Post-natal care: Making the most of your first session with parents

Who is this resource for, and why is it needed?

Child Health Nurses – particularly those who provide more intensive and targeted services to families at risk of (or currently living in) vulnerable circumstances – have identified that gaining and maintaining a family’s engagement, motivation and participation in their service is challenging. While there are a range of factors that contribute to whether a family returns for subsequent sessions, relationship and engagement-building approaches used by a CHN in their first sessions with a family may improve the likelihood of a family returning to the service in the future.

This resource may also be useful to other practitioners in similar service delivery circumstances to CHNs. These are practitioners who deliver ongoing (short- or long-term), voluntary, child-focussed services to families who may be experiencing vulnerability or disadvantages, and who may benefit from the support that is being offered.

Resource aims and outcomes

The aim of this resource is to provide CHNs with practical strategies for making the most of their first session with clients – particularly parents living in vulnerable circumstances – so that:

• parents are supported to meet the needs of their baby and take care of themselves
• CHNs are building a collaborative relationship with the parent, which can be a protective factor for the child and family’s physical and mental health
• CHNs maximise their opportunity to establish a positive, ongoing relationship with families; and
• parents are more likely to attend future sessions with the service.

Resource outcomes for CHNs will include the ability to:

• identify some of the factors that may influence a client’s decision to return to your service
• identify the factors that can increase your client’s engagement with you and your service
• describe ‘rapid engagement’
• describe some tasks and activities you can do
  • before your first session, that can help to engage a client in your service
  • during your first session, that can help to engage a client in your service and motivate them to be an active participant; and
  • after the session to maintain the client’s engagement with your service; and
• identify some evidence-based strategies for quickly building rapport with clients experiencing vulnerability.

CHN service access

The engagement and retention of families in CHN services is generally high, but there can be challenges with engaging and retaining families who are experiencing higher levels of vulnerability and disadvantage. This is a common experience in child health and welfare services.

There are a number of reasons why practitioners in these services find engagement and retention of these families challenging. But what is commonly noted is that the focus, tone and style of a first meeting with a family can have a significant impact on future engagement and retention.

The first session with a family can be ‘full’ of things the service and a practitioner need to do, which may not seem relevant to a parent. This can have an impact on the parent’s perception of the service and its usefulness, negatively affecting their attitude to continued engagement. Therefore, taking the time to learn about the support a family needs or wants is important for future engagement.

The benefits of making an effort to establish and retain positive and useful relationships with families – particularly those who may be more challenging to engage due to greater levels of disadvantage and vulnerability – are that as well as providing ongoing primary care and support, universal service providers such as CHNs play an important role in helping families access secondary and tertiary services when needed.

There are many factors that contribute to whether a family will engage with a health service and return for future sessions. These can be grouped into three main areas: client, practitioner and service characteristics (Dantas, Fleck, Oliveira, & Hamacher, 2018; Kournay, Garber, & Tornusciolo, 1990; McLean et al., 2014; Wierzbicki, & Pekarik, 1993).

Client characteristics

Families will come into your service with a history of experiences and knowledge that can influence how they perceive, value and may make use of your service. Some of the factors that have been shown to influence an uptake of service use by families include:

• Families may not have a (perceived) need for extra support or advice.
• They may lack an understanding of the purpose and benefits of engagement with you and your service.
• They may lack trust in (or fear of) the service, having had negative experiences with your service or other services previously, including as a child or young person. This can also include a parents’ perception of a link between one service and another, such as Child Protection.
• Competing demands on their time and availability: this can include health-related factors, such as hospitalisation, feeling too sick to attend, having a more important medical concern, and anxiety.
• Timing and incompatibility issues, such as having several appointments in a range of different locations; the effort required (distance, transportation, parking); conflicts with other scheduled activities; and generally ‘being busy’.
• Socio-economic factors, such as inconsistent housing and transient living conditions, which may result in a family not being available or able to access your service.
• Errors and miscommunication, such as misunderstandings about appointment times and dates, or scheduling problems.
• Family financial concerns.
• Perceptions of the (dis)benefits of attending, including fear of seeing an inexperienced clinician, or not understanding the importance of the appointment.
• Service fatigue. Families who are experiencing vulnerability and disadvantage are often involved with a broad range of services and supports. The inclusion of another, following the birth of their child, may reach a tipping point.

Practitioner characteristics

As well as what a family brings to the mix, practitioners also have an influence over whether a family will engage with and return to your service. The things you can do to support this can include:

• being clear about the service and what it can offer a family, including effectively communicating the benefits of preventative health, the benefits of your service, and checking the family’s understanding and priorities for their child
• being clear about your processes: focusing on what your service does, while finding out what the priority needs of the family are
• taking a flexible approach; and
• having a contextual (and cultural) understanding of the client and their circumstances.

