Public health nursing practice with 'high priority' families

Nursing Inquiry 2010; 17(1): 27–38

Feature

Public health nursing practice with ‘high priority’ families: the significance of contextualizing ‘risk’ Annette J Browne,a Gweneth Hartrick Doane,b Joanne Reimer,a Martha LP MacLeodc and Edna McLelland aUniversity of British Columbia, Vancouver, BC, Canada, bUniversity of Victoria, Victoria, BC, Canada, cUniversity of Northern British Columbia, Prince George, BC, Canada, dNorthern Health, Kitimat and Terrace, BC, Canada Accepted for publication 22 August 2009

BROWNE AJ, HARTRICK DOANE G, REIMER J, MacLEOD MLP and McLELLAN E. Nursing Inquiry 2010; 17: 27–38 Public health nursing practice with ‘high priority’ families: the significance of contextualizing ‘risk’ Public health nurses (PHNs) play a vital role in supporting families at risk; few studies, however, have focused on how PHNs actually work with families to provide support, build trust, and use their clinical judgment to make decisions in complex, at-risk situations. In this study, we report on findings from research that illustrate how PHNs use relational approaches in their work with ‘high priority’ families. Drawing on data collected from interviews and focus groups with 32 PHNs, we discuss three central features inherent to working relationally with families at risk: (i) contextualizing the complexities of families’ lives; (ii) responding to shifting contexts of risk and capacity; and (iii) working relationally with families under surveillance. These findings show that the ability to recognize risk and capacity as intersecting aspects of families’ lives, and to practice from a stance that recognizes risk as contextualized is foundational to effective working relationships with high-priority families. Key words: Canada, clinical decision-making, families at risk, family care, nurse–patient relationships, public health nursing.

Concern with social justice issues has been a driving foundation of public health nursing practice since its inception. Public health nurses (PHNs) have always played a role in supporting families whose health is affected by social or economic conditions that create various forms of hardship including, for example, families led by single women, families residing in poor neighborhoods, families who are socially isolated, and families with low incomes living in urban and rural communities. The impact of PHNs’ work with families who are at risk due to social disadvantages1 has also been well documented. For example, there is a large body of evidence indicating that PHN home visitations are highly effective in supporting families ‘at risk’, particularly

Correspondence: Annette J. Browne, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5. E-mail: 1

Our use of ‘disadvantage’ is located in structural and social inequities that con-

strain peoples’ access to meaningful employment, housing, child care, nutritious foods, and so on.

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for those with young children (e.g. Browne et al. 2001; Ciliska et al. 2001; Olds et al. 2002; Heaman et al. 2006, 2007; Cohen and Reutter 2007; Aston 2008; Edwards and Smith 2008). However, few studies have focused on how PHNs actually work with families to support them – how they specifically reach out to families who are at risk due to social or economic circumstances, how they effectively build trust, and how they use their clinical judgment and make decisions in complex, at-risk situations. Even less is known about the ways that PHNs work with families in rural and northern communities in the Canadian context. The research inquiry that we discuss in this study arose from a larger qualitative study conducted in a northern and rural region of Western Canada. The overarching research question guiding the larger study was: what is the nature and character of working relationships of PHNs and highpriority2 families? Initial analysis of the data from this larger High-priority families, otherwise known as high-risk or vulnerable families with infants and children, are identified by a Parkyn risk assessment score of >9 (Parkyn 1985; Reiter 2005).

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study revealed that a central feature of PHNs’ relational work was ‘contextualizing risk’. Thus, a second level of analysis of the data was conducted to specifically examine how the PHNs worked in relation with families around health and social risks. The specific research questions guiding this second level of inquiry were: (i) how do PHNs understand, contextualize, and address risk; and (ii) how specifically do they relate and interact with families at risk in ways that promote health and ameliorate potential harm? In this article, we discuss the findings of this second level of analysis by drawing on data collected from interviews and focus groups held with 32 PHNs, and related literature, to depict the ways in which a contextual understanding of risk shaped public health nursing practice with families whose lives were challenged by socioeconomic uncertainties and related vulnerabilities.

NURSING AS A RELATIONAL PRACTICE While often there is a tendency in nursing practice and assessment to objectify and locate risk in people ⁄ families (e.g. by assessing and scoring families according to risk indicator criteria), in this study, we describe the relational approach the PHNs took in their work with high-priority families. Discussions of relational approaches in nursing and healthcare literature have been growing in recent years. A relational approach recognizes that health, illness, and people’s experiences are shaped by their social, economic, cultural, family, historical, and geographical contexts as well as by their biology, gender, age, ability, etc. (Hartrick Doane and Varcoe 2005, 2007, 2008). Relational practice refers to more than interpersonal relations; although interpersonal relationships are an integral element, relational practice focuses attention on how personal, interpersonal, and contextual elements are shaping peoples’ experiences and life situations. Included in this relational approach is an examination of how capacities and socioenvironmental limitations influence people’s health and illness experiences, decisionmaking, and the various ways of managing health and illness. A relational view of nursing has been particularly useful in shifting the focus of analysis away from individualistic perspectives that are predominant in nursing and health-care (Browne and Varcoe 2009). This shift from an individualistic understanding of risk to a contextual one was central to the PHN’s practice in this study. Specifically, the PHNs approached their work by (i) contextualizing and locating disadvantage in social structures and inequities, and (ii) simultaneously addressing the risk situations and circumstances created by those inequities. 28

The findings from this inquiry contribute to existing nursing literature by further explicating and illustrating the integral connection of interpersonal concepts such as trust, respect, and vulnerability (Oberle and Tenove 2000; Marcellus 2005; Heaman et al. 2006) with social justice concepts such as power, structural inequities, and disadvantage within everyday nursing practice (Hartrick Doane and Varcoe 2007). They also broaden the understanding of ‘risk’ and highlight the significance of understanding risk contextually – within the capacities and complexities of families’ lives.

