ABSTRACT

Objective: The aim of this study was to provide insight into how the Child Healthcare Clinic (BVC) nurse supports and encourages the child’s bonding to their parents during the regularly scheduled checkups at the healthcare clinics. Method: The study was done using a qualitative approach. The data was collected from the interviews of four focus groups which were comprised of a total of eighteen BVC nurses who work solely for the BVC. The resulting data was analyzed using qualitative content analysis. Results: The following theme emerged from the research material: Empower the parents in order to enable the child to have a healthy connection to the parents. This is accomplished by the BVC nurse building and creating a trusting relationship with the parents and providing support for them in their new roles as parents. The BVC nurses must have comprehensive knowledge about the needs and development of children and they need to have exceptional communication skills as well. It is also mandatory that the BVC nurse have access to cooperation and support from their colleagues and the support of other related professions. Conclusion: Providing support to parents during the bonding period of their infant children is a most important function for BVC nurses because there is much to be determined about children’s development and future possibilities during this formative period.

1. Introduction

This is the template that Child Healthcare Clinic (BVC) nurses work with to monitor the health of children, with the cooperation of the parents, from their birth to the age of six years. The ambition of the BVC is to promote the healthy development of the child in terms of their physical, mental and emotional health, in order that the child will eventually develop into a healthy contributing member of society. In this study, we attempt to emphasis how the BVC nurse uses regularly scheduled appointments that have been established by the National and Regional guidelines, to promote and establish a good connection between the young child and the parents.

The good connection established during the bonding phase between the parents and the child has an important bearing on mental health in both the short term and long term development of the child [1]. The Medical Research Council writes in their analysis of child healthcare, that there is convincing evidence that early interaction between the parents and the child has an important influence on the development of the child. The influence of the bonding extends into the child’s social, emotional and psychological development [2].

A secure and trusting relationship during the first years of life is a prerequisite for the good health and the development of a child [3]. The connecting and bonding relationships are developed and nurtured in these first formative years of life. Children develop this bond with their parents, but parents do not develop the same type of connection to their children [4]. With the development of this connection, children learn to rely upon the parents for their survival. This dependence ranges from depending upon them for their day to day needs and to using them as a security base for safety and protection when threatening situations occur [5].

The latest research supports the theory that this early interaction between the parents and the infant has a long term influence on the child even in terms of a biological nature [6]. A traumatic experience that occurs during this bonding and connecting process between the parents and the infant can manifest itself in potential dysfunction or with problems of a psychological or emotional nature [6].

The first task of the newborn baby is to learn to recognize their parent in their brand new world. The infant learns to rely on their five senses in order to accomplish this primary lesson. Through the use of seeing, hearing, touching, smelling and tasting the infant learns to identify their parents. The parents learn to respond appropriately to the child’s signals and communications. By being close enough physically, in order to observe the baby at all times and by giving it the appropriate care in terms of its needs and signals, the parents’ presence and what it means to the baby becomes the baby’s world. It becomes “clear” to the infant that the parents are there for its protection and preservation [1]. In order to understand and interpret this brand new world and environment, the child is entirely dependent on the parent’s facial expressions, their tone of voice and their body language [7]. A close physical proximity has two functions and this is to protect the child from danger and to begin to teach the child what it means to exist in a social world [8-10].

During the baby’s first months of life they choose the individuals that they will bond and connect with [4]. A secure base, which is a central concept in the bonding theory, is described as the parent’s ability to provide all the things necessary for the baby in its infant life [5]. The child learns to trust the parents and trusts that they will be there if there is some danger or if a threatening situation develops. When the child confirms the parents as a secure base, it gives them the safety and security to begin and explore their surroundings [4]. By the time children are approximately seven months old they have developed a rather good understanding to whom they belong [11].

