Community nursing

Community Nursing

Assignment #1 Engaging with your Group

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My chosen group are mothers, who live in a socio-economically deprived ward who protect and promote their families’ health, in particular that of their children. Four mothers from a socio-economically deprived ward were recruited and interviewed using an in-depth, semi-structured approach. They were mothers of a child aged three or under, living in the research area,   were identified by the researcher during their face-to-face contacts within a specified two-week period. These mothers were invited by letter to participate. They expressed an initial interest and were subsequently interviewed. Further, the four participants were recruited using a snowballing technique generated by the initial participants. Following a discussion about the study and the nature of confidentiality, written consent was obtained from each mother prior to the interview. The names of all mothers quoted have been changed to protect anonymity.

The sample size in this community study is small. This is because the emphasis is on context-sensitive information that is rich in detail. My aim is to explore and understand the personal and subjective perspectives of the participants about what health means to them, rather than achieve statistically significant results. An interview guide was developed using Shields and Lindsey’s health promotion framework and Kaner`s participatory dialogue strategies drawing on the “Every Child Matters outcomes.”

The researcher was not known to the mothers, who were however, informed that she was a nursing visitor. Mothers were interviewed individually in their homes. The interviews were recorded with the mother’s permission using an audio tape recorder, each lasting approximately an hour.

These mothers regard the family as crucial in reducing health inequalities, and consequently prioritize the health of their families, mothers and children in particular. Mothers hold caring and domestic responsibilities that have a health impact on all family members. Graham (1993) has been interested in the socio-economic context of mothers’ daily caring responsibilities. Most of these mothers of young children, including those who work outside the home, organize their daily lives around the care of their children, for whose well-being they are continually and ultimately responsible. Graham (1993) argues that poorer mothers employ strategies, smoking in particular, that while recognized by the mothers as health damaging, enable them to both cope with their mothering responsibilities and find some respite from them.

The complexity in the lives of these mothers is an important consideration for the researcher working with these mothers in socioeconomically deprived areas. Trebilcock and Bryant (2001) referring to health professionals, suggest there is a ‘lack of understanding about how clients living in a situation of deprivation organize and make decisions about their everyday lives’. More information is required about how mothers living in socio-economically deprived areas protect and promote the health of family members in the context of their childcare, domestic and paid work responsibilities. This may enable health visitors to develop the appropriate and accessible service demanded by the Department of Health,” and to work towards meeting the greater health needs of the worst off. (2004).

The analysis of the interview data generated eight perspectives, several relating to the mothers’ concern about its family’s health, that is to present themselves as responsible, knowledgeable and conscientious careers of family health, particularly in relation to their children. This was very closely related to the presentation of themselves as ‘good’ mothers, who, despite engaging in health damaging behaviors, in particular smoking, prioritized the needs of their children in their activities. The meaning that the mothers attributed to their daily domestic activities demonstrated both the complexity and routine nature of the mothers’ health role. Caring for health through the provision of good diets, the maintenance of a clean home and the protection of children from health damaging environments, enabled mothers to construct and justify a ‘good’ mother identity and attribute the good health of their families’ to their own efforts. In general, their perspective is that, “being a ‘good’ mother was inextricably linked to the promotion of their families’ health, particularly that of their children”.

Being a good mother means having a healthy family

All the mothers interviewed were anxious to describe their family as healthy, particularly their children. Two mothers identified pathways between happiness and the immune system, believing that if they keep their children’s brains stimulated through play and attention their immune systems would also be activated, protecting their health.

He (son) doesn’t get particularly run down and fed up. I think when you’re happy it boosts your immune system up a bit more. If I get run down and fed up and not very happy about things, I get ill. I just keep him happy, give him lots of love and affection and he’ll be fine. (Anne)

Motherhood is hard work

Many of the mothers interviewed found the ceaseless nature of mothering a physically demanding, emotionally draining and isolating experience. The consequences they reported included depression, stress, poor health, bad temper and exhaustion. Many acknowledged that in caring for their children’s health they neglected their own.

