The findings are presented according to the four dimensions of NPT. Coherence describes how clinicians accepted the idea of increasing psychosocial focus in developmental assessments. Cognitive participation relates to how clinicians engaged with the standardised child records. Collective action describes mechanisms related to integration of the new practice and reflexive monitoring outlines how clinicians appraised the child records. Together, these dimensions shed light on barriers and facilitators when introducing the standardised child records into developmental assessments in general practice, in line with the aim of this study.
Coherence: clinicians accepted the idea of increasing psychosocial focus in developmental assessments
Importance of developmental assessments
Developmental assessments formed a large part of the clinicians’ workload and they considered the preventive work an important part of their job. The clinicians found that antenatal and developmental assessments provided continuity of care, increased their knowledge of the families and strengthened clinician-parent relationship.
Interest in psychosocial aspects
Prior to the project, many clinicians were already interested in psychosocial aspects within the family. All clinicians were initially positive towards an increased psychosocial focus in the developmental assessments, and they participated in the study in the hope of becoming better clinicians and contributing to optimising the developmental assessments. A midwife reflected that the purpose of the developmental assessments has changed over the years, which is why the guidelines should be revised accordingly:
“… you have not really revised the child health examinations since the 60s and the purpose of them, and back then there was high child mortality, and that is certainly not the case anymore. Then, how can we use these child health examinations?” – Midwife 9
Cognitive participation: it was novel for clinicians to ask families systematically about psychosocial factors
Relevance of the standardised child records
Most clinics had patients with high socioeconomic status and the pregnant women were generally well functioning. This led some clinicians to feel that increasing psychosocial focus was not relevant in their clinic after all and their engagement decreased over time. Others still found it important because families with high socioeconomic status could still have important psychosocial problems. Prior to the study some clinicians experienced that patients did not always share important psychosocial aspects of their lives on their own initiative:
“... if the parents split up or something bigger happens, then it’s really important. And I have learned over the years that it is certainly not everyone who opens up about it.” – GP 8
Therefore, some clinicians found that it made a lot of sense to approach these themes methodically, as they would during the somatic part of the examination.
Comparison to previous practice
A systematic approach to the developmental assessments was not new to clinicians. Many used self-made templates in the medical records, which were used as checklists during the consultations, so the concept of doing the assessment systematically integrated well with existing practice. Their systematic approach was, however, mainly applied to the physical examination prior to this project, and it varied how in depth the clinicians had recorded social conditions beforehand. Most clinicians found it novel to have the same kind of systematic approach when taking the medical history:
“Something like social resources for example – it is new to ask about this. Relationships with grandparents is a new thing to ask about and then I have probably not asked so systematically about mental wellbeing.” – GP 6
Collective action: clinicians integrated the new practice in various ways
There were different opinions as to whether the systematic approach should be standardised. Some clinicians were confident that the parents themselves would bring up their problems during the consultation because the clinicians knew their patients very well, which also made many of the standardised question superfluous:
“You don’t ask if grandparents are present (laughs), are your siblings there and all those family relations. I asked about that many years ago. I already know that.” – GP 1
This led some clinicians to use only the parts of the standardised child records which they found to be relevant. Other clinicians went through all elements of the record every time as it ensured nothing to be overlooked:
“I think it makes a lot of sense to go forward systematically, so you don’t forget or overlook anything.” – Midwife 10
Some clinicians gained information that they believed parents would not have volunteered and thereby would not have been recorded without the standardised records.
“Well, there is something about those family relations which has been made clearer, where I wouldn’t have caught it before [prior to using the child records]” – Midwife 11
For instance some clinicians uncovered problems with sick grandparents early on and attributed this to the use of the standardised child record. In one of these cases having a sick grandparent contributed to the mother experiencing post-partum depression and the midwife considered it was helpful to know this early on. Applying the systematic approach of the standardised child records also became very useful in a case where the father was moving abroad. The parents were planning on sending the baby to family members in another country during that period. According to the GP all of this led to a planned visit to the home by the community health nurse, who discussed parent–child attachment with the mother and helped to get the child into a nearby day care service in order to keep him with his mother in Denmark.
Some clinicians found that parents would normally talk about certain subjects which they expected the clinician to be interested in. These would primarily be problems regarding the child and its physical wellbeing but less about the family and the child’s environment:
“… they [the parents] only answer regarding how things are with the baby. So [shows tunnel vision with her hands] that is what you get, if you ask such an open question, you get answers to how the baby has slept last night or how much it has vomited… you very rarely get to know anything about how mom actually feels herself.” – GP 3
Some clinicians found it awkward to ask questions about psychosocial aspects especially within resourceful families, and some clinicians completely neglected such questions if they had a feeling that there were no challenges at home:
“These are some silly questions and it’s hard to ask them. We are located in an area where there are many well-functioning people. It’s not a socially burdened area.” – GP 5
All clinicians believed parents should be able to influence what topics were discussed in the consultation and most desired some degree of free space during the consultations to avoid the conversation becoming too manualised. Some feared that using the child records could cause the conversation to be hasty and checking off boxes in a form could prevent parents from going into details and bringing up important elements spontaneously:
“… having to ask, and then there will be a lot of no’s. It makes it a little easier to touch lightly on some things if there are a lot of no’s… it’s nice enough that it’s very specified, but… you may not focus on the one thing that matters the most.” – GP 2
A few clinicians did not experience this dilemma as they used the child records as a conversation starter rather than a checklist, making it possible to have a loose conversation where these psychosocial aspects were included without the consultation becoming rigid. When the same questions were repeated at different developmental assessments clinicians found the record less workable and they feared that parents would find it tiresome.
