An Exploration of the Interface between Public Health Nurses and non-Irish mothers in relation to Child

Protection and Welfare

For part fulfilment of the Post Graduate Diploma in Child Protection and Welfare

Author: Catherine O’Malley

Tutor: Paul Sargent

Course Co-ordinator: Dr Helen Buckley

Date Submitted: 22nd June, 2015

Word Count: 7324

Abstract

This study is an exploration of the interface between public health nurses and non-Irish

mothers in relation to child protection and welfare. A qualitative approach was adopted

using semi structured interviews from with public health nurses and non-Irish mothers who

live in one of the most ethnically diverse communities in Dublin, Ireland.

The results of this study provide an insight into many important issues for both the public

health nurses and the non-Irish mothers. Positive feelings were generally expressed in

relation to services given by the public health nurses. However, this study also identifies

that non-Irish parents may have difficulties in understanding the expectations that they will

parent their children “the Irish way” in order to promote the best interests of their children.

Acknowledgements

The author wishes to thank the following people:-

• The participants of my study, my public health nurse colleagues and the mothers who live in this ethnically diverse area who contributed so willingly and enthusiastically. It was a very insightful and honest experience and I am very grateful to you all for that.

• My Director of Public Health Nursing, Ms Marianne Healy, who assisted me in all aspects of this course, by accessing funding from the NMPDU and for supporting and guiding me with this research process.

• My public health nursing colleagues who enabled me to attend this course by covering my caseload area and for their fantastic support throughout the year.

• My tutor, Mr Paul Sargent, for all support and guidance during the year.

• Dr Helen Buckley, Course Coordinator for all support and guidance.

• My sister, Sarah, for providing invaluable support and assistance.

Table of Contents

Chapter 1

1.1 Introduction 1

1.2 Background 1 - 2

1.3 Role of the Public Health Nurse 2

1.4 Aims and Objectives of the Study 3

1.5 Summary 3

Chapter 2 - Literature Review 4

2.1 Introduction 4

2.2 Culture/Cultural Competency 4 - 5

2.3 Communication Issues 6

2.4 Parenting Style from a Cultural Perspective 7

Chapter 3 – Methodology 8

3.1 Introduction 8

3.2 Research Approach 8

3.3 Sampling 8

3.4 Profile of Participants 9

3.5 Ethical Considerations 9

3.6 Data Collection and Analysis 10

3.7 Summary 10

Chapter 4 - Findings and Discussion 11

4.1 Introduction 11 - 12

4.2 Culture/Cultural Competence 12

4.2.1 Perspective of Non-Irish Mother 12 - 13

4.2.2 Perspective of Public Health Nurse/Specialist 13 - 14

Nurse – Asylum Seeker health

4.3 Communication Issues 14 -15

4.4 Parenting Style in relation to Child Protection Issues 15 - 16

4.5 Issues regarding Parenting Style 16 - 18

4.6 Issues in Relation to Submission of Standard Report Forms/SRF 18 - 20

4.7 Role of Family Support Worker 20

Chapter 5 – Recommendations and Conclusion 21

5.1 Recommendations 21

5.2 Conclusion 21 - 22

Bibliography 23 - 26

Appendices

Appendix A: Invitation Letter to Participants 27

Appendix B: Letter to Director of Public Health Nursing 28

Appendix C: Consent 29

Appendix D: Interview Template- PHN 30

Appendix E: Interview Template- Mothers 31

Appendix F: Standard Report Form 32

1

Chapter 1: Introduction

1.1

The population of Ireland has changed over the last 20 years and now embraces a wide range

of faiths, cultures and ethnic origins (Children First, 2011). The overall increase in caseloads,

together with the increased complexity of care for some and the greater communication

difficulties experienced, when caring for recently arrived people from different cultures, has

resulted in an increase in workload for public health nurses (Nic Philibin, 2010). In my role

as a public health nurse I am professionally accountable to deliver services to families in my

caseload area which includes people with chronic illness, disabilities, older persons and

young families. My caseload has a sixty percent total of non-Irish families. The majority of

these are young families with children from birth to 4 years of age.

Introduction

Practitioners must be acutely aware of the culturally sensitive approaches required to work

with children and families from different backgrounds (Children First, 2011). Cultural

competency incorporates issues relating to developing cultural and ethnic–specific knowledge

about specific ethnic groups, the awareness of and information about differences in religion

and cultural attitudes towards health matters as well as examination of the attitudes that a

health practitioner brings to their work (Raval, 2007).

1.2

The term ‘non-Irish national’ is used by the Central Statistics Office (CSO) to describe those

recorded within the Irish census as being of a nationality other than Irish. A question on

nationality was asked for the first time in Census 2002. A minority ethnic group may be one

of a wide range of groups by virtue of their race, ethnic or national origin who may include

asylum seekers, refugees, migrant workers, Irish Traveller, foreign students (National

Intercultural Health Strategy, 2008). The Census 2011 also highlighted that this area

experienced the largest single increase of 0-4 year olds and now has the highest percentage

ratio of pre-school children in Ireland (Ryan, 2012).