It is also important that you genuinely prioritise the family during your interaction with them. If families perceive you as ’too busy’, they may believe that they (or their problems) are not important, and they may choose to disengage.

Service characteristics

There are also things about a service that can influence and affect a family’s engagement, including:

• performance expectations, including the time-limited nature of your session (or sessions) that you devote to the client and their needs
• inflexible service requirements, such as undue or excessive documentation or administrative requirements
• low responsiveness to the client’s circumstances; and
• service accessibility restrictions, such as only operating during standard business hours, or restrictive service locations (centre-based service provision).

These things alone or combined will have an impact any client’s availability, capacity and willingness to accept the service you offer, and commit to participating.

Family-centred practice

The child and family are considered key decision makers. Your goal is to empower families and work toward things that are meaningful and important to them, customising services and supports to the unique needs of the family and their child.

Practice builds on natural supports

The support you provide to families should seek to draw on the family’s sources of natural support, such as friends, extended family, and other local community services and institutions, including other services the family is linked with. Wherever possible, avoid replicating services that a family is already accessing elsewhere, or that could be provided through other, less intensive or targeted community-based services.

Culturally sensitive practice

Services provided to parents and their children should respect and build on the values, preferences, beliefs, cultures and identity of the child and family, and their community.

Outcomes-focussed support

Your service should aim to provide support to families that is meaningful, purposeful and directly related to meeting the family’s needs and priorities, and enhancing the family’s health outcomes.

Evidence-informed practice

In addition to providing evidence-informed information and services, you should monitor the impact of your work to continuously improve and develop your service delivery to best meet the needs of families.

Building parental capacity

Building the capacity of parents is the most powerful way of promoting children’s wellbeing and healthy development. Developing parental confidence and capacity to address barriers and challenges to healthy development is a very effective approach for achieving meaningful and sustained change. The support you provide should aim to build self-regulation, promote problem-solving, and foster the development of self-regulation skills.

Trauma-informed practice

Many of the families who present to your service – particularly if your service offers enhanced and targeted support for families experiencing greater levels of vulnerability and disadvantage – will have experienced greater levels of trauma.

The effects of trauma can have lasting effects on parent-child relationships (Isobel et al., 2017). The impact of trauma therefore needs to be understood, acknowledged and held in mind when working with families entering your service (Hopper, Bassuk, & Olivet, 2009; Levenson, 2017). Parents and children who have experienced trauma may find it difficult to engage with and trust you and your service. They may feel highly vulnerable when opening-up and sharing their experiences. Indeed, opening-up can increase feelings of insecurity and vulnerability, and potentially trigger feelings of being unsafe. The support you provide should be trauma-aware, incorporating elements of good practice for working with those who have experienced trauma, including:

• Maintaining clarity and transparency in all communications, enabling a trusting relationship to develop over time (Butler, Critelli, & Rinfrette, 2011; Levenson, 2017).
• Adopting an understanding, compassionate, non-judgemental stance that works with strengths and is grounded in genuine collaboration (Hopper et al., 2010; Levenson, 2017).
• Creating predictability, consistency and routine in the work: saying what you will do, then backing that up by doing what you say, is vital when working with individuals who have experienced trauma (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005).
• Emphasising options and providing choice (Elliott et al., 2005; Hopper et al., 2010; Levenson, 2017).
• Supporting children and parents in ways that are mindful of their emotional limits, and respectful of whether or not they choose to disclose information (Butler et al., 2011; Hopper et al., 2010; Levenson, 2017).
• Providing emotional and psychological safety: being aware that unexpected situations or topics may ‘trigger’ emotional distress, or hyper-arousal, and proceeding to discuss potentially distressing issues only when you have permission to do so. This does not mean avoiding confronting topics or circumstances all together – it means working through issues at a pace that is comfortable for the family or individual.

A key feature of establishing and maintaining engagement with a client is to work in partnership with them. The notion of partnership is important because it suggests that you and the parent have come together to achieve something that neither of you could have achieved alone. Working in partnership with parents acknowledges the parent as the expert in their life, and about their children, and that they have strengths that can be enhanced by the work you will do together. It helps you to view them as an active participant in the work you’re doing with them, not just as someone with a problem who needs you to resolve it for them. A collaborative practitioner joins with the parent to pursue a shared interest in the health and welfare of the child.

Establishing positive and collaborative relationships with parents is critical, as it can mean parents are more likely to:

• return to your service
• participate in activities and any intervention or treatment you might suggest
• offer their own ideas and feel that their ideas are valued
• listen to your ideas
• try out new things that you have suggested
• enjoy the experience; and
• are less likely to feel isolated and judged.

