ORIGINAL ARTICLE
Parental groups during the child’s first year: an interview study of parents’ experiences Esther Hj€almhult, Kari Glavin, Toril Økland and Sidsel Tveiten
Aims and objectives. To highlight what was important to parents with respect to consultation groups at well-child clinics. Background. Parents managing of their role as parents affect the child’s health and are therefore an important priority for public health. Well-child clinics in Norway practise consultations in groups to support parents and to facilitate social network; however, few studies explore parents’ perspective of this kind of groups. Design. Grounded theory. Methods. We used classical grounded theory with a generative and constant comparative approach. Data were collected through seven focus groups and two individual interviews with the parents of children aged 8–15 months. Results. The parents were most concerned about how to achieve connection without accountability and how to obtain relevant health information. They managed this by ‘multipositioning’, encompassing the strategies of: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information. The use of these strategies explains how they resolved their challenges. Conclusion. Parental groups seem to be popular and have great potential to establish a social network; however, underestimating the need for structure and continuity in the groups might cause this opportunity to be missed. Relevance to clinical practice. Understanding parents’ perspectives will be useful when planning strategies to strengthen parental groups at well-child clinics and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.
What does this paper contribute to the wider global clinical community?
• Parental
•
groups during the child’s first year have great potential to establish social network and increase parents’ satisfaction and exchange health information. Underestimated need for structure and continuity in the groups might cause this opportunity to be missed.
Key words: grounded theory, health information seeking, infant, parenting, public health nurse, social support Accepted for publication: 10 November 2013
Introduction Parents experience being a parent in the child’s first year, especially the first child, as overwhelming and exciting Authors: Esther Hj€ almhult, PhD, RPHN, Associate Professor, Faculty of Health and Social Sciences, Bergen University College, Bergen; Kari Glavin, PhD, RPHN, Associate Professor, Oslo and Akershus College of Applied Science, Oslo; Toril Økland, MSc, RPHN, Head of Unit of Health Promoting, Arstad, Bergen; Sidsel Tveiten, PhD, RN, Associate Professor, Oslo and Akershus College of Applied Science, Oslo, Norway
2980
€ (Nystr€ om & Ohrling 2004, Forster et al. 2008, Hj€ almhult & Lomborg 2012). How parents manage their parental role affects the child’s health and development and is an important priority for public health. Parents’ mental health Correspondence: Esther Hj€ almhult, Associate Professor, Faculty of Health and Social Sciences, Bergen University College, Møllendalsveien 6, N- 5009 Bergen, Norway. Telephone: +47 55 58 75 00/849. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989, doi: 10.1111/jocn.12528
Original article
and social circumstances is a central factor influencing children (Tarkka et al. 1999, Surkan et al. 2006, LeahyWarren et al. 2011), and their satisfaction is important for their motivation to take care and interact with their child (George 2005, Salonen et al. 2010). Various disease prevention and health promotion programmes target adults to facilitate the parental role in improving children’s health. One idea is developing a supportive social network during the child’s first year (Saetre et al. 1996, Mathiesen & Sanson 2000, Guest & Keatinge 2009, Barnes et al. 2010).
Background The way first-time mothers experience social relationships while on maternity leave reveals that the mothers seek company and want to share experience with other mothers (Alstveit et al. 2010). Other studies (Hanna et al. 2002, Kruske et al. 2004) found that first-time parents benefit from participating in groups for first-time parents in many ways. They develop social networks, gain self-confidence and obtain access to relevant information on child health and parenting. In a Cochrane review, Barlow et al. (2012) advocated using group-based parenting programmes to improve the short-term psychosocial well-being of parents. The group-based programmes had implications for both stress and confidence. Several studies report that maternal and child health nurses play a key role in facilitating groups for parents (Hanna et al. 2002, Petersson et al. 2004, Gardner & Deatrick 2006). Norway’s municipal well-child clinics (WCCs) have a long tradition in health promotion and disease prevention among families. The WCCs combine population-based activities through individual contact (Norwegian Directorate of Health 2004). The frequent and close contact between public health nurses (PHNs) and new families is a unique platform for collaborating on children’s upbringing. This provides a distinctive opportunity for disease prevention (Glavin & Kvarme 2003). In addition to individual consultations, routine consultation groups at the WCCs are recommended such that like-minded parents can meet: exchanging experiences and achieving insight, support and understanding to manage their role as a parent. The idea is that social contact between parents through the WCCs might be a basis for improving the social network in their neighbourhood (Norwegian Directorate of Health 2004). The PHN is the group facilitator. Most of the groups run for five to six sessions during the child’s first year, although this differs around the country. The groups may be important for new families, but research is lacking on how parents experience the parental groups. This study © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Parental groups during the child’s first year
therefore aims to highlight the parents’ view of participating in consultation groups at the WCCs. What is important to them, and how do they bring their issues into the group?
Methods We chose classical grounded theory design, a systematic approach used to explore processes in the context of situated interaction. The aim was to identify how the participants acted to solve their main concern and to generate theory that explained the pattern of behaviour in the study involved (Glaser 1978, 1998, 2005).
Sample The parents were recruited in collaboration with the leaders of public health services and their PHNs, who distributed letters with information to parents visiting the WCC in various districts of a major provincial city. The inclusion criteria were having a child aged 8–15 months, being 18 years or older, speaking Norwegian and having participated in a group at a WCC. Twenty-one parents participated. The aim was to recruit groups of four to six participants, but recruiting was slow, and we included two individual interviews to obtain deeper information. Sixteen mothers and three fathers participated in seven focus group discussions and two mothers in individual interviews. The parents were 18–42 years of age, and 10 were first-time parents and 11 had two to four children. They had participated in the last group four to six times, some two to three times. Several of the participants had higher education.
Data collection and setting We conducted the interviews from November 2011–June 2012 and one group in November 2012. The interviews were conducted at the WCCs except for one individual interview, which was arranged at a quiet office. The first author moderated the discussions, and the co-moderator (TO) assisted and was a discussion partner afterwards. We tried to create a relaxed atmosphere for the participants, starting every session with small talk and giving information about the purpose of the study (Kvale & Brinkman 2009). All parents had their child with them, and they could crawl around in the room or sit with the parents. A semistructured interview guided us with open questions about how they experienced participating in a group at a WCC. The focus groups lasted for 1–15 hours and the
2981
E Hj€almhult et al.
individual interviews 40–55 minutes. First author audiorecorded and transcribed the interviews except for one and took notes manually during that interview and rapidly transcribed the interview. The Norwegian Social Science Data Services approved the study (reference number 27512). The participants gave written information and signed the consent form. We explained the confidentiality issues and the right to withdraw.
Practicing conditional openness
•Curious expecting •Checking mutuality
Seeking to belong
•Want to be listened to •Balancing engagement
Awaiting initiative
•Want structure •Lacking continuity •Appreciate facilitating
Data analysis Data analysis started with open coding, using the constant comparison of incidents exploring similarities and differences (Glaser 1978, 1998). The first author analysed each interview and compared this with the previous one before the next interview, all in a continuous process. Written textual memos enriched the analysis process and facilitated the generation of hypotheses from the data about what happened in the area studied. The co-authors read through the material and contributed to the analysis. Parents’ main concern was identified: what was essential for the parents in the group sessions. First author grouped the codes into broad categories and moved from descriptive concepts such as want to be listened to’ to broader concepts such as ‘seeking to belong’. The study progressed to identify the core category that could capture the patterns of behaviour through which the parents managed their main concern. In selective coding, the focus was on codes related to the core category and, further, we continued theoretical coding, which conceptualised how the substantive codes may relate to each other at a more abstract level. In the process of analysis, we used individual interviews to deepen knowledge and the last focus groups to ensure demographic variety in the data material and thus enrich the emerging codes and hypotheses until we found theoretical saturation (Glaser 1978, 2005).
Results We identified that the parents were primarily concerned about how to achieve connection without accountability and receive health information on a neutral ground. They met this need by ‘multipositioning’. This strategy encompassed four subcategories/strategies: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information (Fig. 1). The parents used these strategies and their properties interchangeably in their search for positioning in the group.
2982
Expecting balanced health information
•Appreciate sorted health information •Expecting facts
Figure 1 Multipositioning to group consultation at well-child clinics.