As trust emerges as an important factor in the protecttion of a human being, it becomes a social capital that provides order and cohesion to existence. Motivating people to trust in their self and others is one of the major driving forces of a society. When a person learns to trust themselves, it gives them the confidence and the courage that is necessary in order to act. Developing trust is one of the keys to encouraging curiosity and creativity. The development of trust is a factor in the cultivation of selfesteem. Self-esteem is largely a product of how one is treated by those closest to them. The level of a person’s self-esteem is an important factor in how one learns to deal with difficulties and how to succeed in their endeavors. A person’s level of self-esteem can be good or bad, or it may be weak or strong. The bond of trust that is formed in the infant’s early interactions with their parents during this early formative period provides a sound foundation for the future possibility of having and developing trusting relationships with other adults, with peers and with the outside world. The parents of newborn infants need to have confidence in their parenting role. If they are lacking in this confidence they should be offered support and encouragement. Without a foundation of trust it will be difficult for children to grow up with a good sense of self-esteem. Society should cultivate a citizenship that has this sound foundation of trust in order to promote a common sense of a good life style within the culture [12].

The nursing theory of Katy Eriksson is based on the concepts of nurturing, playing, learning, faith and hope. Nurturing is the most fundamental form of caring and by definition it means to manage and provide for another human being. The act of playing is a natural way of being and it is an expression of health. Key aspects of play are desire, testing, training, passion and creativity. Through play, individuals find their own resources and the security to test their limits. The learning process includes the development of the individual and is a product of mentorship, encouragement and motivation. Learning should have a close and definite relationship with playing because both are related to natural behavior. Faith and hope are important fundamental concepts in Eriksson’s theory of health. When situations occur where things do not go as expected and the individual finds their self in a crisis, one finds inner strength in faith and hope. According to Eriksson faith does not necessarily have a religious connection, even though throughout the history of mankind religion and even superstition has played a large role in the evolution of faith. But she maintains that faith is a necessary factor in the quest for survival. Faith is a basic ingredient of health and hope provides the direction and impetus for health. Love is the form and the product of this health [13].

The number of mothers that experience depression after giving birth to their children varies from 8% to 15% according to a pair of studies [14,15]. Depression can have a serious influence on the interaction between the parent and child and affect the quality of the connection in the bonding process. It is very important to identify these conditions early on if they exist [16].

According to the MFR in 1999, it is important that the BVC clinic has an adequately balanced combination of general measures that are designed to reach and protect all of the targeted and the vulnerable groups. These general measures should be designed to individually identify these in order to assist parents and children that are at particular risk for an illness or some other form of impaired health.

In 1948 the World Health Organization (WHO) defined health as a condition of complete physical, mental and social well-being. Through the years, the WHO has described health as a resource and as a prerequisite for human life and social development. If an individual has this resource as a part of their makeup, the individual can have more control to master their own life situation in interaction with their environment. At the WHO meeting in Jakarta in 1997, it was noted that health is not only a human right for the individual; it also has implications on the social and economic development of the society (ibid.).

A family can be seen as a group of individuals bound together by various structural, functional and emotional ties [17]. The focus of the family shifted from extended families to the nuclear family. The functions previously performed by different generations within the family, including education and caring responsibilities for the children, were now handed over to the mother and the father in the nuclear family. Over the past fifty years, nuclear family stability has decreased significantly. The interaction patterns between family members have changed as a result of new family configurations [18].

Regularly scheduled appointments for all children have been an important aspect of the BVC’s function since its inception [19]. The mandate of the Swedish Healthcare System is that all families and children should have equal access to the healthcare system, with health and well-being promoted [20]. The main objective of the BVC is to prevent problems related to children’s physical and mental health [19]. By maintaining the objectives of the BVC, the stress that is potentially harmful to both the children and the parents should be reduced and minimized in order to create an environment for the comprehensive and complete development of the children. The program for regularly scheduled appointments is documented in SoS 1981:8 in combination with the immunization program [21]. This comprises the foundation of the BVC function. Any opportunities that may arise through the implementtation of these mandates should be used for further health education, along with potential parental advice and support for the children’s family [19]. The ties and interacttion between the children and parents can be observed during the regularly scheduled visits to the clinic. The nurse should make it a point to note the nature of the eye contact between the parents and children, how the parents and children make touching or holding contact with each other, and to listen to the verbal communication and even the baby talk. Observations about the emotional contact and the parent-child connection can be observed during physical examination and vaccination appointments as well [19,21]. The psychosocial aspect of the BVC nurses can be divided into three different areas in their support of the family. They serve to assist parents in adapting to their new found parenthood role. They provide the extra support that is needed by families that have children with special needs. Finally, they can help in detecting cases where the children are not being cared for properly, are neglected or are victims of child abuse (Protect the safety net 1994:14).

