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Extended plunket service for vulnerable teenage mothers: well child nurses' perspectives.

INTRODUCTION

Since 2011, an extended Well Child/Tamariki Ora (WC/TO) service has been provided through the Royal New Zealand Plunket Society (Inc) (Plunket) to vulnerable teenage mothers in Hawke's Bay. The service arose from the recommendations of Skerman's (2010) research, which found that teenage mothers were not well engaged in the WC/TO service and had parenting needs that were not being met. It began as a pilot service delivered to the teenage mothers of 21 babies born over a period of three months in the Napier/Hastings region, with collaborative funding from the Vodafone Foundation and the Hawke's Bay District Health Board (HBDHB). This service deviates from the usual Plunket WC/TO service in that it is provided to teenage mothers from one month before the birth of their babies and comprises two antenatal visits and one early postnatal visit (within two weeks). These visits are not included in the regular Plunket schedule, which consists of seven targeted "core" visits by nurses, starting when a baby is four weeks old and culminating with the B4 School Check, when the child is approximately four years, six months old. The extended service is also unusual in that it is delivered to each client in her home by one consistent Plunket WC/TO nurse, for whom teenage mothers are her dedicated case role.

An evaluation of the pilot extended WC/TO service was first done when the babies of the teenage mothers were around six months old. It identified very high levels of client satisfaction and engagement with the service, and the babies of these clients were doing better to a greater or lesser extent on various health measures, compared with a randomly matched control group (Skerman, Manhire, Abel, & Thompson, 2012; Thompson, Manhire & Abel, 2012). This evaluation was replicated when the babies of the teenage mothers who comprised the pilot group were around three years of age (Thompson, Abel, Skerman & Manhire, 2014), showing that the positive outcomes of the extended WC/TO service were maintained over the longer timeframe.

Both evaluations included interviews with professionals providing the pilot extended WC/TO service and its subsequent continuation. This article presents data derived from those interviews. It reports the nurses' perspectives on the role demands, key contributors to its successes and the main challenges they faced delivering the service to vulnerable teenage mothers.

BACKGROUND

Although the number of babies born to teenage mothers has been dropping since 2007/2008, teenage pregnancy rates in Hawke's Bay remain consistently higher than the New Zealand average (McElnay, 2014). While a proportion of teenage pregnancies are intended and wanted, and in some cultures are accepted and supported (Breheny & Stephens, 2007), "many do occur to young women who find it difficult to adequately care for a child without significant assistance from social services and family" (Ministry of Health, 2004, p94). Some teenage mothers struggle to cope with the demands of caring for a baby (Wahn, Nissen & Alberg, 2005) and the children of teenage mothers are at risk of low birth weight, perinatal mortality, developmental disabilities and behavioural problems (Hawke's Bay District Health Board, 2010; Johnson & Denny, 2007).

Recent research has challenged the negative social construction of teenage pregnancy and motherhood, where "socially scripted deficit narratives" (Brand, Morrison, Down & WestBrook, 2014) can lead to maternal stigmatisation, distrust and feelings of being judged and treated differently by health-care professionals. Research done in New Zealand by Makowharemahihi et al (2014) found that pregnant Maori teenagers find systemic barriers when they seek to initiate maternity care for themselves. De Socio, Holland, Kitzman and Cole (2013, p168) describe adolescence pregnancy as "a window of developmental opportunity" if judgement-free services with supportive relationships can be developed. Brand et al (2014) call for non-standard approaches to nursing practice that involve relational and responsive social relationships to meet maternal needs and contribute positively to a young mother's experiences of parenting.

As a primary health-care initiative, the WC/TO service is offered free to all New Zealand children from birth to five years of age, delivered by registered nurses to children and their families/whanau in the community (Ministry of Health, 2002). Plunket is the main WC/ TO service provider. A key focus of the initiative is ensuring that all entitled families/whanau receive the service, and those with high needs receive additional support to reduce inequalities and improve child-health outcomes (Ministry of Health, 1996). The extended WC/ TO service provided to teenage mothers in Hawke's Bay represents a non-standard approach to foster positive parenting experiences for vulnerable populations.