Conditions of multipositioning The concept of multipositioning is a dynamic process controlled by the parents, more or less distinct and consciously. Various internal and external conditions influenced multipositioning, such as whether they are first-time parents or not, age, network, personal health and the composition of the group. Multipositioning was related to a consideration based on the specific parents’ situation to join a parent group at a WCC. Some mothers could choose to mix group sessions in addition to individual consultations at a WCC or, alternatively, only individual consultations. Others were told: ‘Here everyone participates in groups’. Or ‘I was asked whether I wanted to join a group or have individual consultations – but I felt that they wanted me to choose a group. Thus, I might not have had a real choice’. According to the parents, they might get some dates for group meetings, but the purpose or expectations of the group were seldom explicitly worded. Several parents did not know the rationale for the composition of a group. ‘Is it the mothers who are alike or is it the babies’ age that matters?’. The composition of the group and the relationship with the group facilitator mutually influenced the groups.
Practising conditional openness Curious expecting One typical dimension of multipositioning was that mothers seemed to seek a potential contact. The participants might have a network, but they wondered whether someone new may have entered their environment, and they © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
could thereby get a new friend for chatting, meeting for a walk with a baby buggy or sharing a cup of coffee. First-time parents wanted to compare with like-minded parents and compare their babies and their skills as parents. Even parents with three or four children might be interested:
Parental groups during the child’s first year
‘the chemistry was perfect’. The parents assessed the basis of comparison and relaxed when their situation and their child seemed to be ‘normal’: Two of us breastfed and two did not; this was a recurring theme. We who breastfed strived more, the kids awoke more during the night and increased less in weight than those who got a bottle: they
My wife and I were interested in such groups and, if possible,
were big and stout. It was conspicuous how they varied. I am glad
developing a social network, but we felt we did not need health
that there were two of us. (Ind. B)
information about the baby, because we thought we perhaps knew enough about babies. This was our starting-point … (FG6)
Other parents said that their network and friends did not have children or had older children. Our participants with older children related positive experiences from earlier groups at a WCC, but everyone was not satisfied with the previous groups. However, they all wanted to see what this new group would bring. For example, a mother might be sceptical about joining a group when she had a new child. The PHN promised her if she tried again she could withdraw if she wanted, and curiosity won: … This group however, demonstrates quite another style than the group I participated in with my first child. This group is nice. (FG5)
In an area with many children, a first-time mother could expect to meet many like-minded parents: I was a bit shocked the first time. We were two, and another arrived later, so we had only three people in a group! I thought there should be more participants in a maternity group. I was really looking forward to that. (FG7)
Checking mutuality Parents appreciated if some of the children in their group had the same sex or age or if they lived in the same residential area, the parents had similar experiences and so on. A mother who struggled with breastfeeding or colic was happy if someone else in her group had the same problem or if somebody else could give her hope and advice on how to manage. Being alone and unlike the others could mean that participating would be risky: We figured out jointly that it was a good thing that we all were first-time mothers and that all four had girls. The WCC was initially a constantly comparing template: the development and growth. I certainly felt that, with my child’s development – ‘You must follow the curve!’. (Ind. A)
Mothers were especially satisfied when they made contact with one or more group members. They also developed connections with mothers in different situations because © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Some mothers commented that it would not be okay to participate in a group if they had a child with delayed development or something else stigmatising. Others mentioned that the PHN was eager to focus on the large normal range and that one child could develop early in one area and another in something else.
Seeking to belong Want to be listened to The participants wanted to be seen and accepted in the group and were careful not to be outsiders. Some mothers missed like-minded mothers in the neighbourhood and appreciated the consultation group. ‘This group is luxurious and the period of leave is fantastic’. First-time mothers commented on the stress at home in the first period and the feeling of relaxation when they discovered like-minded people in the group. Mothers advocated common sense when neighbours delivering the very same week were placed in different groups at a WCC and both wanted to be in the same group. Geographical proximity and walking distance facilitated informal contact. If the child had special problems such as colic, sleeping, allergies or nutrition, the group seemed not to be the right place for several group members. Parents mentioned that PHNs wanted them not to talk about deep problems in the group and just about issues from the current baby. Sibling rivalry, the relationship with the partner or life together as a family was therefore not usually brought up in the groups. Perhaps a mother with problems could get understanding from another participant in the group. In a few groups, they met regularly one to time times a month. In some districts, fathers contributed more to the WCC groups. A mother reported that, during the first group meeting, she was the only one without her husband, and he therefore joined her to the next group session. Then, he was the only man. During the child’s first year, however, everyone continued participating in this group, even privately, and the father said finally: ‘I have looked forward to every meeting!’.
2983
E Hj€almhult et al.
Balancing engagement A characteristic strategy of multipositioning in the groups was balancing engagement. In the focus group interviews, participants discussed the risk of being stigmatised and were therefore quiet and glossed over problems. Perhaps if a fearless participant revealed something, others could acknowledge the same problem: If the PHN asked: “How are you?” “Oh fine, thank you”. Then I
Another issue related to structure was how to organise vaccination of the children. Some mothers did not like it when this was carried out in the group; they were nervous and preferred to be alone with the PHN. Others commented on the disturbance when each parent successively left the group to get the child immunised and talked briefly with the PHN. A third moment was mothers who said, laughing, that it was okay to be alone in the group, because then they could talk about what they wanted.
might say: “Oh, everything is okay for you? So I am the only one who breastfeeds twice a night and so on and I am out of bed and we are sleeping too little?” “Oh no, that is not right, we don’t sleep either”. So we prettify a bit and do not want to show our problems. (FG4)
Participants balanced their engagement regarding the climate in their group. Some said that a 20-year-old mother had dropped out of their group of mothers who were aged 30–35 years; she probably felt excluded. Other groups succeeded despite differences. Combined private engagement might stimulate the mutual connection: Our group has been functioning well! The youngest is about 22 years old, and I think the oldest is 42 years of age. But we are very harmonious. We have a really nice time together in the group, and we have been meeting every other week on average – between the meetings at the WCC. (FG6)
Awaiting initiative Want structure Parents emphasised structure in a group. They appreciated the PHN demonstrating leadership and structure. In most of the groups at the WCCs, they started every meeting with a round of information from everybody. Then the plan could be a theme to discuss or watching a film, all depending on the age of the children. Some groups, however, were too flexible; the PHN acted too discreetly, and the group had to lead themselves: She only asked two questions initially: how we are and whether we sleep enough. The next hour she said nothing more. The groups meeting are okay, however, and we have fun, but why are we at the well-child clinic? We could have been alone at a cafe as well. (FG3)
The parents wanted both predictability and flexibility. They wanted to talk about their expectations towards the group about what was possible or not. If a participant talked too much about her or his problem, they wanted the group leader to round off or generalise the problem or open up for other input.
2984
Lacking continuity Participants experienced extensive absence in their groups, and several mothers lacked continuity in the WCC group sessions. Initially, the number was supposed to be five children with parent(s) in a group, but in reality, there were only three mothers. Sickness or other causes prevented attendance. ‘Sometimes there are two of us, and once I was alone’. Perhaps a father or two participated in the first meeting, but then did not appear again. In some cases, fathers came when the child was about 10 months old, because then the father had started his leave of absence. The group then became different. ‘The meeting takes another direction when [new] fathers join the group; they want more facts’. Others said that their group then disintegrated and felt sorry about that. They wanted a group for mothers only. Occasionally, the group sessions lacked a group feeling. A mother told that the first meeting started when the babies were four months old and only three mothers attended. The next meeting she was alone together with some new mothers, because two groups merged. Sickness, busyness or holidays at the WCCs may contribute to fewer meetings. ‘Three times a year is not much. I have no sense that I am in a group. If they are going to have group sessions, it should be more often!’. Participants mentioned mothers who had not attended the next group session without explanation. The continuity and feeling of a group was threatened, and they wanted a strategy to prevent this. Appreciate facilitating In some groups, they mentioned private initiatives because a mother had invited the group over or the PHN had encouraged them to see each other. Mothers said that they still got together with participants from a group from their first child, but others reported that, although they had three children and groups, none had resulted in any meetings outside the WCCs, and they missed this. ‘Take the first initiative yourself’ was an advice from a participant. Some groups wanted the PHN to present a list of names, addresses and phone numbers at the first meeting: ‘This is © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
your group and here are the planned dates for group meetings. Is it okay to share?’ The idea was to facilitate more contact, early, if they wanted. The participants wanted the PHN to push. In some groups, they had written their names and telephone numbers on a list at the very last group meeting, but this could be a bit late. Then the paid maternity leave has ended for many parents, and their days become busier. ‘Two or three of us have started to work again, and we are too busy to meet. In the period of leave, it would have been more useful, because we don’t make the first move’.
