Introduction. Background

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1 The role of child health nurses in enhancing mothering know-how Jennifer Rowe RN, Dip Ed, BA Grad Dip Ed, MPhil, PhD, School of Nursing and Midwifery, Griffith University, Queensland Margaret Barnes RN, RM, BEd (Nurs), MA, PhD, Faculty of Science, Health and Education, University of the Sunshine Coast, Queensland Supporting early parenting and promoting family health is an important aspect of contemporary child health nursing in Australia. Recent studies suggest that within a service climate that increasingly funds targeted, population-based needs rather than universal needs, child health nurses are concerned about maintaining individual nurse-client relationships, particularly with individual families. There is however, limited evidence available to use in response to these concerns. In this paper the way a group of middle-class mothers of infants, who, in today s health service climate, may not be a target group for health services, develop their caregiving know-how, is discussed. The findings presented suggest that both expert and lay knowledge have a part to play in supporting women in their early mothering. Women such as these, in essence, need a clearing-house to help them sift through the overwhelming information they access, respond to, and turn into everyday practices that work. Well placed child health nursing services may achieve this. While there is significant support for this claim in the literature, mechanisms for effective support remains the challenge. A key may be found in nurses focusing on the promotion of communicative or interactive health literacy as an outcome of their programs. Key Words: child health nursing, mothering, infant health, health literacy Correspondence to: Dr Jennifer Rowe jennifer.rowe@griffith.edu.au Introduction Community preventive health care services such as those provided by child health nurses are organised within a context in which there is keen competition for a share of scarce public health funding. Political, social and economic factors influence the types of service that are considered desirable and affordable. Thus, a strong evidence base demonstrating health outcomes is essential in order to justify any service. In Australia, for much of the 20 th century, a large proportion of child health nursing focussed on the provision of universal services for individual clients - infants, young children and their families. Supporting early parenting and promoting family health remain key goals in the 21 st century, an agenda informed by national and state policy for the health and well being of children (Commonwealth Department of Health & Family Services 1995 & 1997, Queensland Health Child & Youth Health Unit 2002). Integrating this goal within targeted populationbased child health services, rather than universal ones, presents some issues and it is apparent that child health nurses are apprehensive about this (Barnes et al 2003). Recent studies suggest that child health nurses are concerned about maintaining individual nurseclient relationships, particularly with individual families (Reutter & Ford 1998, Barnes et al 2003). One service that illustrates this tension is the well-baby health clinic service. With an increasing focus toward targeted programs, fewer resources are available for universal infant health assessment and individual, early parenting support, services historically provided by well-baby clinics. Child health nurses are concerned about this trend, but arguing this point is difficult, as there is little evidence available to demonstrate the effectiveness of such services. This paper addresses this issue by examining the processes and resources used by a group of middle-class women, who, in today s health service climate, may not be a priority health target group, as they developed their mothering competence and nurtured their infant children. The aim is to provide a platform to examine the potential place and usefulness of child health nursing services to groups such as these. Background The processes through which women re-organise themselves or attain their maternal role are complex, culturally bound and also shaped by everyday experience (Hays 1996, Bergum 1997, Rogan 22 Collegian Vol 13 No

2 The role of child health nurses in enhancing mothering know-how et al 1997, Bailey 1999, Rowe 2003). In the nursing literature a range of studies has examined aspects of maternal experience that relate to the processes, supports and resources women use in order to anticipate and engage, mothering. Much of the literature addresses maternal knowledge and knowing in an unproblematic way, that is, at a level of need, to which nurses and midwives respond in various ways; by providing assistance and helping women to problem solve (Pridham 1997), and by teaching and advice giving (Coveney & Miller 1991, Maloni 1994, Birk 1996, Moran et al 1997, Whelan & Lupton 1998). There has been continued focus on the antenatal period and the education needs of women regarding mothering (Moran et al 1997, Nolan 1997a&b, Britton 1998, Renkert & Nutbeam 2001, Schneider 2002). In this literature there is sustained criticism about antenatal education, in particular the lack of emphasis placed on the postnatal period and childrearing. However little of this literature examines the processes involved in becoming knowledgeable or competent. The ideology of the unknowing mother is pervasive in the nursing and midwifery literature, with the transfer of information thought to be the key. From a more theoretically informed position research has promoted the notion of negotiated knowledge as a key element to successful maternal competence (Barclay et al 1997, Rogan et al 1997). Rogan et al (1997) for example, theorised from a grounded theory inquiry that women move through various points of disruption, and uncertainty about motherhood toward a more satisfying maternal experience. They argued that the transition was negotiated and shaped by their baby s behaviour, level of social support and previous experiences. Further, they argued for a role for nurses and midwives in the process, particularly in providing information. A further group of studies has examined resources, that is, published materials, designed to guide early parenting (Hardyment 1983, Marshall 1991, Rowe & Barnes 1996, Hays 