care, health and development Child: Original Article bs_bs_banner
doi:10.1111/cch.12150
Maternal and child health nurses’ self-perceived confidence in dealing with child behaviour problems A. Sarkadi,*‡ A. Gulenc‡ and H. Hiscock†‡§ *Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden †Centre for Community Child Health, The Royal Children’s Hospital Melbourne, Vic., Australia ‡Murdoch Children’s Research Institute, Melbourne, Vic., Australia, and §Department of Paediatrics, University of Melbourne, Melbourne, Vic., Australia Accepted for publication 29 March 2014
Abstract
Keywords child health services child behaviour disorders, health personnel, maternal-child health centres, parenting Correspondence: Anna Sarkadi, Department of Women’s and Children’s Health, Uppsala University, Uppsala 75185, Sweden E-mail: [email protected]
324
Background Addressing behaviour problems in children is increasingly becoming part of routine care. The question therefore arises as to which workforce members are best suited to deliver structured interventions and what skill sets they might need apart from knowledge of the specific parenting programme offered. Objectives To assess maternal and child health (MCH) nurses’ self-perceived confidence in dealing with child behaviour problems. Design Cross-sectional questionnaire study. Data collection occurred prior to cluster randomization in the Families in Mind trial. Setting MCH clinics in nine local government areas in greater Melbourne, in 2010. Participants All MCH nurses in the nine areas were invited to participate, 153 (79%) completed the survey. Main outcomes measures Nurses’ comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems. Results The majority of nurses (63%) viewed it as their role to deal with, rather than refer, child behaviour problems and felt that the task was rewarding (86%). They believed that parenting advice should be offered universally, rather than only to families with severe problems (94%). Nurses felt rather comfortable and competent to broach and discuss child behaviour problems without need for prior parental request, but somewhat less comfortable and competent to manage child behaviour problems or to make a difference. Experienced nurses (>10 years in practice) felt more comfortable and competent. Nurses described that the major challenge in their dealing with child behaviour problems was parental denial or resistance (60%). Conclusions MCH nurses are at the frontline of preventive medical services for families with young children where behaviour problems are a common concern. Because managing young children’s behaviour problems primarily occurs through adult behaviour change, techniques addressing parent denial and non-compliance, such as motivational interviewing and empowerment should be a part of MCH nurses’ skill sets.
© 2014 John Wiley & Sons Ltd
MCH nurses and child behaviour problems
Introduction
325
Methods
Child behaviour problems are common and one of the leading causes for parents to seek out health professionals during the early years (Sawyer et al. 2001; Sayal 2006). The evidence for parenting programmes in preventing and managing child behaviour problems is growing (Furlong et al. 2013) and they are increasingly becoming a part of publicly financed, universally available interventions for parents of young children (Department for Education 2012). When addressing behaviour problems in children becomes a part of routine care the question arises as to which workforce members are best suited to deliver such interventions and what skill sets they might need apart from knowledge of the specific parenting programme offered. Maternal and child health (MCH) nurses are at the frontline of health and developmental services for Australian families with young children aged from birth to 6 years (Goldfeld et al. 2003). The service is free, universal, and is estimated to be used by 98% families in the first few months of an infant’s life and by 58% at the 3.5-year ‘key ages and stages’ visit (Department of Education and Early Childhood Development 2013). MCH training, practices, guidelines and titles vary by state and territory, but by and large nurses operate in a manner similar to the UK’s health visitors. To practice as a MCH nurse in the state of Victoria, nurses must have three qualifications, i.e. nursing, midwifery and a further year of training in MCH. Because MCH nurses are the first line of contact for families with young children, it is important to know how competent and confident nurses feel about dealing with child behaviour problems and what their educational needs might be. In this study we surveyed Victorian MCH nurses on their comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems in their well child clinics.
Participants All nurses working in nine local government areas of greater Melbourne, Australia were approached to participate. The nine areas are all taking part in the Families in Mind trial, a clusterrandomized controlled trial aiming to prevent early childhood mental health problems (Hiscock et al. 2012). As part of the trial, intervention nurses are trained to deliver a universal parenting programme (Hiscock et al. 2008) providing anticipatory guidance for effectively managing challenging behaviour and preventing mental health problems in preschool children. This survey was done prior to randomization and training.