Expecting balanced health information Appreciate sorted health information Participants wanted a distinct leader who listened and informed with balance. They presented useful information about nutrition, children’s development and safety and talked about how the PHN explained and facilitated various themes related to the baby and parenthood. Some were, however, wondering why the PHN was too careful about delicate issues and perhaps ‘normalised everything’. The parents wanted to hear what was recommended but also why and appreciated alternatives, which gave a feeling of having a choice: Our group is mostly social; we have a network otherwise, but it is nice to see each other. Professionally, I have not got that much benefit from it, but now I’ve been through it once before, and I have health education, and then we have the Internet…. in our group we were joking about ‘the government says that’ – because we are told what to do all the time. (FG5)
They disliked the focus on ‘following the standard and being normal’ and wanted more discussions. Many parents said that they used the Internet to obtain health information, but this could be tricky, and several said that they were confused about information from the Internet. One father emphasised that he wanted to participate because of the professional group leader who could help the parents to sort information. Expecting facts The parents expected well-founded facts, but meetings could have many themes, and discussions became superficial. Knowledge and values might differ in a group, and facts could be short-lived, such as from their first to their second child. Some participants even argued for ‘practical facts’ to facilitate their day with the child. They felt sorry for the PHN being too careful according to marketing. Some group members said that they could talk more easily © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Parental groups during the child’s first year
than at the WCCs. Others said they had fun and talked about everything with their nice, professional group facilitator. ‘The advantage of the WCC groups is getting health information on a neutral ground’.
Consequences of multipositioning The pattern of behaviour of multipositioning encompasses: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative, and (4) expecting balanced health information. These were intertwined; sometimes one or two of the strategies dominated and sometimes another drove parents’ positioning in the group. When practising conditional openness or seeking to belong, the parents needed feedback that they were accepted in the group and managed their parental role normally. An interactive process of considering advantages and disadvantages, independence and connection or need for information defined the position. Thus, lack of initiative and structure in group sessions strained the parents who depended on the need for seeking to belong or conditional openness. Experiencing balanced health information influenced the degree to which parents gave priority to attending group sessions.
Discussion This study clarifies how parents in consultation groups try to achieve connection without accountability and receive relevant health information by multipositioning. Analysing the criteria of fit, work, relevance and modifiability is recommended to assess the quality of grounded theories (Glaser 1978, Lomborg & Kirkevold 2003). This article presents data from one municipality, and this might be a limitation; even more fathers would probably give further details. The strength of the study is the variation, with different demographic characteristics and experiences from one or more children and groups and different group facilitators. We therefore believe that this grounded theory fits the parents’ experiences well. According to the feedback from interviews, the theory seems relevant and works to explain the parents’ experiences. The future will decide how modifiable the theory of multipositioning will be.
Achieve connection without accountability The consultation groups at the WCCs are quite popular, and most of the participants appreciated this form as nice and useful. The parents were curious as to what to expect about the type of group this would be and about the possibility of increasing their social network. Simultaneously, they
2985
E Hj€almhult et al.
expected to receive balanced health information related to their child or themselves as parents. The previously reported aims from the Norwegian Directorate of Health (2004) have thus been partly successful. Parents valued the opportunity to meet and check out other parents with babies, but planned social contact between the sessions at the WCCs was limited. The parents wanted to be free and eventually withdraw, which is parallel to Hanna et al. (2002) discussing when a group does not commit to the complete programme. When the consequences in some groups were instability and low continuity, this seemed to influence the group feeling. The challenge is therefore to maintain parental interest and feeling confident as being cohesive and as having a commitment from the individual parents. The idea of increasing the social network in parents’ neighbourhood seems to be ignored when the WCCs organised the groups based on the baby’s date of birth and not on the address. Many participants appreciated being within walking distance to each other and the possibility for informal contacts. This is in accordance with Naerde (1992), who confirms that mothers living in the same neighbourhood have more contacts outside the WCC group sessions, planned as well as occasional. Further, Leahy-Warren (2007) found that most of the women reported informal social networks as their primary source of support in caring for their infants. Then, to facilitate informal connections, more attention should be paid to parents’ neighbourhood when composing groups. The importance of a social network and social support is well known (Tarkka et al. 1999, Griffiths et al. 2012), and Surkan et al. (2006) indicate that these factors are related to postpartum women’s mental health. Our study indicates that consultation groups for parents might facilitate social support and correlates with Hanna et al. (2002), who found that first-time parent groups provide lasting benefits not only for families but also for society as a whole. Previous research on the coping of first-time mothers with child care when the child was three months old reported a positive correlation between mothers’ coping and the social support received from their social network and from the PHNs at the WCC (Tarkka et al. 1999). Thus, the PHNs planning how to organise the group composition seems to be an important factor for the parent’s social contact between the sessions at the WCC and in achieving the purpose of the groups.
Consultation groups for mothers or parents? It is interesting that our study demonstrated the predominance of mothers in the WCC consultation groups. In some of our groups, mothers said that they wanted to attend
2986
without their partners and they wanted to talk about mothers’ issues. Earlier research confirms that mothers on maternity leave strived to obtain confirmation through social relationships by being confirmed by other mothers (H€ aggman-Laitila & Pietil€ a 2009, Alstveit et al. 2010, Leahy-Warren et al. 2012). Parents in some groups attended the first group session together, but fathers only exceptionally continued during the child’s first year. Some fathers attended when the baby was 10 months because their paid leave had begun. Mothers reported that the group then became different, and this coincided with the time when the group then disbanded. The question is how to optimise the ending of the groups and how to support the father in his role. People involved in planning WCC group need to be aware of whether they want an open or a closed group and discuss this with the participants. Could individual consultations be considered an alternative to the occasional meetings in a group? Experiences of well-functioning groups for mothers or both parents in our study seemed to include evolving into a self-sustaining social network when the group is facilitated to create an atmosphere of trust and to build a sense of group cohesion. This corresponds with other research (Scott et al. 2001, Kruske et al. 2004, Barlow et al. 2012).
A distinct group facilitator Most of the participants were satisfied with the group facilitator and how she created a confident atmosphere and had an agenda. This is in accordance with other studies showing how parents appreciate the availability of information, the ability of the parents to discuss matters, the activities, interaction and good group supervision (H€ aggman-Laitila & Pietil€ a 2009). Nevertheless, some parents were not comfortable with the structure and organising of their groups or the passive and diffuse style of leadership. They wondered why the sessions should be held at the WCC, because the group was quite self-driven and their sessions might take place anywhere. Essentially, the PHN’s interest and competence is important for the group (Hanna et al. 2002, Petersson et al. 2004). The recommendations that parents wanted a list of names, phone numbers and addresses at the first session might be clarifying and facilitating to ‘here is my group’. They even wanted rounded-off expectations to the group, which might give a feeling of predictability and correspond with well-known group theory (Napier & Gershenfeld 2004, Heap 2005) and should be an easy task for the PHN to accommodate. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
Parental groups during the child’s first year
In particular, first-time parents said that they need information about the normal situation with a child and with motherhood and fatherhood to develop competence as a parent. Gardner and Deatrick (2006) reported that theorybased groups comprise a strategy that seems to facilitate the mothering processes. Most participants expressed the benefit of getting health information and discussions among the parents. This combination of parents’ experiences and the PHN’s professional expertise seemed to be useful to increase confidence in parenthood (Bramhagen et al. 2006). A distinct group facilitator has the opportunity to arrange discussion for everyday problems, health information as well as sensitive topics (Colucci 2007, Lambert & Loiselle 2007, Nair et al. 2012). Thus, consultation groups might be valuable for parents and contribute to something more than only individual consultations the first year. Another issue, however, is what happens with the group process and how to ensure the quality of the ‘neutral health information’ when the group facilitator left the group for individual vaccination and mini-consultations. Discussion and support in the role of facilitator might be useful.
openness, seeking to belong, awaiting initiative and expecting balanced health information. The parents used these strategies and their properties interchangeably in their search for positioning in the group. To be seen and accepted in the group seems especially sensitive, and they balanced their engagement regarding the climate in the group when they discussed vital health information. The study shows that parental groups have great potential to establish a social network and exchange experiences and health information during the child’s first year, but underestimated need for structure and continuity in the groups might cause this opportunity to be missed. Another issue is that more attention should be paid to parents’ neighbourhood when composing groups.