It may be tempting to think that the quickest way to help parents is to tell them what to do when they have a problem, or come to you for advice. But if you support parents to make their own decisions, and encourage them to ask for help, they develop confidence to keep making decisions in the future, long after they’ve stopped coming to your service.

As a CHN, you have an important part to play in promoting parenting confidence. How you work with parents will influence whether they become more or less confident in their parenting role. Some concrete and practical approaches are explored below.

Build early success:

• Help parents set small, achievable goals to start with: ‘Could you try tummy time on your chest, rather than on the floor?’
• Break down bigger goals into smaller steps: ‘How about you try for five minutes the first time?’
• Pick goals that the parent can control: ‘Do you think you’d be able to do it two times a day?’

Set realistic between-session tasks together:

• Talk about the reasons for trying things out between sessions: ‘It’s helpful to practice. We can talk about how it went or troubleshoot problems when we next catch up.’
• Encourage parents to come up with their own ideas on what they could try.
• Help parents to come up with tasks at which they’ll likely succeed.
• Check that these tasks are relevant to the goals that the parent sets.

Plan what parents will do between sessions by asking them ‘what, when, where and how’:

• ‘What would you like to do?’
• ‘Where will you do it?’
• ‘How will you do it?’
• ‘When are you going to start?’
• ‘What might get in the way?’
• ‘How will you know it is working?’

Review progress when you next see the parent:

• Encourage parents to notice the small steps that build towards achievements.
• Start by asking for one specific example, so you can picture exactly what occurred.
• Ask about what went well.
• Talk about what went right, rather than what went wrong.
• If parents want to talk about what went wrong, ask them to come up with ideas about how things could have been done differently.
• Ask how they felt about what happened.
• Encourage parents to give themselves positive feedback.

Reinforce successes to develop a sense of personal agency. Parents are more likely to attribute changes to their own efforts, rather than luck or what other people may have done:

• When talking with parents, make the link between what they did and the positive changes that occurred. For example, if a parent reports that their child is starting to say more words, ask them what they did to encourage their child to speak.
• Limit talk about failure; instead, talk about what could be done differently, or what would help make a strategy more successful.
• Help parents recognise their persistence and the effort they invest.
• Give positive feedback for trying out strategies, regardless of outcomes.

An effective service practice is to aim to have all of your client interactions ending with at least one thing that a family will do to utilise their strengths and address a need that they present with. For example, in encouraging a family to establish a routine for their baby, use a series of questions to get the parents to identify their strengths and do something positive that contributes to their child’s healthy development. This approach can help families to build confidence and self-efficacy – and your contribution can have a positive impact on your relationship with your client.

Relationships are important

A key principle to apply in your work with families is to choose the relationship over controlling the engagement. Effective collaboration requires a high level of deliberateness in interactions with families. You may need to pull back if you notice resistance to change and adopt a support mode – using skills such as active listening and empathy. Once you’ve been able to re-engage with the parent by showing them that you have listened and genuinely understood, you can continue the task of working together to achieve positive outcomes for their child’s healthy development.

The relationship you have with your client is important. You can always come back to an issue that is sensitive or demanding if you have a strong relationship; but if the relationship is damaged, it can take a long time to recover.

To work in partnership with parents, aim to:

• be sensitive and responsive to different kinds of families
• take account of what families want
• be flexible: think about what’s most useful to the particular family you’re working with
• respect that parents are the experts on their child, and their family circumstances
• help families get in touch with community, formal and informal supports and resources
• form strong links with other child and family services, so you know where to point families when they need help beyond your expertise
• recognise that each family is different, and understand a family’s particular characteristics and needs; and
• know that all families have strengths that can be built on.

Helpful ways to interact with parents include:

• being available and supportive to families, even when there’s not much you can do to help
• not making assumptions about what parents ‘need to know’
• providing clear, truthful information
• sensitively checking whether the parent has understood you
• listening carefully when they ask questions, acknowledging that they may feel anxious if they don’t know the answers
• knowing that it’s OK to say that you don’t know the answer to something, and that you will find the information they need
• providing support without judging; and
• accepting and respecting parents who are confused or highly emotional if there is a crisis, bearing in mind that a crisis can happen to anybody.

Confrontation and collusion

CHNs are empathic professionals who want the best for the families and the children with whom they work. There will be times when you have a strong view about what is best for the child, and the parent does not agree. Your temptation might be to ‘tell it like it is’. However, often the more someone feels pushed, the more likely they are to resist (Herman, Reinke, Frey, & Shepard, 2014).

However, CHNs have a responsibility to raise issues related to children’s health, development and wellbeing with parents. These conversations can be difficult, but necessary. Arguing with a parent is a sure sign that concern over who is right and who is wrong is taking precedence over arriving at an effective solution that works for everyone. Instead, you should aim for an empathic, open and collaborative exploration of issues, grounded in genuine attempts to understand and respect parents’ perspectives.

