Pediatric care, Parent, Guidance, Provider



  1. Tedder, Jan BSN, RN, FNP
  2. Register, Nancy MSN, RN, FNP


The HUG (Help, Understanding, and Guidance for Young Families) is an innovative approach to pediatric nursing care developed by the authors and designed to support parents in optimizing the health and well-being of their children. Research evidence suggests that there is a gap between what the pediatric world promises and what it delivers and between what parents want from their providers and what they actually get. The HUG is intended to distill aspects of the literature into accessible, memorable, and practical strategies that pediatric nurses at all levels and in varied settings can use. Three HUG strategies are Start Here, Not There; See, Then Share; and Gaze, Then Engage. Nurses' use of the HUG is aimed at helping nurses enhance their relationships with parents, helping parents feel heard and attended to, encouraging parents to share what worries them most, and increasing nurses' job satisfaction.


Article Content

Providing comprehensive pediatric care for well children is particularly complex in an age in which "the prevalence of obesity, ADD/HD, behavioral disorders, depression, adolescent risk behavior, and the stresses faced by parents make the term 'well child care' applicable to fewer children" (Schor, 2004, p. 210). In fact, the multiple wide-ranging needs of today's growing families have caused policy makers to recommend that primary healthcare providers and nurses be trained to enhance child mental health (U.S. Public Health Service, 2000). Research confirms that parents want guidance and that providing teaching about child development enhances parenting skills (Bethell, Peck, & Schor, 2001; Margolis, 2004; Olson et al., 2004). Studies have identified gaps between what parents want and what they get and between what the pediatric world promises and what it delivers (Coker et al., 2006; American Academy of Pediatrics [AAP], 2002; Blumberg, Halfon, & Olson, 2004; Halfon & Olson, 2004; Shonkoff & Phillips, 2000; U.S. Public Health Service, 2000; Young, Davis, Schoen, & Parker, 1998; Zero to Three, 2000; Zuckerman, Parker, Kaplan-Sanoff, Augustyn, & Barth, 2004). This literature has identified challenges that nurses face in helping parents raise healthy and happy children:


1. Given the complexity of today's families, where does the pediatric nurse start in efforts to help parents?


2. How can the pediatric nurse teach about child development in a way that helps parents solve their specific problems?


3. What issues are most important to parents, and how can the pediatric nurse help parents disclose what worries them most?



The HUG, an innovative approach to the pediatric patient developed by the authors of this article includes three strategies nurses can use to address these challenges: Start Here, Not There; See, Then Share; and Gaze, Then Engage.


The First Challenge: Given the Complexity of Today's Families, Where Does the Pediatric Nurse Start in Efforts to Help Parents?

Today's parents face new morbidities in their children and have new problems to solve. Twelve percent to 15% of children have developmental or behavioral disorders, and 30% to 40% of parents worry that their child has a learning disability or a developmental problem (Halfon, Regalado, McLearn, Kuo, & Wright-Kynna, 2003). Studies confirm a surge in postpartum depression with increased realization of the long-term consequences of depression on the baby and the family (Beauchesne, 2006; National Scientific Council on the Developing Child, 2005). Depressed parents report more frustration with their children, yell at and spank their children more, and are less likely to maintain routines and schedules with their children (Young et al., 1998). Economic challenges, single parenthood, and lack of nearby extended family members to offer support and help add to the vulnerability of families (Blumberg et al., 2004). With this plethora of issues to address, which are most important and where does one start?


The First Strategy: Start Here, Not There

The first HUG strategy asks the nurse to consider whose agenda should be addressed. The traditional approach to a pediatric encounter calls for the nurse to clarify her agenda for the patient encounter and pursue the issues she identifies. Research has revealed that conversations between nurses and parents are strikingly dominated by the nurse and that parents introduce significantly fewer topics (Baggens, 2001). Nurses who use the HUG would Start Here (where the family is), rather than There (where the nurse thinks the encounter should be going). Sitting down with the parents, establishing eye contact, and paying attention to what the parents and infants are doing during the interview demonstrates this first HUG strategy (Meisels & Fenichel, 1996).


Twenty-six-month-old Kara is noisily opening and closing kitchen cabinets when the home visiting nurse walks through Mrs. Jones's back door. Mrs. Jones asks Kara to stop, but the toddler shouts, "No, me do it!!" The exasperated mother states, "Kara is so disrespectful of me these days." The nurse, tempted to flip to her visitation check list and get on with her work, sets the chart down and makes a choice for the Here, Not There. She says "Tell me more about what you mean." Mrs. Jones stirs in her chair, sighs deeply, and explains, "See how mean Kara is to me when she talks like that. She used to be so loving, but now she treats me like I don't even matter!!" Understanding the importance of what Mrs. Jones has shared, the nurse briefly explains the normal, predictable, budding independence of a 2-year-old child and the expected challenges this developmental surge brings to parents.


The Second Challenge: How Can the Pediatric Nurse Teach About Child Development in a Way That Helps Parents Solve Their Specific Problems?