We’re too busy to be ill. I ignore it, carry on and get on with it. That’s what you’ve got to do or otherwise you’ll mope around on the sofa and you won’t get owt done (Kathy)

In their determination to struggle on, the mothers revealed both a moral dimension to health and their low expectations regarding their own health. In suggesting that she is ‘too busy to be ill’ Kathy’s moral stance is consistent with the literature that claims that illness can be conceived as a response to symptoms, rather than the symptoms themselves.” Illness can therefore be presented as a sign of weakness or moral failing. This point was reiterated by Joanne who stated: I just seem to carry on, if I’m ill or not. I don’t like to give in to it, it just makes me worse.

Routine and cleanliness are Important In protecting the family’s health

Many of the mothers interviewed felt that routine was important, both for their children and as a way of ensuring that necessary chores were completed. All the mothers interviewed structured their day around their child’s routines of meals, play and sleep. One mother reported ‘my entire life revolves around him’ (April). Another reluctantly admitted ‘I mean it sounds pathetic, but most days are the same’ (Tina). Nevertheless, many of the mothers identified conflicts that exist between getting necessary housework done and the demands of their children for play, as Tina’s comment reveals:

And he’s like, play with me, play with me, and I’m like, just let me do my one thing and then I do’.

For all mothers interviewed, housework and cleanliness were perceived as important in maintaining the physical health of family members and their own mental well-being and positive self-identity. To protect health, the mothers kept the house clear of harmful bacteria, dust and hazards that cause asthma, other non-specific illnesses and accidents. This point was made clearly by Joanne who stated:

I just think you need to get rid of the din and the dust because dust can get down their throats. And I can’t iron unless she’s in bed because she’ll try and get under the ironing board, she’ll get burnt. No it’s just not worth the risk.

A good mother looks after her own children

Prioritizing the care needs of their children had an impact on the mothers’ decisions about paid work. Nine of the mothers felt that they should care for their children themselves, and that any paid work must be organized around this fundamental principle. April explained:

They’re the best years of his life. I’d rather he grew up thinking, “oh I had a really happy childhood” rather than “my mother’s always at work, she left me with strangers”.

This mother’s choices were about being the best mother that she felt she could be and about providing the best life for her young son. However, many of the mothers failed to acknowledge that constraints, such as poor qualifications that limited their employment opportunities, infused the choices that they made regarding what was best for their children. Many of the mothers responded to the contradictory and irreconcilable demands of modern motherhood and paid work in a way that permitted the maintenance of a ‘good mother’ identity. They constructed their social world in a way that placed the needs of their child, as they defined them, at the centre and organized their lives in order to meet those needs.

Accepting the legitimacy of health messages

Health messages regarding diet, exercise and smoking have clearly had an impact on the knowledge and behavior of the mothers interviewed. All mothers were keen to demonstrate their compliance, presenting themselves as good mothers.

Through the provision of a healthy diet, mothers attributed the health of their children to their own efforts, creating and maintaining a positive identity as a mother. All the mothers were concerned about the health aspects of their children’s diets, mentioning specifically their use of fresh fruit and vegetables and the limiting of sweets, convenience foods, salt and additives.

Although all mothers understood healthy food messages, for some of the mothers, food choices were restricted by financial considerations. This created feelings of guilt and anxiety. Money available for food, often the largest household expense in low income households, was dependent on other essential household expenditure.’ Waste was a luxury that these mothers could not afford; it was essential that the food purchased would be eaten and be filling. To reduce waste the mothers overlooked their own preferences and prioritized those of their children; acting as a buffer, absorbing shortages themselves to protect their children. Tina who, ‘just picks and eats whatever’, stated that if she doesn’t need to make anything for her son, she doesn’t eat. Melanie explained that she ‘just eats what she (daughter) likes.’

Like health messages related to food, the legitimacy of health promotion messages regarding exercise was accepted. Several mothers spoke of their concern about being overweight, identifying associated adverse health outcomes such as heart disease, diabetes, strokes, poor physical mobility and low energy levels. Taking their children’s exercise for granted, the mothers incorporated exercise into their daily lives rather than participating in any formal exercise, citing time and money as inhibiting factors. They walked, did their housework and ran around after their children.

Although all the mothers who smoked expressed some level of unease, most also identified positive aspects associated with smoking. Having a cigarette gave the mothers ‘time out’, helped them to ‘unwind’, to ‘carry on’, to ‘de-stress’. Kathy explains:

It helps when I’m stressed out, it’s just if I’m stressed out or whatever, I just have a fag. I can just sit back and leave it for a minute. Otherwise I’ll get too stressed out and I’ll shout or I don’t know.