1997). These studies have identified the sort of information about caregiving and infants health and well-being, that interested stakeholders believe is useful to parents, and specifically, mothers. While these studies help to illuminate the sort of information and support women need, desire or are thought to require, less is known about women s everyday experience, and the place and value of the resources and support they access, to their expressions of motherhood. The study The material discussed in this paper represent a portion of the findings taken from an interpretive study into the infant caregiving experiences of a group of urban, Australian mothers (Rowe 2000, Rowe 2003). By examining how middle-classed, urban mothers of infants develop maternal and infant caregiving know-how and what resources they incorporate in their everyday experience, child health nursing service needs and interactions can be explored and contextualised. The study was grounded in the theoretical understanding that everyday realities are the source of meaning. In everyday experiences it is possible to see the influences or factors that shape activities and understandings and at the same time the constructs of what is valued, considered necessary and desirable, as well as problematic. Further, it is assumed that realities and meanings are specific and context bound, rather than universal or singular. From this perspective, light can be shed on a variety of women s experiences and expressions of maternal caregiving. A narrative inquiry approach was used. The study methods have been reported in detail elsewhere (Rowe 2003). The sampling strategy was purposive and the sample homogenous. There were 21 participants, comprising women with an infant aged between one and 12 months at the time of the study. The participants were all 25 years or older. Fourteen were first time mothers. Nineteen lived with male partners and two were single parents. All were Australians of Anglo-Saxon background. The group had above national average levels of education and income. All the women lived within one urban area of South East Queensland and thus had access to a similar range of government and private sector parenting resources and services. With ethical clearance and after gaining written informed consent, data were collected via in-depth interviews and participants journal entries. Toward maternal competence: Resourcing early mothering practices The participant s experiences revealed patterns in the way in which they accessed and used a range of resources as they prepared themselves and then developed their maternal confidence and know-how. These patterns are named here, Expecting, Testing and Consolidating. Illustrations from the women s accounts are provided using pseudonyms to protect participants identities. Expecting Expecting refers to that space and time when the women in the study imagined their changing roles. Few of the participants had any experience with young children prior to the birth of their first baby and all were employed outside the home up to that point. They needed to make the unknown more familiar, and develop and revise their expectations concerning mothering, infants, and their care. If they attended antenatal classes, the women received information from midwives about childbirth and breastfeeding. During pregnancy, the women s strategies involved surfing for information, skimming across the range of expert materials. Alexis, a first time mother, had read widely during her pregnancy. Using books borrowed from the library she read about topics she felt she needed to know more about the crying and the sleeping and that sort of thing. She expected to breastfeed her infant: I didn t have any doubts about that. I wanted to do it if I could. Yet she found that as she read, breastfeeding became a more difficult thing in her mind: There is so much literature about it and um gosh it must be hard. They seemed to be going on and on about how to do it correct attachment and all of that and all the problems so I thought, you know, you had to think about it and learn how to do it. This process led her to be less confident about her ability to care for her infant. This outcome was not the experience of all the women in the study. Another woman, Ingrid, like Alexis, was Collegian Vol 13 No

3 highly motivated to develop her knowledge and expectations about how to care for her infant. She also relied on printed and internet based expert information producing reference summaries of topics that were important to her. However, she went beyond the texts and in an effort to make a bodily connection with infant care, attended meetings of her local branch of a lay breastfeeding group (Australian Breastfeeding Association) during her pregnancy. She said this of the experience: It really boosted my confidence about breastfeeding. Probably, just being around other women who were doing it and they were really relaxed and talking about it, you know as I said, I d read about it in the books, but being around real live people who were doing it was good. Testing Testing reflects the life-as-it-happens phase, where things expected and learned about are embodied in the realities of everyday infant caregiving and where this embodiment, in turn, challenges and shapes further, maternal wisdom. Over days, weeks and months these women tested and revised their caregiving strategies. Lay and professional advice played an important role and their experiences revealed tensions between nurturing the baby and preserving a sense of self (Rowe 2003). The women told many stories about infant feeding, stories that illustrate these processes. For example, Karla, like most of the participants, had expected to breastfeed, trusting that her body would work. In practice, this was not the case and her experience, a traumatic one for her, involved a series of exchanges with experts, health professionals. She consulted with community midwives, then with a lactation consultant, who referred her to a specialist lactation consultant. They provided information, advice and feeding technologies, all of which helped her to test and negotiate her way through her difficulties with feeding her baby, although one piece of information was influential in helping her finally decide what to do: All the others said don t worry it s going to happen and then she (the community