The aim of this study was to illustrate how BVC nurses support, encourage and promote the child’s attachment to their parents through the process of bonding with the regularly scheduled appointments at the BVC.

2. Material and Method

2.1. Design

The qualitative method was chosen for the collection and analysis of data for this study. The essence of the qualitative method is to gather information and to work with it in order to get a deeper understanding of the subject that is being investigated. In order to obtain meaningful results, the qualitative method is dependent upon the intimate awareness of the interviewees and about the source of their information [22,23]. In this study, the qualitative interviews were conducted in the form of focus groups. Using focus groups is a research technique where data is collected through the group interaction revolving around a particular subject [24]. The qualitative research interview is conducted in order to obtain a description of the themes from the interviewees live world experiences and these themes are the connection between the interpretation of the interviews and the reality of the experience itself [23].

2.2. Informants

The recruitment of interviewees for the focus groups was done with the use of contacts within the healthcare system. These contacts referred eligible candidates to the study and these candidates, in turn, contributed to additional “snowball sampling”. Snowball sampling refers to the process where anyone that has already been recruited to the study can additionally refer the names of other eligible candidates that they know, that might be interested in participating [24].

The inclusion criteria for the study included those district nurses and pediatric nurses whose work was solely based in the BVC of Västra Götaland. Exclusion criteria included those district nurses who have worked in both the BVC and the Healthcare Centre (VC). These nurses were eliminated because the focus of the study was on those nurses that worked primarily with children in the age group from zero to six years old.

The sample was divided into four focus groups; two groups with four participants and another two groups with five participants. All of the participants were women. The length of their experience at the clinic ranged from two to thirty years.

2.3. Settings and Data Collection

The data was collected by conducting unstructured interviews with the four focus groups [23]. An interview guide with three questions was used. The interview questions were; how are the BVC visits used to encourage the connection between the parent and the infant? What do you do when you observe that something is not working as it could? Who do you collaborate with when evaluating issues?

The room that was used for the interviews was located at the interviewer’s worksite and had enough privacy for the participants to engage in private conversation. The length of the interviews ranged from 55 to 65 minutes. Both of the authors were present at all four interviews with the different focus groups. At each interview, one of the authors would serve as the moderator and the other author would serve as an observer. The authors switched their roles from interview to interview. It is helpful to have an observer in the room because while the moderator was conducting the interview via the interview guide, the observer was responsible for taking notes, managing the tape recorder, and taking care of the environment in the room. Another advantage of having both authors present at the actual interview was that they were able to discuss their impressions of the interviews immediately afterwards [23,24].

Before the authors began taping the interviews, the participants were all introduced to each other and they engaged in some informal conversation to create a more relaxed mood [23]. For the actual interview, the participants all sat around a table that the tape recorder was on. A short test was conducted with the tape recorder to see that it was functioning properly. Before the recorder was turned on, the participants were again informed about the objective of the study and about how the interview would proceed.

The moderator instructed the group that she was going to ask them some questions as a group and that they were to freely discuss their thoughts and feelings amongst themselves as a group. Then she posed the three interview questions and the discussion ensued. When the interview was over, each group was given the opportunity to add to the response if they felt that something of importance had been omitted from the group discussion.

