Why Health Visiting? Appendices - King's College London

253 Pages·2013·4.19 MB·English

by  Elizabeth Smith

Why Health Visiting?

(Department of Health Policy Research
Programme, ref. 016 0058)

Appendices

Sarah Cowley
Karen Whittaker
Astrida Grigulis
Mary Malone
Sara Donetto
Heather Wood
Elizabeth Morrow
Jill Maben

12 February 2013

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Acknowledgements

We would like to thank all those who made this work possible. We are indebted to members
of the profession, fellow academics and others who shared their work and supported this
review. In particular we would like to thank Christine Bidmead who generously shared her
work and who has authored an important chapter on health visitor / parent relationships to
be found as an appendix to this document. We would also like to thank members of the
advisory group, in particular Cheryll Adams, and our policy colleagues, who helped shape
our research questions – notably Professor Viv Bennett and Pauline Watts, and our Policy
Research Programme Liaison officer Zoltan Bozoky and Programme Manager Alison
Elderfield, for their insights and support with this work. Finally, our grateful thanks to our
administrative colleagues Isabell Mayr and Estelle Clinton who have supported the work
throughout and particularly during the report-writing stages.

This is an independent report commissioned and funded by the Policy Research Programme
in the Department of Health. The views expressed are not necessarily those of the
Department. The project was undertaken by the National Nursing Research Unit (NNRU) at
the Florence Nightingale School of Nursing and Midwifery, King’s College, London.

Contact address for further information:
National Nursing Research Unit
King’s College London
Florence Nightingale School of Nursing and Midwifery
James Clerk Maxwell Building
57 Waterloo Road
London SE1 8WA
[email protected]

http://www.kcl.ac.uk/schools/nursing/nnru
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Contents

Appendix 1: Health Visitor / Parent Relationships: a qualitative analysis .............................. 1
Appendix 2: Medline broad search ......................................................................... 60
Appendix 3: UK Empirical Literature ....................................................................... 61
Appendix 4: Literature Considered but Not Included for Review .................................... 226
Appendix 5: Multidisciplinary risk assessment in child protection ................................... 247

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Appendix 1

Appendix 1 Health Visitor / Parent Relationships: a qualitative analysis

This appendix reports one part of a larger (doctoral) study that is in progress at King’s College
London. Author: Christine Bidmead
Introduction
This appendix includes a chapter from a doctoral thesis in progress entitled, ‘The development and
validation of tools to measure the health visitor/parent relationship’ [Bidmead, King’s College, London,
2013]. The qualitative data were collected in 2008 to inform the indicators from which questionnaires would
be devised. This appendix will confine itself to describing the methods involved in collecting these data
only, and reporting the results of analysing them.
The aim of this part of the study was to identify key processes used in the practice of promoting child health
specifically focusing on effective parent/health visitor relationships.
NHS ethical approval was obtained, as was the approval of the local Primary Care Trust [PCT] research
and development board.
1.1 Background
There exists within health visiting a long-standing debate about whether the profession serves its purpose
best through a relationship-centred or problem-oriented approach, (Orr 1980; Robinson 1982) This debate
has resurfaced particularly in current practice, in two ways.
First, the national shortage of HVs has led to a plethora of different forms of team working and skill-mix,
which is broadly approved in policies that promote the idea of HVs as leaders of teams, who delegate
functions and families on their caseloads to team members (Lowe 2007; Department of Health 2009;
Department of Health 2011). This approach embodies the problem-oriented approach, assuming that the
HV can identify an issue to address, and then prescribe an intervention, which can be carried out by
another team member. Relationships based on continuity of care appear to be deemed only necessary
when working with families with medium to complex needs, the ‘universal plus or partnership plus’ level of
service, (Department of Health 2011). This is unpopular with parents, who express a clear preference for
being able to develop a relationship with a single HV, even where advice from the team is consistent
(Russell 2008).
Second, professional-client relationships appear increasingly relevant in this field, with rising awareness of
the importance to mental health of the relationship between mothers, fathers and infants. It is suggested
that continuity of care is particularly necessary for assessing the parent-child relationship (Wilson et al.
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2008) and that parent-professional relationships are significant in intensive home visiting programmes
(Olds et al. 2007).