Background

2

I work as a public health nurse, in an area fictionally known as Belltown where sixty percent

of my clients are non-Irish or from an ethnic minority. According to Census data 2011,

Belltown has a high number of ethnic minority groups/new communities of 18.3% of the

population in comparison to the national average of 12%, thus deeming this area to be one of

the most ethnically diverse regions in Ireland (Ryan, 2012).I work with four public health

nurses and a community midwife in a health centre that was established to meet the demands

of a growing community. We work as part of a primary care team which provides

multidisciplinary care to families within a defined geographical area.

1.3

As a public health nurse, I am accountable for implementing evidence based knowledge and

application of best practice standards in my work (Code of Professional Standards and Ethics,

2014). The Department of Health Circular 41/2000 (DOHC, 2000) specifies that a public

health nurse should work closely in partnership with colleagues in the area of child care and

protection. Public health nurses are also governed under the Child Care Act (1991) and as

such are obliged to refer any concerns regarding child welfare or protection to social work

services and/or the Gardaí (Report of the Task Force on Child & Family Support Agency,

2012).

Role of the Public Health Nurse

In my role as a public health nurse, I am a designated officer of the Health Service Executive.

I have explicit responsibilities in responding to child protection and welfare under the

Protection of Persons Reporting Child Abuse Act 1998 (Children First, 2011). Public health

nurses provide a service to families with children which is similar to that of health visiting in

the United Kingdom where the focus is predominantly on prevention, early identification of

problems arising and the implementation of appropriate interventions (Hanafin, 2013). The

Core Child Health Screening and Surveillance (CHSS) Programme, as outlined in Best Health

for Children Revisited (2005) offers every family with children a programme of screening

tests, immunisations, developmental reviews, information and guidance to support parents to

meet the needs of their children (O’ Dwyer, 2012).

3

1.4

In view of the social and demographic changes that have occurred in Ireland and in my

caseload area, I have undertaken this research as part of my Demonstration Practice Project

for the Postgraduate Diploma in Child Protection and Welfare. This study aims to explore the

issue of child protection and welfare from the perspective of the interface between public

health nurses and non-Irish mothers in a defined geographical area.

Aims and Objectives of Study

Awareness of cultural factors must remain high since they influence all aspects of child

protection from the occurrence and definition through to its treatment and successful

prevention (Children First 2011). While a limitation of this study was that the sample was

small in size, this allowed for a very interesting and unique insight into the lived experiences

of all of the participants.

1.5

This chapter has introduced the reader to the research topic, outlined the rationale for the

study. The background or organisational context was identified and the role of the public

health nurse in relation to her caseload management and professional responsibilities have

been described. Chapter 2 comprises a literature review in relation to cultural competency

with a focus on child protection and also explores communication and parenting styles.

Chapter 3 will detail the methodology used for the study. Chapter 4 is comprised of research

findings which include issues related to cultural competency, communication issues and

parenting style in relation to child protection. This chapter also discusses sub themes which

emerge from the data which include the standard report form, and role of the family support

worker. Recommendations and conclusion of the study are outlined in Chapter 5.

Summary

4

Chapter 2: Literature Review

2.1

The Literature review was conducted to obtain all published research relevant to the themes

as outlined in this research which include:-

Introduction

• Cultural competency

• Communication

• Parenting Styles in relation to child protection and welfare

The definition of cultural competency will be discussed and analysed in current nursing and

social work publications from Ireland, United Kingdom, and Australia. The issues of

communication, verbal and non-verbal and the challenges it presents to the service provider

as well as the service user will also be reviewed. The literature review will also explore the

issue of parenting styles particularly from the multicultural perspective which can contribute

to child protection problems or difficulties.

2.2

Ireland has changed from a homogenous population to one of diversity in which the last

Census 2011 reports that 544,357 non-Irish nationals were living in Ireland which is 12% of

the total population (CSO 2012). There are several reasons for this increase in the number of

immigrants living in Ireland which include the increased economic prosperity from 2000 to

2008, the enlargement of the European Union enabling free movement of citizens to work in

Ireland. Other factors include the socio-political events in the world including war and

economic instability in Somalia, Syria, Pakistan, Iraq, Afghanistan, and AIDS epidemics in

countries such as Nigeria, Zimbabwe and Uganda resulting in the movement of people from

their home to seek asylum (Boyle et al., 2008). The changing demographics and economics

of a growing multicultural world and the long-standing disparities in the health status of

people from diverse ethnic and cultural backgrounds has challenged health care providers to

consider cultural competence as a priority(Camphina-Bocote, 2002).

Cultural competency

5

Professional groups, talk differently about their particular approach to providing culturally

appropriate care by using terms such as cultural sensitivity, cultural awareness, cultural

competence and cultural safety to describe approaches taken to meeting the needs of people

from culturally and linguistically diverse communities (Grant et al., 2005).Douglas et al.

(2014) advise that culturally competent care is based on the principles of social justice and

human rights and they support the view that promoting culturally competent health care

within the social justice framework protects the dignity of all people.

