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International Journal of Mental Health Nursing (2019) 28, 140–151 doi: 10.1111/inm.12503

O RIGINAL A RTICLE
Predictors and enablers of mental health nurses’
family-focused practice
Anne Grant,1 Andrea Reupert,2 Darryl Maybery3 and Melinda Goodyear3,4
1
School of Nursing and Midwifery, Medical Biology Centre, Queens University, Belfast, UK, 2Krongold Clinic,
Faculty of Education, Monash University, Clayton, 3Department of Rural Health, School of Rural Health, Monash
University, Moe, and 4Parenting Research Centre, Melbourne, Victoria, Australia

ABSTRACT: Family-focused practice improves outcomes for families where parents have a
mental illness. However, there is limited understanding regarding the factors that predict and
enable these practices. This study aimed to identify factors that predict and enable mental health
nurses’ family-focused practice. A sequential mixed methods design was used. A total of 343
mental health nurses, practicing in 12 mental health services (in acute inpatient and community
settings), throughout Ireland completed the Family Focused Mental Health Practice Questionnaire,
measuring family-focused behaviours and other factors that impact family-focused activities.
Hierarchical multiple regression identified 14 predictors of family-focused practice. The most
important predictors noted were nurses’ skill and knowledge, own parenting experience, and work
setting (i.e. community). Fourteen nurses, who achieved high scores on the questionnaire,
subsequently participated in semistructured interviews to elaborate on enablers of family-focused
practice. Participants described drawing on their parenting experiences to normalize parenting
challenges, encouraging service users to disclose parenting concerns, and promoting trust. The
opportunity to visit a service user’s home allowed them to observe how the parent was coping and
forge a close relationship with them. Nurses’ personal characteristics and work setting are key
factors in determining family-focused practice. This study extends current research by clearly
highlighting predictors of family-focused practice and reporting how various enablers promoted
family-focused practice. The capacity of nurses to support families has training, organizational
and policy implications within adult mental health services in Ireland and elsewhere.
KEY WORDS: family-focused practice, mental health nurses, mental health services, parenting,
parents.

least one parent had a mental health problem (Parrott

INTRODUCTION
Parental mental illness is a major public health issue
internationally. It has been estimated that over 20% of
children live with at least one parent with a mental ill-
ness (Maybery et al. 2009). In the UK, two million
children are thought to live in households where at
Correspondence: Anne Grant, School of Nursing and Midwifery,
Medical Biology Centre, Queens University, 97 Lisburn Rd, Belfast
BT9 7BL, UK. Email: a.grant@qub.ac.uk
Anne Grant, PhD.
Andrea Reupert, PhD, Associate Professor.
Darryl Maybery, PhD, Professor and Director.
Melinda Goodyear, PhD, Research Fellow.
Accepted June 03 2018.
et al. 2008); while in Australia, it is suggested that
there are 1 082 403 children living in 577 507 families
with a parent with a mental illness (Maybery et al.
2015). Parental mental illness (PMI) may adversely
impact children’s cognitive, emotional, social, physical,
and behavioural development (Jacobs et al. 2015).
Twenty-five to 50% of children who have a parent with
a mental illness will experience some psychological dis-
order during childhood or adolescence, and 10–14% of
these children will be diagnosed with a psychotic disor-
der at some point in their lives (Beardslee et al. 2012).
There is an association between stress experienced by

© 2018 Australian College of Mental Health Nurses Inc.