To some extent this practice divide has also split the research community as to what might constitute the
best evidence for health visiting effectiveness. The focus on a problem orientated approach leads to the
provision of evidence of HV effectiveness for interventions to particular problems, for example childhood
behaviour problems (Lane & Hutchings 2002). Investigators ask what the effectiveness of the HV trained in
a behavioural intervention is on the outcomes of children’s behaviour problems. Answers result in
establishing an evidence-base for an intervention but ignore the processes whereby the intervention is
delivered.
On the other hand, a process approach to research asks questions about how HVs achieve positive
outcomes. From enquiries such as these arises evidence to support health visiting practice. Evidence-
based interventions may be necessary but how HVs work is also important for evidence-based practice.
Elkan et al. (2000) suggested that research evidence linking health visiting process and outcomes was
notably lacking and there appears to have been little progress since.
The aim of this part of the study was to identify key processes used in the practice of promoting child
health, specifically focusing on effective parent/health visitor relationships with a view to developing valid
instruments to measure these processes. Once the tools have been created then progress can be made to
answer the questions that have dogged the profession for many decades.
NHS ethical approval was obtained, as was the approval of the local Primary Care Trust [PCT] research
and development board.
1.2 Methods
1.2.1 Study site and sample
Three urban inner city PCTs were chosen for the study. Using theoretical sampling six HV/parent
dyads were recruited for an in-depth analysis of their relationships. Initially health visitors who had
been trained in the family partnership approach (Davis et al. 2002a) were asked to invite parents with
whom they had a good relationship to participate. They explained to them what the study would
entail and sought their permission for the researcher to accompany them. Parents were also
approached through a local breast-feeding café and asked to recruit their health visitors if they felt
that they had a good relationship with them.
Three parents and seven health visitors were also invited to take part in subsequent discussion
groups to further validate the analysis of the qualitative data.
1.2.2 Data collection methods
In this study parents’ and health visitors’ constructs of their relationships with each other were to be
explored in order to produce valid and reliable measure. A process of video stimulated recall was
used to access the participants thought processes about their relationships with each other.
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1.2.2.1 Video stimulated recall
Drawing on the researcher’s previous experience of using this method (Bidmead & Cowley 2005a),
stimulated recall was used to explore the health visitor and parent relationships. ‘Stimulated recall is
an introspective method that represents a means of eliciting data about thought processes involved
in carrying out a task or activity’ (Gass & Mackey 2000). The methodology is based on two major
assumptions: first, that it is as possible to observe internal processes as it is to observe external
events and second, that human beings can access these internal thought processes and verbalise
them to some extent.
Some tangible visual or aural reminder stimulates recall of the mental processes in operation during
the event itself. The foundation of the stimulated recall approach relies on the information-processing
approach whereby the use of and access to memory structures is enhanced, if not guaranteed, by a
prompt that aids recall of information. The crucial assumption behind the stimulated recall is the
basic one of recall accuracy. Used extensively in second language research, recall has been found
to be 95% accurate where used a short period after the event (within 48 hrs.). Accuracy declined as
the time between the event and the recall lengthened. The method has advantages over simple post
event interviews in that the latter relies heavily on memory without any prompts. Quoting brain
research evidence, Gass and Mackey (2000) explain that ‘human beings tend to create explanations
for phenomena, even when these explanations may not be warranted’ (p.6). This finding is important
when considering introspective methods because clearly there is a danger that individuals may
create plausible stories for other descriptions of mental activity, without really knowing what is going
on. Using a prompt such as a video recording makes this less likely to occur.
A researcher may observe an interaction and see that a ‘good relationship’ has been established.
However, what has been observed and heard does not necessarily provide an explanation of how
the relationship has been achieved, in order to do that we have to ask the participants themselves for
an explanation. As an observer the researcher can only report that of which they are conscious, they
have no access to what is occurring on any other level. In order to know what the parent and health
visitor are doing in the interaction they need, therefore to be asked.
1.2.2.2 Verbal Reporting
Following the video recording of the interaction between the health visitor and the client an in-depth
interview was carried out with each of the participants. The video recording was played back to them
and they were asked to stop the recording at any point that seemed significant to them in terms of
their relationship with each other. If the parent or health visitor did not stop the recording then the
researcher did so to ask, ‘What were you thinking at this point?’ or ‘What was important to you about
the relationship at this point?’ The interviews were audio recorded and later transcribed. They were
carried out on the same day as the video recording and usually within three hours of the interaction.
This type of verbal reporting is known as ‘self revelation’ (Ericsson & Simon 1987) and it is also
described as ‘think aloud’. The participant is asked to provide an ongoing report of her thought
processes while performing a task e.g. ‘I was thinking what should I say’. The term ‘process tracing’
is also applied to methodologies using verbal reporting.
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1.2.3 Data Analysis
The audio-recorded interviews were transcribed into the qualitative analysis software package QSR
N-Vivo version 8. The aim of the analysis was to provide some structure and coherence to the data
whilst retaining hold of the original accounts from which it was derived in order to keep the
participants language to the fore. The analysis sought to detect, define, categorise, theorise, explain,
explore and map the data.
In order to do this, the ‘framework’ approaches developed by Ritchie and Spencer (1994) was
utilised. This is an analytical process involving a number of distinct though interconnected stages.
This was to make the analytical procedure as well-defined as possible, in order to make it accessible
so as to enable reworking of the ideas. The analysis is documented at each stage of a systematic
process. The approach involves sifting, charting and sorting material according to key issues and
themes. This was greatly aided by the software which enabled firstly free coding of the data and then
a bringing together of these into common themes in ‘trees’ with the ‘branches’ clearly visible.
Parent and health visitor data were compared with each other. Meetings were held with a group of
parents and one of health visitors to further discuss and validate the findings of the analysis. One of
the main aims of these groups was also to explore with the participants what happened in the
interactions between health visitors and parents where relationships broke down. These discussions
were audio-recorded, transcribed, and analysed using the software package and compared with the
data from the individual dyad interviews.
1.3 Findings
Initially the Family Partnership Model [Figure 1] – a generic way of conceiving helping relationships –
formed a framework for the analysis of the data.

