'Everything's adaptable': A qualitative study of how nurses make decisions in sustained home-visiting care with mothers and children experiencing adversity.

AIMS: To explore nurse decision-making processes in the delivery of sustained home-visiting care for mothers of young children who are experiencing adversity. DESIGN: Qualitative descriptive research design using focus group interviews. METHODS: Thirty-two home-visiting nurses participated in four focus group interviews exploring their decision-making in the care they provide to families. The data were analysed using a reflexive thematic analysis approach. RESULTS: Four steps of a recurring stepwise decision-making process were identified: (1) information gathering; (2) exploring; (3) implementing; (4) checking. The facilitators and barriers to effective decision-making processes were also identified and included elements relating to good relationship skills, a good attitude, high quality training and mentoring and resources. CONCLUSION: The findings indicate that a recurring stepwise process of decision-making requires both analytical and intuitive approaches. The intuition required by home-visiting nurses is to sense unvoiced client needs and identify the right time and way to intervene. The nurses were engaged in adapting the care in response to the client's unique needs while ensuring the fidelity of the programme scope and standards. We recommend creating an enabling working environment with cross-disciplinary team members and having well-developed structures, particularly the feedback systems such as clinical supervision and case reviews. Enhanced skills to establish trusting relationships with clients can help home-visiting nurses make effective decisions with mothers and families, particularly in the face of significant risk. IMPACT: This study explored nurse decision-making processes in the context of sustained home-visiting care, which has been largely unexplored in the research literature. Understanding the effective decision-making processes, particularly when nurses customize or individualize the care in response to the client's unique needs, assists with the development of strategies for precision home-visiting care. The identification of facilitators and barriers informs approaches designed to support nurses in effective decision-making.

Does customised care improve satisfaction and positively enable parents in sustained home visiting for mothers and children experiencing adversity?

BACKGROUND: The Maternal Early Childhood Sustained Home-visiting program (MECSH) is a structured nurse-delivered program designed to address health inequities experienced by families experiencing significant adversity. There is strong evidence for the effectiveness of this program, but limited research exploring the practice and process elements that are core to positive parent outcomes. This study aimed to examine the relationship between customised care related to the mother's risk factors and parent satisfaction and enablement in the delivery of a MECSH-based program. METHODS: A cross-sectional study design was used. Program delivery data collected as part of a large randomised controlled trial of a MECSH-based sustained nurse home visiting program in Australia (right@home) were analysed. This study used the data collected from the intervention arm in the trial (n = 352 women). Parent satisfaction was measured at child age 24 months using the modified short-form Patient Satisfaction Questionnaire. Parent enablement was measured at child age 24 months by a modified Parent Enablement Index. Customised care was defined as appropriate provision of care content in response to four maternal risks: smoking, mental health, domestic violence and alcohol and drugs. Logistic analysis was performed to assess the impact of customised care on parent satisfaction and enablement while adjusting for covariates such as sociodemographic factors. A significance level of 95% was applied for analysis. RESULTS: Our results indicated high levels of satisfaction with the care provided and positive enablement. There were several sociodemographic factors associated with satisfaction and enablement, such as language spoken at home and employment experience. The mothers who received customised care in response to mental health risk and domestic violence had significantly greater satisfaction with the care provided and experienced an increase in enablement compared to those who did not receive such care. CONCLUSION: This study contributes to the existing body of empirical research that examines the relationship between care processes and client outcomes in the delivery of home visiting services. It is essential for the sustained nurse home visiting service model to be flexible enough to cater for variations according to family circumstances and needs while maintaining a core of evidence-based practice.

Developments in Nursing Practice to Address Substance Use in the Perinatal Period.

Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.

Parent satisfaction with sustained home visiting care for mothers and children: an integrative review.