Data collection Nurses were asked to complete a survey to evaluate their selfperceived comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems in their clinics (Table 1). Questions were identical to those previously used in the trial of the universal parenting programme delivered in this study (Hiscock et al. 2008).
Statistical analysis We used descriptive statistics to describe the characteristics of our sample and nurses’ responses (Table 1). To compare responders and non-responders we assigned each nurse a score based on the socio-economic status of their local government areas, using the Socio-Economic Indexes for Areas (SEIFA); higher scores represent less disadvantage) (Australian Bureau of Statistics 2013). To allow for comparisons between different groups of responding nurses, the following dichotomizations
Table 1. Nurses’ self-perceived comfort and competence in dealing with child behaviour problems Response options Question area
Category
Self-perceived comfort with child behaviour problems
Comfortable . . . Broaching child’s behaviour problems with parent Discussing child’s behaviour problems managing child’s behaviour problems Competent . . . Broaching child’s behaviour problems with parent Discussing child’s behaviour problems Managing child’s behaviour problems Making a difference to child’s behaviour problems
Self-perceived competence in child behaviour problems
Not at all % (n)
A little % (n)
Quite % (n)
Very % (n)
0 (0) 0 (0) 0 (0)
5 (7) 4 (6) 12 (19)
40 (62) 37 (89) 59 (62)
55 (84) 59 (89) 29 (44)
1 (1) 0 (0) 0 (0) 1 (1)
9 (13) 10 (15) 20 (30) 24 (37)
55 (84) 52 (80) 60 (91) 57 (87)
35 (54) 38 (57) 20 (31) 18 (27)
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
326 A. Sarkadi et al.
were made. Nurse experience was dichotomized into 10 years of experience or less and more than 10 years of experience. Items with response options Not at all; A little; Quite; and Very were dichotomized into Very versus Not very, whereas items with response options Strongly disagree; Disagree; Neither agree nor disagree; Agree; and Strongly agree were dichotomized merging the Strongly agree and Agree options into one category of Agree and the remaining response options into one variable of Disagree in case of directly coded items. For indirectly coded items the opposite was done, i.e. Strongly disagree and Disagree were merged into one variable of Disagree and the remaining response options into one variable of Agree. Type of difficulty encountered when dealing with child behaviour problems was an open-ended question and responses were coded into five content categories: parental denial or resistance; lack of time; parent mental health or other global family issues; nurse’s own lack of knowledge or resources; other issues. These categories were not predetermined, but generated from the data through manifest content analysis (Graneheim & Lundman 2004).
Results Of 194 eligible nurses, 153 completed the pre-training survey (79%). Mean SEIFA score for respondents was 1033 (SD = 21) compared with 1025 (SD = 31) for non-respondents (difference N.S.); the mean state of Victoria SEIFA score is 997 (SD = 44). Most nurses in the sample were experienced with 56% having worked for more than 10 years in MCH practice. Only one nurse indicated having more than 25% of her consultations occurring in other languages than English. With the categories ‘very’ and ‘quite’ merged, more than 95% of nurses indicated they felt comfortable broaching and discussing child behaviour problems with parents, whereas somewhat fewer (87%) felt quite or very comfortable managing
these problems. Similarly, 90% of nurses felt competent in broaching and discussing child behaviour problems with parents, whereas 80% felt quite or very competent in managing them (Table 1). Looking specifically at the category indicating highest self-perceived comfort and confidence, the pattern became a bit more fragmented. Although more than half of the nurses felt very comfortable broaching the issue of and discussing child behaviour problems with parents (55% and 58% respectively), less than a third (29%) felt very comfortable managing child behaviour problems in their practice. In terms of feeling very competent in these areas, the numbers were even lower: 35% indicated ‘very competent’ for broaching the issue, 37% for discussing it and 20% for managing child behaviour problems respectively. Finally, only 18% of nurses felt very competent in being able to make a difference to a child’s behavioural problems. More than 10 years of experience as an MCH nurse was associated with increased comfort in discussing and managing child behaviour (P = 0.036 and P < 0.0001 respectively). Similarly, nurses with less than 10 years of experience were less likely to feel very competent in discussing and managing child behaviour (P < 0.0001). In addition, less experienced nurses were less likely to feel very competent in making a difference for children’s behavioural problems (P < 0.0001). Although two-thirds of the nurses (63%) did not think that their main role would be to refer children with behaviour problems to other professionals, 26% were actually unsure and 11% thought referral to be their main role. Similarly, although the majority (66%) stated that they would not only offer treatment for child behaviour problems if parents requested it, 18% reported that they would only offer their advice upon parental request and 16% were unsure (Table 2). Nurses generally disagreed (94%) that parenting programmes should only be offered to families with severe problems. Most of the nurses (82%) also disagreed with the