midwife) said sometimes breastfeeding doesn t work out and I thought, well, Oh god, I ve got an out. In the end, the path for her, was to feed her baby with formula so that she could meet other priorities and cope with the demands of mothering: I felt that by that time, I wasn t building a relationship with him and that was much more important (than breastfeeding). Barbara s story provides further illustration of the processes by which the participants tested information and advice. Barbara had expected to keep her baby in a crib beside her bed for several months. Once at home with the baby she found that her own sleep was disturbed and as a consequence she felt unable to cope. She consulted a child health nurse. After this encounter she moved her infant to his own room when he was just six weeks old. She commented on the influence of the advice given to her on her practice: So that was kind of the revolution when she said (the nurse) well go home tonight and move him into his cot, start feeding (less often) Barbara found a way to look after her infant and cope, even though the advice she was given was not optimal in terms of the child s young age. The publicly funded child health clinic was one of the information hot spots for some of the women in the weeks and months following the birth of their child. Chris viewed child health as a source of confirmation and accessed them either in person or by phone: If you re niggling over something silly and sort of getting that reassurance. Jenny tried phone help lines while she struggled to resolve her breastfeeding difficulties over a period of weeks: I needed to know right there and then because it was happening now. In addition to phone help, Jenny also started visiting her local community child health clinic in order to have the baby health checks done. She followed the prescription set out in the personal health record for planning visits. She found the clinic and its nursing staff exceeded her expectations, and suggested that they offered a one-stop shop for things that helped her maternal competence: I just thought it was more, the general sort of community centre where people drop in and get ideas about looking after kids. I mean I knew it was like - immunisation and support (but it s the) same sort of thing plus more. If they don t offer a service they can put you in the right direction and with the playgroup (early parenting group) that s been really good to have, where everyone s got the same age babies. So I mean, I guess they offer more than I thought. Some of the women used their child s personal record and particularly the growth chart information, as a discussion trigger at the child health clinic. The nurses at the community child health clinics served to broker the information the women had garnered about their infant s health, well-being and cares. This information helped them to make decisions about cares and to review the success of their approaches, particularly regarding feeding. Georgia, for example, weighed her infant regularly, plotting the progress against the chart because in her words: Well it shows that she s getting enough food and she s growing. The women tested the strategies they heard about, as shown in Barbara s case in her efforts to get enough sleep. Another strategy was to compare the information they got from the clinic with other sources, such as guides, or advice from friends and relatives. For women with other children, the infants progress could be mapped and compared to previous children, their photos, clothes and charts. Consolidating Consolidating describes the way in which women in this study created order and organisation, either in a general sense, or specifically in relation to one need, desire or care. In some ways it is a contrivance to separate the themes of testing and consolidating, however it is useful to discriminate between the two as this helps to present the right ways in various infant cares that these women settled on. Dina, for example, expected to wean her infant onto solid foods from 4 months, an expectation that was reinforced by the parenting guides she read. To her this was normal. Her reading and advice from the child health nurse lead her to expect that rice cereal would be the first food her baby would eat. She followed this approach when her baby was four months old but found her infant unimpressed. This left her to consider options and she wrote this in her journal: 24 Collegian Vol 13 No

4 The role of child health nurses in enhancing mothering know-how We will persevere and ask the child health nurse on Tuesday if this is normal. It stands to reason that it is I asked the child health nurse s opinion re solids but feel that at this stage we will plod along, adding fruit to the Farax and see if this makes a difference. We can change to follow-on formula for the iron and may consider stopping the Farax. The right way for Dina was based not just on her own assumptions but confirmed in expert advice and in intricate processes in which she shifted, tested, picked up and discarded fragments of information. Right ways of infant care were the outcome of these women s efforts to nurture their infants in the best way possible while also preserving or managing their own wellbeing. For some this consolidation was expressed when they felt knowledgeable and skilled, as one woman said simply: I think it s just experience. Rachel, a mother to two children, described a space, that embraced a balance of nurturance and self preservation and care, a space that reflected maternal competence: Definitely there is a there. It s kind of like a girlfriend and I called it coming out of the fog. That new baby, well you ve got on top of it, you ve got to know your child and you re feeling like you re in the human race again Early mothering and child health nursing services The findings presented above seek to make clear something of the complex processes women engage in as they mother their infants, processes which inform their maternal competence. Specifically, they present an analysis of the way women access and use a range of resources in this pursuit. Generalisations need to be made with caution because of the methodological limitations of the single research context and small homogenous sample. The women s stories revealed that their experience and wisdom was shaped quite purposively by expert