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Practitioner assessments of 'good enough' parenting: Factorial survey

Article  in  Journal of Clinical Nursing · May 2009

DOI: 10.1111/j.1365-2702.2008.02661.x · Source: PubMed

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N U R S I N G W O R K FO R C E

Practitioner assessments of ‘good enough’ parenting: factorial survey

Julie Taylor, William Lauder, Maxine Moy and Jo Corlett

Aim. The aim of this study was to measure health visitors’ professional judgements on ‘good enough’ parenting and identify
what factors and combinations of these are important when making such judgements.
Background. The relationship between parenting and child health is unclear. Whilst agreement exists that ‘good enough’
parenting requires boundary setting, consistency and putting the child’s needs first, attempting to define ‘good enough’ parenting
in precise terms is complex. When faced with a complex situation, practitioners rely on relatively few factors to form judgements.
Design. Factorial survey methods were employed using vignette techniques.
Methods. Vignettes were constructed using previous research on those variables, which may influence nurses’ judgements, for
example, accommodation and child dentition. The level of factors was randomly varied. Two thousand vignettes were admin-
istered to a sample of 200 health visitors in two Health Boards who then made a judgement about this scenario.
Analysis. Data were analysed through multiple regression with dummy variables and one-way analysis of variance. Regression
equations for both good enough mothering and good enough parenting are reported.
Results. The models used are significant predictors of parenting and mothering. Significant predictors on health visitor judge-
ments’ were boundary setting in sleep behaviours, type of housing inhabited and health behaviours. Although parenting and
mothering are often conflated, health visitors appear to separate these aspects when making judgements based on type of housing.
Conclusions. Most professionals can articulate what makes a ‘good’ parent, equally they may have strong views regarding what
constitutes ‘poor’ parenting. The difficulty is in determining when parenting is ‘good enough’ to provide a child with a nurturing
environment.
Relevance to clinical practice. This study suggests that practitioners move their thresholds of what is ‘good enough’ depending on
a narrow range of factors. Awareness of the factors, which influence individuals’ judgements is important in safeguarding
children.

Key words: children, factorial survey, judgement, nurses, nursing, parenting

Accepted for publication: 15 August 2008

Recent UK policy has emphasised the importance of good

Introduction
As front-line clinical workers, nurses are often in a strong position to
identify signs of abuse and neglect in patients, carers and families
across the age spectrum and to trigger appropriate responses from
services (Scottish Executive Health Department 2006).
parenting and nurturing families as a key factor in providing
children with a good start in life (Attree 2004). Indeed, the
need for practitioners to facilitate the development of such
skills within families is recognised internationally (Depart-
ment of Health 2004). However, the relationship between

Authors: Julie Taylor, MSc, PhD, RGN, Professor of Family Health,
School of Nursing and Midwifery, University of Dundee, Dundee,
UK; William Lauder, PhD, RMN, Professor of Nursing, School of
Nursing and Midwifery, University of Dundee, Dundee, UK; Maxine
Moy, MSc, RGN, RHV, Nurse Consultant Vulnerable Children and
Families, NHS Fife, Dundee, UK; Jo Corlett, BA, MSc, PhD, RGN,
RNT, Postgraduate Co-ordinator, School of Nursing and Midwifery,
University of Dundee, Dundee, UK
Correspondence: Julie Taylor, Professor of Family Health, School of
Nursing and Midwifery, University of Dundee, 11 Airlie Place,
Dundee DD1 4HJ, UK. Telephone: +44 0 1382 388532.
E-mail: j.z.taylor@dundee.ac.uk