NURSES’ FAMILY-FOCUSED PRACTICE
parents who have mental illness and depression and
anxiety in their children (Beardslee et al. 2012).
Addtionally, stress from assuming a parenting role may
negatively impact parents’ well-being (Hine et al.
2017). Having to juggle the demands of managing their
own mental illness and additional responsibilities of
managing their children’s problems can further
heighten the risk of parents’ relapse (Falkov 2012). If
parents perceive that they are unable to cope with
their parenting role, it may have a profound impact on
their mood, self-esteem, and self-efficacy (Montgomery
et al. 2011).
Nevertheless, family-focused practice (FFP) helps
parents, children, and other family members prevent
and/or cope effectively with the difficulties associated
with PMI (Foster et al. 2016; Siegenthaler et al. 2012).
Various international policymakers and professional
organizations (Department of Health & Children [Irish
DoHC] 2006; Ministry of Children & Family Develop-
ment [Canada] 2013; Royal College of Psychiatrists
2011) and researchers (Goodyear et al. 2015; Nicholson
et al. 2015; O’Brien et al. 2011) recommend that adult
mental health services adopt a whole family approach.
However, mental health services have varied in their
development of a whole family approach (Goodyear
et al. 2015; O’Brien et al. 2011). In Australia, practice
standards have recently been developed (Goodyear
et al. 2015), while in Finland, there is a multicompo-
nent, national prevention programme where mental
health professionals receive targeted FFP training
(Solantaus & Toikka 2006). By contrast, in the Repub-
lic of Ireland, there has been relatively less FFP orga-
nizational and policy development (Grant & Reupert
2016; Grant et al. 2016).
Maybery et al. (2012) recommended five key fam-
ily-focused activities including (i) assessing the impact
of PMI on the child, (ii) providing family and parent-
ing support to service users, (iii) supporting service
users’ children and family, (iv) referring parents, their
children, and adult family members to additional ser-
vices, and (v) assessing parents’ awareness of their
child’s connectedness to other family members and
community networks. However, studies suggest that
mental health professionals and particularly nurses
generally do not engage in FFP (Goodyear et al.
2017; Grant et al. 2016). While professionals might
want to engage in FFP, deficits in knowledge and skill
have been found in relation to (i) working with ser-
vice users on parenting issues, (ii) working with chil-
dren, and (iii) working with the whole family
(Maybery et al. 2014).
© 2018 Australian College of Mental Health Nurses Inc.
141
That said, there is some evidence that professionals
practicing in community settings may be more likely to
engage in family-focused practice than those in acute,
inpatient settings (Slack & Webber 2008). Additionally,
professionals who are parents may be more likely to
support service users’ children than those without per-
sonal experience of parenting (Korhonen et al. 2010).
Recently, two Australia studies identified important
worker and workplace factors that predict FFP for
mental health professionals. Maybery et al. (2016)
found that professionals’ knowledge and skill was the
most important predictor of FFP. Goodyear et al.
(2015) found that being female, previous family-
focused training and working in a rural location pre-
dicted FFP. However, neither study examined the
influence of practice setting (i.e. acute inpatient vs
community setting) nor other key worker-related vari-
ables such as workers’ life experience (including their
own parenting experience). An understanding of factors
that predict and enable FFP can be used to develop
long-term, multifaceted implementation strategies to
promote mental health professionals’ capacity when
working with families. The purpose of this study was to
(i) identify key predictors of nurses’ FFP, and (ii)
describe key factors that enable FFP.
METHODS
Design
A sequential mixed methods design (explanatory, com-
plementary, follow-up design) was employed (Creswell
& Clark 2007). The nature of the research questions,
which entailed the use of quantitative and qualitative
approaches, guided the selection of a mixed methods
approach (Creswell & Clark 2007). Quantitative, ques-
tionnaire data were collected in 2012 on the predictors
of FFP. Qualitative, interview data were obtained in
2013, from participants who scored high on the ques-
tionnaire, to further extend and explain the question-
naire results with a particular focus on the enablers of
FFP.
Participants
In the quantitative component of the study, a clus-
tered, random sampling approach was used to access
610 nurses in 12 of the 31 mental health services in
Ireland with a 57 per cent response rate (n = 343).
Initially, the 31 services were considered to be
developed or less well developed in accordance with
142
the size of their community mental health teams
(CMHTs). It was identified that 20 of the 31 services
had more developed CMHTs (i.e. at least one CMHT
with three or more nurses) and 11 had less well-devel-
oped teams (i.e. no CMHT had three or more nurses).
Subsequently, using a random number generator, 10
developed and two less developed services were ran-
domly selected for inclusion.
This approach also entailed dividing the nurses into
separate clusters (i.e. CMHTs and acute admission
units/group[s]). A simple random sample of clusters
was then selected from the total nurses (Brown &
Lloyd 2001). All nurses, practicing within 17 CMHTs
(~305), were then invited to complete the Family
Focused Mental Health Practice Questionnaire
(FFMHPQ). In addition, all nurses (~305) practicing in
13 acute admission units, linked to these 17 CMHTs,
within the 12 mental health services were also invited
to participate.
Inclusion criteria included registered nurses directly
delivering care in either acute admission units or
CMHTs in four main areas: day hospital, day centre,
community mental health nursing services, and home-
care. Providing Directors of Nursing with details
regarding inclusion and exclusion criteria helped to
ensure that the FFMHPQ was not distributed indis-
criminately to nurses who fell outside of the study pop-
ulation or to non-nursing members of the
multidisciplinary team.
In the subsequent, qualitative component of this
study, 14 of the 109 nurses who obtained high scores
on the FFMHPQ, in the quantitative component in
Study One (i.e. obtained a score of five or more on at
least three of the behavioural subscales), participated
in semistructured interviews. While 20 nurses initially
agreed to undertake interviews, upon follow-up it was
only possible to make contact with 14.
In the subsequent, qualitative component of this
study, 14 of the 109 nurses who consented to be inter-
viewed and obtained high scores on the FFMHPQ, in
the quantitative component in Study One (i.e. obtained
a score of five or more on at least three of the beha-
vioural subscales), participated in semistructured inter-
views.
Quantitative data collection
The FFMHPQ was employed to measure FFP (May-
bery et al. 2012). The first author established inclusion
criteria and in conjunction with Directors of Mental
Health Nursing invited all eligible participants, from 12
A. GRANT ET AL.
mental health services. The first author provided both
written and verbal information about the study. Ques-
tionnaires were made available to participants in hard
copy format only and returned by post to the first
author anonymously.
The self-report questionnaire employs a seven-point
Likert scale (ranging from one – strongly disagree to
seven – strongly agree) to measure six different family-
focused behaviours (e.g. assessing impact on children)
and organizational-, nurse-, and family-related factors
that may impact these behaviours. Items within each
subscale are summated and averaged to calculate sub-
scale score. Psychometric information of the FFMHPQ
subscales is detailed elsewhere, demonstrating that the
measure has excellent content and construct validity
and generally good internal subscale reliability (May-
bery et al. 2012).
The original version of the FFMHPQ was developed
for the Australian adult mental health service, for vari-
ous professions (e.g. nurses, psychologists, social work-
ers). We adapted the language of the FFMHPQ for
nurses practicing within adult mental health services in
Ireland, in consultation with the developers of the orig-
inal instrument. For instance, the term consumer was
replaced with service user and ‘dependent children’
was explained.
In addition, drawing on the literature (Falkov 2012;
Korhonen et al. 2010; O’Brien et al. 2011) and in con-
junction with the developers of the FFMHPQ, two
new subscales were designed to measure nurse’s confi-
dence around their own or family and friend’s children
(confidence around parenting and children generally)
and interventions to promote parents’ mental health.
See Table 1 below for subscale definitions and example
items.
The validity of the FFMHPQ outside the Australian
adult mental health service context was established by
a panel of six Irish mental health experts including
nurses and academics. Each subscale and its item,
including the two new subscales, was rated using a
five-point Likert scale (not relevant – extremely rele-
vant). If an item had been evaluated as not relevant by
20% of these experts, it would be deleted (Lynn 1986).
All the items were deemed relevant and, therefore,
retained. Subsequently, the FFMHPQ was piloted with
ten nurses from a mental health service to evaluate the
clarity of the questions and overall design, resulting in
minor changes to wording. An analysis of internal con-
sistency reliability indexes showed (compared to the
Australian context) poorer reliability of the majority of
subscales (i.e. most of the subscales had reliabilities
© 2018 Australian College of Mental Health Nurses Inc.
NURSES’ FAMILY-FOCUSED PRACTICE 143