2.4. Data Analysis

The interview transcripts were analyzed systematically using the qualitative content analysis method according to Graneheim and Lundman [25]. There were four analysis units, one for each of the focus groups (Table 1). Each of these provided an interview that was transcribed verbatim shortly after its completion. The transcripts were read through several times separately by both of the authors and the supervisor of the study, in order to get the best impression possible of the analysis units. The authors then read the transcripts together to further understand the analysis units and compare their impressions of the contents of the interviews. Then the analysis units were divided into two domains, which in the end were labeled trust and support. After identifying the two domains, a more thorough reading was performed and the meaning bearing units were highlighted with colored markings. By identifying the meaning bearing units, each of the four large analysis units were made more manageable and easier to comprehend without losing any of the context of the material. Meaning bearing units were words, sentences, or paragraphs in the transcripts that expressed the same idea or impression. This resulted in a condensation of the text, which lifted the meaning bearing units to a higher level of abstraction. The condensation of the text makes it shorter and more manageable while at the same time the essential content of the interview is preserved [25]. The condensed version of the text was then assigned different codes which were then organized into seven categories with sixteen subcategories. The categories in the analysis answer the question about what the BVC nurses do to strengthen the connection between the baby and the parents. Through a combination of the categories on an interpretive level the studies’ theme is identified (Table 1). The theme answers the question about how the BVC nurses strengthen the bond between the baby and the parents [25].

2.5. Ethical Consideration

A written permission was obtained from the relevant managers. The managers had both written and oral information about the study’s purpose and design. Similar information was given to the interviewees. The interviewees were informed that participation was voluntary and that they could withdraw at any time. They were informed that the interviews were confidential and all data regarding their identity was stored in a secure manner. The collected material was solely intended to be used in the present study.

3. Results

From the analysis of the data material, there emerges the theme: Strengthening the parents of the child in order to establish a good connection and bonding. There are two domains of six categories with subcategories. These are presented in the figure below. The different titles and headings are then presented and further illustrated with abstracts and citations included in the text that follows. The subcategories are presented in the Table 2.

3.1. Compliance

Beginning with the first meeting with the family, the BVC nurse observes the interaction between the child and the

parents. She makes observations regarding how effecttively the parents are interpreting the infant’s signals and about the status of the parents physical and mental health. At the same time she attempts to assess the social situation of the family. The BVC nurse also tries to get a picture about what kind of demands the child is putting on the parents and how the child and the parents are functioning with one another. These are the type of things that run like a common thread from the initial meeting and through the subsequent meetings between the nurse and the family. The first meeting lays the groundwork for a basis of building a trusting relationship with the family and it becomes an important aspect of the BVC nurses contact with the family. The establishment of this trust capital confirms to the parents that they have a safe and secure source of support when they are in need of it.

“It’s everything to build confidence … it’s tough to come in and make an impression the first visit, and that first visit is so important.”

The parents get knowledge and support from the BVC nurse on an informal level. This informal contact may appear to be superfluous, but it has the concrete aim of creating trust and positive interaction between the nurse and the parents. The BVC nurse should have a pretty good idea about where the parents are, relative to their role as parents. This knowledge gives the nurses some guidance on what to expect in future visits.

“It is very important to distinguish between our roles as a health care provider versus a friend. I cannot be too friendly with them. It’s really important to maintain a degree of separation in this respect in order for me to manage and function in a professional manner”.

The BVC nurses are aware of how their parents talk to their baby and how they embrace their baby in connection with the dressing and undressing routine. A lot of the observations that the BVC nurses make, they describe as a gut feeling they get about what the interactions between parents and child look like. This becomes particularly evident when things look a “bit shaky”, as the nurses express it. BVC nurses describe the importance of being physically present in the room and using what they see and what they hear to determine if it is going to be a positive meeting.

“Sometimes it’s just that you feel uncomfortable, so to speak … it’s hard to put into words, what it is you are looking at makes you think that something isn’t very nice … Many times it’s that they do not find each other … they are missing the connection in some way.”

“Most of what we see is still very effective in terms of their bonding … it’s really rare that they are not looking for mom’s or dad’s eyes.”

