on the child can be reversed (5-7).

The child health clinic as an arena

Child health clinics are intended to provide a universal service for all pre-school children, and public health nurses are charged with a range of different tasks. Public health nurses see virtually all parents of young children, and they are expected to have a broad focus on physical and mental health. The focus of this article is on the assessments made by public health nurses of the early interaction, which forms the basis for the emotional attachment between parents and their children.

Public health nurses have a unique opportunity to assess and promote the development of a secure attachment.

The child health clinic is one of the public health nurses’ arenas, where they meet families at an early stage, just as their interaction is being established. Consequently, public health nurses have a unique opportunity to assess and promote the development of a secure attachment. In an otherwise specialised health service where everyone is working to specific mandates, public health nurses are charged with working holistically and on a broad front. The range of work that public health nurses undertake has changed considerably over the years, and this requires the resources of the public health nurses as well as local and national authorities.

Earlier research

There is little research available that specifically describes the public health nurses’ assessment of early interaction. Naumann (8) examined why it is difficult to assess interaction and studied the public health nurses’ dilemmas as they work to detect failings in the provision of care. Ulland (9) examined how public health nurses identified and mediated parent-child interaction and identified a need for enhancement of the public health nurses’ competence levels.

International research provides a wealth of knowledge on the importance of interaction and attachment, what is being observed (10), and which methods are used in the process (11). Research describes how attachment may be strengthened, and what tools can have a positive impact on attachment and interaction through the support and follow-up of at-risk groups and home visit programmes (12–14).

The instruments of infant observation that may be candidates for use in the practice of Norwegian public health nurses, include NBO (Newborn Behavioral Observations) (15, 16) and ADBB (Alarm Distress Baby Scale) (17). NBO facilitates structured observations of behaviours, and the ability to adapt in infants between the age of 0 and 3 months (15), while the ADBB was developed to assess social behaviours and withdrawal symptoms in children between 0 and 2 years of age (17).

The objective of the study

The objective of the study was to describe the public health nurses’ practice in order to increase our understanding of their assessments of early interaction between children under six years of age and their parents. The study therefore posed the following research questions: ‘What observations do public health nurses make of early interaction?’, ‘How do public health nurses follow up their own assessments?’ and ‘How do the wider framework conditions influence the actions taken by public health nurses?’

Method

The study had a qualitative design and involved individual in-depth interviews. We chose a qualitative methodology in order to increase our in-depth understanding of the observations made by public health nurses in practice.

Sample

The informants who took part were recruited through convenience sampling organised by child health clinic managers. All seven informants were qualified nurses who had later specialised in public health nursing. The inclusion criteria were current employment at a child health clinic, a minimum of 12 months’ work experience, and working hours of at least 40 percent of a full-time equivalent. All informants were women between the age of 39 and 60 who worked between 70 and 100 percent of a full-time equivalent as public health nurses. Their work experience ranged from five to 22 years.

Two of the informants had no further specialty training beyond their public health nursing course, while five had further additional training. They worked for five different local authorities within the same county in the east of Norway. The local authority areas were demographically different, in terms of size, population makeup and geography. Population-wise they ranged from 4000 to 80 000.

Data collection

We conducted semi-structured in-depth interviews with the informants between April and September 2015. The interviews were conducted at the informants’ place of work and lasted between 60 and 90 minutes. They were recorded on audiotape and subsequently transcribed. The interview guide had been drawn up in advance, featuring main questions and follow-up questions reflecting the study’s objective and research questions. The informants were given the opportunity to talk freely with as few interruptions as possible. 

Data analysis

We analysed the interviews by using Tjora’s stepwise-deductive inductive method. The transcribed material was coded in accordance with Tjora’s coding system, which involves labelling he empirical data before proceeding to further categorisation (18). The categories were formed on the basis of the empirical data, as exemplified in Table 1.

Ethical considerations

Participation in the study was voluntary and based on informed consent. All information is confidential and the content of the transcriptions has been anonymised. The interviews included no personal details so there is no obligation to report the study to the Norwegian Centre for Research Data (NSD). All tape recordings were deleted at the end of the study.

Results

The results show that any assessment of early interaction is a complex mesh, involving observations, actions and wider framework conditions (Figure 1).

All seven public health nurses who took part in the study reported that they observe interaction in numerous situations, and that their observations start when they first see the family. According to a description given by one of the informants the interaction ‘can be seen in lots of situations, constantly’. Someone else said that she would ‘watch the whole scene, their expressions.’

