Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 4th Report - Toddlerhood

5 Parenting, Child Health and Development

Key questions

• Is there any evidence that FNP
  • Engenders positive parenting practices and bonding?
  • Improves knowledge on how infant health can be promoted and that any such knowledge is translated into behaviour?
  • Leads to improved child health and development?
• Is there any evidence that the client knows about key hazards and engages in practices to keep child safe?
• Is there any evidence to indicate that infants meet developmental milestones?

Key findings

• In toddlerhood, Family Nurses reported focusing particularly on how clients communicate with their child and how that impacts on both bonding and attachment. One Family Nurse reported that a key success for FNP for one of her clients was in supporting strong attachment with her child despite the adversity the client had faced in her own life.
• Family Nurses believed they had helped their clients become more confident parents by supporting them to make their own decisions. Clients felt that the advice they received from Family Nurses had helped them better manage their toddler's behaviour (e.g. children were having fewer tantrums or were in a better sleeping routine).
• Diet and nutrition was not an issue for all clients, but for those who were having trouble getting their children to eat new foods, clients believed the tips Family Nurses gave them had a positive effect on their child's diet.
• While not all clients reported FNP having a big impact on child development during toddlerhood, those clients who reported concerns about, for example, potty training or speech and language development gave examples of advice and information their Family Nurses had provided in this area.
• Safety continued to be an important theme in toddlerhood. Clients engaged in practices to keep their child safe by 'child-proofing' their property and teaching their children about, for example, the dangers of fire.

Introduction

5.1 The previous chapter looked at the overall delivery of programme content to clients during toddlerhood. In this and the following chapter, we focus on specific topics relating to parenting practices in toddlerhood, diet and nutrition, child health and safety and child development (Chapter 5) and maternal health, wellbeing and future plans around work and education (Chapter 6). In addition to examining the perceived impact of the programme, these chapters also explore Family Nurse and client perspectives on what has worked well or less well in delivering content on these topics.

5.2 It is important to keep in mind when reading these chapters that the evaluation is not a formal impact evaluation. Further research (such as the Building Blocks RCT referred to in Chapter 2) is required to establish the nature and scale of the impacts FNP is having in a UK context. However, the findings discussed here indicate the potential for FNP in Scotland to impact on client outcomes, based on participants' and Family Nurses' accounts.

Parenting practice in toddlerhood

5.3 Parenting practice remained a key topic for FNP during the toddlerhood period. In general, Family Nurses believed that they had helped their clients become more confident as parents during toddlerhood, citing examples where they felt that clients were more self-reliant (relying less on their family and making more decisions for themselves) and better able to interact with their child as a result. However, while Family Nurses expressed positive views on clients' parenting skills during toddlerhood, they also felt that some clients needed ongoing support around 'parenting' as their child's needs changed over time.

As her child's stage of development changed, her parenting needed to change and she required support throughout that process

(Family Nurse 5)

5.4 Specific areas of parenting practice discussed by Family Nurses and clients related to bonding and attachment, dealing with toddler behaviour, and establishing and maintaining routines.

Bonding and attachment

5.5 Bonding and attachment is a key topic throughout FNP. Approaches to and perceived impacts of promoting bonding have been discussed in earlier evaluation reports (Ormston et al, 2012, Ormston and McConville, 2012). In toddlerhood, Family Nurses reported focusing particularly on how clients communicate with their child, which impacts on both bonding and attachment and on the child's own communication skills (discussed below).

5.6 In an attempt to sum up how the relationship between mother and child develops over time, one Family Nurse recounted the ongoing conversations clients and Family Nurses have been having since the very beginning about "regulation". She described this as starting with parents and babies getting "in sync" with each other, and then moving on to discuss other things such as play, behaviour management, and building a trusting relationship so that children can then feel confident that they are loved and cared for.

5.7 For one Family Nurse, a key success for FNP for one of her younger clients was in supporting good attachment and enabling her to maintain her relationship with her child despite all the adversity the client had faced in her life.