Relevance to clinical practice Understanding parents’ perspectives will be useful when planning strategies to strengthen parental groups at WCCs and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.
Conclusion
Disclosure
Groups for parents might be recommended in the community for improving the social network in their neighbourhood. However, our findings from consultation groups at the WCC show that parents primarily concerned for achieving connection without accountability and to receive relevant health information. They handled this concern by ‘multipositioning’ highlighted by practising conditional
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
References Alstveit M, Severinsen E & Karlsen B (2010) Obtaining confirmation thorough social relationships: Norwegian first-time mothers’ experiences while on maternity leave. Nursing & Health Sciences 12, 113–118. Barlow J, Smailagic N, Huband N, Roloff V & Bennett C (2012) Group-based parent training programmes for improving parental psychosocial health. Cochrane Database of Systematic Reviews, Issue 6, Art. No.: CD002020. Barnes MI, Pratt J, Finlayson K, Pitt B & Knight C (2010) The first step program: a case study of a new model of
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
community child health services. Australian Health Review 34, 386–390. Bramhagen AC, Axelsson I & Hallstr€ om I (2006) Mothers’ experiences of feeding situations – in interview study. Journal of Clinical Nursing 15, 29–34. Colucci E (2007) “Focus groups can be fun”: the use of activity-oriented questions in focus group discussion. Qualitative Health Research 17, 1422– 1433. Forster DA, McLachlan HL, Ryan J, Yelland J, Gold L & Rayner S (2008) The early postnatal period: exploring women’s views, expectations and experiences of care using focus groups
in Victoria, Australia. BMC Pregnancy and Childbirth 8, 27. Gardner MR & Deatrick JA (2006) Understanding interventions and outcomes in mothers of infants. Issues in Comprehensive Pediatric Nursing 29, 25–44. George L (2005) Lack of preparedness: experiences of first time mothers. MCN. The American Journal of Maternal Child Nursing 30, 251– 255. Glaser BG (1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Sociology Press, Mill Valley, CA.
2987
E Hj€almhult et al. Glaser BG (1998) Doing Grounded Theory: Issues and Discussions. Sociology Press, Mill Valley, CA. Glaser BG (2005) The Grounded Theory Perspective III: Theoretical Coding. Sociology Press, Mill Valley, CA. Glavin K & Kvarme LG (2003) Helsesøstertjenesten: fra menighetssykepleie til folkehelsevitenskap [Public Health Nursing Services: From Parish Nurses to Public Health Science]. Akribe, Oslo [in Norwegian]. Griffiths F, Cave J, Boardman F, Ren J, Pawlikowska T, Ball R, Clarke A & Cohen A (2012) Social networks – the future for health care delivery. Social Science and Medicine 75, 2233–2241. Guest ME & Keatinge DR (2009) The value of new parent groups in child and family health nursing. The Journal of Perinatal Education 18, 12–22. H€aggman-Laitila A & Pietil€a AM (2009) Preventive psychosocietal support groups: parents’ criteria for good quality. Scandinavian Journal of Caring Sciences 23, 211–221. Hanna BA, Edgecombe G, Jackson CA & Newman S (2002) The importance of first-time parent groups for new parents. Nursing & Health Science 4, 209–214. Heap K (2005) Gruppemetode for sosialog helsearbeidere [Group Method for Social and Health Care Workers], 5th edn. Gyldendal Akademisk, Oslo [in Norwegian]. Hj€almhult E & Lomborg K (2012) Managing the first period at home with a newborn: a grounded theory study of mothers’ experiences. Scandinavian Journal of Caring Sciences 26, 654– 662. Kruske S, Schmied V, Sutton I & O’Hare J (2004) Mother’s experiences of facilitated peer support groups and individual child health nursing support: a comparative evaluation. The Journal of Perinatal Education 13, 31–38. Kvale S & Brinkman S (2009) Learning the Craft of Qualitative Research Interviewing. Sage Publications, London.
2988
Lambert SD & Loiselle CG (2007) Health information seeking behavior. Qualitative Health Research 17, 1006– 1019. Leahy-Warren P (2007) Social support for first-time mothers: an Irish study. MCN. The American Journal of Maternal Child Nursing 32, 368–374. Leahy-Warren P, McCarthy G & Corcoran P (2011) Postnatal depression in firsttime mothers: prevalence and relationships between functional and structural social support at 6 and 12 weeks postpartum. Archives of Psychiatric Nursing 25, 174–184. Leahy-Warren P, McCarthy G & Corcoran P (2012) First-time mothers: social support, maternal parental self-efficacy and postnatal depression. Journal of Clinical Nursing 21, 388–397. Lomborg K & Kirkevold M (2003) Truth and validity in grounded theory – a reconsidered realist interpretation of the criteria fir, work, relevance and modifiability. Nursing Philosophy 4, 189–200. Mathiesen KS & Sanson A (2000) Dimensions of early childhood behaviour problems – stability and predictors of change from 18 to 30 months. Journal of Abnormal Child Psychology 28, 431–439. Naerde A (1992) Erfaringer med gruppebasert helsestasjonskontroll: en brukerundersøkelse [Experiences with Group-Based Well-Child Clinic Check-Ups: A User Survey]. Master Thesis, University of Oslo, Oslo [in Norwegian]. Nair N, Tripathy P, Costello A & Prost A (2012) Mobilizing women’s groups for improved maternal and newborn health: evidence for impact, and challenges for sustainability and scale up. International Journal of Gynecology & Obstetrics 119, 522–525. Napier RW & Gershenfeld MK (2004) Theory and Experiences. Houghton Mifflin Harcourt Publishing Company, New York, NY. Norwegian Directorate of Health (2004) Kommunenes helsefremmende og
forebyggende arbeid i helsestasjonsog skolehelsetjenesten [The Municipalities’ Work for Health Promotion and Disease Prevention in Well-Baby Clinics and School Health Services]. Veileder til forskrif tav 3. April 2003 nr. 450. Norwegian Directorate of Health, Oslo [in Norwegian]. € Nystr€ om K & Ohrling K (2004) Parenthood experiences during the child’s first year: literature review. Journal of Advanced Nursing 46, 319–330. Petersson K, Petersson C & H akansson A (2004) What is good parental education? Scandinavian Journal of Caring Sciences 18, 82–89. Saetre RH, Mathiesen KS & Nærde A (1996) Barnefamilien – trivsel og levek ar. Helsestasjonens rolle i kommunens forebyggende arbeid for barn [Families with Children: Well-Being and Living Conditions. The role of well-baby clinics in the municipal efforts to promote health and prevent disease among children]. Kommuneforlaget, Oslo [in Norwegian]. Salonen AH, Kaunonen M, Astedt-Kurki P, J€ arvenp€ a€ a AL, Isoaho H & Tarkka MT (2010) Parenting satisfaction during the immediate postpartum period: factors contributing to mothers’ and fathers’ perceptions. Journal of Clinical Nursing 19, 1716–1728. Scott D, Brady S & Glynn P (2001) New mothers’ groups as a social network intervention: consumer and maternal and child health nurse perspectives. The Australian Journal of Advanced Nursing 18, 23–29. Surkan PJ, Peterson KE, Hughes MD & Gottlieb BR (2006) The role of social networks and support in postpartum women’s depression: a multiethnic urban sample. Maternal and Child Health Journal 10, 375–383. Tarkka MT, Paunonen M & Laippala P (1999) Social support provided by public health nurses and the coping of first-time mothers with child care. Public Health Nursing 16, 114– 119.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
Parental groups during the child’s first year
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
2989
Parental groups during the child’s first year: an interview study of parents’ experiences Esther Hj€almhult, Kari Glavin, Toril Økland and Sidsel Tveiten
Aims and objectives. To highlight what was important to parents with respect to consultation groups at well-child clinics. Background. Parents managing of their role as parents affect the child’s health and are therefore an important priority for public health. Well-child clinics in Norway practise consultations in groups to support parents and to facilitate social network; however, few studies explore parents’ perspective of this kind of groups. Design. Grounded theory. Methods. We used classical grounded theory with a generative and constant comparative approach. Data were collected through seven focus groups and two individual interviews with the parents of children aged 8–15 months. Results. The parents were most concerned about how to achieve connection without accountability and how to obtain relevant health information. They managed this by ‘multipositioning’, encompassing the strategies of: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information. The use of these strategies explains how they resolved their challenges. Conclusion. Parental groups seem to be popular and have great potential to establish a social network; however, underestimating the need for structure and continuity in the groups might cause this opportunity to be missed. Relevance to clinical practice. Understanding parents’ perspectives will be useful when planning strategies to strengthen parental groups at well-child clinics and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.