While you should not confront a parent, neither should you collude with them. Collusion occurs when the CHN supports the parent in self-defeating behaviour and beliefs and creates an environment that allows the parent to continue to avoid change. This might take the form of steering away from difficult topics, avoiding negative emotions, confirming unsupported assumptions, or failing to explore the possible negative consequences of a parent’s course of action. It is possible to assist a parent to work through difficult issues, without resorting to judgement or blame.

You can enhance the opportunities to make most use of the time you have with a family, particularly as you aim to build a relationship with them and engage and motivate them to work with you, by using pre-session time to do any necessary administrative tasks. These might include talking about yourself and your service, and preparing the parent for what’s ahead. Your aim is to avoid using your session time to do this, and to focus on using the session to build engagement and motivation with a client who may not yet see the benefit of working with you.

When thinking about how to prepare a parent for their first session, it’s important to keep in mind that they may not be familiar with what a CHN does, and how you can support them. Some parents will simply not know what to expect – but having this awareness can help reduce any anxiety the parent or family might be feeling.

Preparing a parent for their first session can begin before their first face-to-face meeting with you, perhaps with a pre-session phone call. This conversation might cover:

• your name and role
• the anticipated length of the session(s)
• what the session will and can involve
• asking them about their expectations
• providing information about your expectations and requirements
• confirming the best time for the first session
• whether someone else will or should attend (e.g. partner, friends, older children or family members); and
• describing what (if any) involvement their child will have in the session.

If the session is happening in the home, rather than the clinic, your preparatory conversation might provide:

• reassurance that the parent does not have to do anything out of ordinary to prepare their home for the visit, such as clean the house; and
• and explanation that the parent does not have to cater (provide food or drink) for the practitioner (who will have everything they need before they arrive, or with them when they get there).

Warm referrals

If possible, an effective way to begin establishing your relationship with a family is to make use of a ‘warm referral’. Sometimes referred to as a ‘facilitated referral’, a warm referral involves using the relationship the parent has with another practitioner or service provider to introduce them to you and your service. In essence, you are leveraging the parent’s positive relationship with someone else to develop one with you.

To do this well, you will need to establish links and relationships yourself, with the people and organisations who are likely to refer families to you: maternity ward staff at local hospitals, obstetricians and gynaecologists, general practitioners, other CHNs, hospital social workers, child protection workers … Connecting with people who are likely to engage with new parents, and can expand these relationships to include other health and social welfare services, can facilitate referrals to you. For instance, a new parent who is experiencing other disadvantages or vulnerabilities – perhaps housing instability, mental health concerns, or alcohol or drug misuse – may be seeing someone to help them with these concerns. This practitioner can be a source of referral to you, because of their concerns about the mother’s or baby’s health.

Work with and encourage these other service providers to make an active effort to link the parent to you and your service. If possible, ask the referrer to invite you to a meeting with them and the parent, so they can introduce you in person. Or, ask them to be present with the parent when the parent plans to make the initial contact for an appointment.

You can further facilitate this relationship by providing the referrer with information about you and your service, so they are knowledgeable about what the parent can expect from you, or what they will need to bring with them or do when they first meet you. Consider asking the referrer to share the pre-session information detailed herein with the parent, so you don’t have to. They may also give the parent information about the practical things to consider about getting to your service – perhaps where to park, which bus or train line to catch, or which stop to get off at. If there is any paperwork to be completed, you might ask the referrer to help the parent complete it, rather than using your time with the client to do this. Having someone else who already has a positive relationship with the parent do this effectively on your behalf, frees you up to devote your time and effort in your first meeting to building the parent’s engagement and motivation to work with you on an ongoing basis.

If it is not possible to undertake a joint visit with the referrer, then you may need to make contact via telephone. Again, your task here is provide the parent with any necessary information to help inform and engage them in your service, so that they will attend an introductory session with you.

You may want to consider having the client invite others who can be a support and motivate them to actively engage with your service – perhaps the baby’s father, their mother, another family member or friend. This can help to send the message that your service is friendly and inclusive.

Some other useful considerations include:

• reinforcing your scheduled appointment time with the parent and checking that this time still suits them
• asking them if they’d like you to text or phone them to remind them of your appointment time the day before, or on the day of the appointment
• asking them to put your name and phone number in their mobile phone if they have one (many people do not accept calls from unknown numbers; adding yours to their address book can indicate that it is you calling or messaging); and
• asking for contact details for up to two family members or friends, in case you have trouble making contact with them directly.

Engagement

Given the potentially limited opportunity you may have to establish a relationship with your client when you first meet, your priority may be to prioritise engagement between yourself, the parent and your service. In this context, ‘engagement’ means the extent to which a parent is ready to work with you around addressing an issue that they deem to be important. It is not about whether the parent likes or trusts you – which may be the case, but does not necessarily mean that the parent makes progress towards change on the issue at hand. Engagement begins when you or the parent initiate a conversation about something that matters to them, with which you could potentially assist.