OVERVIEW OF THE STUDY Context and settings The findings discussed in this study were derived from a larger study conducted in the Northern Health Region of British Columbia (BC), Canada, which examined the nature and character of working relationships of PHNs and highpriority families in northern communities, with a view to informing practice, education, and policy at the community, regional, and national levels. The idea for this larger study emerged from the PHNs in northern BC, who identified that one of the most important yet difficult areas of their practice was working with high-priority families, otherwise known as high-risk or vulnerable families with infants and young children. Although PHNs were known to play a critical role in assisting high-priority families to access services such as early childhood development programs, social support services, and specific healthcare programs, little was known about what the nurses referred to as effective ‘working relationships’ between themselves and the families. Communities in rural and northern regions of western Canada tend to be resource dependent, with employment opportunities closely linked to the forestry, mining, fishing, and energy industries. In the past few years, the downturn in the economy has resulted in closures and downsizing of these industries, loss of jobs, and in some cases, economic devastation in rural communities. The effects of the current economic climate in rural and northern communities have been particularly significant given the high proportions of young families with small children, and the increasing numbers of families headed by lone-mothers. There are also high proportions of Aboriginal people living off and on reserve whose socioeconomic status has been impacted by the longstanding history of economic marginalization of Aboriginal people in Canada (Adelson 2005). Economic hardships are compounded by the recent cutbacks to social programs, increasingly restrictive eligibility criteria for welfare 2010 Blackwell Publishing Ltd

Public health nursing and families at risk

assistance, and one of Canada’s lowest minimum wages (Wallace, Klein, and Reitsma-Street 2006; Raphael 2007). For example, compared to other regions of the province, the northern region where we conducted our study ranked the highest on income inequality measures, percentage of population receiving social assistance, numbers of teen pregnancies, and numbers of children in foster care (British Columbia Statistics 2007). These social, economic, and political conditions shape public health nursing practice with families whose lives are challenged by increasing levels of poverty, socioeconomic uncertainty, and other structural inequities.

Design and methods Our research is situated within an interpretive approach that seeks to examine everyday practices and understandings, and how they both shape and are shaped by their contexts. We employed a hermeneutic methodology to examine the working relationships between high-priority families and PHNs in rural and remote areas. Qualitative methods were used to gather three sets of data: (i) 18 in-depth individual interviews and four focus groups with 32 PHNs, and a focus group with three lay home visitors; (ii) 20 in-depth interviews and one focus group with family caregivers (mostly mothers and their partners, and in some cases, grandparents, aunts, etc.) of 25 high-priority families; and (iii) fieldnotes from observations of six PHNs who were shadowed as they went about their everyday work in four communities.3 All of the interviews and focus groups were audio-recorded and transcribed verbatim. Participants came from 14 communities in the northern region of the province including small rural, and larger regional municipalities, only one of which was over 50 000 people. Purposive sampling of the PHNs occurred through face-to-face meetings and e-mail communications with PHNs from the regional health authority that encompassed the 14 communities. These meetings were facilitated by the nine PHNs on the research team. PHNs who identified as having experience working with high-priority families were invited to participate in the study. Families from these communities were eligible to participate in interviews if they had recently scored at nine or greater on the Parkyn screening tool (Parkyn 1985), and had stopped working with PHNs at least 3 months but no more than 12 months prior to doing the interviews. The PHN contact in each community sought to identify families whom they thought had had both positive and ⁄ or negative experiences. Eligible families were invited to participate 3

Interviews with PHNs were conducted by the fourth author.


by PHNs who had not worked with those particular families. The PHNs came with a range of experience in public health nursing, several with many years of experience and others as relatively new practitioners. The ‘families at risk’ with whom they worked experienced a range of intersecting vulnerabilities created by economic risk, intimate partner violence (which particularly affected women), single parenting (again, often women), social and geographic isolation, lack of transportation, precarious employment, among others. Ethical approval to conduct the study was granted by four different universities and one Health Authority Research Ethics Board. In this study, we report on findings from the analysis of the PHN interviews and focus groups. Elsewhere, we report on the analysis of interviews with highpriority families (Moules et al. 2010).