That's credit to her, so, you know, success comes in all forms, and, as I said before, I think every one o' my clients is in a different place from when they started. And perhaps some of that would o' happened anyway, but I think the programme supported that I think as well.

(Family Nurse 4)

Toddler Behaviour

5.8 Both Family Nurses and clients identified dealing with toddler behaviour as a key issue during the toddlerhood phase. Family Nurses commented on the challenges parents can experience when moving from a compliant baby to a toddler who can express their own wishes and demands - "it's a very different parenting task".

5.9 Family Nurses reported discussing a combination of strategies clients could use to help their toddler learn appropriate behaviour. They discussed ways to help clients resist the temptation to say 'no' all the time (so that when they really need to say 'no' it will be more effective) and instead to guide their children in a more positive way. For example, one Nurse recalled that one of her client's children kept trying to "fiddle around behind the TV and pull out the wires" despite the client telling him 'no'. The Family Nurse encouraged the client to first think about why their child kept doing this, and what kinds of things she could do instead of telling him 'no'. She suggested the client try some preventative strategies (distraction, play, getting down on the floor) and, as the child's language develops, saying simple things to explain why he should not engage in that behaviour. She felt that these suggestions had a positive impact on how her client dealt with the situation.

5.10 Clients also reported finding speaking to their Family Nurses about their child's' behaviour useful. Examples of FNP information and advice that clients felt had helped them effectively manage their child's behaviour included:

• Telling children what you want him/her to do and expecting them to do it, rather than telling them what not to do
• Leaving children (when they are having a tantrum) as they will soon get bored
• To help clients not lose their temper when their child is misbehaving, counting to ten and then speaking to them, and
• Demonstrating how clients could use the "naughty chair" technique.

5.11 Clients gave examples where they felt that, as a result of following this advice, their children were having fewer tantrums and when they did have a tantrum they were now better able to deal with it. On the other hand, some clients reported that despite trying all the things the Family Nurses advised they were still finding managing their toddler's behaviour difficult.

Routines

5.12 Routines were also discussed in the Infancy phase report (Ormston and McConville, 2012) and continued to be a key theme for FNP Nurses and clients in toddlerhood. As noted in Ormston and McConville (2012) one view held by clients was that advice on sleeping had been the most helpful part of FNP. During toddlerhood, Family Nurses provided further advice about sleeping routines, including, for example, reducing the number of naps the child has during the day, or reading a book instead of letting him/her fall asleep in the front of the television. Again, clients reported positive impacts from this advice:

I would'nae have known to do that, I dinnae ken if I'd been able to do it myself, if I leave him for that long…she said keep having a wee peak, making sure he's alright. He's no' hurt himself, walk away, if he gets up say "mum loves you - night night! Bed time!" Put him back in. And that's what I done.

(Client 11)

5.13 In some instances when clients' children were not in established sleeping routines at the time of their toddlerhood interview, clients suggested that it was their own fault for being too "soft" with their children and not sticking with the techniques their Family Nurse had given them.

Diet and nutrition

5.14 Clients reported talking to their Family Nurses about a range of issues related to their child's diet and nutrition during toddlerhood. The kinds of information and advice they recalled receiving from FNP included:

• Lots of information about the types of foods their child should be eating
• Advice about cooking and eating together
• Suggestions that clients eat the same things as their children.
• (To encourage children to try new foods) introducing new foods more than once so that children can get used to them and to disguise 'healthy foods' that their toddler initially rejects in sauces
• Giving clients a 'nutrition plate' that illustrated the different types of food children should be eating and the correct portion size for their age.

5.15 Diet and nutrition was not viewed as an issue by all panel clients, with some reporting feeling confident about the different kinds of foods their child should be eating. However, others reported that these suggestions from their Family Nurses had a positive effect on their child's diet.

(Family Nurse) suggested maybe the things that she doesn't like putting it in with like a sauce, 'cos it was things like tuna and things, so maybe like putting it in with some sauce. Or egg, maybe try and making it a different way. Or just little things like that.

I: Great. And (…) did that help in any way?

F: Yeah it did, she now eats it. She'll eat anything now.