What does this paper contribute to the wider global clinical community?
• Parental
•
groups during the child’s first year have great potential to establish social network and increase parents’ satisfaction and exchange health information. Underestimated need for structure and continuity in the groups might cause this opportunity to be missed.
Key words: grounded theory, health information seeking, infant, parenting, public health nurse, social support Accepted for publication: 10 November 2013
Introduction Parents experience being a parent in the child’s first year, especially the first child, as overwhelming and exciting Authors: Esther Hj€ almhult, PhD, RPHN, Associate Professor, Faculty of Health and Social Sciences, Bergen University College, Bergen; Kari Glavin, PhD, RPHN, Associate Professor, Oslo and Akershus College of Applied Science, Oslo; Toril Økland, MSc, RPHN, Head of Unit of Health Promoting, Arstad, Bergen; Sidsel Tveiten, PhD, RN, Associate Professor, Oslo and Akershus College of Applied Science, Oslo, Norway
2980
€ (Nystr€ om & Ohrling 2004, Forster et al. 2008, Hj€ almhult & Lomborg 2012). How parents manage their parental role affects the child’s health and development and is an important priority for public health. Parents’ mental health Correspondence: Esther Hj€ almhult, Associate Professor, Faculty of Health and Social Sciences, Bergen University College, Møllendalsveien 6, N- 5009 Bergen, Norway. Telephone: +47 55 58 75 00/849. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989, doi: 10.1111/jocn.12528
Original article
and social circumstances is a central factor influencing children (Tarkka et al. 1999, Surkan et al. 2006, LeahyWarren et al. 2011), and their satisfaction is important for their motivation to take care and interact with their child (George 2005, Salonen et al. 2010). Various disease prevention and health promotion programmes target adults to facilitate the parental role in improving children’s health. One idea is developing a supportive social network during the child’s first year (Saetre et al. 1996, Mathiesen & Sanson 2000, Guest & Keatinge 2009, Barnes et al. 2010).
Background The way first-time mothers experience social relationships while on maternity leave reveals that the mothers seek company and want to share experience with other mothers (Alstveit et al. 2010). Other studies (Hanna et al. 2002, Kruske et al. 2004) found that first-time parents benefit from participating in groups for first-time parents in many ways. They develop social networks, gain self-confidence and obtain access to relevant information on child health and parenting. In a Cochrane review, Barlow et al. (2012) advocated using group-based parenting programmes to improve the short-term psychosocial well-being of parents. The group-based programmes had implications for both stress and confidence. Several studies report that maternal and child health nurses play a key role in facilitating groups for parents (Hanna et al. 2002, Petersson et al. 2004, Gardner & Deatrick 2006). Norway’s municipal well-child clinics (WCCs) have a long tradition in health promotion and disease prevention among families. The WCCs combine population-based activities through individual contact (Norwegian Directorate of Health 2004). The frequent and close contact between public health nurses (PHNs) and new families is a unique platform for collaborating on children’s upbringing. This provides a distinctive opportunity for disease prevention (Glavin & Kvarme 2003). In addition to individual consultations, routine consultation groups at the WCCs are recommended such that like-minded parents can meet: exchanging experiences and achieving insight, support and understanding to manage their role as a parent. The idea is that social contact between parents through the WCCs might be a basis for improving the social network in their neighbourhood (Norwegian Directorate of Health 2004). The PHN is the group facilitator. Most of the groups run for five to six sessions during the child’s first year, although this differs around the country. The groups may be important for new families, but research is lacking on how parents experience the parental groups. This study © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Parental groups during the child’s first year
therefore aims to highlight the parents’ view of participating in consultation groups at the WCCs. What is important to them, and how do they bring their issues into the group?
Methods We chose classical grounded theory design, a systematic approach used to explore processes in the context of situated interaction. The aim was to identify how the participants acted to solve their main concern and to generate theory that explained the pattern of behaviour in the study involved (Glaser 1978, 1998, 2005).
Sample The parents were recruited in collaboration with the leaders of public health services and their PHNs, who distributed letters with information to parents visiting the WCC in various districts of a major provincial city. The inclusion criteria were having a child aged 8–15 months, being 18 years or older, speaking Norwegian and having participated in a group at a WCC. Twenty-one parents participated. The aim was to recruit groups of four to six participants, but recruiting was slow, and we included two individual interviews to obtain deeper information. Sixteen mothers and three fathers participated in seven focus group discussions and two mothers in individual interviews. The parents were 18–42 years of age, and 10 were first-time parents and 11 had two to four children. They had participated in the last group four to six times, some two to three times. Several of the participants had higher education.
Data collection and setting We conducted the interviews from November 2011–June 2012 and one group in November 2012. The interviews were conducted at the WCCs except for one individual interview, which was arranged at a quiet office. The first author moderated the discussions, and the co-moderator (TO) assisted and was a discussion partner afterwards. We tried to create a relaxed atmosphere for the participants, starting every session with small talk and giving information about the purpose of the study (Kvale & Brinkman 2009). All parents had their child with them, and they could crawl around in the room or sit with the parents. A semistructured interview guided us with open questions about how they experienced participating in a group at a WCC. The focus groups lasted for 1–15 hours and the
2981
E Hj€almhult et al.
individual interviews 40–55 minutes. First author audiorecorded and transcribed the interviews except for one and took notes manually during that interview and rapidly transcribed the interview. The Norwegian Social Science Data Services approved the study (reference number 27512). The participants gave written information and signed the consent form. We explained the confidentiality issues and the right to withdraw.
Practicing conditional openness
•Curious expecting •Checking mutuality
Seeking to belong
•Want to be listened to •Balancing engagement
Awaiting initiative
•Want structure •Lacking continuity •Appreciate facilitating
Data analysis Data analysis started with open coding, using the constant comparison of incidents exploring similarities and differences (Glaser 1978, 1998). The first author analysed each interview and compared this with the previous one before the next interview, all in a continuous process. Written textual memos enriched the analysis process and facilitated the generation of hypotheses from the data about what happened in the area studied. The co-authors read through the material and contributed to the analysis. Parents’ main concern was identified: what was essential for the parents in the group sessions. First author grouped the codes into broad categories and moved from descriptive concepts such as want to be listened to’ to broader concepts such as ‘seeking to belong’. The study progressed to identify the core category that could capture the patterns of behaviour through which the parents managed their main concern. In selective coding, the focus was on codes related to the core category and, further, we continued theoretical coding, which conceptualised how the substantive codes may relate to each other at a more abstract level. In the process of analysis, we used individual interviews to deepen knowledge and the last focus groups to ensure demographic variety in the data material and thus enrich the emerging codes and hypotheses until we found theoretical saturation (Glaser 1978, 2005).
Results We identified that the parents were primarily concerned about how to achieve connection without accountability and receive health information on a neutral ground. They met this need by ‘multipositioning’. This strategy encompassed four subcategories/strategies: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative and (4) expecting balanced health information (Fig. 1). The parents used these strategies and their properties interchangeably in their search for positioning in the group.
2982
Expecting balanced health information
•Appreciate sorted health information •Expecting facts
Figure 1 Multipositioning to group consultation at well-child clinics.