The National Intercultural Health Strategy 2007-2012 (Health Service Executive, 2008)

identifies that the health and support needs of children from minority ethnic groups are varied

and multidimensional depending on their individual and particular circumstances. The

strategy was developed to acknowledge the awareness of the needs of a distinctive group in

Irish society. Its objective is to provide a framework through which service users and

providers are supported in addressing the unique care and support needs of people from

diverse and cultural and ethnic backgrounds. This strategy was the first of its kind in response

to the changing demography and the challenges it presented to the health service in Ireland. It

acknowledges that although good practice was evident in the area of minority ethnic health, it

was fragmented across the country dependant on geographical location rather than need

(Health Service Executive, 2008).

Cultural competency remains a challenge for all services and this was highlighted in the

Special Inquiry Report which emphasises” the existing deficit in cultural competence needs

to be addressed across State agencies interacting with minority communities” (Logan, 2014).

The report recommends that training should be provided across public services to ensure that

when engaging with minority communities, including Roma, all staff are culturally

competent and informed about the communities they serve (Logan, 2014). The author is

aware that the impact of the recession and changing demographic has impacted on the ability

to provide adequate resources to promote integration and best practice in all public services.

6

2.3

One of the biggest barriers in providing adequate and informed health care is the inability to

communicate with the client/patient in his or her own language of origin if it is not

English.Tuohy et al. (2008) in a research study in an Irish healthcare service noted that being

unable to understand individuals (who do not speak English) may affect key information

needed for nursing assessment and care planning documentation. One of the participants a

nurse, in this study also noted the disparity in the provision of resources such as access to

appropriate interpreting services between Ireland and the United Kingdom. In the United

Kingdom, there are well established cultural groups which have developed protocols to

ensure access by service users to interpreting services without difficulty.

Communication Issues

Language difficulties can contribute greatly to misdiagnosis, incorrect investigations as well

as lack of welfare rights and the blocking of facilities for disclosure of abuse (Guzman,

2014). On Speaking Terms (2009) is the policy document of the Health Service Executive to

promote best practice in the provision of appropriate interpreting services within the Irish

health service. Service providers should provide literature in several languages and should

make high-quality interpretation facilities available for service users who need them (WHO,

2010) however financial constraints prevent this from happening due to limited resources.

However the author is aware that access to professional interpreting services is not the norm

and the reality in practice, is the reliance on family members or friends to act as translator.

Lyons et al. (2008) confirms that studies show that health service providers have an over

reliance on ad-hoc informal interpretation from family, friends, other patients and non-

medical personnel, raising issues about quality of interpretation and confidentiality. Similarly

Lyons et al. (2008) identifies in their research study of ethnic minority mothers in a Dublin

maternity hospital the biggest difficulties in relation to communication with mothers who are

unable to communicate effectively, was that service providers felt they were missing

important information and therefore may not be providing appropriate care.

7

2.4

Research studies have highlighted the fact that maltreatment or abuse is a global phenomenon

affecting the lives of millions of children all over the world, whether the children are from

low or high income countries or belong to immigrant, ethnic minority or native Caucasian

groups (Cyr et al., 2013).However, there are factors that affect migrant children and may

increase risk of accessing child protection services. Sawriker & Katz (2014) identify these as,

parents’ lack of awareness of child protection laws and the system, fear of authority and lack

of family support or social isolation. However Raman & Hodes (2011) suggest that belonging

to an ethnic group does not necessarily mean that all aspects of that group are embraced but

research suggests that levels of verbal and physical punishment do vary in different ethnic

groups. Furthermore, Grant et al. (2014) also highlights research in Australia which shows

that infants and children in families with parents who have come from refugee backgrounds

are vulnerable with an increased risk of developing physical or psychological problems.

Parenting Style from a Cultural Perspective

In cases of abusive or neglecting parenting, personal and social resources such as inadequate

emotion regulation strategies and low socio economic status are likely to increase parental

stress and cognitive distortions of what is acceptable and in turn may exacerbate the risk of

child maltreatment (Cyr et al., 2013) while Sawriker & Katz (2014) cite that one of the most

commonly cited protective factors in ethnic families is family cohesion. This is defined when

families where grandparents, relatives all live within one household to support each other.

Lewig et al. (2009) support the view that family-centred services that identify and enhance

refugee families’ existing skills and strengths have the potential to improve the mental health

and well-being of all family members, and to promote a home environment that facilitates

positive child development (Dunst et al 2002).

In Ireland, the reality in Irish family courts is that a high proportion of children in child care

proceedings have parents from ethnic minorities (Coulter 2014).The Child Family Law

Reporting Project also recommends that a disproportionate representation of non-Irish parents

in the child care courts makes an urgent case for a renewed focus on integration policies

ensuring that those coming to our shores understand what is expected of them as parents

(Coulter, 2014).

8

Chapter 3: Methodology

3.1

This chapter outlines in detail the design and methods used to obtain data. The aim of this

study is to explore the interface between public health nurses and non-Irish mothers in

relation to child protection. All stages of this process will be discussed which include

research approach, sampling method, profile of the participants, ethical considerations and

data collection and analysis.