Graham (1993) describes the positive aspects of smoking by poorer mothers as a ‘release, as if from nowhere, the physical and emotional energy necessary for successful coping. They provide on the spot relief, well suited to the isolated position, resolve temporarily conflicts of responsibility and shortages of resources’. This leads Graham’·’ to claim that smoking can be understood as a strategy that enables mothers to maintain their unending caring responsibilities, while finding some respite from them. As such, Graham’ argues that smoking promotes and undermines health at the same time. For these mothers, smoking, a relatively cheap form of relaxation, is not easily substituted. The advantages associated with smoking identified by the mothers implies that information and support, centered only on the process of giving up smoking, is totally inadequate for mothers living with the stress of poverty.

Children need to be protected from their environments

Most mothers interviewed built feasible explanatory pathways between mental well being, physical health and the environment of their daily lives, referring to the detrimental impact of pollution, lack of space, poor housing, dangers posed by traffic and anti-social behaviors, including drug abuse. One mother described how the area in which she lived restricted her lifestyle and her willingness to go outside with her baby. She felt threatened by the aggressiveness she sensed around her in an area, known for drugs, prostitution and guns. For many of the mothers, drug abuse and discarded needles near their homes were a major source of worry, both now and for the future; living among drug abusers may result in their children choosing ‘the wrong path’ (Melanie).

Good mothers accept the role of family health career

The pressures of keeping children safe from hazards outside the mother’s immediate control are detrimental to maternal psychological well-being.” Through their daily domestic activities and liaison with health professionals, most mothers took responsibility for their children’s and to some extent their partner’s health needs. The mothers monitored multiple aspects related to their child’s health to compile a picture of health and normality or define illness. They talked about their child’s weight, behavior, energy levels and moods, their eating and sleeping patterns, physical symptoms, such as a temperature or constipation, and the ‘look’ of their child.

Good mothers listen to their own mothers and friends

In taking responsibility for family health, mothers drew on their knowledge gained from a multitude of sources. Many were strongly influenced by their own mothers, whose knowledge was trusted and experience respected. Mitchell and Green” argue that the strong influence of mothers on their adult daughters with children is a prevalent feature in areas of socioeconomic deprivation and is evidence of social support and shared resources.

The opinions of friends also provided a valuable source of information for most mothers. For example, many of the mothers stated that they had read information about the MMR vaccination or talked to their health visitors. However, mothers described how their decisions relating to the MMR vaccination were influenced by the decisions made by their peers.

Conclusions

Despite the additional stresses that deprivation brought into the lives of the mothers interviewed, the study revealed that they were motivated, that their understandings of health, its protection, promotion and damage were wide-ranging, often sophisticated, and of daily concern. For some mothers, health choices were inevitably grounded in socioeconomic resources and opportunities and not in the amount of health information that they held. Weaving together medical knowledge, lay understandings and personal experiences, the mothers constructed relationships between mental and physical health and a host of influencing environmental, psychological and behavioral factors. Their complex understandings led them to form coherent conclusions to guide their mothering activities.

The mothers interviewed recognized that some aspects of their lives – smoking and a lack of money in particular – threatened their capacity to care for family health. This induced feelings of doubt, anxiety and guilt. The importance that the mothers placed on being recognized as a ‘good mother’ is a vital health visiting consideration, if health visitors are to view the social world from the mother’s perspective.

In acknowledging the impact of limited resources, community nurses can engage positively with mothers to promote self-esteem, build confidence and develop constructive relationships that facilitate health-promoting change.

Assignment #2 Assessing Health Issues

The aim of this small community nursing study is to gain an understanding about how mothers, who live in a socio-economically deprived ward, protect and promote their families’ health, in particular that of their children. Out of the ten mothers from a socio-economically deprived ward who were recruited, only four were actually interviewed using an in-depth, semi-structured approach. Following a discussion about the study and the nature of confidentiality, written consent was obtained from each mother prior to the interview. The names of all mothers quoted have been changed to protect anonymity.

They were then informed about the aim of this community nursing research which is  to understand how mothers who live in a socio-economically deprived ward, use their resources and overcome constraints to protect and promote their families’ health, in particular that of their children. Hence, this research core question is:  What are the experiences and life stories of women who are socio-economically deprived?  It is important to take note that this assignment (2) is a diagnostic phase of this community nursing research since here I tried to assess the health issues of these mothers.