The public health nurses explained that they observe how parents handle their children, how they talk to – and about – their children, and how they comfort them. One informant said that ‘good interaction occurs when a parent chats to their child, understands the child and calms the child.’

The informants pointed out that the ability of parents to understand the child and their sensitivity to the child’s emotions were important factors. Examples include whether the parent is focused on the child, respond to what the child is doing, and if they understand the child’s needs. One informant described good interaction as ‘good unity, a red thread’.

Observing the quality of the comfort given

The informants also said that they observe the quality of the comfort that parents offer their children after vaccination. They observe the parents’ actions and the effect they have on their child. This may relate to whether there is bodily contact, how they talk to the child, and whether this calms the child.

One informant said: ‘Good interaction means that they comfort and cuddle the child.’ Someone else put it in these terms: ‘If the comforting is insecure, then mum turns all, you know, doesn’t know what to do. You can see that she isn’t confident, and that the child’s crying accelerates. But with a mother who is confident […] you can see that she handles the child well, and that the child responds by calming down.’ A third informant described an observation in this way: ‘She [the mother] laughed when I injected the vaccine and the child cried. What does it feel like to be laughed at when you’re hurting?’

Observing eye contact

The public health nurses who were interviewed reported that they observe the eye contact made. They look to see how parents look at their children, whether there is reciprocity, how frequent the contact is, and how easily the child allows eye contact to be made with others. One informant said the following about a mother: ‘I can see that she is finding it hard to make eye contact with me during the consultation.’ The informant went on to explain that this mother also struggled with making eye contact with the child, after which she said to the child: ‘Don’t look at me like that.’

The public health nurses also described observations of the child’s behaviour. One informant said: ‘How the child presents, […] whether the child looks secure in mum’s arms and calms quickly, or if the child seems ill at ease. Yes – you can see it in their vitality. You can see that the child is happy because the mother responds and is present.’ Two informants described smiling as an example of good interaction: ‘There is good interaction when you see mother and child beaming at each other’ and ‘good interaction is mutual joy in parent and child.’ Another informant described the sound the child makes as an indication of the same: ‘[…] these cooing noises, which are simply the most wonderful thing in the world.’

Only one of the informants reported that she was using structured infant observation instruments as necessary. Other tools employed for families with children under six months included EPDS (Edinburgh Postnatal Depression Scale), which is a mental health screening instrument (19). Five of the informants reported that they were regularly making use of EPDS.

Positive reinforcement by describing good interaction

The public health nurses explained that whenever they observe good interaction, they describe their observations to the parent in order to support and reinforce the positive: ‘You try to talk about it in positive terms so that mum becomes aware of the good interaction.’ One informant believed it was important to share the observations made: ‘I believe in not keeping it all in my head, but sharing it with them. Whenever I see the parents, I believe [it is] very important to put into words all the things you see and do and think. I believe it is important to be honest about your own thoughts. Equally, if you have concerns, it is important to say so.’

Everyone reported that they provide general information about interaction, with the objective of ensuring that individuals know how to look after their own health (20). They said that they assess the interaction multiple times as necessary, give advice and guidance and are keen to provide specific feedback to parents. All informants said that they focus on the mother’s mental health and the parents’ personal life experiences.

Observations of challenging interaction

The informants reported that they try to understand where the problems lie when they observe challenging interaction, and that their choice of action varies: ‘What action you take during a consultation needs to be a bit spontaneous’, in the words of one of them. All of the informants gave examples from their practice of families they were monitoring more closely, but none of them were clear as to who this applied to. They explained that they give families referrals as necessary, and that this could involve closer follow-up by the child health clinic, a psychologist or the child welfare service.

All of the public health nurses felt it was important to build trust and establish a good relationship with the families, as they saw this as a prerequisite for observing the interaction. In the words of one of them: ‘To get to grips with it, you need to build some good relationships. Because if I haven’t got a good and secure relationship with the parents, then I can’t do anything’.

Three of the seven informants explained that the greatest challenge arises when they observe interaction problems and the parents do not share their view: ‘Some come to us asking for help, and then it’s not difficult at all. But if they feel at odds with us, then it gets complicated.’

Challenges in busy working lives

All of the interviewed public health nurses described a busy working day filled with numerous jobs to be carried out during consultations: ‘You need to weigh and measure them, schedule their next appointment, record the weight and measurements, and show them the percentile form. An awful lot of very heavy tasks are crammed into a short space of time! Which makes it difficult to observe the individual child.’