Introduction

3.2

The research utilised a qualitative design as qualitative data can yield a good understanding

of lived experiences and rich quality data exploring how participants feel on an issue

(Barbour, 2008).

Research Approach

3.3

A purposive sample was adopted, whereby all participants invited to participate in the study

lived in the same community care area. This was advantageous to the researcher to conduct

the research because it enabled the researcher to include all perspectives from the same

geographical area. Purposive sampling can be used as a means of getting the best information

by selecting people most likely to have the experience to provide quality information and

valuable insights on the research topic (Denscombe, 2010). The inclusion criteria for the

study were that each participant either lived or worked in the ethnic minority area identified.

The mothers’ criteria included the fact that they came to live in Ireland within the past fifteen

years, have children less than six years of age and have a child protection concern or issue

that necessitated the sending of a Standard Report Form (Appendix F). The exclusion criteria

restricted mothers who did not have children.

Sampling

9

3.4

All of the participants were invited to participate in the research by the author both verbally

and by letter (Appendix A) as this enabled a source of rich data for this study to obtain the

perspective of the mothers and nurses from a multicultural viewpoint. The mothers who

participated in the study are from Nigeria, Pakistan, Angola and Romania. All of the mothers

have been living in Ireland approximately 12 to 15 years. Two of the mothers have children

with disabilities and two mothers are also lone parents. All of the mothers had a good level of

spoken English language which allowed a free flow of conversation for the duration of the

interview. The mothers chose to be interviewed in their homes at a mutually agreed time.

Profile of Participants

The public health nurses and specialist nurse in asylum seeker health who participated in this

study have an average of 7 to 15 years working experience with non-Irish families in the

community. All of the nurses and the author have previous nursing experience working

overseas namely in England, Saudi Arabia and Australia. This has enhanced their cultural

competency skills and cultural sensitivity. The nurses were interviewed in their health centres

at a mutually agreed day and time.

3.5

The Code of Professional Standards and Ethics (NMBI, 2014) identifies my professional

obligations to practice as a nurse and stipulates that:-

Ethical Considerations

“Every nurse and midwife has a responsibility to uphold the values of the

professions to ensure their practice reflects high standards of professional practice

and protects the public”(NMBI, 2014)

This study was assessed on ethical grounds by the author’s Director of Public Health

Nursing. The research rationale was discussed in detail at the all stages of the research

process. A letter outlining rationale and information regarding the design and methodology

was submitted to my Director of Public Health Nursing (Appendix B) and ethical approval

was obtained prior to proceeding with the study. All participants were assured of

confidentiality and anonymity. Participants were asked to sign a consent form (Appendix C)

and were free to withdraw at any stage throughout the process.

10

3.6

In order to explore the interface or to examine the interaction between public health nurse and

non-Irish mother, I chose to use a semi-structured interview format to allow free expression

of thoughts and dialogue by the participants during the interview process, to enable me to

assess and analyse relevant themes that emerged. A qualitative research interview attempts to

understand the world from the subjects’ point of view, to unfold the meaning of their

experiences (Kvale and Brinkmann, 2009). Consideration was also given to the sensitive

nature of the research questions and I was mindful of the need to be aware and respectful of

all contributions. The semi structure interview template consisted of questions which were

framed around the central themes identified in the literature review (Appendix D, E).

Data Collection and Analysis

All interviews were recorded on a digital Dictaphone and the data was transcribed verbatim

for analysis. Coding was used to extract themes which were analysed in more detail. Coding

allows the researcher to cluster key issues in the data and to take steps towards drawing

conclusions (Bell, 2014).Participants were reassured that all data would be stored safely and

disposed of on completion of the Postgraduate diploma in Child Protection and Welfare.

3.7

This chapter has outlined the methodology of the research study, research approach, sampling

method, profile of the participants. Research design was clarified and its suitability for the

study, data collection and analysis was outlined and summarised. The following chapter 4

will outline the research findings and discussion.

Summary

11

Chapter 4: Findings and Discussion

4.1

This study was a very insightful experience and yielded many interesting issues for both the

public health nursing service and the mothers who participated. The main themes which were

explored in the literature review included cultural competency, communication issues and

parenting style in relation to child protection and welfare. The findings revealed a very

positive response by the non-Irish mothers towards the public health nurse service identifying

the importance of cultural sensitivity while acknowledging their role in assisting these

mothers to promote their child’s development.

Introduction

The public health nurses identified how the issues and challenges and the complex needs of

non-Irish families impact on their practice. This study also highlights the lack of resources

such as access to interpreter service, family support workers, which were seen as essential in

order to provide culturally competent nursing care in the community. The issue of parenting

style in relation to child protection difficulties was explored and revealed that cultural

expectations on parenting style were defined by each mother according to their cultural belief

system. The study also identified a need to inform or educate non-Irish parents on the legal

and socially acceptable parenting style in Ireland or as one mother quoted “the Irish way”. It

was also interesting in the analysis that referral to the Child and Family Agency was seen as a

solution to the child protection issues that were named by the non –Irish mothers in this

study.