METHOD

The two evaluations sought to answer the question, what were the outcomes, successes and challenges of the pilot extended WC/TO service provided by Plunket to teenage mothers in Hawke's Bay. Part of each evaluation involved interviews with the health professionals involved in delivering the service, including the Plunket nurses and their supervisor. These interviews were conducted face-to-face in 2011, and again in 2014. During the interviews, the nurses were asked to reflect on their role and experiences delivering the service to teenage mothers, focusing on their perceptions of success and particular challenges they faced.

The interviews were audiotaped with informed consent and fully transcribed. Thematic analysis was applied to the data, with cross-checking of codes and themes achieved within the research team. Approval for the research was granted by Plunket and the EIT-Hawke's Bay Research Ethics and Approvals Committee. No names appear with the reported data and further details regarding the composition of this group, including its size, are withheld to help preserve the participants' anonymity.

RESULTS

This paper reports the nurses' perspectives on their role delivering extended WC/TO services to teenage mothers. The following subheadings represent the key themes that emerged from the data analysis.

The role of the Plunket WC/TO nurse

The role of Plunket nurses delivering the WC/TO service is to provide well child and well family care in the community, based on the WC/ TO schedule. This schedule includes three strands: health education and promotion; health protection and clinical assessment; and family or whanau care and support (Royal New Zealand Plunket Society, 2003). One of the nurses providing the extended WC/TO service to teenage mothers described her role as "the same Plunket nurse role as [for] everyone else but it is just more intensive".

The intensity referred to begins with the antenatal contact provided to teenage mothers through the extended service. However, it also develops through the need to build a strong, trusting relationship with the mothers, so the service can be successfully delivered; and from supporting these young women emotionally and helping them make good choices for their babies. This involved needs-based visits in addition to the nurses' scheduled core visits. In her own words, one of the interviewed nurses listed the things she did for the teenage mothers, and the needs she met, as including:

* Connecting them with midwives and other services. * They need accurate, timely information and resources. * I encourage them in the first three months to be accessing PlunketLine. * Social needs, referring them to other organisations that can help with the social needs. * The really high-needs families I could be seeing two or three times a week, some of these families are under CYFS [Child Youth and Family Service]. * A lot of phone calls to liaise with other services to ensure the clients' needs are met. * Every week on a Wednesday morning I do an open clinic at TPU [Teen Parent Unit] where a lot of my mums go, so they will approach me weekly to ask little things that are going on for them. * I do lots of referrals, and even just lots of finding out of what is available so that I can let them know, and then maybe helping them to feel confident to make that contact. Lots of that interagency, multi-disciplinary kind of stuff. * I'm an extra person in their lives, making a relationship. * Blankets and baby clothes and food, because some people don't have food. I am finding clothes and I am finding blankets, and I am organising food parcels and I am dropping in car seat information and car seats and arranging all that, and doing all of that stuff which is really important, 'cause it is part of the service. * I use language they can understand.

Many of the listed needs of these clients, catered for by WC/TO nurses working within a needs-based delivery model, arguably fall beyond the normal understanding of clinical care.

Trusting nurse/client relationships

One of the successful outcomes of the pilot extended WC/TO service was the nurses' ability to keep 20 of the 21 teenage mothers engaged in the service for the first year of their babies' lives. After three years, five of seven who had disengaged from the service had done so because they had left the district. Continuing engagement with the service is significant because, as the project supervisor explained, "Ensuring [WC/TO nurses] stay engaged with the mum is essential as they are one of the few health professionals with access to vulnerable families in their homes and who consistently see children until they are five years old."

The professionals involved in the service recognised that its successes were directly due to the trusting relationships the nurses were able to develop with the young mothers. The opportunity to meet clients in the antenatal period was considered pivotal to building that trust, allowing for one-on-one engagement with the mother before her baby became the main focus of attention. It also enabled an early assessment of need. One nurse explained, "It gives you really good outcomes, I think, seeing the mums antenatally; getting that relationship happening, seeing what needs to be put in to place." The nurses considered that consistency and time were essential for developing the relationship, especially with high-needs cases.