Data analysis Data analysis occurred in two stages. As part of the larger study, university-based members of the research team, in collaboration with several PHNs who were members of the research team, initially analyzed the three datasets, focusing on explicating the differing interpretations and meanings within the data (Smythe et al. 2008). Through this initial analysis, the significance of how PHNs understand and locate risk contextually in their work with high-priority families was highlighted. Consistent with Smythe et al.’s description of hermeneutic research, although we still held the purpose that led us to initially undertake the larger research study, a second level of analysis of the PHN dataset was undertaken to further illuminate this aspect of contextualizing risk and the impact on PHN practice. Our intent was to more fully examine the work of the PHNs with the goal of developing a deeper understanding of the interconnection between contextual factors, risk, and health promoting public health nursing practice. In the second wave of hermeneutic inquiry, the focus of analysis specifically shifted to understanding how PHNs understood, contextualized, and addressed risk, and how they related and interacted with families ‘at risk’ to promote health and ameliorate harm. A deconstructive hermeneutic methodology was employed; hermeneutic in the sense of focusing on ‘the necessity of interpretation’ and deconstructive in the sense of critically considering the interpretations we were making (Caputo 2000, 3). This involved re-reading the narrative data, and reflecting on recurring, converging, and contradictory elements within the data. The intent was not to seek a final account but to examine the multiplicity of meanings and identify aspects that required further in-depth 29

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analysis (Smythe et al. 2008). To expand and strengthen the interpretations, the PHN co-investigators were invited to consider the analytic findings within the context of their own practice. Consistent with hermeneutic inquiry, in the discussion of findings, literature is used to form linkages between the empirical data and relevant theoretical perspectives.

FINDINGS AND DISCUSSION Contrary to dominant discourses that tend to locate risk in people ⁄ families, the PHNs brought a contextual understanding of risk to their work with families, locating disadvantage and risk within structural inequities such as poverty, unemployment, geographical isolation, and so on. Specifically, the findings of this study illuminate how working relationally enabled the PHNs to simultaneously recognize, contextualize, and respond to risks and capacities, and attend to the multidimensional ‘whole’ of the family. We discuss three central features that were inherent to relationally working with families at risk: (i) contextualizing the complexities of families’ lives; (ii) responding to shifting contexts of risk and capacity; and (iii) working relationally with families under surveillance.

Contextualizing the complexities of families’ lives Although there is a wealth of literature on the importance of addressing socioenvironmental conditions in the promotion of health, the PHNs in this study worked with those conditions in a somewhat different way than is typical. Rather than viewing social and environmental conditions as ‘environmental factors - as something separate and located in the external surroundings - the PHNs understood social conditions as being quite literally embodied in people. That is, past and present social conditions were recognized as living through and shaping people biologically, psychologically, and interpersonally. Subsequently, the socio-historical context was understood to be integral to a particular person ⁄ family in terms of who they were, how they were living, how they responded to the PHN, the decisions they made, the actions in which they engaged, and so forth. Bringing this contextualized understanding to their work, rather than simply problematizing or pathologizing an individual or family, the nurses sought to understand risk and any ‘risk behavior’ relationally. For example, risk behavior in a mother or a father was not interpreted as a problem of poor parenting or located solely in the individual circumstances of that particular individual. Rather, a relational view was taken to consider how, for example, intergenerational experiences and traumas, and structural constraints might be experienced within 30

a particular person ⁄ family. That relational approach fostered comprehensive clinical decision-making, ensured that people ⁄ families were treated with respect and dignity, and enabled nursing action to be more effective and responsive in addressing risk. Three aspects were central to contextualizing the complexities of the families’ lives: (i) simultaneously working with risk and capacity; (ii) taking a temporal view of families; and (iii) being flexible. SIMULTANEOUSLY WORKING WITH RISK AND CAPACITY

The PHNs who worked with ‘high priority’ families willingly entered into the complexities, immediacies, and uncertainties of families’ lives. The PHNs described anticipating that there would be shifting and multiple challenges to work through in collaboration with families. Working relationally within the uncertainties and risk, the PHNs simultaneously looked for strengths in the midst of the often chaotic lives of families. This capacity to simultaneously focus on strengths and risk was particularly apparent with mothers who were under surveillance by provincial child welfare authorities and thus at risk of having their children apprehended. Oberle and Tenove (2000, 436) have described the ‘exquisite sense of balance’ and ‘finely tuned sensitivity’ that is required for PHNs to attune to people’s strengths, capacities, and possible risks. This PHN’s description of work with one mother helps to illustrate this finely tuned sense of balance: She was a drug abuser and … and as a result of that she actually had lost her children … So when I went in at this point in time she had supervised access to her children and really wanted to have her children. And so working on her strengths … Because here you have somebody who’s lifestyle [was] at such a point that she damaged one of her children from the drug use, lost her children, her relationship is possibly going to break up … But yet she had the incredible strength to love her children, to want her children, to see that she had to make changes in herself in order to keep her children. And at no time did she ever put her children at risk while she was using drugs. (PHN 20)

Contextualizing risk and relationally entering into the complexities of families’ lives meant recognizing the extent to which young mothers (often teen mothers) living in poverty faced stigma and often relentless scrutiny and surveillance by the state. As has been documented elsewhere, insufficient resources provided by the state often exacerbate teen mothers’ poverty and contribute further to their vulnerability to state scrutiny (Rutman et al. 2002; Dominelli et al. 2005). Thus, working to support families to keep their children was a priority for many of the PHNs who recognized that for some families, parenting was a source of strength and motivation in relation to overall health and well-being, particularly for women. 2010 Blackwell Publishing Ltd