Further, some of the questions asked were:

* What barriers do mothers face in the management of their families’ health?

* What sources of information and support do mothers value in caring for their

     families’ health?

·         What factors do mothers identify as influencing the health of the family?

The study’s desire was for the practitioner-researcher to understand the experience of socio-economically deprived mothers from the perspective of the subjects in order to review strategies that would allow for the development of a collaborative and potentially empowering research process. Thus one frequent outcome of community nursing research is growth in professional confidence which parallels the increased understanding of the workplace that comes with careful reflective inquiry (Needham & Bullman, 2000).  The key elements in the reflective inquiry process are community research planning, evaluation, communication, trust and the confronting of difficulties or problem-solving.

Moreover, the significant elements of community nursing research are present in this study.  These are:

1. The identification of a problem area about which an individual or a group is

     sufficiently concerned to want to take some action.

2.      The selection of a specific problem and the formulation of a prediction that implies a goal and a procedure for reaching it.

3.      The careful recording of action taken and the accumulation of evidence to determine the degree to which the goal has been achieved.

4.      The inference from this evidence of generalizations regarding the relation between action and the desired goal.

5.      The continuous retesting of these generalizations in action situations.

These elements greatly helped as a guide in undertaking this community nursing research (Robson, 1993).

The best approach for these questions is using the discussion group method. This is the best approach to answer the research questions as it allowed the participants to share their experiences and life stories but more importantly to relate their own story with the other participants as well.  Further, this method allowed the participants to developed views about each other experiences and stories through conversation with each other.

Hence, in this study, information was gathered using a series of discussion as a group which were held on a weekly basis and facilitated by researcher.  Drawing on focus group methodology, the discussion group was chosen over individual interviews because they allow participants to share and develop their views through conversation with each other (Kitzinger, 1994).

So data collection was done primarily through a small group discussion. There were four meetings scheduled for discussions.  The discussion group was structured.  The first meeting questions were drawn on Chinn`s (2004) peace and power processes and the critical social theory published. In the second and third meeting, issues that aroused from the first meeting was explored and shown in a table. The fourth and final meeting was used to clarify the researcher’s interpretations of the participants’ discussions and to identify ways in which to take the project forward.

For each session, a flip chart and tape recorder were used.  The flip chart was used to record the key points raised while the whole discussion during a meeting was recorded and transcribed in full. The transcripts were read by the women and used as a basis for reflection on their emerging ideas.  In addition, each session began with a summary of the previous week’s work which is of course very important to start and continue the discussions.  The discussions were unfolded in the spirit of co-operative enquiry which according to Chinn (2004), characterize community nursing research.

Moreover, the researcher used a reflective diary as an invaluable tool to monitor beliefs and bias.  This also enabled the researcher to reflect on the true nature of the emerging collaborative process of interaction as community nursing usually requires the joint efforts of a group of people.

The women (given the pseudonyms of Pritney, Ella, Dolla, and Marie in this research) were all living in different types of temporary accommodation hostels for socio-economically deprived families at the time of the study. A group of four women is, of course, by no means `representative’ of the population of socio-economically women as a whole. However, there were advantages to the small group in that participants were not inhibited by greater numbers and were able to explore their experiences in depth. Continuity of attendance was maintained over the four meetings, thus allowing the discussion to unfold in the spirit of co-operative enquiry which characterizes action research (Reason, 1988).

In order to structure the discussion groups, questions were prepared for the first meeting drawing on published studies in the field of socio-economically disadvantaged family. The issues for exploration in the second and third meetings emerged from the previous week’s work. The fourth and final meeting was used to clarify the researcher’s interpretations of the participants’ discussions and to identify ways in which to take the project forward. A flip chart was used to record the key points and each session was tape-recorded and transcribed in full. The transcripts were read by the women and used as a basis for reflection on their emerging ideas; each session began with a summary of the previous week’s work.

The group approach allowed the women to support each other in exploring their views in their own language and within their own `frameworks for understanding the world’ (Kitzinger, 1994 p. 108). Exchanges between them helped the researcher to understand preferred words and phrases and listening to anecdotes and jokes seemed to clarify experiences and difficulties. Sometimes a particular phrase or word led to a consensus and a sense of shared understandings.