Engagement starts with working together on a concern. Then, through this collaboration, engagement at a relationship level develops; and then finally, engagement with the change process. If you take the alternative approach of aiming to build a positive relationship as a first step, without doing anything else with your client, then you risk:

• taking longer to be able to help the family make positive change; and
• significant expense and inefficiency in your service system.

The quality of the relationship between you and the parent is critical to engagement, but that alone is not engagement.

You can do much to make the first session count by prioritising engagement with the parent.

Specialised personal engagement techniques – such as those that contribute to the process of ‘motivational interviewing’ (Miller, & Rollnick, 2013), have emerged that support this approach. There is increasing evidence that quickly identifying a person’s key concerns, helping them to negotiate the ambivalence associated with change, and supporting them to develop and carry out actions that result in the achievement of personally meaningful outcomes, can accelerate the process of personal engagement (Gayes, & Steele, 2014).

Developing engagement is part of your role as a CHN. Quickly identifying how you can best support parents to address issues that are a priority for them, and drawing on practices to do this, can be the focus of your role during this stage of your work with a family. Engagement begins with your first contact with a family, and is the starting point for each and every conversation you have with them. It is also important to remember that a parent can be highly engaged on one issue, such as their child’s sleeping, but less engaged on another, such as their children’s reaction to separation from their mother. This means that they recognise and are willing to do something about their child’s sleep, with your support, but do not yet recognise or are not willing to address their child’s reactions to separation from their mother.

Rapid engagement

Rapid engagement is the process of identifying the issues facing a parent, and moving as quickly as possible to identifying something that is personally important and meaningful to the parent. This often requires you to assist the parent to constructively and productively engage with a concern that has arisen. This can be particularly challenging if the concern has come from someone other than the parent themselves. People will only change when there is a strong motivation to do so. No matter what form it takes, if the underlying problem or concern is not ‘owned’ or seen as important by the parent, it will not power motivation for change.

Parents have many and varied concerns. They may have a concern they wish to have addressed, or they may work with you because others have a concern. There may also be times when you have a concern that you may need to address. The rapid engagement process provides guidance about how to explore concerns with families, raise concerns with families, and discuss concerns of third parties in a way that maintains engagement and quickly moves towards identifying whether the parent would like support from you to address these concerns.

Rapid engagement can be used to quickly establish an effective working relationship with the parent to bring about positive change for their child. This is especially critical when the support delivered to families is time-limited, and you are carrying a large number of families in your caseload. The aim of rapid engagement is to make a connection with the parent, and to develop the basic understanding and trust that will allow a genuinely collaborative partnership to develop. Although engagement will remain relevant throughout the course of your work with a parent, a rapid approach allows you to quickly identify whether the parent would like to work with you on addressing concerns they have, and barriers to their child’s health, development or wellbeing.

The rapid engagement process described here can be used:

• to drive and maintain engagement with a client who has been referred to your service
• to explore issues with a parent that may be barriers to their child’s healthy development
• when you need to raise a concern with a family or have a ‘tricky conversation’
• to quickly establish engagement with limited time; and
• to be able to respond to issues a parent brings to you, quickly and effectively, particularly when you have limited time.

Rapid engagement when the parent is concerned

When the parent raises a concern, you may be able to elicit a genuine concern almost immediately.

• Step 1: Actively listen

As part of the ‘OARS’ approach – Open-ended questioning, Affirming, Reflective listening and Summarising – it is crucial to actively listen to gain an accurate understanding of the parent’s concern and its impact on them and their child. Regularly check-in with the parent to determine if you’ve understood what they are thinking and feeling. The use of open-ended questions can help draw out information from the parent during this step. You can move to the next step once you believe you have a shared understanding of the parent’s concern.

• Step 2: Affirm

It is essential to communicate understanding and acceptance, if not necessarily agreement. A parent who feels understood will be more willing to explore an issue than one who feels like they must argue their point. OARS skills – particularly affirmations, reflections and summary statements – can be used at this time to demonstrate acceptance, and to show that you have heard the parent’s concerns and understand them.

• Step 3: Invite the parent to work with you on the issue

Keep in mind that complaining about something is not the same as asking for help. It is important to explicitly invite the parent to work on the issue with you. If the parent agrees, you can move on to the next phase in the collaborative process.

• Step 4: Begin support

At this point, you will want to refine your understanding of the concern.

• Step 5: Keep the door open

Alternatively, if the parent indicates that they don’t want to work with you on the issue, then you can keep the door open by saying something like, ‘OK, well if you would like to look at ways of tackling that issue sometime in the future, I’d be happy to help.’ Alternatively, you may consider exploring further why they are not concerned at this time (this is described further in the section on Concern development strategies).