The findings will be analysed and discussed within each of the following sub headings:

4.2 Culture/Cultural Competence

4.2.1 Perspective of Non-Irish Mothers (Mother 1; Mother 2)

4.2.2 Perspective of Public Health Nurse, Specialist Nurse (PHN1, PHN2,

Specialist Nurse)

4.3 Communication Issues

4.4 Parenting Style in relation to Child Protection Issues

12

4.5 Issues regarding Parenting Style

4.6 Issues in Relation to Submission of Standard Report Forms/SRF

4.7 Role of Family Support Worker

4.2

4.2.1 Perspective of Non-Irish Mothers.

Culture/Cultural Competence

Reflecting on the changing demography in Ireland as outlined in the literature review all of

the mothers or service users who participated came to live in Ireland 12 to 15 years ago. All

of the mothers referred to the difference between their own country of origin and Ireland by

comparison when expressing the following:-

“A big change”(Mother 1)

“It’s different to Nigeria, you have lights, good roads, it’s easier to live here” (Mother

2)

“In Romania the family is stressed out because they run out of money, here they are

more peaceful” (Mother 3)

“It’s a better life here, more opportunities for my children” (Mother 4)

All of the mothers appear to understand and are very positive about the role of the public

health nurse. They were very open to accepting all advice given regarding their child’s

development. This was evident in the following statements:-

“So for what I know, is that she helps me through stages of taking care of my children from

birth until they are older. She helps me to know what service is available, what they are, how

to use them, how to access them. She has been very good”. (Mother 2)

The importance of the public health nurse monitoring maternal wellbeing and child safety

issues was also highlighted in the following statement

“I know they come to check the child, how the child is doing, how the mother is doing, is

she depressed? and if mother is depressed she will tell the mother what to do, like going

to GP for help. For the child, she talk about child safety and better things for child.”

(Mother 1)

These statements reflect a very positive experience felt by all the mothers regarding the input

of the public health nurse and acknowledging the important role in guiding mothers in

13

relation to child development and welfare. It was also evident how important a good rapport

or relationship with her public health nurse was to each of the mothers. This would concur

with studies in the United Kingdom which illustrates that migrant women value health

professionals who are trustworthy and whose competence includes cultural knowledge and

insights into immigration (Reynolds and White 2010).

This was evident by the following statement:

“I am happy to see nurse all the time, when my daughter was very small, she came to my

house every week to check her weight and sent her to hospital at one time. Now my

daughter is doing very well. I found the nurse’s help very good.” (Mother 3)

This reflects the importance and the evidence of cultural competency and sensitivity in

working with this client group.

4.2.2

The perspective of the public health nurses regarding cultural competency was important in

view of the fact that all of their caseloads comprised of 60 to 100% of non –Irish families.

The general consensus around cultural competency was reflected in the comment:-

Perspective of Public Health Nurse/Specialist Nurse –Asylum seeker health

“You learn as you go along, to address the complex needs of these families”

(PHN 1, 3)

One of the participants in the study works as a specialist nurse in a reception centre for

asylum seekers. He comments that cultural competency is personal and professional, relating

to attitudes towards diversity, ethnicity, and migration. Cultural competency and sensitivity is

also” acquired not only by formal knowledge but also by acquiring informal knowledge based

on people’s experiences”

However this presents difficulties for the service provider,

“I find it mentally hard in dealing with complex needs of families,

overwhelming actually. Sometimes you hear these awful stories and it’s hard

to listen and to cope with them” (PHN 2)

Research studies into the role of the health visitor highlight that work with asylum seekers

and refugees can be both demanding and rewarding (Robinson 2013, Burchill and Prevalin,

14

2011). However, these studies also highlight the feeling of frustration experienced by health

visitors due to lack of resources, time and inflexibility of other members of the primary care

team (Burchill and Prevalin, 2011). This research would reflect similar feelings expressed

by all nurse participants in this study.

Simultaneously some positive aspects were also expressed

“I have seen people coming from rags to riches. I know a lady who came to

Ireland with a blank canvas and who is going to college now. I gave her lots of

support in the early days and connected her to relevant services and yes, she

thrived after that.” (PHN 2)

Education for culturally competent care encompasses knowledge of the cultural values,

beliefs, and health care practices of individuals and/or groups to whom they provide care

(Douglas et al., 2014). Without question, all of the nurses who were interviewed emphasised

the need for cultural awareness education on an annual basis to promote best practice and

cultural competency skills.

4.3

Communication is undoubtedly the main issue for all participants in this study with both

professionals and service users expressing frustration and concerns. All of the mothers

interviewed, did not speak English as their first language but could converse in English

having spent 12 to 15 years living in Ireland.

Communication Issues

“when I came to Ireland I could not speak English. It was when I went to a

mother and toddler group and I learned from other Irish mothers about

services for my son who has autism and the Irish mother taught me how to

speak in English so that I could get help for my son”(Mother 1 from Pakistan)

Mother 3 from Romania expressed concern that she still does not speak English very well and

would sometimes ask her children to assist her with translation. She suggests that literature

in her own language would be helpful. This evidence reflects the reality that non-Irish

families have difficulty accessing information when English is not their first language.