All of the informants explained that professional development tended to be left up to themselves. They had the opportunity to set aside time for keeping up to date, but they rarely did so and normally spent the time on other tasks. They said that they rarely attend courses, and that they look up information only if they need to.

Three of the public health nurses reported that they would read articles presented to them by supervisors, colleagues or others. However, none of them were searching databases for research literature, despite the fact that they all said they knew how to do that. One of the public health nurses who was receiving guidance on a regular basis said: ‘It is absolutely incredible, it is excellent quality time.’

Collaboration with others

All informants said that they took part in interdisciplinary collaborative practice, but they described the collaborative relationships in different terms. Informants in the two smallest local authorities described an orderly collaborative relationship between services, but they pointed out that the professional communities were transparent, and that there were few individuals available for collaborative working. Informants from the two largest local authorities talked of greater opportunities for collaboration, but that the collaborative relationships were disorderly.

All informants explained that with respect to older children, there is systematic collaboration with the local authorities’ educational and psychological counselling service (PPT) and kindergartens. With respect to children under the age of six months, the collaborative practice is however less systematic.

The collaborative relationship with the child welfare service was described as challenging.

Apart from colleagues working at the same child health clinic, the child welfare service was the partner agency mentioned by all informants. However, the collaborative relationship was described as challenging. Only one of the seven informants described it as generally positive. Phrases such as one-way communication, person dependency and limited availability were used.

One informant explained that she had alternative ways of contacting the child welfare service: ‘[…] but obviously, if you just keep at it […] it is possible to formulate something, perhaps in an email. Could we please set aside time to discuss […]’

Two of the public health nurses reported that they found it difficult to discuss cases with child welfare officers because the community was small and transparent. One of them explained the consequences in these terms: ‘What is concerning is that there appears to be a brick wall between us and the child welfare service. It’s as if we’re working in two different worlds. That’s no good for the child.’

Discussion

The study’s findings suggest that all informants observe the parent’s behaviour, the child’s behaviour and the interaction between the two. Their observations generally coincide with what is described in research as important factors of fundamental significance to the child’s development (1–3, 21–23). The informants were concerned with the mother’s mental health and the parents’ own childhood experiences, as in accordance with research that shows how the parent’s mental health impacts significantly on their behaviour towards their children (3, 19, 24, 25).

Furthermore, all of the public health nurses said that they are keen to observe how parents comfort their children at the time of vaccination. It is important to pay attention to comforting behaviours, as described in the study conducted by Klette (2), who demonstrated a link between the quality of the comfort provided and the parents’ ability to promote secure attachment in their children.

Limited use of systematic observation instruments

There are instruments available for the systematic observation of infants (15, 17, 26, 27), but few of them were used by the study’s informants. The reason why appears to be complex, but time limitations seem to play a part. A consultation normally lasts for approximately 30 minutes, during which numerous tasks need to be performed (20). There is little time for each task and using the relevant observation instruments takes time.

Systematic infant observation instruments therefore need to be adjusted to the context of the child health clinic, and until now this has been the topic of few studies. Time, willingness and funding will also be required for the instruments to be implemented. Limited professional updating also means that it is difficult to learn about existing tools. The public health nurses who took part in this study employed very few recognised instruments. While they expressed no desire to have access to more instruments, they did explain that they found it challenging to describe interactions they felt to be difficult.

Observations influence actions

The informants said that they determine their actions based on their observations. When they see positive interaction, they support the parents so that they reinforce the positive aspects. However, if they observe interaction challenges, they continue to monitor the situation in order to establish where the challenges lie. However, their choice of action appears to be somewhat arbitrary.

Their actions appear to be contingent on the services available within the relevant local authority rather than resting solely on their specific observations. Such ‘arbitrary’ choice of action is also described by Neumann (8), who found that public health nurses tend to choose informal and unofficial action strategies when they have concerns.

The public health nurses we interviewed explained that they felt it was difficult to take action when they were concerned about a child and the parents disagreed or did not want any help. They did not explain in specific terms what made it difficult, but this may well be related to competence as well as the wider framework conditions.

Public health nurses need to decide for themselves whether their observations give sufficient grounds for concern to trigger their duty to inform the child welfare service (28). In this study it appears that the public health nurses decide whether a concern should be reported based on their own subjective assessment.

