building resilience in health visitor students for coping with adversity in practice penelope lindley

383 Pages·2015·9.39 MB·English

BUILDING RESILIENCE IN
HEALTH VISITOR STUDENTS
FOR COPING WITH ADVERSITY
IN PRACTICE

PENELOPE LINDLEY

A thesis submitted in partial fulfilment of the
requirements of the University of Brighton for
the degree of Doctor of Education

April 2015

Abstract
Health Visiting (the specialism of public health nursing focusing on families and children) has been
under threat over the last decade, with a considerable reduction in staff establishment. This has
contributed to discrepancies in practice between broad public health standards, against which
health visitor education is validated, and the reality of practice that is dominated by safeguarding
(child protection) work. Negative workplace experiences have coincided with this reduction in staff
numbers, include growing workloads, diminishing resources, and significant organisational change.
Encountering such adversity in practice can impact negatively on the functioning and wellbeing of a
newly qualified health visitor.

Studies drawing on a number of salutogenic concepts and theories have identified orientations and
abilities that promote the capacity to withstand adversity, and the notion of ‘practitioner resilience’
is established within the literature. However, there is a lack of research examining the whole
experience of student learning and the means by which this may enhance practitioner resilience.
The research question underpinning this study was: How do student health visitors’ experiences in
higher education and practice settings contribute to the development of their capacity to respond to
the tensions between expectation and reality in their practice role? In addressing this question the
study explores students’ expectations of their new role and the reality of their experience, and the
learning that contributed to the development of the capacity to respond to this reality.

Case study methodology rooted in a critical realist perspective allowed for the analysis of the
complex, non-linear relationships between what students bring to learning, what they experience
and what causes these experiences. Course documents provided the context of the planned
curriculum. Data were collected from twelve participants through two series of three activity-based
focus groups conducted at the beginning, middle and end of their 52-week full-time course, and
semi-structured interviews carried out with six participants in the final 2 months of the same year.
The longitudinal nature of data collection allowed for triangulation of data and an iterative approach
to both data collection and analysis. A conceptual web of learning for practitioner resilience,
drawing on resilience and transformative learning theory, emerged from initial literature review and
preliminary data collection, providing a framework for data analysis.

Significant differences emerged between student expectation and experience of the health visitor
role. Participants experienced greater complexity than expected, a lack of continuity with clients, a
predominant focus on high risk safeguarding, a lack of autonomy in the role, and a lack of
opportunity for health promotion and ‘upstream’ public health work. For some the reality of the role
was “shocking”, and the emotional impact of exposure to poverty and deprivation was widely
identified. However, motivation to ‘make a difference’ was increased through this exposure, and
commitment to the role grew over the year. An initial preoccupation with instrumental learning gave
way to the emergence of communicative learning as being central to the development of
practitioner resilience. The process of ‘surviving the course’ modelled behaviour that was seen to
support resilience in practice. Learning from observation of others, and reflection, helped
participants to identify positive and negative influences on resilience in themselves and in their
teams.

This study makes an original contribution to the field through the development of a conceptual
framework combining resilience and transformative learning theory, and the application of this
framework to learning for practitioner resilience. The conceptual web of learning, depicting the
complex process of development of practitioner resilience, supports a social theory of resilience.
The study supports the contention that resilience can be learnt through professional education,
contributing new knowledge regarding how this has been achieved during a course leading to a
professional qualification. The study adds to the small volume of research carried out with students
and contributes new insights into the development of resilience as part of a process of
transformative learning. Team dynamics and leadership are confirmed as being key to individual
and team resilience, with positive outcomes emerging from practice contexts that are open, honest
and trusting.
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Table of Contents