Using the parent–child interaction assessment
Most clinicians had observed the interaction between parent and child to some extent prior to the study but the structured observation points in the record had facilitated a more conscious and systematic approach. While some found applying the concepts used to stimulate observation of parent–child interaction (“does the parent collaborate with the child?”, “is the parent sensitive to the child’s needs?”, “does the parent respect the child’s autonomy?”) “really simple”, others felt the concepts overlapped which made them difficult to note separately in the records. Nevertheless, the clinicians generally experienced being more aware of what to look for in the interaction between parent and child due to the use of the parent–child interaction assessment:
“I actually think it has been really good, because it can be very easy to just say: “well, it’s all fine”, whereas here I have really noticed it.” – Midwife 10
“It actually supported me… It has become something I have implemented in my head when I observe a mother and a child.” – GP 8
Moreover, there were examples of specific cases where the clinicians found the parent–child interaction assessment useful. One GP noticed a mother not carrying her child in a loving, caring way. Another GP experienced a case where the parents seemed to have problems understanding their child’s signals and responding properly. They started clapping over his head when he cried, which seemed to make him more distressed. A midwife described yet another case where a parent got frustrated during the developmental assessment:
“When the little one starts to cry… she looks away and: “I just don’t know what to do, when he does that.” And then she can ignore him, and then the other one (parent) takes over” – Midwife 9
Using the parent–child interaction assessment located problems sooner, thereby addressing them early on and helping the couples cope better.
Changes in work-flow
Some clinicians included items from the standardised child records in the medical history in every developmental assessment, where others incorporated the parent–child interaction assessment into their usual workflow. A few GPs planned to teach their colleagues about the parent–child interaction assessment, and some considered using the child record as a guide for trainee doctors.
Some clinicians changed their own behaviour during the developmental assessments. For example, one GP stayed more in the background – pretending to watch the computer for a while – thereby giving room for the parent to interact with the child. Other clinicians felt more professionally engaged in the developmental assessments compared to before. One GP emphasised that developmental assessments were no longer conducted as a physical checklist. All clinicians experienced some extent of increased focus on families’ psychosocial wellbeing:
“… I think it has given a different presence – a different focus on wellbeing, both on mother and child – especially on the parents.” – GP 3
Reflective monitoring: clinicians gained increased psychosocial focus from using the standardised child records but they also experienced barriers when using them
Structured approach to developmental assessments
According to some clinicians the standardised child records with increased psychosocial focus provided an earlier detection of problems with wellbeing and gave a more nuanced and detailed picture of the family situation:
“It was definitely an advantage to ask about their network and living conditions and all these things, which were actually specified.” – Midwife 9
Many clinicians were ambivalent and felt some resistance towards the developmental assessments becoming too standardised:
“I don’t think you can make anything standardised for every clinic. The old solo practitioner, who has to change the approach he had for the last 30 years, compared to a newly educated young female [doctor] who had just become a mother herself, I think they do things differently.” – GP 7
Several clinicians suggested that the child records should only be used with specific, vulnerable families or only in clinics located in more social disadvantaged areas. A midwife pointed out that it was beneficial to ask all families about psychosocial aspects, and to avoid parents from feeling stigmatised as particularly vulnerable she would say: “I actually just have to ask about these things”.
The parent–child interaction assessment gave some clinicians a new vocabulary to describe what they observed, both in relation to documenting findings, but also if the parents needed guidance:
“I could have used the words for what I thought was missing [e.g. in the parent child- relationship]. Sometimes you just can’t see what it is – where it is you don’t feel the parents hear or see the child. I have got words for that now. I just think those were the words I was missing back then to be able to describe it.” – GP 7
Most of the clinicians felt that more consultation time than the usual 15–20 min would be needed to go into detail about psychosocial wellbeing in the developmental assessments. Once an issue was brought up the clinicians did, however, find the setting of primary care useful because of the possibility to invite the families back for extended visits. When using the parent–child interaction assessment, some clinicians found it problematic that they only witnessed a short moment of interaction which could make the assessment difficult.
Some clinicians found it awkward to ask about personal matters – especially if it was not in line with parents’ expectations which revolved around physical aspects. Most clinicians felt it was difficult to comment on areas where parents could improve:
“I think that can also be difficult, because it’s hard to criticise a mother who… does her best, right? And you have to be careful how you do it so that you still have their trust and they don’t feel like a bad mother, right?” – Midwife 11
Discussing psychosocial aspects demanded that clinicians choose their words carefully in order not to push the parents away. Some clinicians hoped that showing interest in families’ psychosocial wellbeing would make it more “straightforward” for parents to reach out and seek help when needed.
Handling psychosocial issues
A few clinicians were frustrated by having to explore psychosocial issues more in depth as they felt they lacked options on how to act on concerns, and that they were unable to access services that could alleviate lack of social networks or parenting problems. On the other hand, some clinicians pointed out that just listening to the parents and letting them get something off their chest in a safe space could have a significant impact on its own.
“… you’re also a pastoral carer when you’re a GP. You’re not just a doctor…” – GP 1
Thereby emphasising that part of a GP’s job is to listen, give guidance and deal with emotional problems as well as physical and mental issues.
Many clinicians thought that findings had to be of a specific character in order to document them because patients/parents have access to the record which could, potentially, be used in later litigation:
“Well, you can say that a medical record follows you for your whole life and similarly in the context of insurance... It must be accurate, but you must be careful not to write anything that could harm the patient in the long run.” – GP 6
In this project the record lends itself to writing about the parents in the child record, which raised another legal concern about third party information. One GP experienced a case where the father sought access to the children’s records in connection to divorcing the mother. According to the GP this could potentially have affected a family lawsuit if the record had said anything problematic about the mother’s behaviour or psyche.