AIM: To synthesise and analyse the existing literature regarding parent satisfaction with sustained home visiting care for mothers and children. BACKGROUND: Sustained home visiting is a service delivery mechanism of both prevention and intervention, in which people receive structured support services within their home environment over an extended period of months or years. For the purposes of this paper, sustained home visiting refers to in-home nursing support to address health inequities for mothers and young children. Sustained home visiting programs have been found to support improved health, wellbeing, and developmental outcomes for children and families. However, there is limited knowledge with regards to the level of parent satisfaction with care provided at home, and the factors and elements of care parents perceive to be critical to their satisfaction. It is important for healthcare practitioners to understand what practices and process parents consider to be a priority in securing their ongoing engagement. DESIGN: Integrative review. DATA SOURCES: PubMed/Medline, CINAHL, Embase, and PsycINFO. METHODS: A multi-step approach was used to search and retrieve peer-reviewed studies from the databases. Study selection, data extraction, data synthesis and critical appraisal were undertaken by two independent researchers. RESULTS: A total of 13 studies met the inclusion criteria, including nine quantitative and four qualitative studies. The review found that parents provided with home visiting interventions had higher levels of satisfaction with care than those who received routine or facility-based care. Service dose was a factor associated with parent satisfaction, however, the direction of impact on parent satisfaction was mixed. Other elements of care parents perceived as important to service satisfaction included the nurse-client relationship, being treated with respect, empowerment, and emotional support. CONCLUSION: While it is critically important that home visiting practitioners provide evidence-based care and interventions, it is equally important that services are delivered in the context of positive and empowering relationships. Further research is recommended to understand the care process and mechanisms that enhance parent satisfaction and positive experiences, providing optimal quality of care.

Variations in sustained home visiting care for mothers and children experiencing adversity.

OBJECTIVE: This study aimed to examine the variations in care received by mothers and families within a sustained home visiting program. We sought to identify the extent to which there were variations in home visiting care in response to the program schedule and families' risk factors. DESIGN AND SAMPLE: Data collected within the right@home program, a randomized controlled trial (RCT) for a sustained nurse home visiting intervention in Australia, were analyzed. A total of 352 women comprised the intervention arm of the trial. MEASUREMENTS: Visit content in the home visiting program, sociodemographic data, and families' risk factors were used for analysis. RESULTS: Our results confirmed that the majority of women received scheduled content on time or within an acceptable timeframe, except for the sleeping program. Women with identified risks were significantly more likely to receive content related to those risks than women without those risks (smoking: Odds Ratio [OR] = 15.39 [95%CI 3.7-64.7], mental health: OR = 15.04 [1.8-124.0], domestic violence: OR = 4.07 [2.0-8.3], and drugs and alcohol: OR = 1.81 [1.1-3.0]). CONCLUSIONS: The right@home program had high compliance with the scheduled content. Capacity development in responding to mothers with the risk of domestic violence and drugs and alcohol is recommended. Further research is required to explore the relationship between variations in care and critical outcomes.

Prenatal methamphetamine-impact on the mother and child-a review.

Methamphetamine (MA) is the second most commonly used illicit drug in the world, after cannabis. There are limited data on the outcomes of pregnant MA users but there is rapidly emerging evidence to suggest that they are more vulnerable, marginalized and impoverished compared with other drug-using mothers. MA use during pregnancy is associated with worse pregnancy outcomes and significantly higher rates of co-existing health and psychosocial problems. Newborn infants exposed to MA are at increased risk of perinatal complications, present differently at birth to infants exposed to other drugs of dependency such as opioids and have poorer neurological adaptation and feeding difficulties. Sparse literature from neuroimaging and cohort studies suggests that the neurocognitive deficits in MA exposed children persist, even into adulthood. Current clinical practice guidelines for the care of substance exposed pregnant women are opioid-centric with little attention paid to the consequences of prenatal MA exposure.

Love and belonging in foster carer recruitment materials in New South Wales, Australia.