ABSTRACT .............................................................................................................. 2
LIST OF FIGURES ................................................................................................... 10
LIST OF TABLES .................................................................................................... 10
ACRONYMS AND DEFINITIONS ................................................................................. 11
ACKNOWLEDGEMENTS ........................................................................................... 14
DECLARATION ....................................................................................................... 15
1. INTRODUCTION .................................................................................................. 16
1.1 Influences from Professional Background ............................................................ 16
1.2 Context of the Health Visitor Role ........................................................................ 17
1.3 Original Contribution to the Field .......................................................................... 19
1.4 Why this is an Important Issue for Health Visitor Education ................................. 19
1.5 Influence of Sustainability and Employability Agenda ........................................... 20
1.6 The Reason for the Focus on Resilience .............................................................. 21
1.7 Inclusion of the Education Theory Perspective ..................................................... 22
1.8 Research Aims ..................................................................................................... 23
1.9 Research Question .............................................................................................. 23
1.9.1 Sub-questions ............................................................................................... 24
1.10 Insider Researcher Perspectives........................................................................ 24
1.11 Summary ........................................................................................................... 27
2. LITERATURE REVIEW ......................................................................................... 29
2.1 Introduction .......................................................................................................... 29
2.2 Search Strategy ................................................................................................... 30
2.3 Theoretical Underpinning for the Study ................................................................ 31
2.3.1 Relevance of Salutogenic Concepts .............................................................. 31
2.3.2 Resilience Theory ......................................................................................... 34
2.3.3 Transformative Learning Theory ................................................................... 40
2.4 Practitioner Resilience ......................................................................................... 45
2.4.1 Experience of Adversity in Professional Practice ........................................... 45
2.4.2 Defining and Understanding Practitioner Resilience ...................................... 46
2.4.3 Practitioner Resilience as a Process in Organisational Systems ................... 57
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2.4.4 Education and the Promotion of Practitioner Resilience ............................... 60
2.5 Summary ............................................................................................................. 62
3. METHODOLOGY ................................................................................................. 64
3.1 Introduction ......................................................................................................... 64
3.2 Establishing an Ontological and Epistemological Position ................................... 64
3.3 Critical Realism ................................................................................................... 65
3.4 Consideration of Alternative Theoretical Frameworks .......................................... 69
3.5 Application of Critical Realism to the Study Design ............................................. 71
3.6 Critical Realism and Case Study Methodology .................................................... 71
3.6.1 Definition of a Case Study ............................................................................ 72
3.6.2 Case Study as a Methodology ...................................................................... 73
3.7 Research Methods .............................................................................................. 75
3.7.1 Focus Groups ............................................................................................... 76
3.7.2 Moderator Roles ........................................................................................... 79
3.7.3 Semi-Structured Interviews........................................................................... 79
3.8 Data Analysis ...................................................................................................... 81
3.9 Managing the Data .............................................................................................. 85
3.10 Ethical Considerations ....................................................................................... 87
3.10.1 Ethical Approval ......................................................................................... 87
3.10.2 Ethical Considerations in Recruitment ........................................................ 87
3.10.3 Ethical Considerations for Data Collection .................................................. 88
3.10.4 Confidentiality, Privacy and Data Protection ............................................... 90
3.11 Participants ....................................................................................................... 90
3.12 Summary ........................................................................................................... 91
4. DATA COLLECTION ............................................................................................ 92
4.1 Introduction ......................................................................................................... 92
4.2 Participant Biographical Information .................................................................... 92
4.3 Focus Groups ..................................................................................................... 93
4.3.1 Pilot Activity .................................................................................................. 93
4.3.2 Organisation and Management of the Focus Groups.................................... 96
4.3.3 Focus Group 1.............................................................................................. 97
4.3.4 Focus Group 2.............................................................................................. 99
4.3.5 Focus Group 3............................................................................................ 100
4.4 Individual Semi-Structured Interviews ............................................................... 103
4.5 Background Context from Course Documentation ............................................. 104
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4.6 Summary ........................................................................................................... 105
5. INTRODUCTION TO THE DATA: PRESENTATION AND ANALYSIS ............................. 106
5.1 Introduction ........................................................................................................ 106
5.2 Authentication of the Data .................................................................................. 106
5.3 Data Preparation ................................................................................................ 107
5.4 Development of a Conceptual Framework ......................................................... 108
5.5 Developing the Conceptual Web of Learning for Resilience ............................... 108
5.5.1 Structures and Mechanisms Providing the Context ..................................... 112
5.5.2 Including Transformative Learning Theory .................................................. 113
5.5.3 Student Experience of Learning .................................................................. 114
5.6 Transforming the Data ....................................................................................... 115
5.7 Introducing the Participants ................................................................................ 116
5.8 Summary ........................................................................................................... 119
6. PRESENTATION OF THE FINDINGS: DESCRIPTION AND ANALYSIS ......................... 120
6.1 Introduction ........................................................................................................ 120
6.2 Applying the Conceptual Framework .................................................................. 120
6.3 Domain 1: Exposure to the Health Visitor Role in the Real Context of Practice .. 122
6.3.1 Identification of Expectation and Reality ...................................................... 122