Conditions of multipositioning The concept of multipositioning is a dynamic process controlled by the parents, more or less distinct and consciously. Various internal and external conditions influenced multipositioning, such as whether they are first-time parents or not, age, network, personal health and the composition of the group. Multipositioning was related to a consideration based on the specific parents’ situation to join a parent group at a WCC. Some mothers could choose to mix group sessions in addition to individual consultations at a WCC or, alternatively, only individual consultations. Others were told: ‘Here everyone participates in groups’. Or ‘I was asked whether I wanted to join a group or have individual consultations – but I felt that they wanted me to choose a group. Thus, I might not have had a real choice’. According to the parents, they might get some dates for group meetings, but the purpose or expectations of the group were seldom explicitly worded. Several parents did not know the rationale for the composition of a group. ‘Is it the mothers who are alike or is it the babies’ age that matters?’. The composition of the group and the relationship with the group facilitator mutually influenced the groups.
Practising conditional openness Curious expecting One typical dimension of multipositioning was that mothers seemed to seek a potential contact. The participants might have a network, but they wondered whether someone new may have entered their environment, and they © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
could thereby get a new friend for chatting, meeting for a walk with a baby buggy or sharing a cup of coffee. First-time parents wanted to compare with like-minded parents and compare their babies and their skills as parents. Even parents with three or four children might be interested:
Parental groups during the child’s first year
‘the chemistry was perfect’. The parents assessed the basis of comparison and relaxed when their situation and their child seemed to be ‘normal’: Two of us breastfed and two did not; this was a recurring theme. We who breastfed strived more, the kids awoke more during the night and increased less in weight than those who got a bottle: they
My wife and I were interested in such groups and, if possible,
were big and stout. It was conspicuous how they varied. I am glad
developing a social network, but we felt we did not need health
that there were two of us. (Ind. B)
information about the baby, because we thought we perhaps knew enough about babies. This was our starting-point … (FG6)
Other parents said that their network and friends did not have children or had older children. Our participants with older children related positive experiences from earlier groups at a WCC, but everyone was not satisfied with the previous groups. However, they all wanted to see what this new group would bring. For example, a mother might be sceptical about joining a group when she had a new child. The PHN promised her if she tried again she could withdraw if she wanted, and curiosity won: … This group however, demonstrates quite another style than the group I participated in with my first child. This group is nice. (FG5)
In an area with many children, a first-time mother could expect to meet many like-minded parents: I was a bit shocked the first time. We were two, and another arrived later, so we had only three people in a group! I thought there should be more participants in a maternity group. I was really looking forward to that. (FG7)
Checking mutuality Parents appreciated if some of the children in their group had the same sex or age or if they lived in the same residential area, the parents had similar experiences and so on. A mother who struggled with breastfeeding or colic was happy if someone else in her group had the same problem or if somebody else could give her hope and advice on how to manage. Being alone and unlike the others could mean that participating would be risky: We figured out jointly that it was a good thing that we all were first-time mothers and that all four had girls. The WCC was initially a constantly comparing template: the development and growth. I certainly felt that, with my child’s development – ‘You must follow the curve!’. (Ind. A)
Mothers were especially satisfied when they made contact with one or more group members. They also developed connections with mothers in different situations because © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Some mothers commented that it would not be okay to participate in a group if they had a child with delayed development or something else stigmatising. Others mentioned that the PHN was eager to focus on the large normal range and that one child could develop early in one area and another in something else.
Seeking to belong Want to be listened to The participants wanted to be seen and accepted in the group and were careful not to be outsiders. Some mothers missed like-minded mothers in the neighbourhood and appreciated the consultation group. ‘This group is luxurious and the period of leave is fantastic’. First-time mothers commented on the stress at home in the first period and the feeling of relaxation when they discovered like-minded people in the group. Mothers advocated common sense when neighbours delivering the very same week were placed in different groups at a WCC and both wanted to be in the same group. Geographical proximity and walking distance facilitated informal contact. If the child had special problems such as colic, sleeping, allergies or nutrition, the group seemed not to be the right place for several group members. Parents mentioned that PHNs wanted them not to talk about deep problems in the group and just about issues from the current baby. Sibling rivalry, the relationship with the partner or life together as a family was therefore not usually brought up in the groups. Perhaps a mother with problems could get understanding from another participant in the group. In a few groups, they met regularly one to time times a month. In some districts, fathers contributed more to the WCC groups. A mother reported that, during the first group meeting, she was the only one without her husband, and he therefore joined her to the next group session. Then, he was the only man. During the child’s first year, however, everyone continued participating in this group, even privately, and the father said finally: ‘I have looked forward to every meeting!’.
2983
E Hj€almhult et al.
Balancing engagement A characteristic strategy of multipositioning in the groups was balancing engagement. In the focus group interviews, participants discussed the risk of being stigmatised and were therefore quiet and glossed over problems. Perhaps if a fearless participant revealed something, others could acknowledge the same problem: If the PHN asked: “How are you?” “Oh fine, thank you”. Then I
Another issue related to structure was how to organise vaccination of the children. Some mothers did not like it when this was carried out in the group; they were nervous and preferred to be alone with the PHN. Others commented on the disturbance when each parent successively left the group to get the child immunised and talked briefly with the PHN. A third moment was mothers who said, laughing, that it was okay to be alone in the group, because then they could talk about what they wanted.
might say: “Oh, everything is okay for you? So I am the only one who breastfeeds twice a night and so on and I am out of bed and we are sleeping too little?” “Oh no, that is not right, we don’t sleep either”. So we prettify a bit and do not want to show our problems. (FG4)
Participants balanced their engagement regarding the climate in their group. Some said that a 20-year-old mother had dropped out of their group of mothers who were aged 30–35 years; she probably felt excluded. Other groups succeeded despite differences. Combined private engagement might stimulate the mutual connection: Our group has been functioning well! The youngest is about 22 years old, and I think the oldest is 42 years of age. But we are very harmonious. We have a really nice time together in the group, and we have been meeting every other week on average – between the meetings at the WCC. (FG6)
Awaiting initiative Want structure Parents emphasised structure in a group. They appreciated the PHN demonstrating leadership and structure. In most of the groups at the WCCs, they started every meeting with a round of information from everybody. Then the plan could be a theme to discuss or watching a film, all depending on the age of the children. Some groups, however, were too flexible; the PHN acted too discreetly, and the group had to lead themselves: She only asked two questions initially: how we are and whether we sleep enough. The next hour she said nothing more. The groups meeting are okay, however, and we have fun, but why are we at the well-child clinic? We could have been alone at a cafe as well. (FG3)
The parents wanted both predictability and flexibility. They wanted to talk about their expectations towards the group about what was possible or not. If a participant talked too much about her or his problem, they wanted the group leader to round off or generalise the problem or open up for other input.
2984
Lacking continuity Participants experienced extensive absence in their groups, and several mothers lacked continuity in the WCC group sessions. Initially, the number was supposed to be five children with parent(s) in a group, but in reality, there were only three mothers. Sickness or other causes prevented attendance. ‘Sometimes there are two of us, and once I was alone’. Perhaps a father or two participated in the first meeting, but then did not appear again. In some cases, fathers came when the child was about 10 months old, because then the father had started his leave of absence. The group then became different. ‘The meeting takes another direction when [new] fathers join the group; they want more facts’. Others said that their group then disintegrated and felt sorry about that. They wanted a group for mothers only. Occasionally, the group sessions lacked a group feeling. A mother told that the first meeting started when the babies were four months old and only three mothers attended. The next meeting she was alone together with some new mothers, because two groups merged. Sickness, busyness or holidays at the WCCs may contribute to fewer meetings. ‘Three times a year is not much. I have no sense that I am in a group. If they are going to have group sessions, it should be more often!’. Participants mentioned mothers who had not attended the next group session without explanation. The continuity and feeling of a group was threatened, and they wanted a strategy to prevent this. Appreciate facilitating In some groups, they mentioned private initiatives because a mother had invited the group over or the PHN had encouraged them to see each other. Mothers said that they still got together with participants from a group from their first child, but others reported that, although they had three children and groups, none had resulted in any meetings outside the WCCs, and they missed this. ‘Take the first initiative yourself’ was an advice from a participant. Some groups wanted the PHN to present a list of names, addresses and phone numbers at the first meeting: ‘This is © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
your group and here are the planned dates for group meetings. Is it okay to share?’ The idea was to facilitate more contact, early, if they wanted. The participants wanted the PHN to push. In some groups, they had written their names and telephone numbers on a list at the very last group meeting, but this could be a bit late. Then the paid maternity leave has ended for many parents, and their days become busier. ‘Two or three of us have started to work again, and we are too busy to meet. In the period of leave, it would have been more useful, because we don’t make the first move’.