In retrospect, the nurse researcher did not anticipate how deeply she would be drawn into the women’s lives through the intensity of the group process. During the study, she wanted to be faithful to the participants and to `illuminate’ their experiences (Titchen, 1995). To do this, a narrative of the groups was provided, to portray the complex lives of the women. Personal bias inevitably shone through on occasions. It is difficult to suspend judgment when working with families who live in poverty and distress and the researcher acknowledges this bias. A reflective diary was an invaluable tool in the process to monitor beliefs and bias. This enabled the researcher to reflect on the true nature of the emerging collaborative process of interaction as an expert in the field of poverty and as a worker `from the inside’ (Holter & Schwartz-Barcott, 1993).

Through this community nursing research, the socioeconomic deprivation among mothers and children are likely to have complex emotional and practical problems (Ovrebo et al., 1994; Collard, 1997). These women allowed the women to describe the experience of being socio-economically deprived in their own words, highlighting the effects on their mental health and making recommendations for improved interagency working.

These mothers who have not led `settled’ lives experience a feeling of powerlessness that undermines their parenting skills (Koch et al., 1998). Many find themselves enmeshed in a child protection system that seems unable to intervene in a cycle of poverty and socio-economic deprivation. For the majority of these women, their experiences are simply another phase in a cycle of deprivation. Many will have spent significant periods of their childhood in the care of the local authority and lack the support networks that would enable them to bring some order into their lives (Speak, 1995).

The problems facing economically deprived mothers are compounded when they are re-housed in neighborhoods with high concentrations of social housing, where many of their neighbors will also be experiencing the effects of poverty and a degraded environment. Based on their stories, the researcher realized that such socially disorganized communities are not the ideal hosts for young vulnerable women who are often the victims of negative stereotypes (East, 1998). Repeated homelessness often reflects the inability of families to settle into their new homes and places limits on their ability to participate in community life. Thus, the problem is not confined to the `socio-economically deprived system’ but has implications for other neighborhood residents. However, this perspective rarely emerges in research and policy documents, where socioeconomic deprivation is conceptualized as a problem for individuals and families rather than the wider community.

In assessing the group’s salient health issues, the contradictions and moral dilemmas in the lives of mothers are perhaps a very important point to consider when studying the relationship between mothering and paid work. In attempting to tackle child poverty and reduce state dependency, present Canadian social policy seeks to draw poorer mothers into the low paid employment sector through a policy of in-work benefits and the expansion of childcare provision. Despite growing numbers of mothers of young children in paid employment it is in their caring responsibilities that women’s moral identity of ‘good mother’ is crucially formed.” These mothers, of low socio-economic status, find themselves in an ambiguous, guilt-ridden position in a modern society that prizes paid work, yet culturally has not fully relinquished a commitment to the exclusivity of motherhood.”

The complexity in the lives of mothers is an important determinant of health applied to this group’s salient health issues. I thus consider that I am working with mothers in socio-economically deprived areas. Trebilcock and Bryant (2001) referring to health professionals, suggest there is a ‘lack of understanding about how clients living in a situation of deprivation organize and make decisions about their everyday lives’. More information is required about how mothers living in socio-economically deprived areas protect and promote the health of family members in the context of their childcare, domestic and paid work responsibilities. This may enable community nurses to develop the appropriate and accessible service demanded by the Ministry of Health,” and to work towards meeting the greater health needs of the worst off.

            Analysis from elements captured reverberate data obtained from other studies about socio-economically deprived mother.  The results of this study were clear as represented in the “our motherhood cycle” model which also suggest that being a socio-economically deprived mother is better understood as a process in the lives of young mothers. Such an approach to understanding motherhood is valid and has important implications for service delivery.

It is made evident in this study that there is a point in life where one can really change which can lead to independence and a sense of self-worth.  The mothers have shown capacities and readiness of change in tables and charts as models to explain their experiences and resolutions. But they did not provide explanations as to how much confidence could be placed in their results as no statistics were employed to interpret confidence level in the result.

            The nurse researcher and the women involved in this project found the experience of participating in the group empowering.  Their work has generated a great deal of interest to the researcher.  This will allow the community nurse researcher to address the question of whether the nonprofessional model they have created can work. In this way, the community research will be completed, from the generation of theory to its testing out and evaluation in practice.