TABLE 1: The FFMHPQ subscales, subscale definitions, Cronbach reliabilities, and items

Subscale (alpha reliability) Subscale definition Example item from scale

Support to carers and children
(0.54) (DV)
Family and parenting support
(0.56) (DV)
Assessing the impact on the child
(0.57) (DV)
Connectedness (0.68) (DV)
Referrals (0.54) (DV)
Interventions to promote parent’s
mental health (0.74) (DV)
Service availability (0.51)
Time and workload (0.51)
Engagement issues (0.51)
Worker confidence (0.61)
Training (0.79)
Confidence around parenting and
children generally (0.91)
Skill and Knowledge (0.76)
Interprofessional practice (0.59)
The level of information, advocacy, and
referral provided to carers and children
Providing resources and referral information
to consumers and their families
How well the worker assesses the impact of
the parent illness on the children
Workers assessment of parent awareness of
child connectedness
Referring family members to other
programmes to
Workers’ interventions to reduce the impact
of the service user’s parenting role on their
mental health
There are programmes to refer families
Time or workload issues regarding family-
focused practice
The opportunity for engagement with family
members
The level of confidence the worker has in
working with families, parents and children
Worker willing to undertake further training
Confidence around own or family and friend’s
children
Worker skill and knowledge regarding impact
of parental mental illness on children
Teamwork and interprofessional practice
Rarely do I advocate for the carers and/or family
when communicating with other professionals
regarding the service user’s mental illness
I provide written material (e.g. education,
information) about parenting to service users
I am able to assess the level of children’s
involvement in their parent’s symptoms or substance
abuse
I am not able to determine the level of importance
that service users place on their children maintaining
strong relationships with others outside the family
(e.g. peers, school)
I refer service user’s to parent-related programs (e.g.
parenting skills)
I assess the impact of the service user’s parenting
role on their mental health
There are no family therapy services to refer service
users and their families to
The workload is too high to do family focused work
The children often do now want to engage with me
about the service user’s mental illness
I am not confident working with children of service
users
I should learn more about how to assist service users
about their parenting and parenting skills
In general I am very happy with my parenting
I am skilled in working with service users in relation
to maintaining the well-being and resilience of their
children
Children and families benefit if health professionals
work together to solve the family problems