TAKING A TEMPORAL VIEW OF FAMILIES

Anticipating the impact of shifting social and economic conditions and the temporal nature of families’ experiences was also an inherent aspect of public health nursing practice. For example, in the following situation, the PHN recognized a young couple’s resourcefulness and strength, and at the same time, remained poised to offer support should their socioeconomic situation change given the context of the rural resource-dependent community in which they lived and where jobs were increasingly scarce. These parents, who were in their teens when they had their first child, were unable to complete high-school education and unable to qualify for welfare because as minors, the expectation was that their family of origin would provide support. However, they were geographically isolated from their parents, and in the recent past, the couple had ‘no house, no income … no money for food, no way of supporting this baby’. Although their situation had currently improved, the PHN explained: He’s working lots … But I think it’s just above minimum wage … If he lost his job they could easily be back out on the street because they’re both considered children according to social services [and ineligible for welfare]. So I mean, that’s kind of a ‘heads up’ that they could be very vulnerable … even though they sometimes can present as very together. (PHN 7)

By viewing this family and their health experience temporally, the PHN is recognizing that the couple are in a stable living situation now, but that there is a continuing vulnerability that may emerge at another time. This is an example of how, in contextualizing ‘being at risk’, the PHNs remained cognizant of the various social conditions and structural barriers that shaped families’ lives, the capacities they had within those barriers (in this example, the young parents’ intent and ability to be good parents) and how the interplay of those could change over time. As Benner, Tanner, and Chesla (2009) have emphasized, responding to a family’s situation as ‘an instance of particular concerns’ at various points in time is central to excellence in practice in public health nursing. In another situation, a PHN described her work with a young single mother who was living on a meager level of social assistance while caring for several young children, and who, ‘in her [the woman’s] words, makes poor choices in her life, and she’s really trying hard to rectify that through being a good mom to her kids’ (PHN 31). As a young woman who was also living without access to transportation in a small rural community, and who was in a custody battle with her ex-husband who was a known drug user, there were few supports to draw upon: in the words of the PHN, there was ‘no structure for her to get that help’. Within this high 2010 Blackwell Publishing Ltd

risk context, while this woman was pregnant, the PHN visited her to provide prenatal support. Over time, the relationship evolved to providing more general support. One way she did that was to respond to the woman’s phone calls and drop in visits – to understand their relational significance. For example, as time went on, eventually, contact was almost exclusively initiated by the mother whose entre´e to asking for support was often a hypothetical need to weigh the babies: There’s absolutely no reason to weigh them [the children] but that’s the excuse she has … ’cause there’s no problem with the children’s growth … She’s going through a custody battle right now so she’s wanting to talk … just wanting to sound off and debrief. (PHN 31)

This example highlights how, as PHNs understood and worked relationally with women and families through a contextual view of risk, they were able to recognize efforts to reach out for help and respond optimally (and opportunistically) to shifting priorities. As Falk Rafael (2001) and Aston (2008) have described, this process of remaining committed to ‘meeting people where they are at’ and following the family’s agenda is critical to PHN’s work with families. BEING FLEXIBLE

One of the key features of effective public health nursing programs is the ability to remain flexible, particularly in homevisiting programs (Heaman et al. 2006, 2007). As described in this study, working within the complexity of families’ lives required the PHNs to remain committed to being flexible as they worked relationally with families to respond to the competing demands of peoples’ lives. Working ‘flexibly’ not only fostered the ability to remain as responsive as possible to families’ immediate needs, but also pre-empted a certain degree of frustration that might otherwise arise. PHNs recognized how challenging it could be for some parents to keep certain appointment times, as this nurse explained: Maybe they haven’t made their visits [or kept their required appointments] because they have to rely on Joe for a car who has to go to work and can’t take a day off work to take them. Like if they get there and they’re late, and you’re cancelling them … you don’t realize how many things have had to happen for them to get there to begin with. (PHN 4)

The PHNs also recognized that high-priority parents’ efforts to initiate an appointment or visit were almost always significant – and were themselves acts of resourcefulness, particularly in communities where few other resources were available to support women and young families. Often, appointments to weigh the baby provided the justification for mothers (in particular) and PHNs to initiate visits with each other. These interactions were a ‘weigh’ in the door – for both the mothers and nurses (Moules et al. 2010). Another PHN 31

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described her work with a First Nations woman who was particularly hesitant to contact the PHN for help: I [the PHN] don’t initiate any of the visits. She [the mother] just calls whenever she needs to touch base. And she says, ‘I think it’s time [for me] to come in and weigh the baby again’ but she’s not really that interested in the baby’s weight because the baby’s always fine. But she just comes [into the PHN’s office] and sort of stays and visits, and as you’re chatting, stuff comes up … She’s not that direct with stuff, so it sort of comes up through the conversation, what’s concerning her, and then I’m able to either provide her with resources or point her in the right direction. (PHN 32)