One Plunket nurse described her interaction with a very young teenage mother with multiple complex issues, clearly illustrating the imperatives of trust and time for issues of child and maternal safety. Her narrative warrants its lengthy inclusion here.

"She didn't have any relationship with me prior to the baby being born, but I still went and talked to her, even though she didn't talk back. So it was important during the pregnancy, because then she knew me and she knew I kept my appointments and I tracked her, you know, chased her down really. I just made sure I found her for those visits and connected with the other agencies that were involved, and so she knew what I was there for ... and I saw her as soon as she had had her baby and delighted in the baby with her. She was really delighted with her baby and I really celebrated that with her. And I think she really enjoyed that and that's when she started really communicating with me.

"She loved that baby and she wanted the best for it despite her circumstances, which were really, you know, deep poverty, CYFS involvement. And I was able to provide other things like food parcels and clothes for her baby, so I wasn't just seeing the clinical stuff, I was sort of making sure that everything was there for her, that the whole picture was seen to. And she had lots of agencies involved and probably the only other agency I referred her to was PAFT [Parents as First Teachers] and she is still connected with PAFT despite her really complex situation. And so we have kept in contact all the way along.

"So, just recently, baby is eight months. I saw her last week and she told me everything was fine and during the process of the hour-long visit it came out. She told me that her partner was still being violent and cutting up her clothes and had been head-butting her and beating her up regularly. And she confessed that she had been smoking dope since she was 10 and that she had an issue and she wanted drug and alcohol [help].

"So, she told me all this stuff and I was really upset, and I was able to honestly say, look I need to make a notification. I need to be doing this and this and this for you, and that you clearly know that by telling me this that you know my responsibilities. And we were able to talk through all that, and what I was going to do and what CYFS would want to know and then we need to work from there, and that is my role. And so we did [baby's] Well Child check but it ended up, that out of all of the stuff that she shared with me, that I was able to make a notification. So, you know, it has taken eight months, no, more, nine months, 10, but in the end she confesses all this stuff that is going on. And I was able to make a move on that. So I think that that's a real success. I think that, despite taking that time and us having what I think is a close relationship, that it has just been a matter of time before she has told me all this stuff."

This extract highlights Plunket nurses' ethical considerations, and obligations to notify CYFS in cases of family violence.

Strong interagency relationships

The evaluation of the pilot service (Skerman et al, 2012; Thompson et al, 2012) showed that, compared to a control group, the teen mothers receiving the extended service were much more frequently referred to a range of other health and social services. This pattern continued over time (Thompson et al, 2014), meaning that the mothers gained access to a range of important support services they may not have otherwise. That they were prepared to engage with these services also demonstrated the significance of the nurse/client relationship. One nurse said,

"And also for the mothers to accept our referrals for services they may never take if they didn't know us or trust us. And that opens up great opportunities for them, I think, and their babies ... I think one of our strengths, too, is making people aware of what is available to them and empowering them to access those things, like PlunketLine and Healthline.

Strong interagency relationships were considered valuable for helping the nurses obtain a comprehensive picture of a mother's situation, so they could provide more appropriate information, advice and/or referrals.

"We find a lot of support from the other services involved. If we're a little concerned or we're not sure, we really use those. So we're ringing and asking opinions. We spend a lot of time doing all that connection stuff."

Team work

The interviewed nurses acknowledged the importance of team work, particularly when managing their clients' high levels of social and material need. The nurses provided each other with peer supervision. They worked very closely with a Maori Plunket kaiawhina, a nursing support worker contracted to support their clients in the community, and debriefed regularly with her about the issues and concerns that arose. They acknowledged the central importance of good clinical supervision by their clinical leader and her manager, which they reported was readily available to them as needed. As one nurse explained,

"I think it's challenging due to the type of client that we deal with--high need ... So it's really important that this role has that close clinical supervision to clarify concerns with family violence or child protection issues quickly and easily. So being able to contact the clinical leader quickly ... It's been amazing. It makes all the difference to be able to clarify your position and your responsibility against their knowledge. And they'll reiterate, reaffirm policies."