It is important for the BVC nurse to build trust and confidence in the parents in order to identify those that are feeling bad or uncomfortable in the parenting role. Parents must have this confidence in the nurses so they will dare to ask the questions that come up in their new role as a parent. For many parents, it is a relief to hear that they are not expected to be perfect. It is important for them to believe that they will be sufficient with the flaws, shortcomings or deficiencies that they might have. In any new living situation that involves a major change in lifestyle, it is normal to feel uncertain and apprehendsive in the initial transition phase. For those that find themselves in such a position there are no unnecessary or stupid questions.

“It’s based a lot on the feeling that they can come to me … they can talk to me … this is all built on their confidence and their trust in me”.

3.2. Model

The BVC nurses experience that many parents today are not initially sure of themselves when it comes to talking to their infant babies. Therefore it is helpful if the nurses can demonstrate specifically how the parents can communicate with their infant children. BVC nurses already begin to communicate with the child with their first meeting. In order to clearly demonstrate effective communication technique, they emphasis that the eye contact combined with their interaction is what registers with the infant best. The role of the BVC nurse is something that develops over time with the family visits to child healthcare and with the child’s development and the evolving needs of the parents.

“If we cannot observe the parents talking to the child here at their appointment first … perhaps they are not talking at home … maybe they are not getting a close connection, an effective bonding.”

It is not always easy to put into words about what is lacking in the parents attempt to bond with the infant. Sometimes the BVC nurse just has a feeling that there is something wrong and as a result they try to make more frequent visits with the family. In these cases it appears that the parents need the support of the BVC nurses and the BVC. In order to determine whether there is some underlying cause to justify these feelings, the nurses feel they need more information in order to get a better picture of what is happening between the parents and the baby.

“It is a delicate balancing act about how much do you dare to say to the parents to make things right with them.”

“If there seems to be some issues they should come all of the time … not to miss any appointments … perhaps even additional visits should be scheduled. This can get a bit delicate.”

3.3. Confirmation

The BVC nurses observe that when there are concerns or worries about the child’s development, these concerns may originate from the parents or the BVC nurse. The BVC nurses use their experience to identify concerns of the parents through their conversations. The awareness that they have of the family and the child, in combination with the trust that they accumulate in their sessions with the family, help them to gather the knowledge necessary to be able to understand and monitor the physical and mental development of each individual child. With the nurse’s support and their confirmation of the parent’s ability to be a parent, the parents gain the ability to formulate and create their own solutions to many of the situations they find themselves encountering as parents. Many of the parents feel that it is sufficient for the BVC nurse to serve as a sounding board in order to generate the level of support that they feel they require. BVC nurses in many cases provide the necessary amount of support by basically confirming to the parents that the job they are doing is adequate and well done. The BVC nurses find that today the lives of many new parents are filled with difficult demands and this can hinder the bonding process.

“They are expected to be so amazingly talented … they can just close up. When they are closed … in this state of unreal expectations … it is difficult to totally embrace and connect with their baby.”

BVC nurses consistently describe that they need to see and to experience the interactions of the family in order to get an idea of what the reason is, for example, children that seem to cry and scream excessively. Extra appointments are utilized to get more information regarding the underlying reasons for any potential abnormalities and they also give the parents additional support by reinforcing them with the positive aspects of their parenting. For the most part BVC nurses feel that it is not overly difficult to get the parents to sit down and talk and it is not unusual that they are quite talkative about their parenting issues.

“The kids are just screaming!!!… and you know … you don’t know if it was the chicken or the egg … All of them may not have colic, but it may be something that I am not aware of.”

The BVC nurses create an atmosphere of understanding by making use of open questions in their conversations with the parents. This requires a knowledge and understanding of counseling skills and an additional factor is that of the nurse’s available time. First, the nurse must make herself physically available for the conversation and she must be able to listen attentively and actively, then she must take advantage of the conversation to ask open ended follow-up questions if time allows. The nurses see this as the foundation of their work with families. If there isn’t sufficient time to ask these questions, then there is the risk of an important question not being asked. If the nurses do not ask the question, then they do not have the opportunity to treat the situation. This can be a source of frustration for the BVC nurses and it is not something that they feel good about.