Table 2. Nurses’ attitudes relating to dealing with child behaviour problems in their practices Response options Questionnaire item Parenting programmes should only be offered to those with severe problems Counselling parents when children have behaviour problems is rewarding MCH nurse’s role is to refer children with behaviour problems to other professionals I would only offer advice on child behaviour problems when a parent requests it Behaviour problems are too difficult due to social and environmental factors for health professionals to have an impact MCH, maternal and child health.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
Strongly disagree % (n)
Disagree % (n)
Neither % (n)
Agree % (n)
Strongly agree % (n)
44 (68) 1 (1) 10 (16) 10 (15) 16 (24)
49 (75) 2 (3) 53 (80) 56 (86) 66 (101)
5 (8) 10 (16) 26 (40) 16 (24) 12 (19)
1 (2) 69 (105) 9 (13) 17 (26) 4 (6)
0 (0) 18 (27) 2 (3) 1 (2) 2 (3)
MCH nurses and child behaviour problems
statement that behaviour problems in children would be too difficult to manage for health professionals and 86% found it rewarding to counsel parents. Almost 60% of nurses indicated parental denial or resistance as the major challenge they have encountered when dealing with child behaviour issues. The second most common challenge was lack of time (18%), and the third parent mental health or other global family issues (15%). Only a few nurses felt that the challenge was lack of knowledge or resources on their own part (4%) or other issues, having to do with the structure of service delivery (3%).
Discussion In summary, the majority of nurses viewed it as their role to deal with, rather than refer, child behaviour problems in the general population and felt that the task was rewarding. They felt rather comfortable and competent to broach and discuss the issue without need for prior parental request, but somewhat less comfortable and competent to manage child behaviour problems or to actually make a difference. Thus, there seems to be room for improvement to enhance nurses’ self-perceived confidence in these areas. Interestingly, nurses described that parental denial or resistance was a major challenge in their dealing with child behaviour problems. This is in accordance with earlier findings on MCH nurses’ perceived challenges on raising issues of child overweight with parents (Edvardsson et al. 2009). This would imply that nurses experience difficulties and lack training to deal with parental motivation and acceptance. Because managing young children’s behaviour problems largely happens through adult behaviour change in the first place, techniques, such as motivational interviewing, enhancing acceptance, empowerment, and dealing with guilt and shame would probably need to be a part of nurses’ skill sets. In fact, a whole new notion of client-provider relationship seems to be under development (Briggs 2006) and will likely have implications for nurses’ continuous education needs.
MCH nurses need support to implement universal prevention programmes From a public health perspective it is an important finding that nurses seemed to have adopted a view that parenting advice should be offered universally. Often professionals feel it is more intuitive to offer help to those most in need and there are a number of targeted programmes offered to vulnerable families in the MCH setting (McDonald et al. 2012). However, in terms
327
of population level change, it is imperative that preventive interventions are universal in both offer and reach (The Marmot Review 2010). It is also important to realize that some nurses neither see it as their role to counsel parents regarding child behaviour problems, nor find it rewarding to do so. The more experienced nurses felt more comfortable and competent so self-perceived confidence it is amenable to support and intervention and increases with practice (Benner 1984). However, a number of nurses indicated they lacked the time to deal with child behaviour problems. Because such interventions are time consuming administrators will have to acknowledge the resource implications of implementing new parenting interventions in the primary care setting.
Key messages • Addressing behaviour problems in children is increasingly becoming part of routine care • The majority of surveyed MCH nurses viewed it as their role to deal with, rather than refer, child behaviour problems and felt that the task was rewarding • Nurses felt more confident broaching and discussing child behaviour problems with parents than managing them • Nurses’ major challenge in dealing with child behaviour problems was parental denial or resistance • Techniques addressing parent denial and non-compliance, such as motivational interviewing and empowerment, should therefore be a part of MCH nurses’ skill sets
Funding This trial is funded by a Partnership Grant from the National Health and Medical Research Council of Australia (project grant number: 546525). A. Sarkadi is supported by a joint grant from the Swedish FORMAS, VR, FORTE, and VINNOVA research councils (grant number 259-2012-68) and a senior lecturer grant from the Gillbergska Foundation in Uppsala. H. Hiscock is supported by NHMRC Career Development Award 607351. Murdoch Childrens Research Institute research is supported by the Victorian Government’s Operational Infrastructure Support Program.