1180  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
doi: 10.1111/j.1365-2702.2008.02661.x
Nursing workforce
parenting and child health, in particular the impact parenting
may have on negating adverse socioeconomic circumstances
is unclear (Taylor et al. 2000). To respond appropriately to
families who may be struggling, practitioners first need to
recognise situations where parenting may not be optimal.
Based on Winnicott’s (1957, 1964) early, yet still relevant
observations, recognising either good or poor parenting is
perhaps quite straightforward: the challenge is to identify
parenting which is ‘good enough’. In line with current policy
shifts (Department of Health 2002, 2003, 2004, Brandon
et al. 2008), safeguarding children at risk or in need is
required to provide support to families where this threshold
may not have been reached. Indeed, the Framework for
Assessment (Department of Health, 2000) used extensively
across disciplines in the UK is predicated on early recognition
and support where there may be unmet needs. This study
focused on how health visitors make judgements regarding
‘good enough’ parenting.
Background and context
Over many years, various researchers have attempted to
develop measuring tools identifying aspects of ‘good’ and
‘bad’ parenting (for example Grusec & Walters 1991, Burke
et al. 1998), with an emphasis on trying to establish what
constitutes ‘good enough’ parenting, as few parents are
perfect all of the time (Hoghughi & Speight 1998). Although
there is general agreement that ‘good enough’ parenting
requires the setting of boundaries, consistency, unconditional
love and most importantly, putting the child’s needs first
(Edwards 1995, Azar & Cote 2002, Budd 2005), to date, the
research suggests that attempting to define ‘good’ or ‘good
enough’ parenting in precise terms is a complex endeavour,
one which is open to ambiguity (Taylor et al. 2000).
Practitioners involved in child care play a central role in
ensuring children are safe and well, in extreme situations
acting as gatekeepers to substitute care for a child (Depart-
ment for Education and Skills 2004). Observing and moni-
toring parenting behaviours and making decisions about
‘good enough’ and ‘not good enough’ parenting skills are
central to this role, but there appears to be some uncertainty
regarding how practitioners arrive at such decisions
(Thoburn et al. 1995). Munro’s (1996, 1999) work on how
practitioners make decisions in child protection work is
particularly relevant, where she concludes that practitioners
intuitively simplify reasoning processes when making com-
plex judgements. The most recent biennial analysis of serious
case reviews (Brandon et al. 2008) reaches similar conclu-
sions: whilst we often have the evidence that something is not
quite right, the complexities involved sometimes mean we
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
Practitioner assessment of ‘good enough’ parenting
screen out certain kinds of information to make judgements
on a narrow range of factors.
Giller et al. (1992) suggested such decisions appeared to be
based on subjective personal or professional intuitions and
experiences and similar reports have been made by many
others, including Munro (1999), Daniel (2000) and Buckley
(2005) in social work, by Appleton (1994, 1996) in health
visiting and Lauder et al. (2006) in nursing. There is,
increasingly, a body of research focusing on the development
of parenting assessment tools (see for example Azar 1997,
Azar & Cote 2002, Shlonsky & Wagner 2005) and a trend
towards parenting assessment as predictive of risk (Baird
et al. 1999, Baird & Wagner 2000, Taylor et al. 2008). The
attention paid then towards parenting capacity and capability
is immense, but there has not always been consistency in how
parenting, or factors that affect it, are assessed (Kähkönen
1999). Despite the inconsistencies, ‘good’ and ‘good enough’
parenting are well-used terms in child care and protection
(Taylor et al. 2000).
Delivering Child Health Programmes to all families is a
central focus within the role of health visitors, with a
specific safeguarding children agenda now imbued within
the role of all professionals (Department for Children
Schools and Families 2008). As subsequent Hall Reports
demonstrate (Hall & Elliman 2003), approaches to child
surveillance, the pivotal position of Public Health Nursing
in delivering programmes, supporting parents and making
use of the necessary contact with families to identify
vulnerability, does not alter (CPHVA 2000, Whitaker &
Cowley 2003, Abbott et al. 2004). It is accepted that early
intervention is crucial and that family need increases in line
with increasing stress within families (Little 1999, Azar &
Cote 2002).
Assessment in practice tends to focus on ‘bad enough’
parenting, thus biasing child care away from preventive and
helpful parenting practices, towards investigation of harm
(Newman 2004). The authors also assert that whilst aware
of the need to take the socioeconomic circumstances of a
family into consideration, practitioners’ assessments tend to
focus on the emotions and behaviour of parents. Profes-
sional insight and experience were seen to be important
elements in assessing parenting capability (Newman 2004).
Elsewhere however, authors have suggested that practitio-
ners’ personal and work experiences with families can