6.3.2 Challenges Emerging from the Structures and Mechanisms ....................... 131
6.3.3 Social Contributions to Building individual and Collective Resilience ........... 136
6.4 Domain 2: The Organisation of Learning ............................................................ 145
6.4.1 Starting Points ............................................................................................. 148
6.4.2 Scaffolding Learning for Resilience ............................................................. 154
6.4.3 Endings ....................................................................................................... 163
6.5 Domain 3: The Experience of Becoming a Health Visitor ................................... 175
6.5.1 Creating an Identity: It’s Not Just Weighing Babies ..................................... 175
6.5.2 Learning from Negative Experience ............................................................ 180
6.5.3 The Health Visitor as a Chameleon ............................................................. 184
6.6 Summary ........................................................................................................... 188
7. DISCUSSION .................................................................................................... 192
7.1 Introduction ........................................................................................................ 192
7.2 Addressing the Research Aims and Questions .................................................. 194
7.3 Definition of Learning ......................................................................................... 197
7.4 Exposure to the Health Visitor Role in the Real Context of Practice ................... 198
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7.4.1 Identification of Expectation and Reality ..................................................... 198
7.4.2 Challenges emerging from the structures and mechanisms........................ 203
7.4.3 Social contributions to building individual and collective resilience ............. 209
7.5 The Organisation of Learning ............................................................................ 214
7.5.1 Starting Points ............................................................................................ 214
7.5.2 Scaffolding Learning for Resilience ............................................................ 216
7.5.3 Endpoints ................................................................................................... 223
7.6 The Experience of Becoming a Health Visitor ................................................... 226
7.6.1 Creating an Identity .................................................................................... 226
7.6.2 Learning From Negative Experience .......................................................... 230
7.6.3 Health Visitor as a chameleon .................................................................... 232
7.7 Transformative Learning: An Appropriate Framework for the Process of Learning
for Resilience? ........................................................................................................ 234
7.8 Summary ........................................................................................................... 239
8. CONCLUSIONS ................................................................................................ 240
8.1 Introduction ....................................................................................................... 240
8.2 Overview of Findings against Research Questions ........................................... 240
8.3 Cross-cutting Abstracted Concepts ................................................................... 243
8.3.1 Professional Identity ................................................................................... 244
8.3.2 Openness and authenticity ......................................................................... 245
8.3.3 Flexibility .................................................................................................... 246
8.3.4 Confidence ................................................................................................. 247
8.4 Contribution to the Field .................................................................................... 247
8.5 Limitations and Scope for Future Work ............................................................. 249
8.9 Recommendations ............................................................................................ 252
8.9.1 Application to selection processes .............................................................. 252
8.9.2 Application to curriculum design ................................................................. 253
8.9.3 Application to students’ and teachers’ learning ........................................... 255
8.9.3 Promoting political acumen through problem-based learning ...................... 257
8.10 Concluding comments ..................................................................................... 257
REFERENCES ...................................................................................................... 259
APPENDICES ....................................................................................................... 279
APPENDIX 1: THE SALUTOGENIC UMBRELLA .......................................................... 280
APPENDIX 2: REFLECTIVE EXTRACTS .................................................................... 281
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2.1 FOCUS GROUP MODERATION .......................................................................... 282
2.2 EXPERIENCE OF WORKING WITH A SECOND MODERATOR .................................. 282
2.3 INTERVIEW .................................................................................................... 284
2.4 WHY HAS IT ALL BEEN SO DIFFICULT? ............................................................. 285
APPENDIX 3: DATA COLLECTION AUDIT TRAIL ....................................................... 287
APPENDIX 4: DATA ANALYSIS AUDIT TRAIL ............................................................ 288
APPENDIX 5: LITERATURE SEARCH STRATEGY ...................................................... 289
APPENDIX 6: FOCUS GROUP ACTIVITY MAPPED AGAINST RESEARCH AIMS AND
QUESTIONS ......................................................................................................... 290
APPENDIX 7: DEVISING THE INTERVIEW SCHEDULE ................................................. 293
APPENDIX 8: ETHICAL APPROVAL DOCUMENTATION ............................................... 297
8.1 RESEARCH ETHICS & GOVERNANCE APPLICATION FORM ................................. 298
8.2 NHS RESEARCH ETHICS COMMITTEE LETTER ................................................. 304
8.3 STUDY PROPOSAL FOR ETHICS SUBMISSION ..................................................... 305
8.4 PARTICIPANT INFORMATION SHEET ................................................................. 325
8.5 PARTICIPANT CONSENT FORM ........................................................................ 328
8.6 PARTICIPANT RECRUITMENT LETTER .............................................................. 329
8.7 INITIAL UNIVERSITY ETHICS DECISION LETTER ................................................. 330
8.8 FINAL UNIVERSITY ETHICS DECISION LETTER .................................................. 332
8.9 CONFIRMATION NHS PERMISSION NOT REQUIRED. .......................................... 333
8.10 PERMISSION TO ACCESS PARTICIPANTS ......................................................... 334
APPENDIX 9: FOCUS GROUP PILOT ....................................................................... 335
APPENDIX 10. FOCUS GROUP PLANS .................................................................... 336
APPENDIX 11: DISSEMINATION AND EXTERNAL DISCUSSION .................................... 345
11.1 INTERNATIONAL CONFERENCE FOR COMMUNITY NURSING RESEARCH MARCH
2013 .................................................................................................................. 346
11.2 ROYAL COLLEGE OF NURSING CONFERENCE: APRIL 2014 ............................. 348
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11.3 SECOND WORLD CONGRESS ON RESILIENCE: ROMANIA MAY 2014 ................ 349
APPENDIX 12: FOCUS GROUP ACTIVITY AND DATA COLLECTION ............................ 351
12.1 FOCUS GROUP 1 .......................................................................................... 352
12.2 FOCUS GROUP 2 ......................................................................................... 354
12.3 FOCUS GROUP 3 ......................................................................................... 355
APPENDIX 13: EXTRACTS FROM TRANSCRIPTS ...................................................... 356
13.1 EXTRACT FROM FOCUS GROUP 3. ................................................................. 357
13.2 EXTRACT FROM BECKY’S INTERVIEW ............................................................ 362
APPENDIX 14: PRACTICE TEACHER SUPPORT PROCESSES ...................................... 368
APPENDIX 15: SUMMARISED PERSONAL DEVELOPMENT PLAN ................................. 369

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