Assessments are influenced by several factors

The study appears to suggest that there is no one single factor that influences the public health nurses’ actions with respect to early interaction. Neumann (8) found that the assessments made by public health nurses were influenced by several concurrent factors: personal experiences and frames of reference, a professional eye and expertise, and structural limitations.

All informants reported challenges with low staffing levels, a heavy workload and interdisciplinary collaboration of varying quality. They also reported that professional updating was generally left up to themselves, and that this was often down-prioritised in a busy working day. Public health nurses have a statutory duty to keep up-to-date in many areas, pursuant to s. 4(28) of the Norwegian Health Personnel Act. Keeping professionally updated requires an effort to be made by the individual nurse, but is also dependent on knowing what competencies are needed.

All informants reported challenges with low staffing levels, a heavy workload and interdisciplinary collaboration of varying quality.

Under the Health Personnel Act the employer is responsible for organising services in a way that allows health personnel to meet the legal requirements pertaining to safe practice (28). Unlike the situation within other nursing disciplines there is no national centre of excellence specifically for public health nursing (29). Such a centre could combine with interdisciplinary centres of excellence, such as the RBUP regional mental health centre for children and young people, to provide quality assurance of the service provision.

The study’s limitations

The study is small and of limited scope, and its findings cannot be generalised to a wider context. Our own bias as public health nurses may also have influenced the study, positively as well as negatively. Knowledge of and proximity to the field of practice may be a positive factor in terms of insight, but can also lead to preconceptions with respect to the results.

Conclusion

It is of great importance that public health nurses are able to assess early interactions between children and parents, and that they can assist with interaction challenges. This study suggests that the public health nurses’ assessments of early interaction make up a complex mesh of observations, actions and wider framework conditions (Figure 1).

In the light of existing research the observations made by public health nurses appear to be relevant, but they are not recorded as inputs to a clear system. Although there are several appropriate systematic instruments available for observing infant interaction, none of the interviewed nurses made use of such instruments in their work.

It also appears that the public health nurses’ actions often depend on the services available from their local authority. The study also suggests that the framework provided for professional updating and interdisciplinary collaboration impacts significantly on the actions taken in connection with interactions that give grounds for concern.

The study suggests that there is a need for systematic work on several levels. There is a need for the field of practice to increase the level of awareness surrounding the requirement for safe practice and professional updating. Additionally, degree courses for public health nurses should focus more strongly on practical observation instruments that may come in useful.

In terms of further research, there is a need for a major survey to examine how public health nurses generally assess early interaction, and what actions they take on the basis of these assessments. 

References

1.       Hart S, Schwartz. Fra interaksjon til relasjon: tilknytning hos Winnicott, Bowlby, Stern, Schore og Fonagy. Oslo: Gyldendal Akademisk; 2009.

2.       Klette T. Tid for trøst: en undersøkelse av sammenhenger mellom trøst og trygghet over to generasjoner. Oslo: Det medisinske fakultet, Universitetet i Oslo; 2007. NOVA-rapport 17/2007.

3.       Bowlby J. En sikker base: tilknytningsteoriens kliniske anvendelser. Frederiksberg: Det lille forlag; 1994.

4.       Schore AN. Affect regulation and the origin of the self: the neurobiology of emotional development. New York: Routledge; 2015.

5.       Steinsvåg PØ, Heltne U. Barn som lever med vold i familien: grunnlag for beskyttelse og hjelp. Oslo: Universitetsforlaget; 2011.

6.       Killén K. Barndommen varer i generasjoner: forebygging er alles ansvar. Oslo: Kommuneforlaget; 2013.

7.       Kvello Ø. Barn i risiko: skadelige omsorgssituasjoner. Oslo: Gyldendal Akademisk; 2010.

8.       Neumann CB. Helsesøstres dilemmaer: kategoriseringer, tvil og grensefigurer. Tidsskrift for psykisk helsearbeid. 2008;5(3):268–77.

9.       Ulland E. Hvordan oppdager og formidler helsesøstrene et godt samspill mellom foreldre og barn i alderen 0–3 år? (Master's thesis.) Göteborg: Nordiska högskolan för folkhälsovetenskap; 2005.

10.     Grossmann KE, Bretherton I, Waters E, Grossmann K. Maternal sensitivity: observational studies honoring Mary Ainsworth’s 100th year. Attachment & Human Development. 2013;15 (5–6):443–7.