Assignment # 3 Determining Health Action

Looking back on the first group discussion, the women began to explain to each other how they had discussed the purpose of the groups with key people in their lives, and how they wanted to continue meeting. At this point, there was a shift towards empowerment of the women in line with the `empowering’ type of action research described by Hart & Bond (1995). The `professionalizing’ type, characterized by research for practice development, emphasizes the tension between research and action but leans towards research. The `empowering’ type, on the other hand, is distinguished by an emphasis on action. According to Hart and Bond’s typology, `empowering’ action research becomes a reality when the researcher and participants become genuine co-researchers in shaping the development of the project.

Pritney wanted to describe how the group helped to identify `what the pattern is, what makes people move on, and what makes it worthwhile to stay’. At this point, she expressed a desire to be employed in running future groups:

        I’d like to be able to hear somebody say `She really helped me through that’.

Ella agreed:

You can’t do it on your own, it’s impossible. You’ve got
to have someone out there to help you.
She felt that there should be support groups similar to the research group set up in order to `keep people out of the socio-economically deprived system’. Each woman wanted to tell others their `story’ and the idea of a presentation began to take shape.

‘Our Motherhood Cycle’

The group discussions were very open and painfully honest. The use of the terms `settled’ and `unsettled’ emerged early in the focus groups, and illustrate the difficulty of describing the process of being socio-economically deprived. Ella had spent many years in children’s homes and also in temporary accommodation:

        Elaine: If you’ve always been settled, then it’s bound to
bother you when you’re socio-economically deprived, but as for me, I’ve always
been unsettled, so what’s the problem?
Pritney: If you’re used to being unsettled it doesn’t affect you that much, but if
you’re used to being settled in a nice house …
These comments indicate that being socio-economically deprived is not, in itself, the central concern of the women. In an attempt to explain this more fully, the women explored their life histories in order to recall a point at which they had felt settled. They all felt that they had been settled while in socio-economic deprived accommodation at some point in their lives. In a `socio-economically deprived place’ you could choose to be with people or not, but living alone in a house was unsettling. Marie recalled feeling settled during a time she spent living in a `bed and breakfast’ hostel where the residents shared childcare. Trying to distinguish what caused unsettled periods was difficult:

    Marie: Some people put that settled is in a home, with a
partner. But the times I’ve felt settled haven’t
always been like that …

Ella: That’s when I got unsettled, when I got a
relationship.
Pritney made the following statement as a sudden realization:

    I’ve been unsettled since I was 7.
Following this dialogue there was an intense exchange about the reasons for not settling when re-housed.  Even though the women could not make an easy connection between being socio-economically deprived and being unsettled, they were sure of the negative impact on their self-esteem:

    Dolla: When you feel being socio-economically … you’re not a
person … you have no self respect — it
takes your identity away.
The women had all experienced negative stereotyping which affected their confidence as mothers:

    Dolla: They think you’re stupid, don’t they? Coz you’re
young!

Pritney: It’s judgment day, like you’re automatically
labeled as `She’s a right –‘

Marie: Yeah — When you’ve been poor a lot, it’s
like `There must be something bad about
her’.

Ella: Especially if you’ve got a social worker …
you’re a `bad mother’.
In the first group, Pritney described her experiences of being socio-economically deprived as a `never-ending cycle’ which she could not see a way out of:

    I always thought what was missing was a family. I had a
daughter, but that didn’t fill it. I don’t fit in, like a
piece missing from a jigsaw …
Dolla and Ella nodded in agreement, and considered ways in which they had tried to break out from their own cycles:

    Dolla: Yeah, Yeah! That’s what I used to think, if I had a
Family, as a mother, I’d be all right. The only trouble is, it’s
hard on the children, but you don’t realize you’re doing
it. It’s a never-ending cycle.

Pritney: It would be nice … to try and figure out what
would stop the cycle …

The second and third groups built on this major theme. Using the flip chart, the women developed a diagrammatic representation of common features in their life stories that they named `our motherhood cycle’.

Each element of the cycle can stand alone or overlap with others. One element relates to the relationship between domestic violence and socio-economically deprived:

    Ella: What it is, when you’re unsettled, these violent men
give the impression of being dead nice, so you
believe it straightaway, coz you’re unsettled.