Working in smaller rural communities provided PHNs and family members with a wider sense of perspective that was often conducive to their working relationships. For example, this PHN had worked in the community for 25 years, and had worked with a new mother’s family when the mother herself was a child. The wider, contextual knowing of the family shaped not only the PHNs understanding, but also the family’s understanding of the PHN. The following quote illustrates how that contextual knowledge was embodied relationally by both the mother and the PHN and how it shaped their working relationship. The woman said, ‘it wasn’t a big leap to then talk to you when I was older because I knew you’d seen our house inside and outside’, with all its warts and everything else. So she said, ‘I know it’s not a big deal when you come to my house and I have laundry from one end to the other. I know that’s okay. I know if I say to you I don’t have any money for food, that’s okay, I can tell you that … It’s because I’ve known you long enough that I can say that to you’. (PHN 6)

Overall, contextualizing risk and relationally being in the complexities of families’ lives had a profound effect on the families and on PHN practice. It required that PHNs form meaningful, responsive relationships with families and also understand and recognize the way in which risk, as a contextual phenomenon located within structural inequities, was being embodied in people ⁄ families and their life situations. It also involved entering into the complexities of those life situations, listening carefully for capacities and cues (e.g. understanding a request to weigh a baby as call for support), creating time and space for the families and remaining flexible to respond to the multiple and shifting challenges that arose within their precarious life situations.

Working relationally: responding to shifting contexts of risk and capacity Central to the relational approach the PHNs employed was their emphasis on mitigating risk and promoting health. 32

Overall, the relational stance and contextual view the PHNs used in working with families created a transparent process and way of working with risk. While PHNs worked collaboratively with families, they simultaneously engaged in an ongoing process of self-reflexivity. Those two processes, collaboration and self-reflexivity, supported the development of a relationship where each could feel both vulnerable and safe, where trust and acceptance between the families and the PHNs could be communicated and developed and where risk could be addressed. WORKING COLLABORATIVELY

The importance of working in a participatory way with families has been described by others as a central feature of public health nursing practice (Aston et al. 2006, 2009; Heaman et al. 2007; Aston 2008; Mulcahy and McCarthy 2008). As Falk Rafael (2001, 13) has argued, supporting others to increase control over their own health requires active participation of those ‘becoming empowered’, being non-judgmental, and creating a safe environment for the development of a trusting relationship. In the following situation, a conversation ‘over coffee’ provided a PHN and the mother she was working with to be direct and frank with one another about the potential risks to the children and the mother. This discussion is not ‘just’ about risks; rather, both the PHN and the mother are transparent about the family context, and use a transparent process of problemsolving to mitigate potential risks: I asked her [the mother], ‘Can you plan ahead? You’re going to be drinking on the weekend, so is there somebody who would look after your child so that your child isn’t going to be in the center of it all? Because you know that if you’re going to be drinking you’re going to end up in a fight’. You can sit at their kitchen table, have coffee with them, and talk to them in a non-confrontational way. So they can say, ‘oh, yeah, if we’re going to be drinking on the weekend or if we’re going to go away, I’ve got somebody that will look after my child’. (PHN 20)

Through this transparent, collaborative approach, the PHN and mother are able to anticipate and plan to mitigate the effects of the risk behavior. They were able to move beyond the individualizing of risk whereby risk is narrowly located in the individual behaviors of the mother ⁄ father ⁄ family and thereby beyond conventional interventions (e.g. removing the children from the home or surveillance). Rather, the PHN and mother collaboratively addressed the risk by enlisting the capacity of the mother to more constructively handle risk situations that were going to potentially arise. Thus, the PHN was able to enact her obligation to foster the safety of children in the household, and open up the possibility of supporting and enhancing the health and 2010 Blackwell Publishing Ltd


well-being of the family through the development of more effective parenting (Hartrick Doane et al. 2009). ENGAGING IN SELF-REFLEXIVITY

described how she found herself responding differently to beer bottles or wine bottles stacked up in a recycling bin outside a home depending upon whether it was a middle-class home versus a poorer family’s home. She found she was much more likely to query ‘risk’ in the lower income home than in the middle-class home (Hartrick Doane et al. 2009).

To work relationally also required that the PHNs engage in their own process of ongoing self-reflexivity so that they could remain mindful of the larger contexts of families’ lives, and their own judgments and assumptions about a family’s vulnerability, risks, or strengths. As Benner, Tanner, and Chesla (2009) note, it is important in learning from experience to learn from one’s questions, unknowns, misperceptions, and contingencies, which can only be addressed through being open to practice, and reflecting upon it. This PHN described a particularly challenging family situation she was involved in, and the role that reflexivity played in helping her to make sound clinical judgments:

The significance of conveying a non-judgmental stance was repeatedly emphasized as paramount to effective working relationships with high-priority families. As this PHN described:

You know, she [the mother] might have been … doing drugs and getting into trouble with alcohol but at no time was she ever not a caring parent … I didn’t judge her for that. I always use the approach that we all make mistakes … And that as long as I could see that she wasn’t … again, putting the children at risk through her behaviours, I could be there to support her. (PHN 20)

Public health nurses also acknowledged the other side of the equation – when families revealed the nature or extent of their living circumstances or situations to nurses – and how that brought an added layer of vulnerability:

Critical self-reflection on the part of PHNs was central to conveying, in a genuine way, a stance of acceptance and trust toward families. This self-reflection involved critically scrutinizing the assumptions, blind spots, or biases that they may have been holding in relation to particular families. Marcellus (2005) describes how this level of critical self-reflection is paramount when PHNs are working with families at-risk or under surveillance by the state. In the above example, the PHN demonstrates how her own beliefs about mistakes and the ability to change strongly affected the way she responded to this mother. Rather than labeling her, or viewing her through her past behaviors, she purposefully enlisted assumptions ⁄ beliefs that would open the possibilities for change. Aston et al. (2006) similarly described how PHNs working with mothers in the early postpartum period gave careful consideration to their actions and words, and the impact they would have on mothers’ beliefs and choices. This reflexive process was challenging as it required thoughtful, critical attention to values and habitual ways of thinking and acting. To support their reflexive attention, the PHNs described using cues and prompting themselves with questions such as: would I be drawing these conclusions about this family if they were from a higher socioeconomic status, if they were from a different ethnocultural background? And, what biases might I be imposing because of my own preconceived ideas, values, misconceptions, or stereotypes? For example, one PHN


DEVELOPING TRUST THROUGH TRANSPARENCY

You [have to convey that you’re] sincerely interested in them as a family, and that each of them are striving to be the best that they can be. And that ‘bar’ may be different for some families than others but it’s not an arbitrary bar that I set … Because we all have different strengths. (PHN 6)

Once [a mother or family] opens up to somebody like that … they’re really letting themselves be vulnerable … But it was … a very open relationship where I knew that she felt safe to tell me what she needed in order to get the help she wanted. (PHN 15)

The ramifications are far reaching when trust is fostered with mothers who realize that they are putting themselves at further risk by asking for help. As this PHN described, ‘I keep reminding her that she’s a great parent. And she always says, ‘‘well, people never tell you that, right, they only tell you all the things you do wrong as a parent’’ ’. (PHN 6). Within these contexts of trust, both PHNs and mothers or parents, were able to speak frankly about their concerns. Another PHN, who had many years of experience, explained how central a two-way trusting relationship was to her work with high-priority families. PHNs in other research have similarly described the reciprocity that can arise when establishing trusting relationships with families (Falk Rafael 2001). In this situation, the PHN conveys her level of trust in the mother’s abilities, and at the same time, is direct about why additional support may be required for the well-being of the children: I think it has a lot to do with trust … That I trust her to look after those children, that I feel she’s a capable mother, that she’s got the skills … She just hasn’t really developed the ability to organize her skills … So by … giving her the feeling that I can trust her … Like, I haven’t called the social worker in … people who would come in and … and remove the children … She knows that I would do that if I didn’t

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trust her. I’ve told her that: ‘if I see that you’re doing something here that is putting the children at risk or shows me that you are leaving them uncared or at risk for injury or not feeding them, then I have to call somebody. And at this point in time, I don’t see that. I see that you’re a good mom … you never would leave your child in the care of somebody who was not capable of looking after them. So I trust you. But I feel that you need a little bit more help’. (PHN 20)

In the above quote, it is possible to see the integral relationship between trust and transparency and how transparency offered a foundation for the development of trust. Significant to this transparency was the PHN’s willingness and ability to: (i) be honest and forthright about the importance of anticipating risks and the need to act at the warning signs of risks; and (ii) simultaneously convey trust in the woman’s capacities and sense of agency. Hartrick Doane and Varcoe (2007) argue that one of the central obligations we have as nurses is to ‘be in the difficulty’ of people’s lives. Rather than seeing the difficulties as negative or as something to be avoided, understanding difficulty as an inherent feature of people’s lives, and therefore nursing relationships, paves the way not only for more ethical, but also for more effective and efficient nursing care. Similarly, Benner (2000) describes these inter-related processes of emotional engagement, and openness to dialogue as features of nurses’ embodied caring capacities. Using a transparent process as part of the approach to problem-solving was critical in some cases. We illustrate with the following example – involving a young woman who lived alone, had recently given birth, was caring for another small child, and who was involved with a boyfriend who also had a young child. This PHN, who had had a working relationship established with both the woman and her boyfriend, was in the process of re-engaging with the woman after the birth of her baby. The woman lived in a small rural community, was living on meager welfare payments, and was in the process of going back on medication for postpartum depression and bipolar illness. As the PHN described, ‘the mental health [team] was also involved and we were sort of ‘‘tag teaming’’ it a little bit so we didn’t overwhelm this mother’. The interaction that unfolded during one of the PHN’s home visits illustrates the way risks can arise for women, children, and families in the context of their daily lives, and how PHNs use their judgment to respond in ways that protect the safety of women and children, and at the same time, encourage and support families themselves to take action. In this case, there was a palpable and immediate urgency required in terms of the action taken by the PHN in partnership with the family; action that could have unfolded otherwise if the nurse had not permitted the family time to act in a way that illustrated 34

their commitment to making decisions that would ameliorate the risky situation that unfolded. During the home visit, the PHN assumed that the mother was living alone with her children. She was therefore surprised and became increasingly concerned when, during the home visit, three men unexpectedly came up the stairs with pieces of plywood and other sharp items in their arms. The PHN describes the action she took: I think they [the three men] were as surprised to see me as I was to see them … So I [the PHN] called to her and said, ‘did you know you have company’? And the one fellow just stopped; he had the 2 · 4 held up high. And you could see that the woman was a little uncomfortable. (PHN 6)

After introducing herself to the men, the PHN proceeded to describe the interaction: I said, ‘you might want to put down that 2 · 4 because there’s a newborn here, so you might want to set that outside’. The one man hummed and hawed, and I said again, ‘I’m asking you to set that outside’. The kitchen was small and those three big men are massive, and they’re between me and the door, and the back door is nailed shut. I’m thinking, this is not a good situation. So I said [again], ‘you need to set that outside, truly you do. That would make me feel a whole lot better’.