adversely affect their perceptions and colour their judge-
ment (Voight et al. 1996). Research suggests parenting
practices may vary according to culture, with different
interpretations of appropriate and inappropriate parenting
across diverse ethnic groups (ISPCAN 2006). Practitioners
need to be aware of their own beliefs and how these might
1181
J Taylor et al.
influence their interpretation of the parenting practices they
come across within a multiracial society (Maiter et al.
2004).
Holistic and objective assessment is needed of all those
factors affecting a family and parenting ability including
socioeconomic, psychological and emotional factors and the
cultural environment within which parenting now occurs
(Taylor et al. 2000). The understandable aspiration for
holistic assessment is somewhat confounded by the psychol-
ogy of judgement formation and decision making. When
operating in complex and fast moving situations individuals
rely on rules of thumb or fast and frugal heuristics to make
decisions quickly and efficiently (Gilovich & Griffin 2002)
Fast and frugal heuristics allow community practitioners to
focus on a relatively few pieces of information (Lauder et al.
2006).
Assessing need within families is a complex process
central to the role and service delivery of health visitors.
The Department for Children Schools & Families 2008) has
recognised this complexity: it requires high level skills,
working to safeguard children by managing risk and
decision making and building therapeutic relationships in
families with complex needs. Luker (1992) confronts the
belief of some health visitors that the effect of their practice
is too subtle, intangible and elusive to be evaluated.
Randomised controlled trials, the gold standard for estab-
lishing valid evidence in relation to many health care
professions, are not always appropriate in relation to health
visiting as the effect of many variables can influence practice
delivery (Campbell et al. 1995). This does not mean,
however, that practice cannot be evaluated.
It is worth noting too within these debates that ‘parent-
ing’ and ‘mothering’ are often used interchangeably, yet they
are not necessarily one and the same. Using the term
parenting (for example in parenting support programmes)
very often means only mothers, with different approaches
perhaps required for men and tending then to marginalise
the role that fathers have in the parenting process (Daniel &
Taylor 2001). Interviews with professionals reveal that
parenting is seen as domestic work, which is women’s work
(Edwards 1998). Further, parenting is equated with nurtur-
ing, again equated with mothering. As a result of the
marginalisation of fathers, mothers tend to become the
target of intervention, the potential risks fathers pose can be
minimised and the potential assets that fathers bring can be
overlooked (Daniel & Taylor 2001). In our study, we
wanted to take care that we did not fall into a trap of
conflating parents with mothers (Taylor & Daniel 2000)
and were anxious to see if health visitors themselves made a
distinction.
1182  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
Method
Aim of the study
The aim of this study was to measure health visitors’
professional judgements on ‘good enough’ mothering and
parenting and to identify what factors and combinations of
factors are important when making such judgements and
decisions.
Factorial surveys
Rossi and Nock (1982) first developed the factorial survey as
a distinct design to measure judgement formation and
measure the unique contribution that a large number of
variables make to such judgements without the problem of
co-linearity found in surveys. The factorial survey uses
vignettes (case scenarios) that are administered to a decision
maker who is then required to make a judgement about this
scenario. The vignettes are constructed from practice knowl-
edge, previous research or a pilot study to identify relevant
factors. The vignettes comprise a series of sentences in a fixed
order that contain factors relevant to the decision. The level,
or presence, of the factors within the sentences is randomly
varied amongst the vignettes. The capacity of written
vignettes to capture the complexity and nuance of decision
making in ‘real life’ is cited as a limitation in factorial
surveys. There is always a trade-off between the control
needed in experimental designs and the lack of control in
naturalistic environments. There is strong support for the
claim that factorial surveys to both exercise experimental
control and satisfactorily approximate the real world (Rossi
& Nock 1982, Ludwick & Zeller 2001, Lauder et al. 2006,
Taylor 2006).
A randomly selected unique set of vignettes is then
presented to each decision maker (Ludwick & Zeller 2001).
There are (at least) two stages of randomisation, which
increases the rigour of the research design. The factorial
survey thus contains the essential elements of an experimental
design in that the factors presented to the decision maker (the
independent variables) are not only controlled by the
researcher but also randomly assigned. The factorial survey
also contains the essential elements of a sample survey design
in that a random sample of a target population can be
obtained and respondents answer interview-type questions.
Sampling