Acknowledgements We wish to thank the co-ordinating MCH nurses in Bayside, Casey, Darebin, Hobsons Bay, Knox, Manningham, Mornington
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
328 A. Sarkadi et al.
Peninsula, Port Phillip, Yarra Ranges in greater Melbourne for their support and participation in the Families in Mind trial. We are also grateful to the Department of Education and Early Childhood Development and Municipal Association of Victoria for their support and participation in the trial.
References Australian Bureau of Statistics (2013) Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia [Online]. Available at: http://www.abs.gov.au/Ausstats/[email protected]/0/ 4E5531D7B85288A9CA2577E4000E1F9E?OpenDocument (last accessed 14 October 2013). Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley Pub. Co, Menlo Park, CA, USA. Briggs, C. (2006) Nursing practice in community child health: developing the nurse-client relationship. Contemporary Nurse, 23, 303–311. Department for Education (2012) Find a parenting programme. In: GOVERNMENT, U. (ed.). Department of Education and Early Childhood Development (2013). Early identification and attention to child health needs [Online]. Victorian Government. Available at: http://www.education .vic.gov.au/about/research/pages/305stagesvisit.aspx (last accessed 10 October 2013). Edvardsson, K., Edvardsson, D. & Hörnsten, Å. (2009) Raising issues about children’s overweight – maternal and child health nurses’ experiences. Journal of Advanced Nursing, 65, 2542–2551. Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S. M. & Donnelly, M. (2013) Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
early-onset conduct problems in children aged 3 to 12 years (Review). Evidence Based Child Health, 8, 318–692. Goldfeld, S. R., Wright, M. & Oberklaid, F. (2003) Parents, infants and health care: utilization of health services in the first 12 months of life. Journal of Paediatrics and Child Health, 39, 249–253. Graneheim, U. H. & Lundman, B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105–112. Hiscock, H., Bayer, J., Lycett, K., Ukoumunne, O., Shaw, D., Gold, L., Gerner, B., Loughman, A. & Wake, M. (2012) Preventing mental health problems in children: the Families in Mind populationbased cluster randomised controlled trial. BMC Public Health, 12, 420. Hiscock, H., Bayer, J. K., Price, A., Ukoumunne, O. C., Rogers, S. & Wake, M. (2008) Universal parenting programme to prevent early childhood behavioural problems: cluster randomised trial. BMJ (Clinical Research Ed.), 336, 318–321. McDonald, M., Moore, T. & Goldfeld, S. 2012. Sustained home visiting for vulnerable families and children: a literature review of effective programs. The Royal Children’s Hospital Centre for Community Child Health, Murdoch Childrens Research Institute. Sawyer, M. G., Arney, F. M., Baghurst, P. A., Clark, J. J., Graetz, B. W., Kosky, R. J., Nurcombe, B., Patton, G. C., Prior, M. R., Raphael, B., Rey, J. M., Whaites, L. C. & Zubrick, S. R. (2001) The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being. The Australian and New Zealand Journal of Psychiatry, 35, 806–814. Sayal, K. (2006) Annotation: pathways to care for children with mental health problems. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 47, 649–659. The Marmot Review (2010) Fair Society, Healthy Lives, 2010.