BACKGROUND: In order for foster care placements to be considered good, research has identified that children need to experience love and belonging in the home. It is therefore important that foster carer recruitment target individuals who are able and willing to attempt to provide love and belonging to the children placed with them. OBJECTIVE: To quantify the extent to which and how foster carer agencies represent love and belonging in foster carer recruitment materials. PARTICIPANTS AND SETTING: Foster carer recruitment material collected in New South Wales (NSW), Australia between August 2016 and March 2017. METHODS: Phrases including the word "love," "belong," or "belonging" or text that described aspects of belonging were identified in recruitment materials and coded using conventional content analysis. RESULTS: Eleven agencies (42%) did not address the need for children to be loved in foster care, ten agencies (38%), did not address the need for children to experience belonging in foster care, and eight agencies (31%) did not address either love or belonging in recruitment materials. Where recruitment materials included the word love, it was used in a very limited way. Belonging was more explicitly and practically addressed however, some recruitment materials contained content describing policy or encouraging practice that would undermine belonging. CONCLUSIONS: In order to recruit foster carers who are willing to attempt to provide love and belonging to children, recruitment materials need to be clear that children in foster care need to be loved and to feel like they belong and that foster carers should seek to provide this.

Australian foster carers' views of supporting maternal breastfeeding and attachment in out-of-home care.

BACKGROUND: Breastfeeding supports infant health, growth and development, and promotes maternal attachment and sensitive caregiving. Maternal separation due to child protection concerns can result in termination of breastfeeding with associated adverse outcomes. How to preserve breastfeeding when infants are placed in out-of-home care is an issue of concern. OBJECTIVE: To consider the views of foster carers towards provision of breastmilk and breastfeeding for infants in their care. PARTICIPANTS AND SETTING: Foster carers (including kinship carers), in Australia, who had cared for at least one infant in the years 2013-2018 completed an online survey. METHODS: Foster carer's views were collected via an online survey and subjected to content analysis. RESULTS: Respondents (n = 184) expressed mixed views about; mothers breastfeeding during contact visits, increased frequency of contact visits for breastfeeding; and the provision of expressed breastmilk to infants in their care. Concerns were raised about the safety of breastmilk from mothers abusing substances and the value of breastfeeding if reunification was not possible. Because of these concerns, some carers discarded expressed breastmilk and resisted frequent contact. Conversely, breastfeeding was also viewed positively as a way for mothers to maintain attachment with their infants, where reunification of the mother-infant dyad was the goal. CONCLUSIONS: This study highlights foster carers' view of breastfeeding as a facilitator of attachment between mothers and their infants. While fosters carers were largely supportive of breastfeeding as a way to improve infant health and facilitate mother-infant attachment, they held concerns regarding the safety of breastmilk supplied to them.

Australian Foster Carers' Views and Concerns Regarding Maternal Drug Use and the Safety of Breastmilk.

Parental substance misuse and mental health issues are major factors associated with infant placement into out-of-home care. Such placements may result in disruption and/or cessation of breastfeeding. Provision of breastmilk to infants in out-of-home care (OOHC) is desirable in terms of infant health and development, and also in supporting maternal caregiving. However, little is known about how breastfeeding is supported for infants in out-of-home care. This study used an online survey to explore the facilitation of breastfeeding in the context of OOHC and foster carers' management of expressed breastmilk (EBM). Foster carers were generally open to the idea of maternal breastfeeding and infants in their care receiving EBM from their mothers. However, the majority of respondents expressed concern regarding the safety of EBM for infant consumption due to the possibility of harmful substances in the milk. Concerns regarding the safety of handling EBM were also prevalent. These concerns caused foster carers to discard EBM. Findings suggest foster carers' may lack knowledge related to maternal substance use and breastmilk. Better integration between health care and social service systems, where the voices of mothers, foster carers and child protection workers are heard, is necessary to develop solutions enabling infants living in OOHC access to their mother's breastmilk.

The Complexities Associated with Caring for Hospitalised Infants with Neonatal Abstinence Syndrome: The Perspectives of Nurses and Midwives.

