Applying normalization process theory to understand implementation of a family violence screening and care model in maternal and child health nursing practice: a mixed method process evaluation of a randomised controlled trial

Abstract

BackgroundIn Victoria, Australia, Maternal and Child Health (MCH) services deliver primary health care to families with children 0–6 years, focusing on health promotion, parenting support and early intervention. Family violence (FV) has been identified as a major public health concern, with increased prevalence in the child-bearing years. Victorian Government policy recommends routine FV screening of all women attending MCH services. Using Normalization Process Theory (NPT), we aimed to understand the barriers and facilitators of implementing an enhanced screening model into MCH nurse clinical practice.MethodsNPT informed the process evaluation of a pragmatic, cluster randomised controlled trial in eight MCH nurse teams in metropolitan Melbourne, Victoria, Australia. Using mixed methods (surveys and interviews), we explored the views of MCH nurses, MCH nurse team leaders, FV liaison workers and FV managers on implementation of the model. Quantitative data were analysed by comparing proportionate group differences and change within trial arm over time between interim and impact nurse surveys. Qualitative data were inductively coded, thematically analysed and mapped to NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) to enhance our understanding of the outcome evaluation.ResultsMCH nurse participation rates for interim and impact surveys were 79% (127/160) and 71% (114/160), respectively. Twenty-three key stakeholder interviews were completed. FV screening work was meaningful and valued by participants; however, the implementation coincided with a significant (government directed) change in clinical practice which impacted on full engagement with the model (coherence and cognitive participation). The use of MCH nurse-designed FV screening/management tools in focussed women’s health consultations and links with FV services enhanced the participants’ work (collective action). Monitoring of FV work (reflexive monitoring) was limited.ConclusionsThe use of theory-based process evaluation helped identify both what inhibited and enhanced intervention effectiveness. Successful implementation of an enhanced FV screening model for MCH nurses occurred in the context of focussed women’s health consultations, with the use of a maternal health and wellbeing checklist and greater collaboration with FV services. Improving links with these services and the ongoing appraisal of nurse work would overcome the barriers identified in this study.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0230-4) contains supplementary material, which is available to authorized users.

Child healthcare nurses’ experiences of asking new mothers about intimate partner violence

“…The CHCN did, however, express a hesitance towards asking about IPV at home visits. This is somewhat contrary to findings in a RCT in Australia, where the maternity and child healthcare nurses participating in a structured screening and care model for IPV were found to gradually feel safer at home visits, as compared to the nurses in the control group (Hooker et al., ). Jack, Jamieson, Wathe, and MacMillan () found that universal screening for IPV using a standard set of questions was difficult to implement during home visits to a general population of new mothers.…”

“…However, the findings of this study also suggest that nurses may need more training to ask new mothers about IPV. This is in line with the abovementioned Australian study, where ongoing training was empathised by the nurses involved in screening for IPV within maternal and child health care (Hooker et al., ). Also Gutmanis, Beynon, Tutty, Wathen, and MacMillan () found that nurses’ and physicians’ educational and experiential preparedness emerged as a key factor that facilitate routinely initiating the topic of IPV.…”

“…In the upcoming implementation, the mothers will be asked about IPV when their infant is about 2–3 months old, in connection with the screening for postpartum depression, using the Edinburgh postnatal depression scale (EPDS). A similar time‐point (when the child is 3–4 months old) has been found to be well regarded by maternity and child health nurses in Australia (Hooker et al., ).…”

“…In a similar vein, Hooker et al. () found that a screening tool was found to be valuable, rather than just ask about IPV in maternal and child health care. In addition, the CHCNs identified important spillover effects of asking mothers about IPV.…”

Home level bureaucracy: moving beyond the ‘street’ to uncover the ways that place shapes the ways that community public health nurses implement domestic abuse policy

“…, Hooker et al . , ). In addition, this study identified the ‘universality’ of the HV service and increased provision of home visits as a key area of concern.…”