As the men proceeded to go outside, the woman immediately explained to the PHN that the men were friends of her boyfriend ‘who needed a place to crash’, but that they also had a ‘lot of drug stuff happening’, which was confirmed by the supplies of drug paraphernalia in the room in which the men were staying. The following discussion illustrates the way the PHN used a combination of transparency, frankness, and self-reflexivity in responding to the woman’s living situation and immediate need for action: I said, ‘Okay, we need to take a step back and make some choices around your family and who these people [the men] are and what connection they have to your family. So you need to decide because … social services is already involved, and they’ve been involved in your boyfriend’s life in the past, and with his son. So you’re going to have to make some hard and fast choices here or the choices will be made for you’.

As the woman became increasingly upset, she said to the PHN, ‘but I’m not worried about my safety’. In response, the PHN reiterated, ‘I am. So if I’m worried about my safety, you better believe I’m worried about yours’. Soon after, the woman’s boyfriend came home, creating an opportunity for the PHN to talk with the young couple together. In the process, the PHN explained that unless action was taken immediately, she would have to notify the home support worker, and in turn, the social worker who was the case manager. Faced with the prospect of increasing involvement by social 2010 Blackwell Publishing Ltd


services, the woman and her boyfriend removed the drug paraphernalia and required the other men in the home to move out permanently. We present this case not with a view to determining the rightness or wrongness of the nurses’ actions, but rather to show how transparency, directness, openness, and frankness were used to convey the seriousness of the situation, and the potential consequences that could ensue, depending on the action taken. This particular PHN was very experienced, had lived in the community for many years, and knew the larger context of this woman’s life, and as it turned out, her boyfriend. Conveying her own sense of feeling that the situation was unsafe to the woman, she was able to include the woman in the problem-solving process. Conveying her concerns in a transparent and direct manner was, in fact, the intervention in this case. The PHN, perhaps because of her pre-existing knowledge of life contexts of both the woman and her boyfriend, also exercises her clinical judgment in permitting them the time and space to think through their predicament, the consequences that they may face, and to take action. By using her own ability to reflect back to the young couple, the concerning elements of the situation from her professional perspective, and explaining the possible courses of action in concrete terms, the PHN was able to engage the couple in a way that was meaningful and relevant in the context of their everyday lives. Action was taken to prevent further trauma to the children (e.g. a safer home was created, which in turn preempted the children’s removal from the home they knew), she modeled a way of working across differences including making important judgment calls without being judgmental, and demonstrated and enhanced the trust and relationship between the parents and the PHN to address future situations.

support women and families to buffer against further risk and, at the same time, worked within the complexities of their situation to prioritize the safety of children. Tensions were inevitable given PHNs’ simultaneous responsibilities to support families and engage in some degree of surveillance – and a great deal of clinical judgment, critical reflexivity, and transparency was required. This was particularly evident when the mothers sought help from PHNs to address areas of vulnerability in their lives, as exposing their vulnerabilities ran the risk of further scrutiny, which in some situations, resulted in child apprehension by child welfare authorities. Other researchers have similarly written about the vulnerability of women related to child protection issues, and how this creates a potentially tenuous relationship with PHNs, who may initially be viewed by parents as part and parcel of the state’s child-welfare surveillance systems (Jack, DiCenso, and Lohfeld 2002; Peckover 2002; Marcellus 2005; Kirkpatrick et al. 2007). Well aware of the role of the state in intervening in the lives of women and children living in poverty, and in the lives of Aboriginal women and children in particular,4 the PHNs in this study used their relational skills to assess and address risk – and in the process, were clear and transparent about their obligation to both intervene to prevent harm and support women and families. ADDRESSING BOTH SAFETY AND VULNERABILITY

One of the foremost concerns for some of the PHNs was to find ways of focusing on the present context of risk, have the mother’s and children’s safety as their core concern, and at the same time, relate to women and parents in ways that would help them ‘feel safe enough to be vulnerable’. As this PHN explained: I aim to help her [the mother] feel that we’re moving forward and what’s behind us is behind. I’m not going to … be judging her in any way due to choices she may have made [in the past], but rather … accepting her with what she’s doing now … which are more conducive to her children and herself and her future. (PHN 16)

Working relationally with families under surveillance As the PHNs contextualized risk and engaged relationally with families in the complexities of their lives, one of the distinctive aspects of their work was the way they supported women and children who were under surveillance by child welfare authorities. This has been identified as a particularly challenging aspect of public health nursing practice because of the potential for surveillance practices to represent ‘power-over’ (Marcellus 2005). Of particular significance was the way they managed the sometimes conflicting mandates of child welfare authorities in relation to their own work with women and children at risk, and how they simultaneously addressed safety and vulnerability and assessed risk within the capacities of the families. PHNs employed strategies to 2010 Blackwell Publishing Ltd

It was the relational approach of the PHNs – the way they contextualized and located disadvantage in social structures and inequities, and simultaneously assessed how those inequities were being embodied in people ⁄ families and creating risk situations - that provided the bridge between risk and safety. While PHNs were clear that a child’s safety was ‘not negotiable’, they were equally adamant that families (and the mothers in particular) had to be involved in decision-making In Canada, Aboriginal children continue to be greatly overrepresented in child apprehensions by the state (Cull 2006).