The sample comprised health visitors in two Health Board
areas (n = 200). All health visitors were provided with a
Nursing workforce
vignette package and 70 returned the vignettes, providing a
35% response rate. This provided 672 and 677 for the two
regression analyses and given that rule of thumb that multiple
regression requires 10 vignettes for every dependent variable,
this return rate provides a sample size which provides
sufficient power for the regression analyses (Tabachnick &
Fiddel 1989).
Data collection
Data were collected through administration of vignettes.
Each participant received by post a random sample of
vignettes (n = 10). The vignettes were constructed following
discussion with health practitioners regarding factors seen
as important indicators of a child’s well-being, informed by
the current evidence base. These factors were age of the
child and gender, mother’s age, family context, past
medical history of the child, boundary setting, child
behaviour, health behaviours and location. For example,
the age of two years was identified by local consultant
nurses and health visitors as an appropriate age to
demonstrate maternal awareness of a range of issues which
may cause concern in relation to parenting. The topics
listed within the past medical history dimension are
indicative of common medical problems experienced by
this age group and the peak referral time to local sleep
clinics is at two years. The child behaviour dimensions
were identified by health visitors as being indicative of
behavioural difficulties at this age, which may in turn result
from poor parenting practices.
The factors selected for inclusion within the vignettes are
also supported by a range of research studies. For example,
the age range covered the normal distribution of maternal
age and there is evidence to suggest that older (over
35 years) and younger (adolescent) women may find the
mothering role challenging (Koniak-Griffin et al. 2006).
The family context dimension reflects the usual range of
family situations found within the study area and
Kavanaugh et al. (2006) report that single mothers are
more likely to experience depressive symptoms, which in
turn impact on parenting behaviours such as dental care
and consistency of discipline. Hutchings et al. (2007) also
report that children with conduct disorders are more
common in single parent families, or where parental figures
are continually changing.
The parental expectations variables are indicative of
common scenarios identified by health visitors, based on
their professional experience. Owens et al. (2005) states that
25% of children will experience some type of sleep
disturbance, whilst Meltzer and Mindell (2007) report that
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
Practitioner assessment of ‘good enough’ parenting
the quality of a child’s sleep affects the quality of the
mother’s sleep, which in turn impacts on maternal mood,
stress and fatigue. Similarly, the range of health behaviours
identified were routinely reported by health visitors and
supported by published work. Limiting fizzy drinks and
encouraging regular toothbrushing are activities associated
with positive parenting practices. Declerk et al. (2008)
report that dental caries in children are associated with fizzy
drink consumption, whilst Gibson and Williams (1999)
demonstrate that regular brushing with fluoride toothpaste is
the most effective way of preventing dental caries. Finally,
Matthews (1999) summarises the impact of adverse housing
conditions on child development, advising amongst other
considerations that private sector regulation is necessary to
improve standards and management of children at risk. The
range of housing options identified within this dimension is
typical of housing provision within the geographical area
studied.
Each factor in the vignette had three levels (except age of
the child, which was always 2 years old and gender which was
male or female). Table 1 summarises the factors used. The
primary dependent variable was the health visitor’s judge-
ment on good enough mothering and good enough parenting.
This was scored on a 10 point anchored visual analogue scale
which was treated as a continuous measurement.
Data analysis
The data were analysed using both multiple regression with
dummy coding and analysis of variance (ANOVA ) with
post-hoc tests. One-way ANOVA s were performed to establish
statistical significance for each independent variable and
two-way ANOVA s to establish first-order interaction effects.
Findings
Initial examination of the data matrix revealed that there was a
high level of accuracy in the data and low levels of missing data
were observed. There were a total of 699 returned vignettes,
with complete data being available for 672 of the 699
vignettes. Mothering judgement had 680 observations ranging
from 1–9 with a mean of 5Æ13 (SD 1Æ74). Parenting judgement
had observations for 677 vignettes ranging from 0–9 with a
mean of 4Æ52 (SD 1Æ95). A strong positive correlation was
found between mothering judgement and parenting judgement
(G = 0Æ630, p = 0Æ001). This correlation is high enough to
suggest that these two concepts have some characteristics in
common. At the same time, it is low enough to suggest that
respondents have differing thoughts about what constitutes
mothering judgement and parenting judgement.
1183
J Taylor et al.