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doi:10.1111/cch.12150
Maternal and child health nurses’ self-perceived confidence in dealing with child behaviour problems A. Sarkadi,*‡ A. Gulenc‡ and H. Hiscock†‡§ *Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden †Centre for Community Child Health, The Royal Children’s Hospital Melbourne, Vic., Australia ‡Murdoch Children’s Research Institute, Melbourne, Vic., Australia, and §Department of Paediatrics, University of Melbourne, Melbourne, Vic., Australia Accepted for publication 29 March 2014
Abstract
Keywords child health services child behaviour disorders, health personnel, maternal-child health centres, parenting Correspondence: Anna Sarkadi, Department of Women’s and Children’s Health, Uppsala University, Uppsala 75185, Sweden E-mail: [email protected]
324
Background Addressing behaviour problems in children is increasingly becoming part of routine care. The question therefore arises as to which workforce members are best suited to deliver structured interventions and what skill sets they might need apart from knowledge of the specific parenting programme offered. Objectives To assess maternal and child health (MCH) nurses’ self-perceived confidence in dealing with child behaviour problems. Design Cross-sectional questionnaire study. Data collection occurred prior to cluster randomization in the Families in Mind trial. Setting MCH clinics in nine local government areas in greater Melbourne, in 2010. Participants All MCH nurses in the nine areas were invited to participate, 153 (79%) completed the survey. Main outcomes measures Nurses’ comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems. Results The majority of nurses (63%) viewed it as their role to deal with, rather than refer, child behaviour problems and felt that the task was rewarding (86%). They believed that parenting advice should be offered universally, rather than only to families with severe problems (94%). Nurses felt rather comfortable and competent to broach and discuss child behaviour problems without need for prior parental request, but somewhat less comfortable and competent to manage child behaviour problems or to make a difference. Experienced nurses (>10 years in practice) felt more comfortable and competent. Nurses described that the major challenge in their dealing with child behaviour problems was parental denial or resistance (60%). Conclusions MCH nurses are at the frontline of preventive medical services for families with young children where behaviour problems are a common concern. Because managing young children’s behaviour problems primarily occurs through adult behaviour change, techniques addressing parent denial and non-compliance, such as motivational interviewing and empowerment should be a part of MCH nurses’ skill sets.
© 2014 John Wiley & Sons Ltd
MCH nurses and child behaviour problems
Introduction
325
Methods
Child behaviour problems are common and one of the leading causes for parents to seek out health professionals during the early years (Sawyer et al. 2001; Sayal 2006). The evidence for parenting programmes in preventing and managing child behaviour problems is growing (Furlong et al. 2013) and they are increasingly becoming a part of publicly financed, universally available interventions for parents of young children (Department for Education 2012). When addressing behaviour problems in children becomes a part of routine care the question arises as to which workforce members are best suited to deliver such interventions and what skill sets they might need apart from knowledge of the specific parenting programme offered. Maternal and child health (MCH) nurses are at the frontline of health and developmental services for Australian families with young children aged from birth to 6 years (Goldfeld et al. 2003). The service is free, universal, and is estimated to be used by 98% families in the first few months of an infant’s life and by 58% at the 3.5-year ‘key ages and stages’ visit (Department of Education and Early Childhood Development 2013). MCH training, practices, guidelines and titles vary by state and territory, but by and large nurses operate in a manner similar to the UK’s health visitors. To practice as a MCH nurse in the state of Victoria, nurses must have three qualifications, i.e. nursing, midwifery and a further year of training in MCH. Because MCH nurses are the first line of contact for families with young children, it is important to know how competent and confident nurses feel about dealing with child behaviour problems and what their educational needs might be. In this study we surveyed Victorian MCH nurses on their comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems in their well child clinics.
Participants All nurses working in nine local government areas of greater Melbourne, Australia were approached to participate. The nine areas are all taking part in the Families in Mind trial, a clusterrandomized controlled trial aiming to prevent early childhood mental health problems (Hiscock et al. 2012). As part of the trial, intervention nurses are trained to deliver a universal parenting programme (Hiscock et al. 2008) providing anticipatory guidance for effectively managing challenging behaviour and preventing mental health problems in preschool children. This survey was done prior to randomization and training.
Data collection Nurses were asked to complete a survey to evaluate their selfperceived comfort, competency, attitudes and perceived difficulties in dealing with child behaviour problems in their clinics (Table 1). Questions were identical to those previously used in the trial of the universal parenting programme delivered in this study (Hiscock et al. 2008).