“So a lot of it is being present physically and emotionally in the room … so I must have the energy to inquire … I must have time to take the time to ... to be there and see the parents and that the appointment is not just to measure the child’s weight … so I must be there with all my abilities … all of myself.”

“Suddenly she is making her problem my problem … she is putting it in my lap. What do I do with it? Well, that depends. I must be on my toes and ready to capture that thread … her train of thought.”

3.4. Inform

At the first meeting, the BVC nurses provide the parents with some practical information about normal development and about what the child’s basic needs are for food, sleep and intimacy. The nurses dispense the information based on guidelines that are provided by the regional healthcare administration and they try to adapt this information to individually suit each family’s needs. In this way, the information is given on both a general and a personalized level. During the visits with the parents the BVC nurses attempt to identify those parents and families that are in need of additional support and additional information.

Parents that are experiencing parenthood for the first time tend to need considerably more information when compared with those parents that have had babies before. Becoming a parent comes with a complete change in lifestyle, so all of the families are provided with general information regarding infant’s needs and information about the parenting role. The family receives frequent visits from BVC nurses until the nurses feel in their professional opinion that the new parents have become comfortable with their new role of being a parent.

“A lot of the discussion is about the child’s development … about how important it is for them to talk to their child … to connect with their babies … at the same time I try to show them that this is fun, this is the joy.”

This information is conveyed additionally through their parent groups. Participation in parent groups begins as early as the early contacts with the MVC (Maternity Health Care) and will continue through the first year of the child’s life. Parent groups are organized participation in group sessions that are structured according to relevant themes. The themes are compatible and adapted to the child’s age, in order that each of the parent groups consists of parents who have children that are of the same age and in the same stage of development. The BVC nurses observe that this provides the parents with an opportunity to meet other parents of children of a similar age. In this manner they can trade and share their parenting experiences and use each other as sounding boards and role models. The parent groups give parents the opportunity to create a parenting network.

“Parent groups are important for those parents who feel isolated … it strengthens them in their parenting when they meet other parents who have children in the same stage of development … close to the same age … I think that for some, more so than others, it is really important that they have their parent groups.”

3.5. Tools

Toys of different types are used to illustrate and assist in deciphering the baby’s signals. The types of toys that the BVC nurse use varies and how she goes about using this method largely depends upon the child’s temperament and level of development. The BVC nurses adapt their rooms to show how the parents’ interactions with their children may get initiated and how they can proceed. For instance, they use the overhead mobile over the diaper changing table to show how the small child follows and holds on to objects that are attracted to their eyes. Toys such as balls can be used to develop hand to eye coordination, to develop the gripping function in the hands and to develop coordination of the limbs, in general, for throwing and kicking. Toys for older children are used to demonstrate the development of motor skills and their ability to socialize.

3.6. Collaboration

The collaboration of efforts is built on different levels. On one hand, there is the collaboration between the parents and the nurses and on the other hand, there is collaboration between colleagues and partners. The BVC nurses maintain that it requires considerable time and consistency, both in terms of the composition of the staff and in terms of the organization itself, in order to get effective collaboration. The opportunity to discuss issues with competent colleagues is regarded as indispensable to the nurses. These discussions, or peer counseling, often take place on an impromptu basis in the corridors at work, as well as during coffee and lunch breaks.

“It is difficult to find the time and it is rare to have the time … so we do it during coffee breaks or during lunch … you never seem to have a gap in the day where you get the chance to just sit down and discuss … every day is filled to the brim.”