A 2000 nationwide study surveyed 3,000 adults and parents to assess what they know about the emotional, intellectual, and social development of children (Zero to Three, 2000). This survey illustrated misunderstandings parents have about how children grow and learn. One sample question was, "While his parents are watching TV, a 12-month-old repeatedly changes the TV station." Thirty-nine percent of parents erroneously identified the child as angry at the parent and trying to get back at them (Zero to Three, 2000). By attributing negative intent to a 12-month-old child's normal exploration of cause and effect, these parents miss out on the joy of appreciating their child's remarkable mental development. In addition, the parents' frustration may create an environment that negates the chances of a positive parent-child relationship.


Parents in several surveys expressed their desire that pediatric providers spend more time helping them understand how children develop and what they can expect from their children (anticipatory guidance) (Bethell et al., 2001; Nevin & Witt, 2002; Schuster, Duan, Regalado, & Klein, 2000). One study looked at the actual time spent on anticipatory guidance defined as counseling and advice given to parents and/or the child. This study found that an average of 200 seconds was spent with parents of infants, 95 seconds with parents of 7- to 12-year-old children, and 120 seconds with an adolescent. If a family keeps all the recommended health supervision visits, the average American family would have received 26 minutes of anticipatory guidance during all their pediatric care (Dinkevich & Ozuah, 2004). Although many parents report satisfaction with the physical care of their children, they consistently report that they want more information on discipline, sleep issues, and how to help their child learn (Blumberg et al., 2004). Studies document that when given more information and support, parents are more likely to comply with recommendations regarding breastfeeding, immunizations, back-to-sleep, avoiding physical discipline, and reading to their child (Schempf, 2007; Schor, 2004). Parents who receive guidance on parenting issues also report higher confidence in their parenting and greater satisfaction with their healthcare system (Bethell et al., 2001; Zuckerman et al., 2004)


The Second Strategy: See, Then Share

This second HUG strategy is aimed at teaching parents about child development by encouraging the nurse to See what the child is doing Then Share the observed behavior with the parent. Work by Dr. T. Berry Brazelton (1999) is especially salient in describing the power of sharing a child's behavior with the parent. Looking and seeing are not the same. Looking at a child is what all nurses do when they enter the room; in order to see behavior, nurses must have more training in the process of child development and know how to handle the common bumps along the developmental road. The nurse shares that behavior in two ways: first by "broadcasting" the behavior and second by "commentating" on the behavior. As in the sports arena, "broadcasting" is simply describing exactly what one sees (Howard, 1999). "Commentating" is explaining the behavior.


A WIC nurse walks into her office and looks at Ryan sitting on his mom's lap. The nurse then sees the 9-month-old child's behavior change as she crosses the room. The nurse broadcasts, "Oh, he suddenly got quiet and still on your lap when I came close to you. I noticed he put his head on your shoulder and began twisting his hair." Mom looks distressed. "I know, he's gotten so shy these days!!" The nurse commentates on the behavior, "I'm excited to see Ryan hesitate around me. This is completely normal for this age." Mom looks surprised and relieved as the nurse goes on to explain, "It's called 'stranger anxiety' and lasts only a month or so. Look how your capable little boy shows us his effort to comfort himself by twisting his hair as well as his confidence that he can lean on you for comfort and protection."


Broadcasted information should be specific rather than general. Specific description of a child's behavior ("He got quiet and still on your lap, placed his head on your shoulder, and began twisting his hair") will give the parent greater insight into their child's behavior than will a general statement such as "It's normal for children his age to get stranger anxiety." In addition, such specific broadcasting is more meaningful to the parent because you are not describing a general child development concept but instead talking specifically about the parent's own child. Research shows the positive influence on parents' perceptions of their child when the provider joins in celebrating a child's little accomplishments and when that provider helps a parent be more objective about troublesome behavior (Howard, 1998).


The Third Challenge: What Issues Are Most Important to Parents, and How Can the Pediatric Nurse Help Parents Disclose What Worries Them?

Getting to a parent's true concern is not always easy. Medical literature documents the high incidence of "hidden agendas" that parents bring to their primary care provider. Although parents might present a child's physical complaint as their entree into the healthcare system, 34% of parents report being more concerned about behavioral problems, family stress, and fear of serious illnesses (Dixon & Stein, 2000). The Promoting Healthy Development Survey revealed that half of parents surveyed had one or more concerns about their child's behavior that were insufficiently addressed (Bethell et al., 2001). Other studies reported that minority parents more often feel that providers do not understand their child-rearing preferences or understand their child's needs (Flores, Olson, & Tomany-Korman, 2005). Such work suggests that providers of pediatric care tend to underestimate how concerned parents are about their children's behavior or development. Discovering the real needs or "hidden agendas" of parents requires establishing an alliance with parents based on an enhanced parent-provider relationship (Brazelton, 1999; Zuckerman et al., 2004). Providing continuity of care to establish and maintain these relationships is an important means of forging alliances between parents and providers (Nutting, Goodwin, Flocke, Zyzanski, & Stange, 2003).