The global incidence of Neonatal Abstinence Syndrome (NAS) has increased significantly in the last decade. Symptoms of NAS manifest from the central and autonomic nervous systems as well as the gastrointestinal system and vary in severity and duration. The clinical management of infants experiencing NAS is dependent on symptoms and may include both pharmacological and non-pharmacological measures. In cases where symptoms are severe, infants may be admitted to special care nurseries or neonatal intensive care units. Existing research on nurses' involvement in caring for infants with NAS focuses on pharmacological and non-pharmacological interventions to treat physical symptoms associated with NAS. This research sought to add to the body of knowledge around NAS and conveys nurses' and midwives' experiences of delivering care for infants with NAS. Semi-structured interviews were held with nine nurses/midwives. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Five themes emerged from the data. These themes are: Complex care needs; Prioritising physiological care; Experiencing compassion fatigue; Lacking continuity of care; and Stigma. The findings demonstrated the complex nature of care provision for infants with NAS. Competing priorities and the stigmatising nature of NAS threaten optimal care being delivered to these vulnerable infants and their parents.

The Challenges to Promoting Attachment for Hospitalised Infants with NAS.

The postnatal period is crucial for infants in establishing a connection with and security in primary caregivers and can have enduring effects on attachment patterns. However, due to the need for symptom management, many infants diagnosed with neonatal abstinence syndrome (NAS) may be separated from primary caregivers and cared for in a neonatal intensive care unit (NICU) or special care nursery (SCN) soon after birth. Research has shown that substance-exposed infants are more likely to experience insecure attachment patterns with their primary caregivers and that mothers with a history of substance abuse are less sensitive to their infants' cues. Therefore, the aim of this research was to explore nurses' and midwives' experiences in promoting the attachment relationship for infants admitted to an NICU/SCN with NAS. A qualitative research design was used to gather data on the experiences of nine nurses/midwives from various NICU and SCN settings in Australia. Individual, semi-structured interviews were conducted, and transcribed interviews were coded using thematic analysis. While nurses/midwives valued the attachment relationship for infants with NAS, facilitation of the attachment relationship was mainly promoted when the mother was present. However, parents were often reported to be absent from the nursery. Difficulties in promoting an attachment relationship were also identified when an infant had child protection involvement. This research identifies areas in need of innovative change regarding the approach taken to promote the attachment relationship for infants with NAS when they are admitted to an NICU/SCN.

The health promotion role of Australian early primary school teachers supporting students with type 1 diabetes.

ISSUE ADDRESSED: Early primary school children with diabetes require adult support for insulin therapy and primary school teachers often fulfil this health promotion role. Availability of support is inconsistent across Australia and insulin administration at school is avoided for some children. The aims of the study were to explore the experiences of Australian early primary school teachers who were supporting a student using intensive insulin therapy and to identify facilitators and implications of this support. METHOD: A qualitative research design using narrative inquiry was utilised. Early primary school teachers (n = 11) from six Australian states/territories and across Government, Catholic and independent schools participated in semi-structured telephone interviews between August 2015 and May 2016. Narrative analysis was used to interpret the interview data. RESULTS: Six narrative threads told a collective story of early primary school teachers' experience of supporting a student using intensive insulin therapy. The factors that facilitated support were: suitable class allocation, a transition process, and diabetes education and diabetes models of care. The implications of providing intensive insulin therapy support were legal considerations and burden of responsibility. The outcome was that all teachers supported intensive insulin therapy. CONCLUSION: School teachers in this study had a pivotal role in promoting the health of students with type 1 diabetes. This role was often associated with anxiety and the burden of responsibility. Support strategies for teachers include formal diabetes skills training, ongoing assistance from both teacher's aides and Diabetes Educators, and greater understanding of the legal aspects of intensive insulin therapy support. The development of consistent health promotion policy for students with type 1 diabetes across all Australian schools is required. SO WHAT?: Adopting the supportive strategies for teachers identified in this study will further promote the health of early primary school children with type 1 diabetes.

Models of care for neonatal abstinence syndrome: What works?

Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.

Facilitation of Intensive Insulin Therapy in the Early Primary School Setting: Narratives of Australian Diabetes Educators.