Rapid engagement when someone else is concerned

It can be tricky talking with parents about concerns that others have raised. The best approach is to do this in a way that preserves or continues to foster engagement and builds parent motivation to act on the issue.

• Step 1: Clarify whose concern it is

Who has raised the concern: perhaps a GP, a paediatrician, or hospital staff?

• Step 2: Be clear about what the concern is

Clarify what the concern is: ‘Your doctor has expressed some concern about Adam not feeding regularly and that his growth has really slowed down.‘

• Step 3: Explore the parent’s agreement with the underlying facts

Investigate how the parent perceives the issue. Do they see or notice the same thing? Do they agree that this is happening or has happened?

• Step 4: Explore whether the parent is concerned

This means finding out what the parent thinks and feels about the concerns raised: do they believe this concern will affect their child? Again, you are not seeking the parent’s agreement about what they will do. Rather, the aim is to assess whether or not the parent is concerned about the facts as they see them: ‘Are you also concerned about Adam’s feeding and growth?’

•  Step 5: Invite the parent to work with you

If the parent does express a concern (or agrees that there is a concern), invite the parent to work with you on the issue: ‘Would you like to work with me on Adam’s feeding and growth?’

• Step 6: Leave the door open

If the parent is not concerned, what you do next will depend on your assessment of the situation.

If you are not concerned either, leave the door open to the parent raising the issue with you in the future. This approach informs the parent that should they become concerned, they can approach you for help: ‘You are confident that Adam will grow and develop once he settles down in the new circumstances. But if you do become worried or need help with this, please don’t hesitate to contact me.’

If you are concerned, explore why the parent isn’t concerned right now, and what may trigger their concern in the future. If you believe that the issue poses a threat to the child’s health, development or wellbeing, you may choose to explore and develop the parent’s concern.

Rapid engagement when you have a concern

You can use a similar approach when you are concerned about an issue and would like to raise this with the family.

• Step 1: Assume responsibility for the problem

At this time, you have a concern, not the parent. Aim to avoid alarming or provoking defensiveness in the parent by taking ownership of the concern: ‘I’m a bit worried about Adam’s feeding and growth. Can I talk with you about this now?’

• Step 2: Use observational language to describe the problem

If the parent agrees, describe your concern in observational language. Avoid leading with a potential solution, or an interpretation of the issue. Stick with observable facts: ‘I’ve noticed that Adam’s growth record shows that he’s not putting on weight over the last few weeks.’

• Step 3: Seek the parent’s observations – establish shared facts

Aim to establish a shared understanding of the facts: ‘Have you noticed that Adam is not putting on any weight?’ or, ‘Are you aware that increases in weight for children of Adam’s age are important for their healthy development and wellbeing?’

• Step 4: Explore whether the parent is concerned

If the parent has noticed the issue too, find out whether they are worried about it: ‘What do you think about this? Does this worry you?’

• Step 5: Invite the parent to work with you

If the parent is concerned, invite them to work on the issue with you. If they agree, you can begin working together to address the issue.

• Step 6: Leave the door open

If the parent is not concerned or decides not to work with you on the issue, what you do next will depend on your assessment of the situation. You may choose to leave the door open for them to raise it with you, if and when they do become concerned; or explore further why the parent isn’t concerned right now, and what might make them concerned in the future, possibly using a concern development strategy.

Concern development strategies

There will be times when you may choose to develop a parent’s concern around an issue, or prompt them to think through the impact of not addressing an issue. This might arise when there are significant implications of the parent not engaging with a concern, such as:

• the child experiencing significant health and development problems
• the child needing to be hospitalised; or
• increased involvement with the child welfare and protection system.

The aim here is not to win an argument with the parent. This approach is designed to help the parent to think through all the options and repercussions, ensuring informed decision-making by the parent. Note that there is no place for manipulation or rhetorical questions in a collaborative approach: all questions are asked in the spirit of genuine curiosity and interest in the parent’s views.

Avoid arguing with parents; arguments are rarely productive. If a parent has to defend their position, they will be increasing their belief in their own argument. Be attentive to your use of, ‘Yes, but …’ in your conversations with the parent. This can be a sign that you’ve stopped listening and are engaging in an argument.

Gentle, respectful questioning is more effective than putting up and defending counter-propositions. You need to remain constantly vigilant for signs that the parent is engaging with an issue, and use that opportunity to extend an invitation to the parent to join with you in working on the issue together.

Be ready to be patient. If the initial approach has been gentle and empathic, a parent may go away and think about it further and decide that you can be trusted to talk with in more depth. They might also simply be alerted to something that they now observe more closely, and may be in a different place on the issue the next time they talk to you.