(Client 9)

…we've been trying loads of different foods with her, healthy options, and things, because before I was bad for just a quick meal, like shove it in the oven - let it cook! But like she said "well why do you not cook things fresh, freeze it, and then defrost it and heat it up?" And I'm like "I'll need to start trying that". I did start; (child)'s eating a lot better with it to be honest.

(Client 12)

5.16 Another client view was that the advice from the Family Nurse had not helped yet, but the client was still trying and hoping for a "breakthrough" with their child's diet.

Breastfeeding

5.17 Breastfeeding among the first cohort of FNP clients in Lothian with their first babies is discussed in the second and third evaluation reports (Ormston et al, 2012, Ormston and McConville, 2012). One possibility raised by Family Nurses in report two (pregnancy and early infancy) was that where clients had not initiated or continued breastfeeding with their first child, they might do so with their second child as a result of the support and information they had received from FNP around this issue. Only a very small number of clients (two) interviewed for this evaluation were either pregnant or had gone on to have second babies by their toddlerhood interview (c. 22-24 months after their first baby was born). However, within this very small group, there was an example both of a client who reported deciding not to speak to their Family Nurse about breastfeeding their second child because they had already made the decision not to breastfeed, and a client who had breastfed their second baby for longer than their first child, attributing this at least in part to the support they had received from FNP (see case study below).

Case study - Breastfeeding second babies

In her earlier evaluation interviews, this client talked about her feelings of disappointment at stopping breastfeeding her first child at 12 weeks. She had wanted to breastfeed her baby for longer (upto six months) and did not feel she had been as successful as she want wanted to be. Her Family Nurse had helped her work through her negative feelings about this.

With the client's second baby, she reported that her Family Nurse knew how much breastfeeding meant to her and had supported her with this - for example, helping her when she was having issues getting her second baby to latch on. At the time of her fourth evaluation interview (c.22-24 months after her first child was born), the client had been breastfeeding her second child for 14 weeks and intended to continue with this.

In relation to both her first and second babies, client also commented that she did not think that there was much support in hospitals when it came to breastfeeding. The client said she had been lucky to have her Family Nurse as when things did not go according to plan, the Family Nurse could teach her what to do.

As a result of her experiences with breastfeeding, the client (after being signposted to it by her Family Nurse) had been trained as a peer supporter as part of a programme being run by NHS Lothian's Infant Feeding Team to support mothers with breastfeeding.

Child Health and Safety

5.18 Clients continued to state that their Family Nurse was usually their first port of call when they had questions about their child's health. Health and safety topics covered during the toddlerhood period included: dental health, immunisations, and safety in the home and wider environment.

Child dental health

5.19 Clients reported that they would not have known when to register or take their child to the Dentist if it had not been for their Family Nurses, who recommended registering for the dentist as soon as the child's first tooth came in.

Immunisations

5.20 Scotland's routine Childhood Immunisation Schedule ^[12] recommends children should receive three doses of diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b (Hib) vaccine (the 'five-in-one' vaccine) at two, three and four months of age, one dose of Meningitis C (MenC) vaccine at three months of age, two doses of Pneumococcal (PCV) at two and four months of age, and two doses of Rotavirus vaccine at two and three months of age. Children should then receive a further dose of Hib and MenC (given as the Hib/MenC booster vaccine), the PCV booster, and one dose of Measles, Mumps and Rubella (MMR) at 12 to 13 months of age.

5.21 Of the 110 children in the first NHS Lothian, Edinburgh FNP cohort for whom data was recorded, 97% (n = 107) were up to date with all their child's immunisations at 24 months.^[13] Comparison figures for all children of young mothers across Scotland were not available. The target of the national immunisation programme in Scotland is for 95% of children to complete courses of the following childhood immunisations by 24 months of age (Health Protection Scotland).^[14]

5.22 As reported in Ormston and McConville (2012), clients who were apprehensive or unsure about vaccinations described their Family Nurse providing reassurance. Other clients reported that they did not need to speak to the Family Nurse about immunisations, as their children were already up to date with them. In one case, a client who had very definitely decided (for reasons connected with her family history) not to get her child immunised described discussing this with her Family Nurse and her Family Nurse liaising with midwifery to explain the client's views on this issue. The client also felt her Family Nurse had supported her in discussions with the baby's father about immunisation, pointing out that he could get the child immunised if he wanted, which had reduced conflict between the client and the baby's father. This example illustrates how FNP gives clients information but ultimately supports them in their decisions, even where these may not be the decisions Family Nurses would prefer them to take. It also shows the role FNP can play in mediating conflict over parenting within the family.