between 0.60 and 0.70 with one subscale greater than
0.90). Consequently, five subscales (time and workload,
support to carers and children, engagement issues, ser-
vice availability, and interprofessional practice) were
modified by removing unreliable items (De Vaus 2002)
and this increased reliability.
Qualitative data collection
Semistructured interviews were conducted with high
scorers in the FFMHPQ who also had recent (within
the last 12 months) professional experience of caring
for parents who have mental illness. High scoring
nurses would be more likely to be engaging in FFP
than those with lower scores and thereby able to
identify and describe enablers of FFP. An expert per-
formance framework was employed as the basis of this
approach as is often used in sports coaching (Cote
et al. 1995) and in nursing research (Ericsson et al.
2007). The expert performance framework was chosen
as it allows for the identification of representative
tasks that capture the essence of expertise in any
given domain, as well as those activities that promote
effective learning and development in that domain (in
this instance FFP; Ford et al. 2009). Participants were
asked to explain what actions they undertook and
how, when focusing on family, for example, ‘what do
you do (if anything) when focusing on the family of
your service user?’ and what factors, if any, enabled
their FFP, for example, ‘what might help you and
your colleagues (if anything) to engage in FFP?’
(Please see Appendix S1 for further information).
Interviews ranged from 45 to 90 min (average
60 min).

© 2018 Australian College of Mental Health Nurses Inc.