Language barriers and communication difficulties were also highlighted by the public health

nurses and specialist nurse as a major problem in order to ensure that all information is

communicated effectively.

15

This is evident when:

“poor English is the biggest factor as families use their children to act as

translators, you never get a true picture” (PHN 1)

In practice communication difficulties were further identified when:

“in my practice I feel that there is no regular access to an Interpreter service to

address complex needs of some families.” (PHN 2)

Lawrence (2014) cautions that practitioners should be mindful of the appropriateness of the

interpreter they use e.g. avoid using children where possible and consider clan/tribal

allegiances and comments that even when there is an interpreter available, effective

communication may still be challenging and it is important to check what has been

understood by the client. Although these issues have been highlighted in the National

Intercultural Strategy (2008) and recommendations from the WHO (2010) it is evident that

they have not been successfully implemented at a local level within the health service.

4.4

This research study is exploring the interface between non-Irish mothers and public health

nurses in relation to child protection and welfare. The issue of parental style is a dominant

theme from the data and it evoked a varied response from all participants. Child protection

is defined as the process of protecting individual children identified as either suffering, or

likely to suffer, significant harm as a result of abuse or neglect (Children First 2011). One of

the key practice principles outlined in the Child Protection and Welfare, Practice Handbook

(Health Service Executive 2011.3) is that:

Parenting style in relation to Child Protection Issues

“A proper balance must be struck between protecting children and respecting

the rights and needs of parents/carers and families. Where there is conflict, the

child’s welfare must come first”.

Research studies in Australia have demonstrated the fact that infants and children in families

with parents who have come from refugee backgrounds are vulnerable with an increased risk

of developing physical or psychological problems (Grant et al. 2014; Sawriker and Katz

16

2013).Cultural heritage is important to many people, but it cannot take precedence over

standards of childcare embodied in law (Laming, 2003).

4.5

Public health nurses have identified in this research study that parenting style is a major issue

in their practice, in particular with families not originally from Ireland. Parenting style can

vary between different cultures. Common problems cited by public health nurses in this study

include, lack of stimulation for the child from birth, to promote speech and language

development, and lack of awareness of the importance of socialisation of the child. One

public health nurse participant outlined the effect of a different parenting style:

Issues regarding Parenting Style

“They may not talk to their children; they may not see them as a person until

they are 5 years of age. They would not see value in talking to their child, the

child would come to clinic with poor speech and language development and

possible behavioural problems as a result” (PHN 1).

This view was echoed by another participant who observed:

“Sometimes you may observe lack of parenting knowledge, maybe they were not

parented well themselves but you know what’s accepted in our country versus

what’s accepted in their country” (PHN 2)

Another perspective was

“One challenge would be looking at cultural differences, to consider parenting

differences in understanding around child safety and around supervision of a child”

(Specialist Nurse)

Another observation among public health nurses when visiting families in their home is an

absence of appropriate toys to aid development which demonstrates lack of awareness or

importance on the need for toys to promote their child’s development. The mothers in this

research study all said that they did not have the public health service in their country of

origin and they all learned about the importance of monitoring child development from their

public health nurse. This was noted as a positive aspect:

“When you become a parent for the first time here, you learn the Irish way”

(Mother 3)

Conversely one mother reflected her difficulty in adapting to a different parenting approach

when commenting:

17

“I know the system is good in Ireland but in my country in Africa we have to

teach a child by discipline and in Ireland we talk to the child, I find that difficult”

(Mother 4)

This sentiment was also repeated when PHN I commented that she has observed:-

“The view that non-Irish parents would view their style of parenting as normal

and our style of parenting as extreme”

In the context of parenting in a centre for asylum seekers the specialist nurse highlights:

“The cultural complexities of parenting in a different environment, which is

also a different legal environment for non-Irish parents, where we interpret

laws around child safety and child protection. Parents would have different

thoughts and understanding and therefore, delivering this message is very

important”

This research also highlighted the mitigating factors that increase the risk of non- Irish

children accessing child protection services as identified in studies by Sawriker and Katz

(2013) which include parental mental health issues, lack of awareness of child protection

laws and social isolation.

“I would have experience with some families in denial of mental health issues

which has affected their parenting style, and capacity. Consequently this may

affect a child’s behaviour and I would see this as mild neglect of their

parenting duties. Parents do not see their role in the management of their

child’s behaviour” (PHN 1)

Another aspect is the consideration of the parent’s previous experiences prior to arriving in

Ireland. This was illustrated by the following comment

“Big difficulties when you consider where international families have come

from and that they may have experienced violence in the past. The Dads could

have been soldiers at war and the mothers may have been victims of sexual

assault and this is very difficult for them when they come to live in our

country”(PHN 2)

Refugee populations are recognised as having unique and complex needs that require

attention both on arrival and throughout the process of resettlement (Harris and Telfer, 2001).