Safety in the home (and wider) environment

5.23 As in the previous stages of the programme, safety continued to be a major theme for FNP. During toddlerhood, the focus expanded to encompass not only safety in the home, but also safety in the wider environment.

Here we've got a little person becoming more autonomous and more mobile. (…) (We're) thinking about, you know, all aspects of safety - indoors, outdoors, wherever you are. Dogs. Everything. Safety is a... a big issue.

(Family Nurse 4)

5.24 Clients' continuing discussions with their Family Nurses about keeping their child safe at home appeared to be reflected in their awareness of key hazards. For example, clients knew only to give their child toys that are suitable for their age, they recognised hazards associated with normal household items ("even a mop and bucket can be dangerous to a toddler"), and, as their children grew, they discussed how they had again reassessed the hazards at home. Examples of client engaging in practices to keep their children safe included: child proofing the house with cupboard clips, baby gates, plug covers, cushion corners; moving the television to a safer position; keeping household items like washing tablets out of reach; and teaching children about fire and hot drinks.

5.25 As discussed in the Infancy phase report, clients indicated that they might not have been able to purchase safety equipment without support from their Family Nurses in accessing grants. However, one client view was that information from Family Nurses around safety, although useful, was not new to them (it was all 'common sense').

Child development

5.26 Again, child development is a theme throughout FNP but the precise focus changes with the growth and stage of the child. During toddlerhood, key topics include potty training, speech and language development, and socialisation.

5.27 Where clients described their child developing normally during toddlerhood, it was not always clear whether or not they felt their Family Nurse had made a difference in this area or not. However, where clients had experienced concerns about their child's development, they were able to give examples of Family Nurses providing advice that they had found helpful, as described under the more specific headings below.

Potty training

5.28 Potty training was an issue that clearly caused anxiety for some FNP clients. They reported that their Family Nurses provided them with:

• Leaflets to see what techniques would work best for them
• Advice about when to start potty training and the signs to look for to indicate their child was ready. This included reassuring clients that they did not have to rush into potty training and that it is better to wait until the child understands what she or he is being told.
• Advice on how to go about potty training including role modelling (i.e. taking the child to the toilet with them to see the different stages)
• Advice that they could go straight to the toilet rather than using a potty first.

5.29 Clients felt they could open up to their Family nurses about their anxieties around potty training in a way they did not always feel able to do with others. They reported feeling reassured and supported by their Family Nurses.

Like when (Family Nurse) was here I was just like…I do not have a clue what I'm doing with potty training, I'm actually scared to start, but I probably wouldn't have said to anybody else I'm scared to start this. I probably would have just kept it to myself.

(Client 13)

Speech and language development

5.30 According to those clients who voiced concerns about their children's speech and language development, Family Nurses had provided them with various kinds of advice about how to help with this, including:

• Speaking properly to the child (don't speak 'silly')
• Reading books and singing songs to aid development
• Avoiding using bad language because the child will copy you
• Encouraging clients to take child to the library, and
• Giving examples of or worksheets on developmental activities.

Socialisation

5.31 Clients also talked about the impact that taking part in FNP had on their willingness to take their child out more, citing for example Family Nurse advice about encouraging outdoor play, like jumping in puddles, to engage their senses.

I kinda take him out a lot more than I probably would have initially done.

(Client 10)

5.32 However, one Family Nurse view was that while many of clients understood the need to increase their child's experiences and socialisation, supporting clients to engage with community groups was nonetheless challenging.