144
The first author conducted all 14 interviews.
Methodological rigour was maintained through journal-
ing, which reflected interaction with the text and possi-
ble interpretive assumptions (Noble & Smith 2015).
For example, the author’s familiarity with mental health
nursing may have caused her to ascribe or assume cer-
tain meanings to participants’ words or jargon, beha-
viours, and decisions. The second author independently
analysed five (a third) of all transcripts, as recom-
mended by Noble and Smith (2015) to further take
account of possible personal agendas and hidden
assumptions. The researchers then compared and con-
trasted their interpretations by referring back to partic-
ipants’ responses, to reach a consensus through
discussion rather than a numerical agreement. New or
contradictory aspects of practice were further explored
in subsequent interviews. Weeks after the interview
with each participant, they were sent their individual
interview transcript and invited to delete any informa-
tion they believed to be potentially identifiable, add
anything they considered to be relevant, and/or change
anything they considered to be inaccurate (King &
Horrocks 2010). No changes were made on transcripts.
Ethical considerations
Ethics approval was provided by participants’ organiza-
tions (mental health services) and the relevant univer-
sity committee. Implied consent was obtained through
completion of the anonymous, hard copy, and question-
naire, and prior to commencing the interview, partici-
pants were invited to complete an informed consent
form.
Data analysis
The statistical package for the social sciences (SPSS
version 20, IBM, Chicago, IL, USA) was used to anal-
yse the quantitative data utilizing descriptive and infer-
ential statistics including hierarchical multiple
regression. The 16 subscales in the FFMHPQ were
categorized as either (i) family-focused practices (classi-
fied as dependent variables [DVs]), or (ii) predictors of
family-focused practices (independent variables [IVs];
see Table 1 above). Seven demographic variables (i.e.
gender) were converted to dummy variables and also
included as IVs in the regression analysis. Forward
regression was used to assess the relative contribution
of each of the IVs in predicting six DVs. The IVs were
entered in three blocks, the order based on previous
literature. All demographic IVs, such as age, were
A. GRANT ET AL.
entered into block (step) one. Seven known predictor
(IVs) were entered at block (step) two. Block three
included two new predictors that had recently emerged
in the literature, including confidence around parenting
and children in general.
In the qualitative component of the study, we
employed a thematic analytic process, with six distinct
but interconnected steps, to create core constructs
from the qualitative (textual) data through systematic
reduction and analysis (Braun & Clarke, 2006). The six
steps involved (i) familiarizing ourselves with the data,
(ii) generating initial codes, (iii) searching for themes,
(iv) reviewing themes, (v) defining and naming themes,
and finally (vi) writing this paper (Braun & Clarke
2006). An essentialist, realist perspective was employed,
focusing on participants’ experiences of FFP and those
processes that fostered a family focus. There was one
round of data analysis. Themes are presented using
quotations. Participants are identified by number (e.g.
P1 is participant one) and setting (cmhn is community
mental health nurse).
QUANTITATIVE FINDINGS
Sample demographic details
The majority of participants were female (n = 247,
71%) and aged between 21 and 64, with an average
age of 39.02 (SD = 9.64). The majority practiced on a
full-time basis (n = 306, 88%), and the mean length of
experience as a nurse was 14.4 years (SD = 10.81).
Fifty-six per cent worked in acute admission units
(n = 194), and the rest worked in four areas within
community mental health services (n = 152, 44%). The
majority of participants were parents (n = 209, 60%). A
minority (n = 54, 16%) had received family training
and/or child training (n = 51, 15%). The focus of fam-
ily training tends to involve how to involve and support
adult family members in parents’ care (Coyne et al.
2013) while child training focuses on child develop-
ment and well-being.
Extent of nurses’ FFP
There were generally low scores on the six behavioural
subscales in the FFFMHPQ (between 1 and 4 on the
Likert scale), with the majority (n = 234, 68%) scoring
between 3 and 4 on all but one subscale (i.e. interven-
tions to promote parents’ mental health). However, a
third of participants (n = 109, 32%) scored at a high
level (between 5 and 7) on at least three of the six
© 2018 Australian College of Mental Health Nurses Inc.
NURSES’ FAMILY-FOCUSED PRACTICE
FFP behavioural subscales and had higher mean scores
on all 14 FFP subscales when compared with the rest
of the sample. For a description of subscales, see
Table 1. While (n = 36) 33% of these high scorers
were practicing within the acute inpatient setting, the
majority practiced in the community setting (n = 73,
67%) and in particular within community mental health
nursing services (n = 48, 44%).
Predictors of FFP
The predictors in the regression analyses explained a
small to moderate proportion of the variance in the
DVs (see Table 2). Fourteen of the 17 IVs were identi-
fied as significant predictors, in the third step, in one
or more of the six multiple regression models. In com-
bination, they predicted between 23.1 and 38.5% of
variance. The significant variables in the 3rd block of
the multiple hierarchical regressions are shown in
Table 2. Standardized beta coefficients illustrate that
self-perceived skill and knowledge was the single most
important predictor of nurses’ FFP as it was significant
in all six dependent variables (DVs) tested. Confidence
around parenting and children and work setting (acute
inpatient unit vs community setting) were also key.
QUALITATIVE FINDINGS
Sample demographic details
Nine participants were female and 12 were parents.
Participant’s ages ranged between 26 and 55 years.
Length of experience as a nurse ranged between six
and 35 years with 18 years being the average duration.
Participants had spent between 4 and 18 years in their
current position (mean 9 years). Six had a bachelor’s
degree, while five had a masters level qualification.
Four had also received some form of family-focused
training and five had received child-focused training.
Interview themes
The main themes generated from the interviews in
relation to enablers of FFP were participants’ parenting
experiences and the opportunity to visit service users’
homes.
Parenting experience
All participants who were parents indicated that their
skills, knowledge, and attitudes to engage in FFP were
© 2018 Australian College of Mental Health Nurses Inc.
145
developed through their experiences of caring for their
own children as this helped to increase their awareness
of service user’s needs as parents and the needs of
their children. Participant 8 (P8) (cmhn) stated, ‘a lot
of nurses are in the process of becoming first time par-
ents and this motivates them to think about the chal-
lenges experienced by service users who are parents’.
Similarly, P3 (cmhn) contended ‘my own experience as
a mother is one of the most important factors in it.
Most of us are aware of our own children’s needs and
then when you see a service user’s child and you think
their needs aren’t being met you are more aware’.
In further response to this issue, participants pro-
vided detail on how their own parenting experience
also enabled them to be nonjudgemental and that this
in turn helped them to forge and sustain partnerships
with parents. For instance, P14 (acute) indicated:
My own experience as a parent gives me insight into
how challenging parenting can be. Without that insight
I would find it difficult to support parents as I would
have a preconceived idea of how things should be.
P4 (cmhn) provided yet more detail when she sug-
gested that:
You would see things that are wrong in the house-
. . .and you would broach that very gently. . .like if the
children weren’t washed and looking for food. . .my
experience of the challenges of meeting my own chil-
dren’s needs helps me be more mindful of the need to
avoid sounding judgemental.
Alternatively, both participants who were not par-
ents suggested that this made it more difficult for them
to support parents and their families because they were
not fully aware of the challenges of parenting and were
not sure how to advise parents about parenting. More-
over, they perceived that parents may think that they
could not advise or support them without having per-
sonal experience of parenting. This is perhaps best
demonstrated by P1 (cmhn) who reported ‘I don’t have
children myself so it can be difficult. . .to understand
the challenges of parenting or to advise parents about
their relationships with their children’. When working
with a parent who experienced mental health issues,
P7 (cmhn) suggested, ‘I think if I had kids she would
have spoken to me more openly about it. . . she might
think that I would be able to understand her challenges
as a parent and be able to empathise’.
Those with parenting experience supported parents
by being empathetic and disclosing their own parent-
ing experiences to engender parents’ trust, normalize
146 A. GRANT ET AL.

TABLE 2: Forward regression analyses of predictors of family-focused practice behaviours/activities

Dependent variable Significant predictors Stdised beta Adj R2 df F-test Sig.