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regarding actions to be taken in situations of risk – versus reporting a family for child protection services as a discrete action to be taken in isolation of the family. In cases where parents had prior challenges related to child safety issues, using a transparent process was particularly important in relating with parents. The following PHN described the importance of clarifying her role, and the responsibilities inherent to her role, while simultaneously conveying her genuine intent to offer support: And so I go in and say to the family, ‘I’m going to be coming in to see you … but this is what my role will be, and it’ll be to work with you … to look at what the strengths of your family are so that you can keep your children at home’ … to realize what they have available to them to raise this little child. (PHN 20)

ASSESSING RISK WITHIN CAPABILITIES

A growing body of literature has focused on the importance of a strengths-based approach in public health nursing practice (e.g. Falk Rafael 2001; Aston et al. 2006, 2009; Heaman et al. 2006, 2007). In the present study, working with mothers and parents who were affected by fetal alcohol spectrum disorder (FASD) highlighted the significance of contextualizing risks based on a family’s actual capabilities, versus assumptions about such capabilities. For example, the PHN below described working with an FASD affected woman who she described as a ‘bad housekeeper’ but as intent on being a good mother. The woman, who was being monitored by child protection services, was at risk of having her children removed from her care – in large part because of concerns about the condition of her home. In this situation, the PHN was adamant about the need to support the woman to keep her children, recognizing the good parenting that the children were receiving despite ‘appearances’, and the importance, in the context of this family’s life, of keeping the children in the home as a source of strength and stability: She needed help. She had somebody report her to social services for her house. One of the social workers had threatened to take her children. I didn’t have safety concerns with the parents or the children, it was just the house …. The house was dirty, it was a mess, but the kids were healthy, content, happy. (PHN 7)

This PHN echoes concerns raised by Rutman (2008), who argues that there are benefits to supporting FASDaffected parents to retain custody of their children because of the motivation that children provide for parents to ‘stay on track’. The PHN explained her sense of obligation that, ‘when somebody’s a bad housekeeper and they actually have a diagnosis of FASD, I mean, the least you can do is try to 36

help them to cope with the housework’. In this case, the PHN described how she ‘worked the system’ to negotiate with a social worker to obtain respite care for the woman, despite the fact that ‘there was technically no funding’ for this service. Working in smaller communities sometimes made it easier to negotiate directly with other providers and sectors within public health and social services; in these ways, PHNs worked to navigate current policies and structures to maximize the extent to which ‘the system’ could be mobilized to meet the needs of families at risk.

CONCLUDING COMMENTS A decade ago, Falk Rafael (1999) described the invisibility of public health nursing’s legacy in, and unique contribution to, health promotion work in Canada. The findings from this study help to make visible the essential roles that PHNs play in supporting and promoting the health of high-priority families. In the context of increasing social and health inequities in Canadian communities and elsewhere, it will be vital to increase the visibility of PHNs’ contributions to supporting families. Such visibility is needed to: (i) reinforce the legitimacy of PHN’s roles; (ii) demonstrate the impact of public health nursing interventions; and (iii) argue for adequate administrative, staffing, and organizational resources to better support and sustain this type of family work (Heaman et al. 2006, 2007). Working with high-priority families is a complex and often challenging area of public health nursing practice. This is particularly the case for inexperienced nurses working in the context of generalist practice in rural or northern communities, where nurses often lack access to educational opportunities, or administrative or collegial support. Adequate organizational, administrative, and practice supports are therefore needed to ensure, for example, adequate staffing levels, mentoring of new nurses by experienced PHNs, and flexibility in programmatic expectations. Ultimately, mitigating the root causes of ‘risk’ will require shifts in the structural conditions that sustain health disparities and social inequities. However, the capacity to practice relationally, to contextualize risk, and to recognize risk and capacity as intersecting aspects of families’ lives, will be foundational to establishing effective working relationships with high-priority families.

ACKNOWLEDGEMENT Funding for this study was provided by the Canadian Institutes of Health Research (CIHR). We wish to thank the families and nurses who participated in this study, and North 2010 Blackwell Publishing Ltd


ern Health for their in-kind support. The extended research team of academic researchers and PHNs was led by Martha MacLeod. We would like to acknowledge the following team members: Nancy Moules, Margo Greenwood, Neil Hanlon, Lesley Cerny, Brenda Fraser, Shannon Peden, Jacqueline Malkinson, Deanna Thomas, Sarah Brown, Melanie Martin, Kara Wood, Lorraine Thirsk, and Donna Bentham. Annette J Browne is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Scholar Award from the Michael Smith Foundation for Health Research.

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