Statistical analysis We used descriptive statistics to describe the characteristics of our sample and nurses’ responses (Table 1). To compare responders and non-responders we assigned each nurse a score based on the socio-economic status of their local government areas, using the Socio-Economic Indexes for Areas (SEIFA); higher scores represent less disadvantage) (Australian Bureau of Statistics 2013). To allow for comparisons between different groups of responding nurses, the following dichotomizations
Table 1. Nurses’ self-perceived comfort and competence in dealing with child behaviour problems Response options Question area
Category
Self-perceived comfort with child behaviour problems
Comfortable . . . Broaching child’s behaviour problems with parent Discussing child’s behaviour problems managing child’s behaviour problems Competent . . . Broaching child’s behaviour problems with parent Discussing child’s behaviour problems Managing child’s behaviour problems Making a difference to child’s behaviour problems
Self-perceived competence in child behaviour problems
Not at all % (n)
A little % (n)
Quite % (n)
Very % (n)
0 (0) 0 (0) 0 (0)
5 (7) 4 (6) 12 (19)
40 (62) 37 (89) 59 (62)
55 (84) 59 (89) 29 (44)
1 (1) 0 (0) 0 (0) 1 (1)
9 (13) 10 (15) 20 (30) 24 (37)
55 (84) 52 (80) 60 (91) 57 (87)
35 (54) 38 (57) 20 (31) 18 (27)
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
326 A. Sarkadi et al.
were made. Nurse experience was dichotomized into 10 years of experience or less and more than 10 years of experience. Items with response options Not at all; A little; Quite; and Very were dichotomized into Very versus Not very, whereas items with response options Strongly disagree; Disagree; Neither agree nor disagree; Agree; and Strongly agree were dichotomized merging the Strongly agree and Agree options into one category of Agree and the remaining response options into one variable of Disagree in case of directly coded items. For indirectly coded items the opposite was done, i.e. Strongly disagree and Disagree were merged into one variable of Disagree and the remaining response options into one variable of Agree. Type of difficulty encountered when dealing with child behaviour problems was an open-ended question and responses were coded into five content categories: parental denial or resistance; lack of time; parent mental health or other global family issues; nurse’s own lack of knowledge or resources; other issues. These categories were not predetermined, but generated from the data through manifest content analysis (Graneheim & Lundman 2004).
Results Of 194 eligible nurses, 153 completed the pre-training survey (79%). Mean SEIFA score for respondents was 1033 (SD = 21) compared with 1025 (SD = 31) for non-respondents (difference N.S.); the mean state of Victoria SEIFA score is 997 (SD = 44). Most nurses in the sample were experienced with 56% having worked for more than 10 years in MCH practice. Only one nurse indicated having more than 25% of her consultations occurring in other languages than English. With the categories ‘very’ and ‘quite’ merged, more than 95% of nurses indicated they felt comfortable broaching and discussing child behaviour problems with parents, whereas somewhat fewer (87%) felt quite or very comfortable managing
these problems. Similarly, 90% of nurses felt competent in broaching and discussing child behaviour problems with parents, whereas 80% felt quite or very competent in managing them (Table 1). Looking specifically at the category indicating highest self-perceived comfort and confidence, the pattern became a bit more fragmented. Although more than half of the nurses felt very comfortable broaching the issue of and discussing child behaviour problems with parents (55% and 58% respectively), less than a third (29%) felt very comfortable managing child behaviour problems in their practice. In terms of feeling very competent in these areas, the numbers were even lower: 35% indicated ‘very competent’ for broaching the issue, 37% for discussing it and 20% for managing child behaviour problems respectively. Finally, only 18% of nurses felt very competent in being able to make a difference to a child’s behavioural problems. More than 10 years of experience as an MCH nurse was associated with increased comfort in discussing and managing child behaviour (P = 0.036 and P < 0.0001 respectively). Similarly, nurses with less than 10 years of experience were less likely to feel very competent in discussing and managing child behaviour (P < 0.0001). In addition, less experienced nurses were less likely to feel very competent in making a difference for children’s behavioural problems (P < 0.0001). Although two-thirds of the nurses (63%) did not think that their main role would be to refer children with behaviour problems to other professionals, 26% were actually unsure and 11% thought referral to be their main role. Similarly, although the majority (66%) stated that they would not only offer treatment for child behaviour problems if parents requested it, 18% reported that they would only offer their advice upon parental request and 16% were unsure (Table 2). Nurses generally disagreed (94%) that parenting programmes should only be offered to families with severe problems. Most of the nurses (82%) also disagreed with the
Table 2. Nurses’ attitudes relating to dealing with child behaviour problems in their practices Response options Questionnaire item Parenting programmes should only be offered to those with severe problems Counselling parents when children have behaviour problems is rewarding MCH nurse’s role is to refer children with behaviour problems to other professionals I would only offer advice on child behaviour problems when a parent requests it Behaviour problems are too difficult due to social and environmental factors for health professionals to have an impact MCH, maternal and child health.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
Strongly disagree % (n)
Disagree % (n)
Neither % (n)
Agree % (n)
Strongly agree % (n)
44 (68) 1 (1) 10 (16) 10 (15) 16 (24)
49 (75) 2 (3) 53 (80) 56 (86) 66 (101)
5 (8) 10 (16) 26 (40) 16 (24) 12 (19)
1 (2) 69 (105) 9 (13) 17 (26) 4 (6)
0 (0) 18 (27) 2 (3) 1 (2) 2 (3)
MCH nurses and child behaviour problems
statement that behaviour problems in children would be too difficult to manage for health professionals and 86% found it rewarding to counsel parents. Almost 60% of nurses indicated parental denial or resistance as the major challenge they have encountered when dealing with child behaviour issues. The second most common challenge was lack of time (18%), and the third parent mental health or other global family issues (15%). Only a few nurses felt that the challenge was lack of knowledge or resources on their own part (4%) or other issues, having to do with the structure of service delivery (3%).