The majority of BVC nurses regard the MVC as their most important collaborators. From the nurse’s experience, parents get support earlier when their problems and issues are identified in their contact with the MVC, who in turn report their findings to the BVC. These parents can be offered the opportunity to meet with a BVC nurse before the baby is born and this is thought to be advantageous. The parents fill out a form at the end of the pregnancy that provides information about themselves and there is space provided in the form for them to express their expectations of BVC nurses.

“It is important to have a good transition between the MVC and the BVC. Before we were working all the time to identify those at risk … but now the MVC is screening families … to identify those that may be at risk to violence and substance abuse. It is really important for the MVC to report these things to the BVC. These are the types of behavior we must be on the lookout for because they can really affect the bonding process.”

The BVC nurses see the BVC physician as an important partner. The child is to meet with the BVC physician at regularly scheduled appointments. In addition to the medical examination, the child’s visit with the BVC physician has another important aspect because it means that there is one more qualified and competent professional that is seeing the family on a regular basis. Sometimes it is easier for those parents who need extra professional support to accept an appointment with the clinic doctor than to have an appointment with a psychologist.

“The parents tell me that they would rather not talk to the psychologist … but they prefer to talk with the BVC physician … so we can use these channels to provide the necessary support.”

The nurses find the BVC psychologist to be another important partner in the organization. The nurses describe closeness to the BVC psychologist in the sense of their physical nearness in the same building and in their close proximity within the organization. The nurses find that the BVC psychologist can fulfill the role of their mentor and they are someone who they can rely upon to consult with about how to best support the family. If the consultation between the nurse and the psychiatrist is not enough they will arrange an appointment with the family and the psychiatrist.

BVC nurses describe how they cooperate with Social Services in providing extra support to those families that are in need of extra assistance and are interested in it. Long term care is usually centered on special counseling and training for the parents to effectively interact with the infant. The BVC nurses consistently describe the importance of the family having easy access to these social service functions. The BVC nurses’ duties are based on an offer of assistance and it is not forced or mandatory for the families. If the family does not want to receive the support of the Social Services and the BVC nurses have recommended it, this can become an obstacle in the cooperation between the BVC and Social Services. If the BVC nurses have legitimate concerns about the welfare of the child they are obligated under the Social Services Act to notify the Social Services.

“It’s important that you don’t react too passively with these situations … it’s important not to DAWDLE too much … before you know it six months has gone by and all of a sudden it has been a year and nothing has been done … and it’s the child’s welfare that is at stake.”

“To detect a problem and to not have the resources to make the situation better … this is almost unethical … it’s the child that will suffer.”

BVC nurses expressed the importance of providing the time to collaborate. The cooperation process between the nurses and Social Services takes time. Among the BVC nurses, there is concern that the preventive healthcare program will have access to fewer resources in terms of support to families with children.

3.7. Development

The BVC nurses expressed a need to be provided with opportunities and access to more education. It is important for them to have access to current information in order to be able to provide the necessary support to parents with children. The nurses also felt that the development of quality assurance as it related to their function was an integral part of the development of the BVC.

4. Discussion

The results of the study show that the BVC nurses, with the use of regularly scheduled appointments at the clinic, encourage bonding and the building of the connection between the parents and their child. These appointments were fundamental in building trust by giving the parents the support that they needed in their parenting roles.

Katy Erickson [13] describes the nursing process as the care for patients based on the concepts of nurturing, play, learning, hope and faith. The concept of nurturing includes the use of the fundamental knowledge that nurses are trained with. This knowledge that the BVC nurses specialize in, includes all of the relevant information of the basic biological needs of infants such as proper feeding, the digestive process and elimination and the infant’s need of sleep and rest. The BVC nurses, through their training can distinguish the normal from the abnormal, because she has specific knowledge of child development and the associated needs. As she continues to see the family on a regular basis, she becomes more familiar with their behavior and the state of the families health. The total outlook for the family and the child requires that the parents be of sound health in order for the infant to have every chance to develop in a healthy manner.