Consequently cultural sensitivity is seen as vitally important as this difficult history may

never have been addressed and results in mental health issues for parents, post-traumatic

18

stress disorder and as a result impacts on their ability to parent effectively. The expectation of

some non-Irish parents to delegate responsibility for parenting to their older children was also

discussed:-

“The older children move from being children to mini adults, often left home alone to

care for younger siblings.”(PHN 3)

Grant et al (2014) suggests that as parents are the first adults with whom children develop a

relationship, further research is necessary to investigate the effects of forced migration and

settlement on this relationship in order to support parents for the future.

4.6

A Standard Report Form is described as the referral form which documents and describes

child welfare and protection concerns and is submitted to the Child and Family Agency

(Tusla).The discussion in relation to sending of a Standard Report Form to the Child and

Family Agency in relation to child protection concerns appeared to confirm the findings in

the previous studies in the United Kingdom. Burchill (2011) identified that health visitors

referred families with complex issues to Children and Young People’s services due to

concerns about risk of significant harm as a precautionary measure. This is evident in this

paper when discussing the issue of child protection with the mothers who participated in this

study.

Issues in relation to Submission of Standard Report Forms/SRF

One mother expressed “fear” around the word child protection as her understanding was:

“That they will come and take my child away” when recalling an incident when a neighbour

called to her to comment on her autistic son’s behaviour and threatened to report her to social

workers. This mother also said “People are judging you, they don’t know what’s really going

on” (Mother 1).

This was corroborated by the specialist nurse who explains

“In my experience in working with families with welfare issues and possible child

protection issues, there is a “fear” a different type of understanding of what

social services are, what social workers do. While we would encourage parents to

disclose or be honest about their capacity to parent there is a fear by mothers that

their child might be taken off them”

19

These findings are also evident in a research study by Buckley, et al. (2010) among Irish

service users which indicates the negative and inevitably intimidating image of child

protection workers as hostile, powerful and to be avoided if possible. Two of the mothers

who were interviewed had children with disabilities and both mothers were parenting alone

without any support.

Each of these families had times of crisis which resulted in a Standard Report Form being

submitted because of a child protection concern. Mother 2 described her situation:

“I have two boys with autism and they had challenging behaviour, it got to a point,

I was pregnant with my third child and my blood pressure was going up, their

needs were high. I could not cope, it was an emergency. I called the social worker

to help. They are now living in care permanently”.

This highlights the difficulties for children with disabilities who cannot receive adequate

supports in the community and the adverse effects of minimal resources which results in

referral to the Child Family Agency. Furthermore, Mother 2 explained that initially she was

relieved that her boys were taken into full time care and then she was worried as to how they

would adapt.

“Later I saw that they were adjusting fine, I was no longer scared, I was more

comfortable.”

Conversely, Mother I from Pakistan and Mother 2 from Nigeria reported that services for

their disabled children were very good in Ireland in comparison to their country of origin:

“In Pakistan they do not understand that he has autism, they think he is bold

there is nowhere to take him, only to the Mosque to make him better. I was living

in Kerry first but I moved to Dublin to give my son a proper education and to use

better services in Dublin“(Mother 1)

“I don’t think there is any provision of services for children with autism in

Nigeria, I didn’t know anything about it myself. I only got to know about it here, I

am happy they are getting all supports. I have two sons with autism quite severe,

they have no speech“((Mother 2)

Similarly PHN 3 reports a positive reaction to submission of a Standard Report Form in

relation to a domestic violence incident when she says:

20

“This mother felt happy that the standard report form had been submitted as it

was “a way out”. I think it was good for her as she could be able to at last talk

about the abuse, her relationship breakdown, which was culturally not acceptable

to her family”.

It is clear from this research that non -Irish mothers believe that accessing the Child and

Family Agency is seen as a solution or a way to access supports when crisis situations

develop within their family.

4.7

This research study has supported the findings of the Child Family Law Report which

recommends an urgent case for a renewed focus on integration policies ensuring that those

coming to our shores understand what is expected of them as parents (Coulter, 2014). In

order to support these families from other countries and cultures the public health nurses and

specialist nurse in asylum seeker health were unanimous in the opinion that the family

support services would be instrumental in assisting and guiding these families in the

transition to their new home and its culture and practices in relation to the protection of all

children.

Role of Family Support Worker

However, they also emphasise the current reality that the demand for Family Support services

in their area is very high and currently families in crisis are prioritised to receive this service.

This reflects the huge lack of resources needed to support these families at pre-crisis stage to

prevent potential risk of significant harm or neglect. This also addresses the fact that in order

to engage with these families and work in partnership, a culturally sensitive approach must be

considered when allocating a family support worker.

21

Chapter5: Recommendations and Conclusion

5.1

This research represents a snapshot of the realities for the families from a non-Irish culture

and the public health nursing service but it reveals many relevant and important issues. The

following are recommendations which include:-

Recommendations

• Cultural competence and awareness training should be mandatory on an annual basis

for all staff in the health service.