Challenges and difficulties in providing the service

The nurses felt that helping their teenage clients manage the many, varied social issues they encountered was the biggest challenge of their nursing role and of the WC/TO service. Many issues were ongoing and stemmed from the family/whanau's relative social and economic deprivation, or the mother's sense of disempowerment, lack of life experiences or dependence. One nurse stated,

"The big thing was the social issues, the overwhelming social issues ... These young parents have lots of social challenges. They might have whanau around them but they're not necessarily good support ... Finances, stability of living arrangements, power over their own outcomes. They might want to go to the doctors but they don't have anyone to take them or someone else might say the baby's fine. It's all that kind of stuff, related to being teenagers still, themselves, and being parented, being still children of parents."

For a period of time during delivery of the pilot extended service, the WC/TO nurses had a social worker working alongside them. The need for this was recognised early in the delivery of the pilot service and its provision allowed the nurses to concentrate on the tasks that were more within their scope of practice. As one nurse explained,

"It would mean that I would do the clinical stuff, and enhance the health promotion and health education, and the clinical stuff ... There is so much social stuff, that is a huge part of my job ... They [social workers] can be working with the family to really build on the strengths that those mums have, and their futures and where they are going from here ... It makes sense to have a [social worker] because I am not a trained social worker. And then we would probably be able to see more mums."

Despite favourable evaluation (Harvey, 2013), funding for the collaborative social worker for the extended Plunket service was discontinued after one year, returning the nurses to circumstances where they would again be the "front line" dealing with complex social issues.

Family violence and child protection issues

Family violence was reported as being a very difficult and sensitive area, and helping some of the young mothers to deal with this was a significant challenge for the nurses. Partner violence, in particular, was not uncommon among the service's clients. In addition to ensuring the mother was kept safe and well-informed about options for support, a major consideration for the nurse was ensuring the safety of the child and, if necessary, making a referral to CYFS. The nurses were well aware that this would be done at the risk of damaging their relationship with the family/whanau, and possibly their ability to continue to provide well child care. One nurse recalled a particularly volatile situation in which she found herself, and described the dilemma she faced as follows,

"I wrote a report of concern to CYFS and filed it in the notes. My dilemma was that if I sent it in, I risked jeopardising any chances of getting back into that house, and sabotaging the relationship I had with [the mother]. And I was the only agency in there. But then, how great was the risk to the baby in not filing a report of concern?"

DISCUSSION

A key success of the extended WC/TO service for teenage mothers in Hawke's Bay was the nurses' ability to achieve the kind of relationship with their teenage clients that allowed for successful delivery of the service. This required nurses to meet clients' needs that were often more social than clinical, while also maintaining clinical practice and levels of client trust necessary to keep them engaged with the service. In some cases, and with time, this relationship could lead to disclosures related to maternal and child safety.

The importance of strong, trusting, respectful nurse/client relationships is well understood and a number of studies have stressed its importance for engaging well with, and empowering, teen mothers, many of whom feel judged and patronised by health service providers (Breheny & Stephens, 2007; SmithBattle, Lorenz & Leander, 2012; Skerman et al, 2012). Strong inter-agency relationships are also necessary when the social issues surrounding teenage mothers, including poverty and violence, become complex, overly burdensome and dangerous. Such issues provide particular challenges to nurses delivering the WC/TO service, which may be the only service with consistent access to the teenage mother's home and delivering a sustained health-care service for babies. There is a strong argument for social workers to be formally placed alongside the WC/TO service for vulnerable clients, to help ensure nurses' safe practice and the successful delivery of health services.

REFERENCES

Brand, G., Morrison, P., Down, B. and WestBrook, B. (2014). Scaffolding young Australian women's journey to motherhood: a narrative understanding. Health and Social Care in the Community, 22(5), 497-505.