You can develop a parent’s concern in the following way:

• Step 1: Explore why the parent is not concerned

Do this with openness and curiosity. Carefully listen and summarise key points fairly and objectively. Check you have fully understood: it’s important that parent feels heard and understood through this discussion. Careful listening and reflection may reveal new information that casts a different light on the situation, or misunderstandings that are preventing the parent from productively thinking about the issue. From time to time, check whether the new information changes the parent’s stance on the issue.

• Step 2: Use concern development strategies

These are motivational interviewing strategies for building motivation to act on a concern. The purpose of these strategies is to assist parents to consider the consequences or potential advantages in addressing a concern. The focus is on questions that will prompt parents to consider or build the motivation towards change.

• Strategy 1: Explore the parent’s certainty

Ask the parent to rate how certain they are that the issue isn’t a problem, on a scale of one to 10, with 10 being absolutely certain, and one being not certain at all. For example:

‘So, Tamika, Adam’s weight gain is not worrying you at the moment, and you think he will start to gain weight as he gets older. How certain are you that this isn’t a problem, with 10 being absolutely certain, and one being not certain at all?’

If the parent gives a rating of 10, then summarise what they have said and leave the door open:

‘So, you are totally confident that this won’t be a big problem for Adam. Would it be OK for me to check-in with you in two weeks, to make sure that’s still the case?’

‘You are certain that this isn’t a problem at the moment, but feel free to get in touch if things change down the track.’

If the parent gives a rating less than 10, ask them why they didn’t rate it a 10, and explore any doubts or factors that prevented a 10 rating:

‘OK, so you’ve rated this as seven out of 10 – so you are pretty sure that Adam’s growth will improve. But you aren’t 100% sure. What’s stopping you from being totally confident that things will improve?’

Once you have explored the parent’s reasons, consider whether there is an opportunity to investigate these factors further:

‘What if we looked at some information about weight gain and growth in children? Would that help you be more certain that this isn’t a problem?’

• Strategy 2: Determine when the parent will become concerned

A second strategy that can be used to develop parents’ concerns about an issue is to ask questions around what would trigger the parent to become concerned. You may try asking the parent to imagine whether they would be concerned if the problem continues, or gets worse. This strategy also helps identify the point at which parents would become concerned about an issue. See the following table for some examples.

• Strategy 3: Are there any advantages in addressing this now?

A third strategy involves exploring with the parent whether there are any advantages in taking action now, even if they aren’t concerned – if action would stop a situation from getting worse. See the following table for some examples.

• Step 3: Find another point of engagement

Sometimes it may be possible to boost engagement by linking an issue that is not currently a concern for the parent, with another issue that they are worried about. For example, the parent may not be concerned about the impact their child’s poor growth trajectory is having on their child’s healthy development, but they may be concerned with the effect of taking leave from work because of the medical appointments they need to attend because of their child’s poor health. It may be possible to engage the parent around the child’s health from the perspective of the impact it has on their work.

You can do several things after your first session with your client to maintain the gains made in your relationship, and the family’s engagement with you and your service. These include:

• Book-in and confirm your next appointment time before the parent leaves the first session. Give them an appointment card, or encourage them to add it to their phone if they can.
• If you’ve agreed on some activities or tasks to complete before the next session, check-in with the parent before the next session. Depending on the difficulty or complexity of the task or activity, you may choose to check-in several times between sessions. You may need to be prepared to spend some time amending the task or activity if the parent is finding it too difficult to undertake. Normalise the challenge they are experiencing, and problem-solve with the parent to identify possible solutions.
• In the subsequent session, remember to ask about activities the parent took responsibility for: ‘It’s great to see you and Adam back, Tamika. I’m really interested in hearing how you went with the settling technique we discussed. Tell me how it went.’
• Ensure you update the parent on any actions that you had following the session – e.g. finding out the availability or details of a local support service, such as a lactation consultant. Demonstrating your commitment to the parent and your relationship goes a substantial way towards maintaining the parent’s commitment to you.

Where possible, establish contact with the mother before birth. This may enhance an alliance with the mother directly (Watson, 2005).

Use another practitioner who is already well known to the mother/family, such as an antenatal health practitioner or mental health specialist, to introduce you and invite you to meet the parent (Watson, 2005).

How you act and talk can make a difference to engaging a family. Useful suggestions include:

• being respectful, consistent and reliable (schedule regular session times if possible)
• being supportive and non-judgemental
• adopting a strengths-based approach
• including the family in decision-making from the start; and
• offering immediate concrete support to build ‘buy-in’ quickly (Watson, 2005).

Providing immediate, concrete support may also provide lasting positive impact, should subsequent sessions not take place. Examples include referral information to important services, or access to material supports.