The results of the study clearly show that the role of the BVC nurse is to support parents during regularly scheduled appointments to the BVC to strengthen their ability to connect and bond with their babies. This is a large part of the responsibility of the BVC nurse and the regularly scheduled appointments allow the nurses to fulfill the demands of their role. The continuing evolution of the modern family has also contributed to the need for the support that the BVC nurses provide to the parents of newborn babies. In many ways, they have inherited the roles that extended members of the family traditionally fulfilled [18].

Halldórsdóttir [26] describes how contact between parents and the BVC nurse becomes a basis for the relationship between the healthcare system and the family. When the BVC nurse creates a meaningful and trusting relationship with the family, it creates more positive energy and commitment from the parents, which in turn is delivered to the child. It is very rewarding for the nurses to see that they have created this energy with the parents, to the extent that the parents are truly enabled to use and develop their own resources in their roles as parents. With each visit to the BVC, the nurses try to give the parents some positive reinforcement. They try to give the parents the feeling that they are competent in their roles as a parent, which gives them a basis for hope in the future [13]. It’s normal to feel a bit uncertain at times but by instilling confidence in their parenting technique they manage to feel during these uncertain periods that they will manage, and they will suffice as they are.

An important aspect of child rearing is the creation of an environment that is conducive to both play and learning [13]. These two areas of child development are closely related to each other and these areas are also where the nurses endeavor to instill confidence in the parents. This trust and confidence building period is a product of multiple and regularly scheduled meetings that are arranged over a period of time. The process takes time, patience, skill, mutual respect and it is important that the nurses are found to be trustworthy and communicative [27,28].

The office of the BVC nurse becomes her workroom and she can use children’s toys as her tools. Using toys as tools require the nurse to have a specific knowledge about children and the stages of child development. Other important activities that take place in the nurse’s workroom include conversations and the advice that they bestow upon new parents. The nurses use an interview technique of open questions in order to get the parents to open up about their feelings regarding their situation and any complications that they may need to discuss. Some nurses have gone through training in motivational speaking to help motivate the parents in their parenting role [29].

In the organization of the BVC, nurses play the central role [30]. Even so, if they are to be as effective as possible, they rely on the collaboration with the other professsionals in the organization. The nurses express the need for continuing education in their role of providing support to parents. The roles of family members have been evolving at a very fast pace in recent times, and the nurses feel that they must constantly have their information refreshed in order to be kept up to date on evolving developments in related areas of their field of work.

The subject of breastfeeding and its influence on the bonding process came up in the discussions with a couple of the focus groups. When breastfeeding was not working as well as it could, it often left the mother with a feeling of inadequacy and subsequently may interfere with the bonding process. This puts a demand on the BVC nurse to have the time and to listen attentively to the mother’s thoughts and concerns about breastfeeding. It is important that the difficulty being experienced in the breastfeeding does not get over exaggerated and become a hindrance to the mother feeling good about her ability as a mother.

The importance of a sound bonding between the child and their parents and the influence it has on the child’s mental and physical health is a subject that gets more and more discussion [5]. The most recent research provides consistent results that stress that the bonding between the parents and child is necessary for the child’s health and their development in the social sphere during their infancy, preschool and early school years [7].

We hope that this study and work will motivate some to reflect and discuss this most important field of work with colleagues and partners. Providing support to parents during the bonding period of their infant children is a most important function because there is much to be determined about children’s development and future possibilities during these formative years.

The rate of change that modern society is experiencing today is unprecedented. The evolution of the family and the relationship between children and their parents has been fundamentally changed in the last few decades. We are of the opinion that research done in this field of work is most valuable because it is very important that we study and understand what the effects of these changes are having on the development of our children. Because of these changes the modern family may find itself in need of more support to encourage a strong bonding between children and parents.

5. Acknowledgements

We would like to acknowledge and express our appreciation to the Primary Health Foundations in Skaraborg and in Gothenburg, Sweden for their generous contributions in the funding of this study. We would also like to thank those BVC nurses who contributed their time and experience with their participation in the interviews conducted for the study. Finally, a word of thanks to Stephen Navarro for his translation services.

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