Breheny, M. and Stephens, C. (2007). Irreconcilable differences: Health professionals' constructions of adolescence and motherhood. Social Science & Medicine, 64 (1), 112-124.

DeSocio, J. E., Holland, M. L., Kitzman, H. J. and Cole, R. E. (2013). The influence of socio-developmental context and nurse visitation intervention on self-agency change in unmarried adolescent mothers. Research in Nursing and Health, 36 (2), 158-170.

Harvey, S. (2013). Evaluation of the Family Works Hawke's Bay young parent social work programme. Havelock North, New Zealand: Presbyterian Support East Coast.

Hawke's Bay District Health Board. (2010). Health Status Review. Retrieved March 23, 2010, from www.hawkesbaydhb.govt.nz/ web_content2.asp?ID=100008661

Johnson, R. and Denny, S. J. (2007). The health and wellbeing of secondary students attending teen parent units in New Zealand. Auckland, New Zealand: University of Auckland.

Makowharemahihi, C., Lawton, B, Cram, F., Ngata, T., Brown, S. and Robson, B. (2014). Initiation of maternity care for young Maori women under 20 years of age. The New Zealand Medical Journal (online), 127(1393), 52-61.

McElnay, C. (2014). Health (in)equity in Hawke's Bay: Key findings. Hastings, New Zealand: Hawke's Bay District Health Board. Ministry of Health. (1996). The New Zealand health strategy. Wellington, New Zealand: Author.

Ministry of Health. (2002). The Well Child/ Tamariki Ora framework. Wellington, New Zealand: Author.

Ministry of Health. (2004). Child and youth toolkit. Wellington, New Zealand: Author.

Royal New Zealand Plunket Society (Inc). (2003). Plunket nurse job description. Wellington, New Zealand: Author.

Skerman, N. (2010). What do teenagers want from the Well Child/Tamariki Ora service? Unpublished master's thesis, Eastern Institute of Technology, Taradale.

Skerman, N., Manhire, K., Abel, S. and Thompson, S. (2012). Making engagement with Plunket's Well Child service meaningful for teenage mothers. Kai Tiaki Nursing Research, 3(1), 31-36.

Smith Battle, L., Lorenz, R. and Leander, S. (2013). Listening with care: Using narrative methods to cultivate nurses' responsive relationships in a home visiting intervention with teen mothers. Nursing Inquiry, 188-198. doi:10.1111/j.1440-1800.2012.00606.x.

Thompson, S., Manhire, K. and Abel, S. (2012). 'Changing the next generation'. An evaluation of the pilot extended Well Child/Tamariki Ora service for teenage parents in Hawke's Bay. Taradale, New Zealand: Eastern Institute of Technology.

Thompson, S., Abel, S., Skerman, N. and Manhire, K. (2014). 'Yes I am a good mother'. A follow-up evaluation of the pilot extended Well Child/Tamariki Ora service for teenage mothers in Hawke's Bay now the children are three years old. Taradale, New Zealand: Eastern Institute of Technology.

Wahn, E., Nissen, E. and Alberg, B. (2005). Becoming and being a teenage mother. How teenage girls in southwestern Sweden view their situation. Healthcare for Women International, 26, 591-603.

About the authors: Nicky Skerman, RN, MN, is population health strategist for woman, child and youth at Hawke's Bay District Health Board. (At the time of this study she worked for the Royal New Zealand Plunket Society.) Her correspondence address is: nicky.skerman@hawkesbaydhb.govt.nz

Kathy Manhire, RN, RM, MMid, is a senior lecturer at the Eastern Institute of Technology's School of Nursing, Taradale, Hawke's Bay.

Sally Abel, PhD, is an independent health researcher in Napier, Hawke's Bay.

Shona Thompson, PhD, is a senior research fellow at the Eastern Institute of Technology, Taradale, Hawke's Bay.
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Author:Skerman, Nicky; Thompson, Shona; Manhire, Kathy; Abel, Sally
Publication:Kai Tiaki Nursing Research
Article Type:Report
Date:Sep 1, 2015
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