MATRICULA DE COMERCIO

Taken together, the findings identified skilful attention and response to the psychosocial needs of families during the perinatal period as essential. The panel and nurses agreed that a robust understanding of the concept of mental health was imperative for the delivery of effective mental health care. Mothers described their experiences of their new parenting role, the emotional issues that came with it and the type of support they expected from their carers during the perinatal period. Importantly, participants from the three studies identified optimal child development and wellbeing as a main purpose of effective parental mental health care. This is consistent with findings from previous studies that have examined the interconnecting concepts of complex needs and mental illness as parental risk factors for child maltreatment, as discussed in Chapter 2 (Huntsman, 2008; Jordan & Sketchley, 2009; Mayberry, Goodyear, & Reupert, 2012).

7.1.1.1 Expert panel

Findings from Study 1 highlighted the links between adult and infant mental health, domestic violence and child protection. The participants drew a distinction between adult mental health knowledge linked to psychosocial screening and referral to specialist services and infant mental health knowledge that focused on early infant-carer relationship formation and attachment. Several participants noted the benefits of motivational interviewing (MI), which is a directive counselling approach originally developed to encourage behaviour change in patients with addictive behaviours (Miller & Rollnick, 1991). More recently, health professionals working with families with complex needs have adopted

148

this approach to deal with a range of behaviours that are potentially harmful to the child, such as smoking and harsh parenting practices (Iannos & Antcliff, 2013).

Despite general agreement about core adult and infant mental health knowledge and skills, some differences in the responses between rounds one and two of the Delphi study indicated a lack of consistency in the use of the term ‘mental health’. According to one participant, it could apply to the prevention of mental illness and the promotion of maternal mental wellbeing or it could be used to describe individuals with a diagnosis of mental illness; in the latter case, preventive perinatal interventions aim to prevent maternal relapse and promote the infant’s emotional health and

wellbeing. These interpretations, while not mutually exclusive, are significantly different and suggest the need for separate nursing roles and distinct skill sets. Researchers, policy makers and clinicians have been reluctant to use the term ‘mental illness’, preferring instead to refer to ‘mental health issues, emotional problems or emotional distress’. This may have contributed to the uncertainty that exists around the diagnosis and management of high incidence perinatal mental illnesses such as depression and anxiety within a primary health care setting (beyondblue Perinatal Mental Health Consortium, 2008). Both depression and anxiety have significant negative impact on parenting capacity and early relationship formation (ARACY, 2009; M. Austin & Highet, 2011; R. Austin & Farlinger, 2015; Glover, 2011; Woodhouse et al., 2009).

7.1.1.2 Mothers

The mothers in Study 2 supported the finding that assessment and referral for mental health issues was an important role for nurses. When nurses asked them about their past and present emotional state using structured questionnaires, they said this was surprising, but not unacceptable to them. Most mothers had been asked to complete the Edinburgh Depression Scale (EDS) and they were aware that the questionnaire was a screening tool for depression. The mothers did trust the nurses to be able to identify if they were not coping and recognised that the nurse’s role was to refer them to relevant specialist services. It is worth noting that mothers did not acknowledge having a mental illness, but did report experiencing extended periods of sadness, anxiety and stress. They described emotional distress as an adjustment to motherhood which, at the time, impaired their ability to function effectively. Commenting on reluctance to disclose psychosocial issues, one mother hinted at the stigma associated with mental illness:

Your main priority is self-preservation. You try to project to the world that you are coping. The nurse needs to be very intuitive to realise that the mother is not telling the truth because she thinks, ‘If I tell the truth what they are going to do?’ (M6)

This obstacle to disclosure is well documented in the literature (Myors, Johnson, Cleary, & Schmied, 2014; Reupert & Mayberry, 2007; Woodhouse et al., 2009). This finding, consistent with those from

149

other studies (Shepherd, 2011; Woodhouse et al., 2009), suggests that, while the women may have cooperated with routine psychosocial screenings, they may also have minimised their symptoms. Despite such apprehensions among some mothers, successful previous experiences with CFH services may have encouraged others to seek the support they needed (Marshall, Green, & Spiby, 2012). A mother of four (including newborn twins), who had struggled with mental health problems since early childhood, reported how her self-efficacy and confidence as a parent had been enhanced by accessing CFH services while she was still pregnant. Because of her mental health history, she was well

informed about the roles of existing services and about the type of intervention she believed she was likely to require in the postnatal period. She relied on the strong relationship that she had built with CFH services in the past to seek their help in planning specific postnatal interventions that she thought would meet her current mental health needs. The plan included risk assessment of potential child maltreatment resulting from the family’s psychosocial complexities. When reflecting on the implication of a child protection assessment and the nurse’s sensitive approach, she remarked:

The person’s good language and her ability to express herself; this made a difference to why you have to put a risk of harm form…She worded it in a way that I did not look like a crap mum who did not look after my kids or could not cope looking after four children (M9).