Providing support to Skill and knowledge 0.34 0.20 16 309 6.22 P < 0.000
carers and children Work setting 0.30
Service availability 0.15
Worker confidence 0.12
Confidence around parenting 0.11
and children generally
Providing family and Skill and knowledge 0.44 0.27 16 309 8.69 P < 0.000
parenting support Work setting 0.20
Training 0.17
Time and workload 0.16
Assessing impact on Skill and knowledge 0.43 0.19 16 309 5.80 P < 0.000
children Work setting 0.16
Length of time in current position 0.14
Confidence around parenting 0.10
and children generally
Referrals Work setting 0.31 0.21 16 309 6.46 P < 0.000
Skill and knowledge 0.20
Worker confidence 0.16
Length of experience 0.16
Service availability 0.12
Family training 0.11
Interventions to Skill and knowledge 0.46 0.35 16 309 12.09 P < 0.000
promote parent’s mental Interprofessional practice 0.20
health Length of time in current position 0.11
Work setting 0.11
Service location 0.12
Connectedness Skill and knowledge 0.45 0.33 16 309 11.08 P < 0.000
Work setting 0.10
Engagement issues 0.17
Interprofessional practice 0.13
Confidence around parenting 0.12
and children generally
Time and workload 0.11
Gender 0.11

The overall significance of the model and each variables significance are important. Adj R2 is the variance explained in the model, standard-
ized beta indicates the individual contribution of each predictor in its relationship with the DV. The P value indicates the significance level in
predicting the DV.

parenting challenges, and help parents discuss their
child caring experiences. P1 (acute) reported ‘because
I have a sense from rearing my own children that
these are the trigger times I can ask, empathise,
understand and I am able to say to parents I know
what that’s like, I have kids’. P6 (cmhn) summarized
the impact of sharing their parenting experiences when
she described saying to a parent, ‘God I remember
when they were that small and it’s not easy’, to convey
to parents that ‘everybody experiences difficulties as a
parent and to get across to them. . .don’t be afraid to
ask for support’.
Some drew on their practical parenting experiences
to support parents. For example, P3 (cmhn) reported:
The child had head lice. . .the mother wasn’t doing any-
thing about it. Most school aged children, including my
own, have this problem at some time. I went down to
the house and I brought treatment for head lice with
me and said to the mother come on, we’ll wash their
hair together.
In a similar way, five participants drew on experi-
ences of personal parent–child interactions to engage
directly with service user’s children, for example, ‘I
talk to the children in the way I would talk with
my own children’ (P11:cmhn). Some participants
noted the benefit of other team members being par-
ents: ‘I tend to talk to other staff about it and I
think I would always veer toward staff who, like

© 2018 Australian College of Mental Health Nurses Inc.