Table 1 Vignette model with

Dimension Levels
dimensions and levels
Child age 2 years
Mother age 15
25
40
Blank
Family context Cared for by mother who is a single parent
Cared for by two adult parenting situation
Cared for in an identified extended social support
Blank
Past Medical History Has a history of ongoing chest infections
of child Has a history of sleep disturbance
No significant medical history
Blank
Child gender Male
Female
Blank
Parental expectations Mother reports her child will not go to sleep in her own bed
so ‘I cuddle her in on the sofa until she drops off’
Mother reports her child only goes to bed after a struggle so
‘I let her stay up as long as she wants and she watches the TV
in her bedroom she does seem tired during the day
but will not go for a nap’
Mother reports her child is afraid of the dark and ‘I leave a
light on in the hall and give her a story in bed to
help settle her down’
Child behaviour The child immediately initiates physical contact with HV
Child refuses to engage in eye contact with HV
Good eye contact with HV & parents
Blank
Health behaviours Child has history of significant dental caries
Child displays temper tantrums
Child will only drink fizzy juice she will not take milk or water
Blank
Location Lives local authority home
Lives in three bedroom owner occupied home
Lives in privately rented accommodation
Blank

A second multiple regression equation was calculated

Predicting mothering judgements
A multiple regression equation was calculated predicting
mothering judgement from the 23 non-redundant dummy
variables using k – 1 dummy variables for each independent
variable. The analyses are presented below. An examination
of the analyses showed an R2 = 0Æ246 and an adjusted
R2 = 0Æ219 (F = 9Æ290, df = 23, 656, p = 0Æ001). Dummy
variables representing ‘location’, ‘boundary setting’ and
‘health behaviours’ had significant effects on mothering
judgement. The remaining dummy variables representing
‘gender’, ‘family context’, ‘age’, ‘medical history’ and ‘child
behaviour’ were not significant predictors on mothering
judgement.
predicting mothering judgement from the eight non-redun-
dant dummy variables using k – 1 dummy variables for each
of the three significant independent variables. An examina-
tion of the analyses showed an R2 = 0Æ190 and an adjusted
R2 = 0Æ180 (F = 19Æ644, df = 8, 671, p = 0Æ001). Dummy
variables representing ‘location’, ‘boundary setting’ and
‘health behaviours’ had significant effects on mothering
judgement (Table 2).
A comparison of the original 23 variable regression model
with the reduced eight model reveals a minimal reduction in
the adjusted explained variance (adjusted R2 = 0Æ219–
0Æ180 = 0Æ039). The three included dimensions (‘location’,
‘boundary setting’, ‘health behaviours’) accounted for an

1184  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
Nursing workforce Practitioner assessment of ‘good enough’ parenting

Table 2 Reduced multiple regression of

Unstandardised
HVs’ judgements of quality of mothering
coefficients Standardised coefficients
Coefficients(a)
Model B Std. error Beta t-value Sig.

1 (Constant) 4Æ946 0Æ186 26Æ531 0Æ000

Location 1 0Æ572 0Æ169 0Æ142 3Æ388 0Æ001
Location 3 0Æ283 0Æ175 0Æ067 1Æ618 0Æ106
Location 4 0Æ412 0Æ167 0Æ104 2Æ468 0Æ014
Boundary 1 0Æ863 0Æ147 0Æ238 5Æ890 0Æ000
Boundary 3 1Æ656 0Æ151 0Æ440 10Æ930 0Æ000
Health 1 0Æ746 0Æ175 0Æ186 4Æ271 0Æ000
Health 2 0Æ076 0Æ170 0Æ020 0Æ448 0Æ654
Health 3 0Æ499 0Æ178 0Æ121 2Æ807 0Æ005

adjusted 18Æ0% of the variance. The omitted dimensions
(gender, family context, age, medical history and behaviour)
accounted for only 3Æ9% of the variance. All further analyses
were focused solely on the effects of location, boundary
setting and health.
A threeway ANOVA predicting mothering judgement from
p = 0Æ001). An LSD post hoc test revealed that all pair-wise
comparisons were statistically significant.
The mothering judgement by health actions showed means
that varied from a low for ‘History of Significant Dental
Caries’ (x = 4Æ70) to a high for ‘Null’ (x = 5Æ45). A one-way
ANOVA test was significant (F = 7Æ169, df = 3, p = 0Æ001). An