The number of early primary school (EPS) children (aged 4-8 years) with type 1 diabetes mellitus (T1DM) rises each year. Intensive insulin therapy (IIT) can be challenging for these children, as adult support may not be available in the school setting. Diabetes educators (DEs) working in the health system facilitate school diabetes care, which can be time-consuming given the large numbers of children with diabetes. These factors are potential barriers for IIT use in the EPS setting. To explore the experiences of Australian DEs who facilitate IIT use in the EPS setting, a qualitative, narrative inquiry method was used to conduct semi-structured telephone interviews with Australian DEs (n = 13) between December 2014 and June 2016. The interview transcript data were analyzed using a narrative analytical approach. Approaches to facilitate IIT use in the EPS setting were normalizing IIT at diagnosis, simple care plans and insulin pump therapy, prioritizing school support, DEs in private practice, and working with school nurses and parents. Despite numerous barriers, Australian DEs implemented varied methods to facilitate IIT use in the EPS setting.

A novice researcher's reflection on recruiting participants for qualitative research.

BACKGROUND: This paper is a reflection by a PhD candidate on her qualitative study involving parents, diabetes educators and school teachers who were caring for a child with type 1 diabetes using intensive insulin therapy in primary school. AIM: To reflect on a novice researcher's experience of recruiting research participants from community, health and education settings in Australia. DISCUSSION: Participants were successfully recruited for the study using internet communication tools: Facebook support groups; the Australian Diabetes Educators Association (ADEA) e-newsletter; and emails sent to school principals. These methods were successful as Facebook and online support groups are popular, the study topic was of interest, the ADEA has many members, and numerous emails were sent to schools. Potential barriers to recruitment were a lack of access to those who did not use Facebook or the internet, gatekeepers, the high workloads of diabetes educators and teachers, and the time needed to obtain ethics approval and send a large number of emails to schools. CONCLUSION: Internet communication tools were successful in recruiting participants from community, health and education settings. However, different approaches were required for each type of participant. Lessons learned from this experience were: the importance of taking time to plan recruitment, including an in-depth understanding of potential participants and recruitment tools, the benefit of being an insider, and the need to work closely with gatekeepers. IMPLICATIONS FOR PRACTICE: An understanding of recruitment is essential for ensuring access to appropriate participants and timely collection of data. The experience of the novice researcher may provide insight to others planning to use internet communication tools for recruitment.

NEONATAL ABSTINENCE SYNDROME AND INFANT MENTAL HEALTH.

Neonatal Abstinence Syndrome (NAS) is a term used to describe withdrawal symptoms of infants who became physically dependent on drugs of addiction while in utero (Prabhakar, 2014).

NEONATAL ABSTINENCE SYNDROME AND THE ATTACHMENT RELATIONSHIP.

Approximately 4.2% of pregnant women consume illicit drugs during pregnancy (AIHW, 2011). Drug exposed infants are more likely to be born small for gestational age, be pre-term, and be admitted to special care or intensive care nurseries (AIHW, 2007).

The foster carer's experience: an integrative review.

BACKGROUND: Foster carers have a significant responsibility in caring for children who are unable to live with their birth families and represent a key determinant in child outcomes. Difficulties in recruiting and retaining quality foster carers have resulted in an increase in research investigating foster carers and their experiences in recent years. AIM: To synthesise current literature investigating foster carers and their experiences to enable a better understanding of their unique care-giving context. METHOD: The electronic databases CINAHL, Health Source, MEDLINE, Pscyh-articles, PsycINFO and socilNDEX were searched using the key terms; 'foster carer', 'foster parent', 'foster mother' and 'foster father'. Articles were included if they reported primary data about foster carers experiences in the English language. Papers published prior to 2000 were excluded in order to provide a contemporary perspective of the foster carer experience. Data was extracted, tabulated and thematically analysed. FINDINGS: The findings from this review revealed the provision of foster care to have both positive and negative effects on foster carers personal well-being. These effects are largely reliant of foster carers perception of their role as either parental or professional, the nature of their relationships with child welfare personnel, and their ability to manage children's difficult behaviours. CONCLUSION: It is important for nurses to understand caregiving as it occurs in a variety of contexts. Nurses need to have an awareness and understanding of the value and role foster carers have in the lives of vulnerable children. In so doing, nurses are well positioned to assist foster carers to identify and express their needs in relation to their important caregiving role.