Figure 1. The Family Partnership Model (Davis & Day, 2010)

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However, as the analysis progressed a different model evolved which more clearly demonstrated
HV/parent helping relationships [Figure 2].

Organisational Factors
Health Visitor Qualities and Skills Parent Qualities and Skills
Parent Health Visitor
Outcome/Ending Exploration
Relationship
Review Understanding
and Clarification
The Health VisitingProcess
Aims and Goals
Implementation
Strategy
Planning

Figure 2. A Model of Parent/HV Working Relationships

The five themes that contributed to the major changes to the family partnership model were:
1. Organisational factors
2. Parent qualities and relational skills
3. Health visitor qualities and relational skills
4. Parent/health visitor relationship
5. The health visiting process.

The service or organisational factors head the list as they were not just the context for service
delivery – as in the Family Partnership Model - but were found to have a direct influence on the
ability of HVs and parents to use their qualities and skills to form positive working relationships.
These relationships were found to be crucial to the work of health visiting. Outcomes in health
visiting fed back into the relationship and became part of the health visiting process. For example if a
parent received sound advice from the HV this fed back into the relationship, building trust for further
issues or problems to be explored.
1.4 Organisational factors
This section of the chapter reports and discusses the findings around the theme of organisational
factors. To both HVs and parents these were important because they impacted heavily on HV/parent
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relationships [Figure]. Parents wanted continuity of care from one HV and preferred to be home
visited rather than attend busy, often crowded clinics. HVs were also concerned about caseload
sizes, which affected their ability to provide continuity of care and the business of clinics. However,
they also worried about other issues such as record keeping, and clinical supervision. The HV group
added further information to the data reporting the effects of unsupportive management and working
in skill mix teams.

Figure 3. Organisational Factors. Comparison of HV and Parent Themes

Research into organisations has demonstrated that they can be highly influential in promoting worker
wellbeing or stress and burnout. Three core features of successful organisations have been
identified: worker involvement, management commitment to shared values and a supportive
organisational culture (Murphy 1999). The data in this study revealed that many of these core
features were absent from the Primary Care Trusts [PCTs] involved.
The following themes, which emerged from the data under the heading of organisational factors, will
now be explored:
Clinical supervision
Continuity of care
Home visiting versus busy clinics
Record keeping.
Lack of management support
Working with other agencies
Skill mix
Caseload size

1.4.1 Clinical Supervision
This was only mentioned by one HV and not by any of the parents interviewed. The HV concerned had
been qualified for two and a half years and considered supervision very helpful but something that she had
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to seek out and find for herself. It appeared to confirm her in her practice and as a result she felt more
confident.
[HV 6] ‘I'm one person here who gets clinical supervision on a regular basis because I am the
baby in the family whatever they say, I've only been a health visitor for two and a half years and
I feel that I need regular supervision so I've found someone to supervise me and she's been a
health visitor for a long time..... she says that it seems to her that … I'm doing the right
thing……

1.4.2 Continuity of Care
HVs and parents valued the fact that they were able to meet each other on a regular basis. When a person
who was unfamiliar was encountered then there was reticence on the part of the parent to share how she
was really feeling, or perhaps ask questions that she had.
[P 2] Once when I've been there was someone else. and that's strange because you feel less
inclined to talk to someone you've not talked to before, because there is a degree of relationship
that's built up over the last three or four months, I suppose, and then when you're faced with
someone you've never met before there's a definite element of 'yes everything's fine'. Maybe it is
fine, maybe you've nothing to talk about but I'm sure if it was someone you had known before
you'd be more likely to ask.

A parent complained about the number of different HVs who visited her at home [3] and found that
she could not establish a relationship with any of them.
HVs too, spoke about the importance of being able to see the same client and build relationships
with them over time. Because this no longer happened the relationship did not have sufficient time to
become established and the work with the families suffered from an inability to raise difficult issues.
[HV grp K.] Well it’s difficult to form relationships with clients in the [HV locality] team. Most
clients are lucky to get one visit, the new birth visit, and follow up visits have now gone and also
parents now visit a different child health clinic to the one that you work at so in effect you may
never see those clients again.

This was in stark contrast to the service that the HVs felt they were once able to provide where they
were able to visit more frequently particularly in early parenthood.
Reminiscing about a parent with whom it had been difficult to establish a relationship a HV
suggested that in order to access some of the more vulnerable parents it was important to have the
time to continue visiting even though the parent was not in or did not answer the door. In the
discussion group HVs agreed that just being persistent may be enough to help establish a
relationship.
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