‘location’, ‘boundary setting’ and ‘health behaviours’ re-
vealed that all three of these dimensions had significant main
effects on mothering judgement and no two- or three-way
indirect interaction effects were statistically significant. Each
of these three dimensions was examined by further one-way
ANOVA s.
The mothering judgement means varied from a low for
‘Privately Rented Accommodation’ (x = 4Æ91) to a high for
‘Local Authority Home’ (x = 5Æ43). This was significant
(F = 2Æ949, df = 3, p = 0Æ032) and an least significant differ-
ence (LSD) post hoc test revealed that ‘Local Authority Home’
was significantly higher than ‘Privately Rented Accommoda-
tion’ and significantly higher than ‘Null’. None of the other
pair-wise comparisons were statistically significant.
The mothering judgement of the boundary setting in sleep
behaviour dimension showed means which varied from a low
for ‘Cuddles Child on Sofa until he/she drops off’ (x = 4Æ31)
to a high for ‘Night Light and Story’ (x = 5Æ97). One-way
ANOVA showing the effects of ‘Boundary Setting’ on moth-
ering judgement was significant (F = 57Æ792, df = 2,
LSD post hoc test revealed that the ‘Null’ and ‘Displays
Temper Tantrums’ were significantly higher than ‘History of
Significant Caries’. There were no other significant pair-wise
comparisons.
Predicting parenting judgement
The statistical analysis of the parenting judgement (Table 2)
mirrors the statistical analysis of the mothering Judgement. A
multiple regression equation was calculated predicting Par-
enting Judgement from the 23 non-redundant dummy vari-
ables using k – 1 dummy variables for each independent
variable. An examination of the analyses showed an
R2 = 0Æ163 and an adjusted R2 = 0Æ133 (F = 5Æ513, df = 23,
p = 0Æ001). Dummy variables representing ‘location’, ‘bound-
ary setting’ and ‘health actions’ had significant effects on
parenting judgement. The remaining dummy variables rep-
resenting ‘gender’, ‘context’, ‘age’, ‘medical history’ and
‘behavior’ were not significant predictors on Parenting
Judgement (Table 3).

Table 3 Reduced multiple regression

Unstandardised
analysis of parental judgement
coefficients Standardised coefficients

Model B Std. error Beta t-value Sig.

1 (Constant) 4Æ157 0Æ178 23Æ294 0Æ000

Expect 1 0Æ628 0Æ172 0Æ154 3Æ659 0Æ000
Expect 3 1Æ452 0Æ178 0Æ345 8Æ166 0Æ000
Health 1 0Æ697 0Æ205 0Æ155 3Æ406 0Æ001
Health 2 0Æ098 0Æ199 0Æ023 0Æ490 0Æ624
Health 3 0Æ481 0Æ208 0Æ104 2Æ310 0Æ021