This mother’s positive experience is consistent with findings from studies that explored the benefits of moral, trusting relationships between nurses and parents (Marcellus, 2005; Shepherd, 2011; World Health Organisation, 1986). Success depends on the credibility of clinicians and on interventions that are relevant to the parents and tailored to the family’s needs (Donetto et al., 2013). Another mother was faced with complex family issues and lack of support. She described the skilled and sensitive response of the CFH nurse who visited her at home following her discharge from maternity care:

The second visit was not about the baby, it was about me. The nurse may have thought that I was depressed; she had sensed that I was unhappy; she wanted to know that I was alright. She said ‘I am here for you’ (M8).

The interaction that followed resulted in long-term support being instituted for the family. Similar findings were reported by Shepherd (2011), who showed how CFH nurses were able to meet the emotional needs of mothers “hiding behind the mask of motherhood” (2011, p. 145) using the monitoring of the infant to justify their cautious probing of maternal emotions.

7.1.1.3 Nurses

Nurses were invited to participate in the study through the NSW CFH nurses’ professional

organisation. The 12 nurses who self-selected to be interviewed for Study 3 worked in primary health care settings providing early interventions to families with complex needs during the perinatal period. It was assumed that all 12 nurses would hold a CFH nursing qualification, as this is a recommended (although not essential) condition of employment in their role (NSW Health, 2010a). Eight nurses

150

held a CFH qualification, ten had postgraduate qualifications in adult and infant mental health, psychology and social work, and seven held both CFH and mental health qualifications. This level of mental health expertise reflects the focus of the service. More speculatively, it might also indicate the capacity of the workforce to deliver mental health expertise.

While the panel in Study 1 adopted a broad view of mental health, paying particular attention to the inconsistencies and lack of clarity in the concept itself, the nurses were more pragmatic in their approach. Findings from Study 3 were consistent with the beyondblue practice guidelines and education program for primary health care workers (beyondblue, 2010; beyondblue Perinatal Mental Health Consortium, 2008). The nurses reflected on their past and current clinical practice, their nursing education and their personal experiences of working with families with complex needs. This enabled them to articulate the competencies they believed were required to deliver the quality mental health care that is necessary for enhancing parenting capacity and child protection. They commented on the dangers associated with supporting the emotional needs of families without understanding the aetiology of mental illnesses, treatment options, care pathways and community resources. The nurses pointed out that, while various postgraduate courses had been useful for building their theoretical knowledge and skills in mental health, ongoing participation in continuing professional development and supervision had been essential to allow them to practise at an advanced level. Nurses practising, often in isolation, in rural and remote areas of NSW were particularly conscious of their mental health knowledge and skills deficits and chose, whenever the opportunity arose, to collaborate closely with local specialist services.

Nurses in the study subscribed to the recommendation in the literature (Cowley et al., 2013; Donetto et al., 2013) that the ability to assess the family’s needs comprehensively and to develop acceptable and effective responses was crucial to their practice. They described psychosocial assessments, monitoring of parents’ mental state and parenting capacity, assessment of present and potential safety risks and assessment of the parent-infant relationship as essential components of their practice. Several nurses singled out the importance of finely-tuned assessment and observation skills to promote healthy relationships with parents who were reluctant to engage with them:

You gather data without questioning…You become able to assess parents by what they are not telling you rather than what they are telling you (N3).

Several nurses agreed with the literature that, although extensive training in the use of psychosocial risk assessment tools was available to NSW nurses, further education in comprehensive psychosocial assessments of mothers throughout the perinatal period was indicated (National Health & Medical Research Council, 2003; Rollans, Schmied, et al., 2013a, 2013c). In addition to advanced assessment skills, the nurses identified a combination of important clinical skills gained while working with families, notably their ability to use attachment-based interventions to support early relationship

151

formation and to use supportive non-directive counselling techniques to de-escalate acute maternal distress and manage mild to moderate symptoms of depression and anxiety (Roden, Jarvis, Campbell- Crofts, & Whitehead, 2015). Finally, several nurses agreed with the panel on the importance of behaviour change skills acquired through programs such as Motivational Interviewing to help parents modify potentially harmful behaviours.