NURSES’ FAMILY-FOCUSED PRACTICE
me, had grown up children that were that age’
(P14: acute).
Home visiting
All participants based in the community described how
home visits were employed to foster a family stance.
P5 (cmhn) summarizes these sentiments when she
reports:
The home is the centre point of the family. Being
able to go into the home is pivotal in being family
focused because you’re not only working with the par-
ent but you’re also able to gauge the feelings and
interpretations of the children and other family mem-
bers.
Participants described using home visits to observe
and monitor normal family life: ‘you make sure you can
spend time in the home environment to watch the
interaction between parents and their children’ (P11:
cmhn). Similarly, P3 (cmhn) contended:
I need to see what that house looks like and feels like.
The happy kids are obvious the minute you look at
them and you can see they’re close to their parent
while at other times you can feel the tension in the
house.
In further response to this issue, a number of partic-
ipants also indicated that they would use home visits
specifically to access to children so as to observe and
monitor their well-being, for example, ‘. . .one of the
main reasons that we would do a home visit is if people
have young children and the kids were at home and we
would go out and visit people whilst their children are
present. . .’ (P6:cmhn).
Home visits facilitated accurate assessments, for
example, P6 (cmhn) contended ‘if we’re not sure
whether a parent is being honest with us about their
capacity to cope with parenting a home visit can speak
volumes’, while P4 (cmhn) suggested:
Sometimes I see mums on their own and they’re mak-
ing it out to be rosy. I go back the next evening when
the children are in to see how things are and there’s
chaos. It’s a good learning curve for me as well as for
the mum to see how she is managing. (P4:cmhn)
Some participants also implied that their col-
leagues in the acute setting were disadvantaged by
not being able to do home visits, for example, ‘the
community perspective is so different to working in
an inpatient setting because we see it as it is’ (P12:
cmhn).
© 2018 Australian College of Mental Health Nurses Inc.
147
Participants also suggested that caring for parents in
the home environment, when they were managing their
mental illness in conjunction with their normal daily
activities, including parenting, enabled them to focus
on children’s needs, for instance:
. . . we’re trying to treat people who are unwell in their
home environment so. . .we’re a bit more clued in to
what’s going on with the kids and are they getting to
school, who’s getting them to school, who’s making
their lunches, and how’s all that happening. (P4:cmhn)
This contrasted with the hospital setting ‘If you’re in
the hospital ward your focus is much narrower. You’re
just dealing with the issues with the parent on the
ward. . .you don’t have all those things that affect them
when they are unwell and having to manage daily living
in their own homes’ (P3:cmhn).
Additionally, home visits were used to forge a rela-
tionship with the parent and to work in partnership
with them. For instance, P11 (cmhn) reported:
You can’t support the parent unless you’ve an emo-
tional connection with them. Being in their home envi-
ronment, helps you to better understand them as a
person and parent and the challenges they experience
in their daily lives and this can help you to develop a
good relationship with them and to work in partnership
with them to support both them and their children.
(P11:cmhn)
DISCUSSION
This research aimed to identify and describe the key
predictors and enablers of nurses’ FFP in adult mental
health services. The key variables contributing to
higher FFP levels were nurses’ level of knowledge and
skill, followed by nurses’ confidence around parenting
and children and practicing in community settings,
alongside opportunities to engage in home visiting. It is
important to identify and describe factors that predict
and enable nurses’ FFP to promote their capacity to
engage in FFP.
The findings showed the majority of nurses were
not particularly family-focused although a third of the
sample (primarily nurses practicing within community
settings) scored at a higher level on the FFMHPQ
subscales. Previous research suggests that mental
health professionals, including nurses, rarely acknowl-
edge and/or support service users’ parenting responsi-
bilities (Houlihan et al. 2013; Korhonen et al. 2010).
However, our research shows that, while on average
FFP is low, a significant minority of nurses,
148
particularly in community settings, practice in a fam-
ily-focused manner.
The most significant predictor of nurses’ FFP was
knowledge and skill. This relates to nurses’ knowledge
of the effects of PMI on children and their skill in
working with parents to reduce negative outcomes on
children. Similarly, Maybery et al. (2016) found that
knowledge and skill was a key predictor of Australian
mental health professionals’ FFP and recommended
that they receive training in FFP to support parents,
children, and adult family members. When nurses
report adequate knowledge and skills, they perceive
fewer barriers to FFP and are more likely to engage
(Grant et al. 2016; Korhonen et al. 2010). Our study
suggests that high scoring nurses who perceive they
have the knowledge and skill to engage in FFP pre-
dominantly practice in community settings (with oppor-
tunity for home visiting) and have parenting
experience. Whether these factors are causative or
associative requires further investigation.
Home visits have been shown to be particularly ben-
eficial for families where a parent has mental illness
(Isaacs 2007; Van Doesum et al. 2008). Home visiting
programmes may be effective because these allow
nurses to accurately gauge the needs of families and
can provide an early identification of indicators of dis-
tress (Cummings & Whittaker 2016). Home visits may
also promote an equal relationship and collaboration
between nurses and service users (Mayor & Bietti
2017). However, our study provides evidence that it is
the nature and quality of the home visit that has an
impact. All the high scoring nurses practicing in the
community reported intentionally using home visits to
observe how parents functioned in their daily lives and
interacted with children. Observing parents and chil-
dren’s interactions enabled nurses to identify emerging
difficulties related to parenting, the parent–child rela-
tionship, and children’s development. This information
was then used by nurses to work with parents in a col-
laborative manner to address parenting and to directly
support their children. Perception of negative judge-
ments about parenting capacity is one of the most com-
mon reasons for resistance to FFP by mothers with
mental illness (Montgomery et al. 2011). Home visiting
may potentially promote parents’ trust and acceptance
of a family-focused approach by enabling an equal rela-
tionship and collaboration.
In comparison, there are limited opportunities for
children to visit their parents in acute inpatient units
(Korhonen et al. 2010) and there may be less scope for
partnerships between parents and professionals (Mayor
A. GRANT ET AL.
& Bietti 2017) and, therefore, few opportunities for
nurses to observe parenting behaviour and engage par-
ents in discussions around parenting (Maybery & Reu-
pert 2009). This may partially explain the differences
between the two groups of nurses in the present study.