11.     Tryphonopoulos PD, Letourneau N, DiTommaso E. Caregiver–infant interaction quality: a review of observational assessment tools. Comprehensive Child and Adolescent Nursing. 2016;39(2):107–38.

12.     Deatrick JA, Kearney MH, York R. Effects of home visits to vulnerable young families. Journal of Nursing Scholarship. 2000;32(4):369–75.

13.     Horowitz JA, Murphy CA, Gregory K, Wojcik J, Pulcini J, Solon L. Nurse home visits improve maternal/infant interaction and decrease severity of postpartum depression. Journal of obstetric, gynecologic, and neonatal nursing. 2013;42(3):287–300.

14.     Wu YC, Leng CH, Hsieh WS, Hsu CH, Chen WJ, Gau SSF, et al. A randomized controlled trial of clinic-based and home-based interventions in comparison with usual care for preterm infants: Effects and mediators. Research in developmental disabilities. 2014;35 (10):2384–93.

15.     Brazelton TB, Nugent JK, eds. Vurdering av nyfødte barns adferd: neonatal behavioral assessment scale. Oslo: Cappelen Damm Akademisk; 2013.

16.     Myers BJ. Early intervention using Brazelton training with middle-class mothers and fathers of newborns. Child Development. 1982;53(2):462–71.

17.     Puura K, Mäntymaa M, Luoma I, Kaukonen P, Guedeney A, Salmelin R, et al. Infants' social withdrawal symptoms assessed with a direct infant observation method in primary health care. Infant Behavior and Development. 2010;33(4):579–88.

18.     Tjora AH. Kvalitative forskningsmetoder i praksis. Oslo: Gyldendal Akademisk; 2012.

19.     Eberhard-Gran M, Slinning K, Rognerud M. Screening for barseldepresjon – en kunnskapsoppsummering. Tidsskrift for Den norske legeforening. 2014;134(3):297–301.

20.     Helsedirektoratet. Nasjonal faglig retningslinje: Helsestasjons- og skolehelsetjenesten. Oslo; 2019. Available at: https://helsedirektoratet.no/retningslinjer/helsestasjons-og-skolehelsetjenesten (downloaded 09.09.2019).    

21.     Mesman J, Emmen RA. Mary Ainsworth's legacy: a systematic review of observational instruments measuring parental sensitivity. Attachment & Human Development. 2013;15 (5–6):485–506.

22.     Pederson DR, Bailey HN, Tarabulsy GM, Bento S, Moran G. Understanding sensitivity: lessons learned from the legacy of Mary Ainsworth. Attachment & Human Development. 2014;16(3):261–70.

23.     Bretherton I. Revisiting Mary Ainsworth’s conceptualization and assessments of maternal sensitivity-insensitivity. Attachment & Human Development. 2013;15 (5–6):460–84.

24.     Santos H, Yang Q, Docherty SL, White-Traut R, Holditch-Davis D. Relationship of maternal psychological distress classes to later mother–infant interaction, home environment, and infant development in preterm infants. Research in Nursing & Health. 2016;39(3):175–86.

25.     Vik K, Aass IM, Willumsen AB, Hafting M. «It's about focusing on the mother's mental health»: screening for postnatal depression seen from the health visitors' perspective – a qualitative study. Scandinavian Journal of Public Health. 2009;37(3):239–45.

26.     Tryphonopoulos PD, Letourneau N, Ditommaso E. Attachment and caregiver–infant interaction: a review of observational-assessment tools. Infant Mental Health Journal. 2014;35(6):642–56.

27.     Killén K, Klette T, Arnevik E. Tidlig mor-barn-samspill i norske familier. Tidsskrift for Norsk psykologforening. 2006;43(7):694–701.

28.     Lov 2. juli 1999 nr. 64 om helsepersonell m.v. (helsepersonelloven). Available at: https://lovdata.no/dokument/NL/lov/1999-07-02-64/%C2%A7amp;#%C2%A7amp (downloaded 09.09.2019).

29.     Norsk Sykepleierforbund, Landsgruppen av helsesøstre. Nasjonalt kompetanse- og utviklingssenter for helsestasjons- og skolehelsetjenesten. En idé- og planskisse. Available at: https://www.nsf.no/Content/254457/NASJONALT%20kompetansesenter%20%20Presentasjon%20(2).pdf (downloaded 09.09.2019).