Expecting balanced health information Appreciate sorted health information Participants wanted a distinct leader who listened and informed with balance. They presented useful information about nutrition, children’s development and safety and talked about how the PHN explained and facilitated various themes related to the baby and parenthood. Some were, however, wondering why the PHN was too careful about delicate issues and perhaps ‘normalised everything’. The parents wanted to hear what was recommended but also why and appreciated alternatives, which gave a feeling of having a choice: Our group is mostly social; we have a network otherwise, but it is nice to see each other. Professionally, I have not got that much benefit from it, but now I’ve been through it once before, and I have health education, and then we have the Internet…. in our group we were joking about ‘the government says that’ – because we are told what to do all the time. (FG5)
They disliked the focus on ‘following the standard and being normal’ and wanted more discussions. Many parents said that they used the Internet to obtain health information, but this could be tricky, and several said that they were confused about information from the Internet. One father emphasised that he wanted to participate because of the professional group leader who could help the parents to sort information. Expecting facts The parents expected well-founded facts, but meetings could have many themes, and discussions became superficial. Knowledge and values might differ in a group, and facts could be short-lived, such as from their first to their second child. Some participants even argued for ‘practical facts’ to facilitate their day with the child. They felt sorry for the PHN being too careful according to marketing. Some group members said that they could talk more easily © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Parental groups during the child’s first year
than at the WCCs. Others said they had fun and talked about everything with their nice, professional group facilitator. ‘The advantage of the WCC groups is getting health information on a neutral ground’.
Consequences of multipositioning The pattern of behaviour of multipositioning encompasses: (1) practising conditional openness, (2) seeking to belong, (3) awaiting initiative, and (4) expecting balanced health information. These were intertwined; sometimes one or two of the strategies dominated and sometimes another drove parents’ positioning in the group. When practising conditional openness or seeking to belong, the parents needed feedback that they were accepted in the group and managed their parental role normally. An interactive process of considering advantages and disadvantages, independence and connection or need for information defined the position. Thus, lack of initiative and structure in group sessions strained the parents who depended on the need for seeking to belong or conditional openness. Experiencing balanced health information influenced the degree to which parents gave priority to attending group sessions.
Discussion This study clarifies how parents in consultation groups try to achieve connection without accountability and receive relevant health information by multipositioning. Analysing the criteria of fit, work, relevance and modifiability is recommended to assess the quality of grounded theories (Glaser 1978, Lomborg & Kirkevold 2003). This article presents data from one municipality, and this might be a limitation; even more fathers would probably give further details. The strength of the study is the variation, with different demographic characteristics and experiences from one or more children and groups and different group facilitators. We therefore believe that this grounded theory fits the parents’ experiences well. According to the feedback from interviews, the theory seems relevant and works to explain the parents’ experiences. The future will decide how modifiable the theory of multipositioning will be.
Achieve connection without accountability The consultation groups at the WCCs are quite popular, and most of the participants appreciated this form as nice and useful. The parents were curious as to what to expect about the type of group this would be and about the possibility of increasing their social network. Simultaneously, they
2985
E Hj€almhult et al.
expected to receive balanced health information related to their child or themselves as parents. The previously reported aims from the Norwegian Directorate of Health (2004) have thus been partly successful. Parents valued the opportunity to meet and check out other parents with babies, but planned social contact between the sessions at the WCCs was limited. The parents wanted to be free and eventually withdraw, which is parallel to Hanna et al. (2002) discussing when a group does not commit to the complete programme. When the consequences in some groups were instability and low continuity, this seemed to influence the group feeling. The challenge is therefore to maintain parental interest and feeling confident as being cohesive and as having a commitment from the individual parents. The idea of increasing the social network in parents’ neighbourhood seems to be ignored when the WCCs organised the groups based on the baby’s date of birth and not on the address. Many participants appreciated being within walking distance to each other and the possibility for informal contacts. This is in accordance with Naerde (1992), who confirms that mothers living in the same neighbourhood have more contacts outside the WCC group sessions, planned as well as occasional. Further, Leahy-Warren (2007) found that most of the women reported informal social networks as their primary source of support in caring for their infants. Then, to facilitate informal connections, more attention should be paid to parents’ neighbourhood when composing groups. The importance of a social network and social support is well known (Tarkka et al. 1999, Griffiths et al. 2012), and Surkan et al. (2006) indicate that these factors are related to postpartum women’s mental health. Our study indicates that consultation groups for parents might facilitate social support and correlates with Hanna et al. (2002), who found that first-time parent groups provide lasting benefits not only for families but also for society as a whole. Previous research on the coping of first-time mothers with child care when the child was three months old reported a positive correlation between mothers’ coping and the social support received from their social network and from the PHNs at the WCC (Tarkka et al. 1999). Thus, the PHNs planning how to organise the group composition seems to be an important factor for the parent’s social contact between the sessions at the WCC and in achieving the purpose of the groups.
Consultation groups for mothers or parents? It is interesting that our study demonstrated the predominance of mothers in the WCC consultation groups. In some of our groups, mothers said that they wanted to attend
2986
without their partners and they wanted to talk about mothers’ issues. Earlier research confirms that mothers on maternity leave strived to obtain confirmation through social relationships by being confirmed by other mothers (H€ aggman-Laitila & Pietil€ a 2009, Alstveit et al. 2010, Leahy-Warren et al. 2012). Parents in some groups attended the first group session together, but fathers only exceptionally continued during the child’s first year. Some fathers attended when the baby was 10 months because their paid leave had begun. Mothers reported that the group then became different, and this coincided with the time when the group then disbanded. The question is how to optimise the ending of the groups and how to support the father in his role. People involved in planning WCC group need to be aware of whether they want an open or a closed group and discuss this with the participants. Could individual consultations be considered an alternative to the occasional meetings in a group? Experiences of well-functioning groups for mothers or both parents in our study seemed to include evolving into a self-sustaining social network when the group is facilitated to create an atmosphere of trust and to build a sense of group cohesion. This corresponds with other research (Scott et al. 2001, Kruske et al. 2004, Barlow et al. 2012).
A distinct group facilitator Most of the participants were satisfied with the group facilitator and how she created a confident atmosphere and had an agenda. This is in accordance with other studies showing how parents appreciate the availability of information, the ability of the parents to discuss matters, the activities, interaction and good group supervision (H€ aggman-Laitila & Pietil€ a 2009). Nevertheless, some parents were not comfortable with the structure and organising of their groups or the passive and diffuse style of leadership. They wondered why the sessions should be held at the WCC, because the group was quite self-driven and their sessions might take place anywhere. Essentially, the PHN’s interest and competence is important for the group (Hanna et al. 2002, Petersson et al. 2004). The recommendations that parents wanted a list of names, phone numbers and addresses at the first session might be clarifying and facilitating to ‘here is my group’. They even wanted rounded-off expectations to the group, which might give a feeling of predictability and correspond with well-known group theory (Napier & Gershenfeld 2004, Heap 2005) and should be an easy task for the PHN to accommodate. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
Parental groups during the child’s first year
In particular, first-time parents said that they need information about the normal situation with a child and with motherhood and fatherhood to develop competence as a parent. Gardner and Deatrick (2006) reported that theorybased groups comprise a strategy that seems to facilitate the mothering processes. Most participants expressed the benefit of getting health information and discussions among the parents. This combination of parents’ experiences and the PHN’s professional expertise seemed to be useful to increase confidence in parenthood (Bramhagen et al. 2006). A distinct group facilitator has the opportunity to arrange discussion for everyday problems, health information as well as sensitive topics (Colucci 2007, Lambert & Loiselle 2007, Nair et al. 2012). Thus, consultation groups might be valuable for parents and contribute to something more than only individual consultations the first year. Another issue, however, is what happens with the group process and how to ensure the quality of the ‘neutral health information’ when the group facilitator left the group for individual vaccination and mini-consultations. Discussion and support in the role of facilitator might be useful.
openness, seeking to belong, awaiting initiative and expecting balanced health information. The parents used these strategies and their properties interchangeably in their search for positioning in the group. To be seen and accepted in the group seems especially sensitive, and they balanced their engagement regarding the climate in the group when they discussed vital health information. The study shows that parental groups have great potential to establish a social network and exchange experiences and health information during the child’s first year, but underestimated need for structure and continuity in the groups might cause this opportunity to be missed. Another issue is that more attention should be paid to parents’ neighbourhood when composing groups.