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J Taylor et al.
A three-way ANOVA predicting Parenting Judgement from
‘location’, ‘boundary setting’ and ‘health actions’ indicates that
boundary setting (F = 31Æ620, df = 2, p = 0Æ001) and health
actions (F = 5Æ035, df = 3, p = 0Æ002) had significant effects on
parenting judgement, but location did not. None of the two- or
three-way interaction effects were statistically significant. The
two included variables (boundary setting and health actions)
accounted for an adjusted 10Æ4% of the variance. The omitted
variables (gender, location, context, age, medical history and
behaviour) accounted for only 2Æ9% of the variance. All further
analyses were focused solely on the effects of boundary setting
and health actions.
The parenting judgement in the boundary setting in sleep
behaviour dimension showed means which varied from a low a
low for ‘Cuddles Child on Sofa until he/she drops off’ (x = 3Æ83)
to a high ‘Night Light and Story’ (x = 5Æ31) (F = 34Æ054,
df = 2, p = 0Æ001). An LSD post hoc test revealed that all
pair-wise comparisons were statistically significant.
The parenting judgement means for health actions varied
from a low for ‘History of Significant Dental Caries’ (x = 4Æ11)
to a high for ‘Null’ (x = 4Æ83) (F = 4Æ999, df = 3, p = 0Æ002).
An LSD post hoc test revealed that the Null was significantly
higher than ‘History of Significant Caries’ and ‘Child will only
drink fizzy juice she will not take milk or water’ while ‘History
of Significant Dental Caries’ was lower than ‘Displays temper
tantrums’ and ‘Null’. There were no other significant pair-wise
comparisons.
Discussion
The results demonstrated that when presented with an array
of information on which to base judgements about moth-
ering and parenting, health visitors actually focused on only
a narrow range of available factors. Surprisingly, family
context, age of the mother, medical history and child
behaviour were not significant predictors of either mothering
or parenting judgement. Significant predictors of health
visitor judgement were boundary setting, health behaviours
and the type of housing inhabited. For example, if a mother
lived in privately rented accommodation, the child had
dental caries and they cuddled their child to sleep on the
sofa until they dropped off to sleep, the health visitor was
more likely to form a judgement of poor mothering and
parenting.
At first sight it might appear that health visitors are simply
ignoring large amounts of available information, however,
these findings need to be explained within the complexity of
thinking when making clinical judgements. The weight given
by practitioners to the significance of private and rented
accommodation is a good example of this.
1186  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
In the geographical location within which the study was
conducted, families living in private and rented accommoda-
tion come from a broad distribution of need. However, they
share certain characteristics. The accommodation is fre-
quently short term and social support is often not present or
at least not through extended family support. For example
service (e.g., armed forces) families, who often have to make
use of private rented accommodation.
These general characteristics are often compounded by
other factors, for example families who have been excluded
from social/local authority housing because of financial or
anti-social behaviours often have to use private rented
accommodation. Private tenancies do not have the level of
support provided by housing officers and anti-social behav-
iours may therefore be more problematic. Alternatively, a
family may choose to access privately rented accommodation
as they wish to decrease their visibility with statutory
organisations, for example, those engaged in previous crim-
inal activity or substance abuse and those trying to escape
domestic violence.
Health visitors are less likely to have links with private
landlords and this factor, together with those described above
may result in them viewing private rented housing as a less
desirable mothering and parenting situation than other types
of accommodation. The results suggest that the effects of
living in such accommodation, particularly for families with
young children, may need further research and consideration
of the local authority housing policies in place. The impli-
cations for the future of community nursing are that there is a
need for a universal service which ensures young children
living in these settings remain visible and are provided with
appropriate support and services.
The scenario information on sleep management was
included because the peak referral to sleep clinics within
the two Health Boards studied is around the age of
two years. The most appropriate response was to read the
child a story and settle them in their own bed. To cuddle the
child on the sofa was a less appropriate response, but not as
inappropriate as allowing the child to stay up as long as they
wanted in their bedroom. It was interesting to note therefore
that health visitors felt cuddling the child was evidence of
poorer parenting than allowing them to stay up in their
room. This emphasises the need to ensure that health
visitors have sufficient knowledge and tools relating to sleep
behaviours to be able to provide appropriate advice and
support.
Evidence of dental caries in the two year old child was the
most significant issue in influencing health visitors’ judgement
of poor parenting. This was an expected finding as dental
caries in such young children is indicative of dietary concerns
Nursing workforce
and poor dental hygiene, possibly influenced by problems in
accessing dental care. Unless a child has been affected by
maternal antibiotics, dental caries in this age group can be
prevented by effective parenting. The presence of dental
caries can also be an indicator of problems with the child’s
diet and may possibly be a predictor of childhood obesity.
Hence the significance attributed to this factor by the health
visitors participating in the study.
Limitations of the study
The sample was recruited from only two health board areas
in Scotland. The health visitors who participated are not
necessarily representative of all UK health visitors. Vignettes
have been suggested to not fully replicate the context in
which decisions are made (Lauder et al. 2006). The judge-
ment models require to be developed to explain more
variance in judgements. Judgements may be influenced by
characteristics of the health visitor such as education,
experience and personality although previous research sug-
gests these factors may explain little of the variance in
decision making (Ludwick et al. 2004).
Relevance to clinical practice
Most people can articulate what is a ‘good’ parent. Equally,
they may have strong views on what is ‘poor’ parenting. The
difficulty is in-between: when is parenting ‘good enough’ to
provide a child with a safe and nurturing psychosocial,
environmental and physical milieu? If, as the literature
suggests, practitioners move their thresholds depending on
the circumstances in which the parents live, or according to
their own beliefs or experiences, then there is potential for
children to fall through a gap in the child health service. The
extent to which this may happen has not been previously
measured systematically or statistically. This study has begun
to determine where training and resources may need to be
targeted. It is fully congruent with the recommendations of
Health for all Children (Hall & Elliman 2003) and Every
Child Matters (Department of Health 2003) and will inform
the development of the generic community health nurse
proposals in Scotland (SEHD 2006).
Conclusion
Factorial survey was an efficient method of gaining informa-
tion about the decision-making processes of community
nurses when making judgements about family situations.
Although the results show that nurses make fast and frugal
decisions, these are based on both evidence and experience.
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1180–1189
Practitioner assessment of ‘good enough’ parenting
Further work could be usefully employed with different
professional groups.
Acknowledgements
Eastren provided funding for the main study, and QNIS
funded the stakeholder dissemination event. Irene McTaggart,
Rich Zeller and Jan Winchell all helped with data analysis.
Contributions
Study design: WL, JT, JC, MM; data collection MM, JC;
data analysis: WL, JC, JT, MM and manuscript preparation:
JT, JC, MM, WL.
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