information; variously packaged information and guidance, which they actively sought. They subjected this information to comparison and testing. Expert knowledge played a significant and on-going role in the women s caregiving. The sources were various and numerous; books, help services and community chid health as well as knowledgeable friends and relatives. The order that they achieved as mothers and carers was fragile, negotiated and subject to change and upheaval, developing in a complex web of expectation, desire, advice and everyday interactions with their infants. The findings suggest two, interrelated things that may inform child health service planning. The first concerns the participants high level of health literacy and the second, the associated complex and dialogical processes in which they engaged to find meaningful ways of doing things. Health literacy is a concept that refers to factors that influence people s ability to not only access health information but also their capacity to use it effectively (WHO 1998 p10). The participants in this study were highly educated, highly motivated, and demonstrated a high degree of skill in both accessing and utilising information. The process may be described as one of shopping around. The women shopped the multi-media materials, knowledge of friends and family and health services. Testing information against other guidebooks, service providers and family and friends was one step in the testing process. They tested as they cared for their infants. In this study the women shopped for expert information in order to develop their expectations, only to find these expectations were challenged by the everyday realities in which they found themselves caring for their infants. They needed more information and so shopped some more. In a further cycle they became more discerning about information, as they became more confident in their maternal know-how. The ideal or idealised practices suggested in the various sources of information, neat, logical and sequential, didn t always reflect participants realities. The available information was influential in shaping the way the participants looked at, examined, and experienced their babies and made decisions about care. Through these processes the participants developed a sense of security, confidence and competence in a situation where they started with little practical knowledge or experience to draw upon. Shopping around also defines experts and expertise in a certain way. Women such as these actively seek out expert knowledge in an accepted path to self management, a strong value in contemporary western societies (Giddens 1991, Bauman 1995). The findings suggest that both expert and lay knowledge have a part to play in supporting women in their early mothering. Professional expertise was revealed in this study to be partial, momentary, and fragmented. The motivated and educated women in this study gathered a wide array of information yet placed a heavy emphasis and reliance on themselves, to determine and organise the shape and substance of their daily life. Experts in this model may be important but this is transitory and their relevance is contingent on how they are situated by those who access them. If this is the case the moments during which they are engaged by mothers must matter if they are to provide effective support. To this end supporting parenting requires being ready with a useful product in the right place, at the right time, in order to help build bridges and facilitate practical wisdom. Women such as these, in essence, need a clearing-house to help them sift through the overwhelming information they access, respond to, and turn into everyday practices that work. In addition the findings demonstrate that during their pregnancy, women such as these are thinking about childrearing, and their infant s health and care. This supports the argument that health education provided antenatally, that aims to improve health literacy about these matters, is important (Nolan 1997a&b, Renkert & Nutbeam 2001). While there is significant support for these claims in the literature, mechanisms for effective support remains the challenge. A key may be found in nurses focusing on the promotion of communicative or interactive health literacy as an outcome of their programs. That is, education that enables women to both extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances (Nutbeam 2000 p264). The current model of child health nursing service that includes the provision of facilitated peer networking, is appropriate to support this need and there is evidence that this service is being provided (Scott et al 2001, Barnes et al 2004). In a recent study Collegian Vol 13 No

5 examining the roles, responsibilities and professional development needs of child health nurses in Queensland, Barnes et al (2004) discuss the emphasis child health nurses place on their supportive and nurturing role. Nurse participants felt that they provided the support that was once provided by extended families and that they facilitated the development of ongoing support networks. This supportive role was considered core business of the child health nurse and the most satisfying part of their role. This supportive role is reported elsewhere in the literature. For example, Fagerskiold and Ek (2003) found that both nurses and mothers expectations of the child health nurse in Sweden, were one of supporter, counsellor, safety provider and parent group organiser. Child health nurses are described as having a key role as supporter and resource person for new mothers, with the importance of the relationship between nurse and client being emphasised (Fagerskiold et al 2001, Jansson et al 2001). These services illustrate parenting support in which there is more than a functional model of education (which focuses on information transmission and uptake). Rather, as Renkert and Nutbeam (2001) argued, they aim to be enabling, that is, confidence and competence, building. Conclusion In this paper we have demonstrated processes through which women negotiate information and services in order to nurture their infants and develop a sense of maternal identity and knowhow. In these processes there is evidence that there is a role for child health nursing services in facilitating women s efforts. 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