When you’re actively trying to engage with a family, considerations include:

• Be sensitive and careful when exploring concerns with a parent who doesn’t share those concerns. Don’t push too hard – and if they are still not concerned despite discussion, move to focus on something else the parent is concerned about and is willing to work on. While it may not address the concern at hand, it can keep you connected with the parent and helps to build your relationship, so that they might be willing to revisit the issue later, or if things change.
• Regardless of how strongly you pursue an issue, if the parent decides they don’t share your concern, be prepared to move on but keep the door open in case things change.
• Choose your timing carefully. It may be better to raise potentially challenging issues once trust is well established. On the other hand, if the issue is a key reason for the service involvement in the first place, little is to be gained by avoiding it; instead, a supportive and constructive discussion may be the best way through the issue to a stronger relationship.
• Offer your observations or the observations of others tentatively. Think about concerns held by others as hypotheses to be tested, rather than facts. When you put them on the table, you are looking at them together with the parent as issues that need exploring, rather than confronting the parent with facts.
• Monitor how the parent is feeling and thinking about challenging information. Frequently check in with the parent as you discuss the issues: ‘How does that sound?’; ‘What do you make of that?’; ‘How do you feel about that?’ Slow down if the parent is finding the situation hard to deal with. Be ready and willing to acknowledge and validate the difficulty associated with addressing such concerns.

Some practical things you can do to maintain engagement include:

• Scheduling your follow-up session during your current session, while you’re together and as soon as practical after the first session. Evidence shows that quick follow-up reduces early drop out (Watson, 2005). It can also help to talk to the parent about possible barriers to follow-up sessions, such as child-care, unsettled routines, illness, transport challenges, changes to contact details, etc. You can assist by identifying strategies or solutions the parent might try to address these obstacles should they arise.
• Actively follow-up non-attendance multiple (three or four) times. If you undertake home visits, returning to the address has been shown to improve retention rates (Watson, 2005).
• Ask the client to provide you with contact details for other important people in their lives, so you can follow-up through them if you’re having no luck contacting the client directly.
• Ask the parent for feedback on the session:
  • Did it meet their needs and what was important to them?
  • Is there anything you could have done differently that could have improved the session?
  • Are there any other questions they have?

The following behaviours may unwittingly undermine engagement and decrease rapport:

Being abrupt – Behaving in a business-like manner and seeking to deal with an issue efficiently with a quick response may be well-intentioned, but it can shut down productive conversations and limit or even harm relationship-building.

Carrying on with activity while talking – This can include doing other important activities – such as weighing a child or child health checks – while talking to the parent. Multi-tasking is a good attempt at being efficient and productive, but it can inadvertently give the impression the parent is not important.

Assuming parents want to work on/change something – Be wary of moving into ‘helping mode’ or trying to guide the parent towards a solution too soon. The parent may have just wanted to air their issues (complain) or be uncertain about how to proceed. Again, you may have been genuinely trying to help, but may lose the opportunity to collaborate by rushing the parent or losing the opportunity for rapport-building.

Prematurely expressing an understanding or knowledge of the problem – You may be keen to demonstrate your understanding and empathy by showing how well and quickly you understand – by indicating that you ‘get it’ – if you do so too early, you lose the opportunity to have the parent feel listened-to and understood.

Prematurely giving a solution without gaining a good understanding of the problem – While it can be an attempt at being helpful and efficient, this can leave the parent feeling unheard and not valued as an individual. It also risks harming the parent’s sense of competence and confidence, particularly if the solutions offered do not take into account what the parent may have tried previously. This approach does not value the parent as an active problem-solver.

Over-generalising – This involves making a statement that aims to show you understand, but can be too general. This can lead the parent to feel that while you might understand this general type of issue, you’re not so interested in them as an individual or their specific circumstances.

Disavowing – This occurs when you try to reassure the parent by indicating that their concern doesn’t apply in this case. This has the effect of shutting down the conversation and losing an opportunity to develop parental confidence and competence.

Not following through – Not doing what you said you were going to do can put the relationship and parent’s engagement with you at risk.

Child Health Nurses and other practitioners in similar roles are vital to the support of first-time parents, particularly in the early days after the birth of their child. The strategies presented in this resource will help CHNs put methods in place to create a positive and collaborative environment with parents, even prior to their first session together. This resource can be used as a reference, to help CHNs and other professionals identify and address factors that impact on engaging parents, particularly those living in vulnerable circumstances – and to reinforce skills and practical tips on how to engage, build rapport and effectively support parents. The resource will assist practitioners to better prepare and organise their first session with parents, to ensure they make the most of this opportunity to establish a positive, ongoing relationship with the new family.

Resources

• Online course: Communication techniques to influence change
• Online course: Introduction to motivational interviewing
• Online course: Engaging with parents
• Practice paper: Exploring child mental health concerns with parents

References

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