• Recognition of the complex needs of refugee and migrant families when they arrive to

Ireland and to allocate resources to promote positive health outcomes with particular

emphasis on parental mental health and parenting skills.

• Recognition of the need to promote integration while at the same time respecting each

individual culture in all communities.

• Increase in resources for public health nurses to access interpreter services without

difficulty,

• Recognition of the need to allocate Family Support Service to families of all cultures

at pre- crisis stage with aim of prevention of escalating risk of potential harm to

children.

5.2

This research has explored the interface between public health nurses and non-Irish mothers

in relation to child protection and welfare. This study described the role of the public health

nurse in relation to child development, child protection and outlined the legislation and

professional documents which guide best practice.

Conclusion

22

The themes which emerged from the research included cultural competency, communication

issues and parenting style in relation to child protection which reflected the topic discussed in

the literature review. The findings and discussion focused on the main themes and outlined

the wealth of data retrieved from the qualitative interviews. The recommendations were then

documented in the hope that the need for cultural competency skills could be addressed as an

important part of professional development for all public health nursing staff. The

recommendations also include the recognition to promote integration and to recommend that

family support workers be allocated to assist families to adapt to the “Irish Way” of

parenting.

23

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Appendix A - Invitation Letter to Participants

Information Letter re Demonstration Practice Project Aim of Study: To explore the relationship between the public health nurse and non- Irish Mother in

relation to child protection. I would like to invite you to take part in a research study I am completing which explores the service given by Public Health Nurses to international families. This study involves a 30-40 minute interview with you which will be digitally recorded. This information will then be studied in detail and I hope to obtain results which will help me to make recommendations to improve our service to multicultural families. All information obtained will be strictly confidential and stored in a secure manner until my study is completed. You will be asked to sign a consent form before the interview commences and you may withdraw at any time. If you wish to clarify any further details I can be contacted on 087 2954387. Thank you for taking time to read this information leaflet. Catherine O’Malley Public Health Nurse Riverside Health Centre Dublin

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Appendix B - Letter to Director of Public Health Nursing

Riverside Health Centre,

Dublin

Ms Marianne Healy, Director of Public Health Nursing, LHO Dublin North West; Lower Ground Floor, Nexus Building Dublin

Dear Marianne,

I wish to inform you that I am in the process of preparing to undertake a research project as part of my Postgraduate Diploma in Child Protection and Welfare in Trinity College.

I hope to complete research as part of my Demonstration Practice Project entitled Exploration of the interface between Public Health Nurse and Non-Irish Mothers in relation to Child Protection.

I am requesting your permission to undertake this study from within my LHO area where I will invite colleague Public Health Nurses who have caseloads with cohort of international families. I hope to select 3 to 4 PHN who would also assist me to select 3 to 4 mothers who may wish to participate in this study.

I intend to give each PHN and mother a formal letter outlining my rationale and format of this study which includes an interview using a list of 10 questions designed to retrieve data which will be analysed and interpreted. Each interview will be digitally recorded and transcribed.

I hope to proceed with identifying my sample group as soon as I have obtained your consent.

If you wish to clarify or discuss any other issues in relation to this matter, please contact me on 087 2954387 or by email at catherine.omalley2@hse.ie

Yours sincerely,

Catherine O’Malley

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Appendix C - Consent

Consent Form

Aim of Demonstration Practice Project:

To explore the interface between the Public Health Nurse and Non –Irish Mother in relation to child protection.

I have read the attached letter outlining the aim of this Demonstration Project and I agree to be interviewed for the purpose of this study.

Signed _____________

Date________________

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Appendix D - Interview Template - Public Health Nurse (PHN)

Introduction:

What is your current role / caseload area profile?

• Do you work with non-Irish mothers and their families?

• From your experience how would you describe your understanding of cultural competence Or transcultural nursing

• How would you describe your working relationship with culturally diverse families?

• Do you think there are different approaches to parenting from a cultural perspective?

• Have you experienced child protection issues with this client group

• If so, can you give example of issue that resulted in submission of Standard Report Form?

• What was the outcome for the child and parent?

• How could the episode that warranted reporting be prevented or avoided if intervention was to be made at an earlier stage?

• What supports or other interventions were offered or available to non-Irish mothers After the incident occurred?

• Do you think your relationship with your client/mother/family changed after the incident was reported to Duty Social Worker?

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Appendix E Interview Template – Mothers who are not Irish

• Introduction

• What is your nationality and how long are you living in Ireland

• What is your family background? If married/lone parent, no of children

• Have you encountered cultural differences and/or difficulties since you came to Ireland?

• How would you describe your relationship with your Public Health Nurse?

• Do you understand her role in relation to monitoring your child’s development?

• Have you encountered difficulties in relation to child protection and welfare?

• If so can you give an example of a difficulty or problem that you experienced?

• How was this problem managed or addressed?

• What other supports/interventions were offered to you to address or resolve this?

• What was positive about this?

• What was negative?

• Do you think that cultural competency/awareness needs to be promoted to PHN nursing

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Appendix F – Standard Report Form

(TUSLA – Form Number: CC01:01:01)

33