Dolla: You get to know them for about a month or so, really
nice and then that’s it and they start showing
their true colors.
Another element captures the desire to protect the children from becoming socio-economically deprived so `you stay put and keep your mouth shut’. On the other hand, Pritney and Ella’s comments confirm that there are rewards being socio-economically deprived as well as in difficulties and stress:

    Pritney: I think that you don’t mean to do it, but you
deliberately get yourselves in a situation where you
become socio-economically deprived.

Ella: I think it’s when you get insecure, when you’re not
happy.
The idea of wanting to be in a socio-economically deprived situation is not found in previous literature, and is a disturbing thought. It confirms that there are rewards in being socio-economically deprived areas as well as difficulties and stress.

At first, the women felt that they were trapped in the motherhood cycle and could not see a means of escape. However, in a later session Pritney said that participating in the group had given her the confidence to make a change in her life:

    I’ve finally broken down my motherhood cycle … I’m running from
the man who abused me..
As well as conceptualizing their own experiences in a model, the women discussed the kinds of services they thought could make a difference. They felt it was very important that services should be mediated by women like themselves who had `been there’. Pritney coined the term `Reality Mother Worker’ for their vision of a volunteer link worker who would help socio-economically deprived women and resettling them to connect with agencies and communities. Both researchers and participants developed a pyramid through which women could rise as their problems were addressed, envisaging that becoming a Reality Mother Worker would empower the volunteers as well as the women entering the pyramid at its base. Importantly, the Reality Mother Workshop model allows plenty of time for women to work through their problems but does not encourage long-term (more than 2 to 3 months) engagement with the project. Success is achieved when a woman has settled into her new home, is integrated into the community and ready to `let go’ of her socio-economically deprived identity.

Thus, the mothers in this study developed a conceptual model that captured the essence of their experience. They named this “Our Motherhood Cycle” which is a diagrammatic representation of common features in their life stories which conceptualizes their experiences.   The motherhood cycle has several elements which can stand alone or overlap with the other elements.  Further, both researchers and mothers developed a pyramid through which women could rise as their problems were addressed.  This is known as the Motherhood Reality Workshop model which is a non-professional model proposed for service delivery. More importantly, the Motherhood Reality Workshop model allows plenty of time for mothers to work through their problems but does not encourage long-term (more than 2 to 3 months) engagement with the project. Success is said to have achieved when a woman has settled into her new home, and is integrated into the community and ready to ‘let go’ of her socio-economically deprived identity.

‘Breaking the motherhood cycle’: a discussion

The elements captured in `our motherhood cycle’  resonate with the findings of previous research into socio-economically deprived families. However, one difficulty with such studies is that they take a `snap shot’ approach, often using critical incident techniques to explore homelessness as an episode or crisis. The findings of this study as represented by `our motherhood cycle’ suggest that being socio-economically deprived is better understood as a process in the lives of young mothers. Such an approach to understanding socio-economically deprived family has important implications for service delivery. The conventional wisdom is that being socio-economically deprived is the `cause’ of the family’s problems, and therefore speedy re-housing is the absolute priority. Other problems, such as disturbed behavior in children or self-harm in women are seen as a `consequence’ of being socio-economically deprived. For example, I was reluctant to work with these women in temporary accommodation because `they need a house, not therapy’. In fact, a socio-economically deprived woman argued that interventions with children at this stage of the cycle could be crucial in determining the chances of the family becoming `settled’ in the future. A possible reason for the loss of a tenancy after re-housing is the disruptive behavior of children, leading to tensions with neighbors and difficulties in entering community support networks. In this case, the behavior of the children could be a cause rather than a consequence of being economically deprived. Further crises may have been averted had the children received supportive interventions at an earlier stage in the process.

In this study, there were relatively few direct references in the women’s dialogue to the effects of being socio-economically deprived on their children, although they often spoke of being blamed or labeled as `bad mothers’. Ovrebo et al. (1994) found that the experience of mothering can offer a positive antidote to the effects of being socio-economically deprived, with the connection to a child becoming a catalyst for change. However, the tension between protection and prevention is acute in relation to work with children in temporary accommodation. A survey carried out in London found that half of the families in hostels and refuges had received social work support at some point, and 9% of the children were on the child protection register (Firth, 1995). The survey led to the conclusion that being socio-economically deprived is, in itself, a trigger for child protection referrals and that, without adequate support from other agencies, young mothers who experience socio-economic deprivation may be unable to maintain independent living with their children even when re-housed.