The Third Strategy: Gaze, Then Engage

The third HUG strategy, Gaze, Then Engage, encourages the nurse to gaze at the parent and engage with the parent on two fronts: What meaning does the parent attribute to the child's behavior? How does the parent feel about that behavior? The authors of this article refer to the complex emotions parents have about their child's behavior as "sticky spots." At one minute a parent feels successful in understanding and responding to their child, but the next minute, that same parent may feel confused and frustrated. Sources of sticky spots vary. One example is what Brazelton (1999) refers to as "touchpoints," a time when a normal developmental surge temporarily disorganizes a child and confuses the child's family. Other sticky spots include misperceiving a child's behavior, attributing inappropriate meaning to the child's behavior, and experiencing a clash between a parent's personality and that of his or her baby. Sticky spots also can occur when parents feel vulnerable because of their own depression, anxiety, or other unmet needs (National Scientific Council on the Developing Child, 2005; Tapia, Gill, & Orozoco, 2005). This has been described as "toxic stress" resulting in long-term physical, emotional, and intellectual challenges (Shonkoff & Phillips, 2000). Another sticky spot occurs when parents see their child as vulnerable due to the child's life events such as prematurity or significant illness. Research concludes that children identified by their parents as "vulnerable" have more behavioral problems, growth problems, accidents, and affective disorders (Young et al., 1998). The last sticky spot concerns childhood issues of the parents that have not been adequately addressed. Meisels and Fenichel (1996) suggest that pediatric providers need to discover these issues with parents.


Research confirms that parents are willing to discuss sensitive family and psychosocial issues but that providers might underestimate parental concerns (Bethell et al., 2001). Concerned parents might send up a "trial balloon" about a worry. When providers notice this subtle communication, parents may discover that problems they might have considered "off limits" in the past might now be freely discussed and addressed (Meisels & Fenichel, 1996). Engaging with parents by reflecting on concerns might be initiated with statements such as, "You seem a bit concerned (angry, worried, overwhelmed) about your baby's behavior." A follow-up question might be, "Does your feeling about this behavior remind you of any other times in your life?" Some parents can make a quick connection between their child's current, worrisome behavior and their own past experience. Nurses may find that using this HUG strategy to facilitate parental reflection is sufficient for some parents, but other parents with more traumatic childhood experiences will most likely need referral to a mental health professional for evaluation and treatment.

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Many nurses feel comfortable with both their efforts to use the HUG and the time it takes to integrate the Gaze, Then Engage strategy into their practice. Others may feel the need to discuss this strategy with colleagues who have more experience in mental health. Nurses' education, ability to establish professional boundaries with patients, and access to mental health referral resources support the implementation of this HUG strategy.


During a health supervision visit with a pediatric nurse practitioner, the parent of 16-month-old Ella is discussing her struggle to get her child to sleep at night. When invited to discuss the issue further, the mother shares that "I just can't let little Ella cry in her bed at night. She might feel abandoned." "You seemed to have such strong feelings about this. Does it remind you of anything else in your life?" the PNP asks. Ella's mom is quick to explain that her dad deserted her and her mom when she was only 7 and she remembers many tearful nights in her bed alone. The PNP recognizes that the mother's experience of abandonment might contribute to her difficulty leaving her child at night. After acknowledging the significance of the mother's past experiences, they discuss the normal process of a toddler's learning to sleep at night and the remarkable passion and dedication this mom has for her young one.


Research on mothers' sensitivity to their babies' behaviors shows that a parent's perception of his or her child and perception of his or her own parenting skills, even when erroneous, can shape how the parent feels and what the parent does (Leavitt, 1998). Using HUG strategies could enable the provider to become a "translator" for the parents, shifting a family's negative understanding of their child and their parenting to a more positive perspective.


Kara is not disrespectful, as her mother presumed, but instead "a newly independent and capable toddler." Ryan is not shy, as his mom dreaded, but instead "bonded to his mom in a beautiful and helpful way." Ella is not fragile and insecure but instead "vigorous and obviously adored by her mom."



While recognizing the need for further HUG research and program development, we suggest that using HUG strategies may help to optimize the health of children and enhance parental confidence and skills. Parents who connect with a nurse over the challenges of parenting feel "heard" and could be more likely to seek an ongoing relationship with their nurse. That relationship can enhance continuity of care and increase compliance with healthcare recommendations. Although numerous parenting issues can be dealt with by the nurse, we think parents benefit most when their foremost concerns are addressed. When parents are given new insight into their child's development and their own parenting issues, they can become more confident and competent in their parenting.


Nurses, too, could benefit from implementing the HUG strategies. Routine home and office visits are anything but "routine" when attention is paid to the HUG strategies. It is possible that nurses will find their work more satisfying when parents appreciate the enhanced care they receive. Nurses who practice HUG strategies have the opportunity to experience greater sharing with parents of the burdens, the joys, and the passion of nurturing children while at the same time working toward improving the health and well-being of their children.


H.U.G. Your Baby




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