Discussion In summary, the majority of nurses viewed it as their role to deal with, rather than refer, child behaviour problems in the general population and felt that the task was rewarding. They felt rather comfortable and competent to broach and discuss the issue without need for prior parental request, but somewhat less comfortable and competent to manage child behaviour problems or to actually make a difference. Thus, there seems to be room for improvement to enhance nurses’ self-perceived confidence in these areas. Interestingly, nurses described that parental denial or resistance was a major challenge in their dealing with child behaviour problems. This is in accordance with earlier findings on MCH nurses’ perceived challenges on raising issues of child overweight with parents (Edvardsson et al. 2009). This would imply that nurses experience difficulties and lack training to deal with parental motivation and acceptance. Because managing young children’s behaviour problems largely happens through adult behaviour change in the first place, techniques, such as motivational interviewing, enhancing acceptance, empowerment, and dealing with guilt and shame would probably need to be a part of nurses’ skill sets. In fact, a whole new notion of client-provider relationship seems to be under development (Briggs 2006) and will likely have implications for nurses’ continuous education needs.
MCH nurses need support to implement universal prevention programmes From a public health perspective it is an important finding that nurses seemed to have adopted a view that parenting advice should be offered universally. Often professionals feel it is more intuitive to offer help to those most in need and there are a number of targeted programmes offered to vulnerable families in the MCH setting (McDonald et al. 2012). However, in terms
327
of population level change, it is imperative that preventive interventions are universal in both offer and reach (The Marmot Review 2010). It is also important to realize that some nurses neither see it as their role to counsel parents regarding child behaviour problems, nor find it rewarding to do so. The more experienced nurses felt more comfortable and competent so self-perceived confidence it is amenable to support and intervention and increases with practice (Benner 1984). However, a number of nurses indicated they lacked the time to deal with child behaviour problems. Because such interventions are time consuming administrators will have to acknowledge the resource implications of implementing new parenting interventions in the primary care setting.
Key messages • Addressing behaviour problems in children is increasingly becoming part of routine care • The majority of surveyed MCH nurses viewed it as their role to deal with, rather than refer, child behaviour problems and felt that the task was rewarding • Nurses felt more confident broaching and discussing child behaviour problems with parents than managing them • Nurses’ major challenge in dealing with child behaviour problems was parental denial or resistance • Techniques addressing parent denial and non-compliance, such as motivational interviewing and empowerment, should therefore be a part of MCH nurses’ skill sets
Funding This trial is funded by a Partnership Grant from the National Health and Medical Research Council of Australia (project grant number: 546525). A. Sarkadi is supported by a joint grant from the Swedish FORMAS, VR, FORTE, and VINNOVA research councils (grant number 259-2012-68) and a senior lecturer grant from the Gillbergska Foundation in Uppsala. H. Hiscock is supported by NHMRC Career Development Award 607351. Murdoch Childrens Research Institute research is supported by the Victorian Government’s Operational Infrastructure Support Program.
Acknowledgements We wish to thank the co-ordinating MCH nurses in Bayside, Casey, Darebin, Hobsons Bay, Knox, Manningham, Mornington
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 2, 324–328
328 A. Sarkadi et al.
Peninsula, Port Phillip, Yarra Ranges in greater Melbourne for their support and participation in the Families in Mind trial. We are also grateful to the Department of Education and Early Childhood Development and Municipal Association of Victoria for their support and participation in the trial.
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