Relevance to clinical practice Understanding parents’ perspectives will be useful when planning strategies to strengthen parental groups at WCCs and that the engaged organisers will account for this need to ensure public health work of high quality and effectiveness for parents.
Conclusion
Disclosure
Groups for parents might be recommended in the community for improving the social network in their neighbourhood. However, our findings from consultation groups at the WCC show that parents primarily concerned for achieving connection without accountability and to receive relevant health information. They handled this concern by ‘multipositioning’ highlighted by practising conditional
The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
References Alstveit M, Severinsen E & Karlsen B (2010) Obtaining confirmation thorough social relationships: Norwegian first-time mothers’ experiences while on maternity leave. Nursing & Health Sciences 12, 113–118. Barlow J, Smailagic N, Huband N, Roloff V & Bennett C (2012) Group-based parent training programmes for improving parental psychosocial health. Cochrane Database of Systematic Reviews, Issue 6, Art. No.: CD002020. Barnes MI, Pratt J, Finlayson K, Pitt B & Knight C (2010) The first step program: a case study of a new model of
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
community child health services. Australian Health Review 34, 386–390. Bramhagen AC, Axelsson I & Hallstr€ om I (2006) Mothers’ experiences of feeding situations – in interview study. Journal of Clinical Nursing 15, 29–34. Colucci E (2007) “Focus groups can be fun”: the use of activity-oriented questions in focus group discussion. Qualitative Health Research 17, 1422– 1433. Forster DA, McLachlan HL, Ryan J, Yelland J, Gold L & Rayner S (2008) The early postnatal period: exploring women’s views, expectations and experiences of care using focus groups
in Victoria, Australia. BMC Pregnancy and Childbirth 8, 27. Gardner MR & Deatrick JA (2006) Understanding interventions and outcomes in mothers of infants. Issues in Comprehensive Pediatric Nursing 29, 25–44. George L (2005) Lack of preparedness: experiences of first time mothers. MCN. The American Journal of Maternal Child Nursing 30, 251– 255. Glaser BG (1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Sociology Press, Mill Valley, CA.
2987
E Hj€almhult et al. Glaser BG (1998) Doing Grounded Theory: Issues and Discussions. Sociology Press, Mill Valley, CA. Glaser BG (2005) The Grounded Theory Perspective III: Theoretical Coding. Sociology Press, Mill Valley, CA. Glavin K & Kvarme LG (2003) Helsesøstertjenesten: fra menighetssykepleie til folkehelsevitenskap [Public Health Nursing Services: From Parish Nurses to Public Health Science]. Akribe, Oslo [in Norwegian]. Griffiths F, Cave J, Boardman F, Ren J, Pawlikowska T, Ball R, Clarke A & Cohen A (2012) Social networks – the future for health care delivery. Social Science and Medicine 75, 2233–2241. Guest ME & Keatinge DR (2009) The value of new parent groups in child and family health nursing. The Journal of Perinatal Education 18, 12–22. H€aggman-Laitila A & Pietil€a AM (2009) Preventive psychosocietal support groups: parents’ criteria for good quality. Scandinavian Journal of Caring Sciences 23, 211–221. Hanna BA, Edgecombe G, Jackson CA & Newman S (2002) The importance of first-time parent groups for new parents. Nursing & Health Science 4, 209–214. Heap K (2005) Gruppemetode for sosialog helsearbeidere [Group Method for Social and Health Care Workers], 5th edn. Gyldendal Akademisk, Oslo [in Norwegian]. Hj€almhult E & Lomborg K (2012) Managing the first period at home with a newborn: a grounded theory study of mothers’ experiences. Scandinavian Journal of Caring Sciences 26, 654– 662. Kruske S, Schmied V, Sutton I & O’Hare J (2004) Mother’s experiences of facilitated peer support groups and individual child health nursing support: a comparative evaluation. The Journal of Perinatal Education 13, 31–38. Kvale S & Brinkman S (2009) Learning the Craft of Qualitative Research Interviewing. Sage Publications, London.
2988
Lambert SD & Loiselle CG (2007) Health information seeking behavior. Qualitative Health Research 17, 1006– 1019. Leahy-Warren P (2007) Social support for first-time mothers: an Irish study. MCN. The American Journal of Maternal Child Nursing 32, 368–374. Leahy-Warren P, McCarthy G & Corcoran P (2011) Postnatal depression in firsttime mothers: prevalence and relationships between functional and structural social support at 6 and 12 weeks postpartum. Archives of Psychiatric Nursing 25, 174–184. Leahy-Warren P, McCarthy G & Corcoran P (2012) First-time mothers: social support, maternal parental self-efficacy and postnatal depression. Journal of Clinical Nursing 21, 388–397. Lomborg K & Kirkevold M (2003) Truth and validity in grounded theory – a reconsidered realist interpretation of the criteria fir, work, relevance and modifiability. Nursing Philosophy 4, 189–200. Mathiesen KS & Sanson A (2000) Dimensions of early childhood behaviour problems – stability and predictors of change from 18 to 30 months. Journal of Abnormal Child Psychology 28, 431–439. Naerde A (1992) Erfaringer med gruppebasert helsestasjonskontroll: en brukerundersøkelse [Experiences with Group-Based Well-Child Clinic Check-Ups: A User Survey]. Master Thesis, University of Oslo, Oslo [in Norwegian]. Nair N, Tripathy P, Costello A & Prost A (2012) Mobilizing women’s groups for improved maternal and newborn health: evidence for impact, and challenges for sustainability and scale up. International Journal of Gynecology & Obstetrics 119, 522–525. Napier RW & Gershenfeld MK (2004) Theory and Experiences. Houghton Mifflin Harcourt Publishing Company, New York, NY. Norwegian Directorate of Health (2004) Kommunenes helsefremmende og
forebyggende arbeid i helsestasjonsog skolehelsetjenesten [The Municipalities’ Work for Health Promotion and Disease Prevention in Well-Baby Clinics and School Health Services]. Veileder til forskrif tav 3. April 2003 nr. 450. Norwegian Directorate of Health, Oslo [in Norwegian]. € Nystr€ om K & Ohrling K (2004) Parenthood experiences during the child’s first year: literature review. Journal of Advanced Nursing 46, 319–330. Petersson K, Petersson C & H akansson A (2004) What is good parental education? Scandinavian Journal of Caring Sciences 18, 82–89. Saetre RH, Mathiesen KS & Nærde A (1996) Barnefamilien – trivsel og levek ar. Helsestasjonens rolle i kommunens forebyggende arbeid for barn [Families with Children: Well-Being and Living Conditions. The role of well-baby clinics in the municipal efforts to promote health and prevent disease among children]. Kommuneforlaget, Oslo [in Norwegian]. Salonen AH, Kaunonen M, Astedt-Kurki P, J€ arvenp€ a€ a AL, Isoaho H & Tarkka MT (2010) Parenting satisfaction during the immediate postpartum period: factors contributing to mothers’ and fathers’ perceptions. Journal of Clinical Nursing 19, 1716–1728. Scott D, Brady S & Glynn P (2001) New mothers’ groups as a social network intervention: consumer and maternal and child health nurse perspectives. The Australian Journal of Advanced Nursing 18, 23–29. Surkan PJ, Peterson KE, Hughes MD & Gottlieb BR (2006) The role of social networks and support in postpartum women’s depression: a multiethnic urban sample. Maternal and Child Health Journal 10, 375–383. Tarkka MT, Paunonen M & Laippala P (1999) Social support provided by public health nurses and the coping of first-time mothers with child care. Public Health Nursing 16, 114– 119.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
Original article
Parental groups during the child’s first year
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2980–2989
2989