As this study progressed the women began to `make sense of their past’ through sharing their life stories, and gained confidence in recognizing the needs of their children. Tied into this process was the recognition that past experiences makes it difficult to relate to professionals and `hear’ any offers of support. Trust and continuity were identified as key issues:

    Pritney: You have to get to know someone for them to help you.

Ella: Sometimes, you’ll get somebody who expects a leap of
faith. They expect you to depend on this person,
when you’ve only met them a few times.
Trust is a casualty of being in and out of socio-economic deprivation, a result of an accumulation of life experiences. The women in this study related similar difficulties from their upbringing in children’s homes:

    Ella: You bond with a couple (of key-workers) that you
really like and they either move on or you get
moved.
Kryder-Coe (1991) suggests that a family which cannot stabilize itself has difficulty nurturing its children. This is clearly an important concept when working with families who are more likely to have contact with child protection agencies. It does not mean that women are deliberately neglecting their children, but indicates that some families may need extra help to reach a point at which they can address parenting issues. This study suggests that sharing life histories with women in similar circumstances can help young mothers move towards this point.

Assignment #4 Closing

The Reality Motherhood Workshop

A model of practice which returns control to economically-deprived mothers may help to break the cycle of deprivation and in turn help the children in those families. Women who have been damaged by `the system’ need help to make sense of what has happened to them and `to reflect on the root cause of their deprivation’ (Ovrebo et al., 1994 p. 193). The women in this study felt strongly that this process should be predicated on the non-professional model. The non-professional or link worker model has been used successfully in developing countries, where community health workers are trained to provide basic health education and emergency treatment. Family support initiatives are also organized by the voluntary sector in the UK such as Newpin (Potrykus, 1989) and Homestart (Homestart, 1993). Newpin, a befriending scheme for new parents, claims to intervene in destructive life cycles and offer an opportunity to change life patterns (Potrykus, 1989). Like Homestart, it involves training volunteers to visit vulnerable families in their own homes, offering a sympathetic, listening ear and social support.

However, the model proposed in this study is different in that it involves women who have themselves experienced socio-economic deprivation. Peer support, both practical and emotional, will be offered by the volunteer `Reality Mother Worker’. Women will also have regular access to a multi-agency team composed of social workers, health visitors and resettlement workers. The project will offer an informal `drop-in’ session supported by a crèche and with refreshments available. It will also offer a therapeutic group and individual work for mothers, support for children and on-going friendship when families are re-housed. One aim of this community nursing project is to produce information on community facilities and activities in the different neighborhoods of the city, and to enable women to access local support networks. The role of Reality Mother Worker will be available to all women entering the project and a training course is being established covering issues such as housing allocation policy and child protection procedures. In this way, women will be supported until they are finally able to move away from the `socio-economically deprived ward ‘.

The results of this study suggest that this is the point at which lives can really change, leading to independence and a sense of self-worth. The alternative for many women is that they continue to move in and out of low socio-economic status, are labeled `bad mothers’ and are unable to break out of the destructive cycle. Collard (1997) has pointed out the high costs of the failure to `settle’ in terms of worsening health, loss of opportunities, and increasing debt.

There are implications for the wider community as well as the families themselves. When previously homeless families put down roots they are in a position to participate in neighborhood life and contribute to processes which build social capital:

    Social capital is produced within communities through
activities as diverse as taking part in community group
meetings, exchanging childcare with neighbors, being
involved in neighborhood watch schemes and voting —
activities which we know build trust in neighborhoods and
society at large. (Gillies, 1997 p. 6)
The challenge for any family to put down roots when they are entering communities where there is much social housing, unemployment, poverty and crime is huge. The task facing socio-economically deprived families who seek to rise above a degraded social and physical environment can seem quite overwhelming. The need for support is clear if such families are to become part of the solution to neighborhood social disorganization rather than part of the problem.

Conclusion

The women involved in this project found the experience of participating in the group empowering, and their work has generated a great deal of interest to the nurse researcher. However, to fully realize the potential of the Reality Mother Workshop model, financial support is needed.

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