That said, four of the high scoring nurses practiced
within the acute inpatient setting, which suggests that
factors related to nurses’ personal attributes may have
primarily enabled their FFP.
Another key predictor and enabler for FFP in the
current study was nurses’ personal experience of caring
for their own or a family member or friend’s children.
Findings from the interviews demonstrate how nurses
draw on their personal experience of caring for chil-
dren to engage parents in conversations around parent-
ing and engage with children directly. This finding
suggests that an appreciation of the normal challenges
of parenting may increase nurses’ awareness of the
needs of service users who are parents and give them
motivation and confidence to address parenting as part
of routine practice.
Limitations
While the FFMHPQ had documented validity and reli-
ability in the Australian context (Maybery et al. 2012),
there was poorer reliability of the majority of subscales
in the Irish context. Poor reliability may be partly due
to a lack of sensitivity of nurses in Ireland to FFP and
limited understanding of concepts being measured.
However, as the qualitative findings resonated with the
quantitative findings, this provides a degree of reassur-
ance that the findings are reliable and valid. Given the
large number of statistical tests conducted, caution
should also be used in interpreting the results for some
of the subscales. However, all subscales, with the
exception of worker confidence, would still maintain a
statistically significant difference if we were to control
for multiple testing. Furthermore, while the study
identified 14 predictors of FFP, these only explained
between 23.1 and 38.5% of variance across the six FFP
behavioural subscales measured, suggesting that a con-
siderable amount remains unexplained, offering fertile
ground for future research. Future research should
build on this work to validate the findings, particularly
regarding the impact of different work settings and to
determine any additional predictors of mental health
professionals’ FFP, including personal attributes. While
information was collected on prior training experiences,
we did not collect how recent this training was, which
may impact on knowledge and skill. The data reported
© 2018 Australian College of Mental Health Nurses Inc.
NURSES’ FAMILY-FOCUSED PRACTICE
here represent nurses’ self-reported views of their FFP
and this may not reflect their actual practice. Also, the
qualitative component focused only on those nurses
who self-identified as family focused. Further research
could consider low scoring nurses’ perspectives of FFP.
Observational research might also be conducted to pro-
vide additional data regarding the core components of
nurses’ FFP and could include the perspectives of
other mental health professionals and family members.
CONCLUSION
Nurses’ knowledge and skills, parenting experience,
and work setting (i.e. community) are significant pre-
dictors of FFP. Nurses’ who disclosed their parenting
experiences described how this fostered trust and
encouraged service users to open up about their par-
enting issues. The opportunity afforded to community
nurses to visit a service user’s home allowed them to
observe how the parent and family were coping and
forge a close relationship with the family.
RELEVANCE FOR CLINICAL PRACTICE
The findings of our study are consistent with the litera-
ture in highlighting the important part that nurses’
knowledge plays in predicting and enabling FFP. While
training programmes can impart this information and
develop awareness of importance of FFP, the findings
here suggest that nurses’ experience of parenting and
relating to, and caring for their own children, can fur-
ther boost their knowledge and skill, motivation, and
confidence to engage in FFP. The findings also suggest
that nurses who have the necessary knowledge and
skills and motivation to engage in FFP may be better
positioned to intentionally use home visits to observe
normal family life and to actively collaborate with par-
ents to support them in their parenting and engage
their children.
To foster and sustain a whole family approach, par-
ticularly in acute inpatient settings, the central role that
home visiting and nurses’ parenting experience play in
enabling FFP needs to be considered in routine prac-
tice and service development, including training. Pro-
fessional organizations and training programmes should
consider how home visiting may be used by nurses
when engaging with service users who are parents. As
not all those nurses practicing in the home environ-
ment were family focused, managers and trainers could
draw upon the findings of our study to explicitly high-
light how home visits can be intentionally used by
© 2018 Australian College of Mental Health Nurses Inc.
149
nurses to engage in FFP. Service managers could also
develop a process whereby nurses practicing within
acute inpatient units are afforded regular opportunities
to work alongside nursing colleagues providing services
to parents in the home environment, to learn about the
family and observe how home visiting might promote
FFP. Additionally, family rooms in acute settings need
to be promoted as a means of providing family-focused
care, although further work is required on how nurses
might use these spaces (Isobel et al. 2015).
The study findings also clearly indicate a need for
child- and family-focused training to enable nurses to
develop the appropriate knowledge, skills, attitudes,
and competencies to support parents, their children,
and adult family members in a strengths-based and
early intervention manner. Nurses’ parenting experi-
ence was an important resource for FFP. However, not
all nurses who were parents were high scorers, so edu-
cational programmes could encourage critical reflection
on parenting experience, so that it can inform how
nurses engage in FFP. It is also important that trainers
consider how to support nurses without parenting
experience to gain commensurate knowledge. Trainers
could encourage nurses who are not parents to draw
on their experiences of caring for a family member or
friend’s children, as well as reflecting on their experi-
ences of being parented. The sharing of personal expe-
rience may also help nurses, irrespective of parenting
status, to learn from each other and to dispel attitudes
that first-hand parenting experience is essential to
engage in FFP. It may also develop nurses’ awareness
of the range of challenges that parents experience and
promote their capacity to adopt a nonjudgemental
approach in supporting parents who have mental ill-
ness.
Nonetheless, while it is important for nurses to pro-
vide FFP, it has been argued that not all nurses will
have an opportunity to come into direct contact with
service users’ children (i.e. those working in out-patient
clinics) (Reupert & Maybery 2014). What a particular
professional group or service could or should do in
relation to FFP warrants further research, especially
from the perspective of families. Such information
would also inform mental health policy more broadly
across services.
ACKNOWLEDGEMENTS
We would like to thank the mental health nurses
involved in the study and their managers for facilitating
access to mental health nurses.
150
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SUPPORTING INFORMATION
Additional Supporting Information may be found in
the online version of this article at the publisher’s web-
site:
Appendix S1. Interview schedule