Corporate working in health visiting: a concept analysis

AIM OF THE PAPER: The aim of this paper is to examine individualized health visiting care and compare it to corporate working within a consensual management style. Corporate working has been discussed and used in many different ways since the idea first came to light at the end of the 1980s. Resource management makes it an appealing model, however, analysing how corporate working functions in the practice setting reveals the complexity of this method of service provision. BACKGROUND: This paper is based on a method of practice developed by health visitors in Haywards Heath, West Sussex, who implemented the process. The article examines individualized health visiting care and compares it to corporate working within a consensual management style. Important in this analysis are the elements of reflexivity, active listening, reflection and the application of 'praxis' within the corporate caseload approach. METHODS: Rogers' evolutionary concept model was used to illuminate and explain the different ways of delivering the health visiting service. FINDINGS: There are benefits in working corporately: shared workload, increased professional support and improved accountability. Alongside the integrated supervision of this model is the opportunity offered to practitioners to innovate. This offsets any initial difficulty experienced in setting up this method and makes it a worthwhile change of style in health visiting practice. Improved service delivery, enhanced professional growth and increased opportunity for public health work can be demonstrated as outcomes of this model. For professionals this method may prevent 'burn-out', enhance practice and increase innovation in health visiting practice. Using this method as a blueprint, practitioners can develop their own style of corporate working that offers a service that is equitable, proactive, efficient and accessible to clients.     

Gaining access to clients: the case of health visiting

The aim of this paper is to explore the concept of gaining access to clients as it emerged from an in-depth qualitative study of health visiting practice. The study was conducted using a grounded theory approach to data collection and analysis. Forty-five experienced health visitors were interviewed using a semi-structured interview guide. The interviews were tape recorded and later transcribed. A detailed analysis of the processes involved in 'entering' into client situations to begin health visiting work is presented. Entry into the client/family situation is a process which involves both obtaining access to the client in the environment where health visitor and client meet and 'entering' into the client situation more fully to continue the health visiting work. The data from this study would suggest that the work involved in entering client situations involves many strategies to ensure entry and re-entry. This process is influenced by many factors within the client, the health visitor, and the health visitor-client encounter. This paper makes a contribution to our understanding of the processes involved in everyday health visiting practice.     

Health visiting as therapy: a phenomenological perspective

In the course of their work British health visitors encounter many individuals and families with problems. Support is usually offered, but if that support is for psychological health needs, it is less likely to be accepted as legitimate health visiting practice. Where a referral is either not accepted, or placed on a waiting list, the health visitor will support the client through a holding relationship until the other appropriate professionals can accept the referral. From a literature review, helping styles and holding relationships provide a 'listening to' opportunity, a 'being there for' and an exploration of the presenting problems. This paper aims to explore the practice of health visiting as therapy and urges health visitors to expand their psychological support of clients in preference to other role developments.     

The development of the health visitor-client relationship

The aim of this paper is to explore the health visitor-client relationship as it emerged in an indepth qualitative study of health visiting practice. Despite the emphasis in health visiting practice on developing relationships with clients, there is little empirically based knowledge as to how health visitors develop relationships with clients and what effect relationships have on clients' health outcomes. Forty-five experienced health visitors were interviewed and asked to discuss cases where they felt they had had a positive effect and cases where they thought they had not had any impact. The interviews were tape-recorded and later transcribed. A detailed analysis of the processes involved in developing relationships is described. The data from this study suggest that health visitors develop relationships with clients in an attempt, not only to provide services to clients, but also to ensure access to clients over time. This study makes a contribution to our understanding of the processes involved in everyday health visiting practice.     

Working with vulnerable families: a health visiting perspective

The aim of this paper is to describe part of the findings of a research study which explored the health visitor's role in identifying and working with vulnerable families in relation to child protection One objective of the study was to describe and analyse the work which health visitors undertake with vulnerable families aimed at preventing crisis, ill-health and child abuse This paper outlines this aspect of the research and looks specifically at health visitors'perceptions of their work and interventions with vulnerable families and children Health visitors working m an inner city area and a suburban area were sampled and pilot work was undertaken in a third suburban area Stage one involved a postal survey of 102 health visitors, in which a response rate of 58 (57%) was obtained Stage two involved 12 in-depth interviews with health visitors One major finding of this study highlighted the fact that the health visitor's role when working with vulnerable families appears to be one of diversity and conflict In the light of the current National Health Service reforms it seems of paramount importance that health visitors illustrate to others, both managers and other health/social service professionals alike, the important function of their work with these vulnerable groups This is essential to ensure that health visitors'work with vulnerable families in relation to child protection is understood and valued and that the needs of vulnerable families continue to be identified This paper contributes to the knowledge base of health visiting and raises some important issues for professional health visiting practice     

Health visiting assessment processes under scrutiny: a case study of knowledge use during family health needs assessments

BACKGROUND: Accurate assessment of family health need is a core health visiting skill, requiring considerable knowledge and expertise. To date, there has been only limited empirical examination of the types of knowledge and ways of knowing which are likely to influence health visiting practice during family health needs assessments. OBJECTIVES: This paper will present a detailed analysis of health visiting assessment processes and will explicate some of the many elements associated with the processes of identifying and assessing family health needs. DESIGN: An in-depth case study was undertaken to explore health visiting practice across three study sites. The focus of interest was to attempt to understand the factors that may influence a health visitor in making a professional judgement to offer a family extra support. SETTINGS: The study was conducted in three community Trust case sites in England, UK. METHODS AND PARTICIPANTS: The study was informed by a constructivist methodology. Data collection took place during 56 observed home visits to families receiving increased health visiting support and intervention. Following the home visits separate in-depth interviews were undertaken with the health visitors and the clients. RESULTS/CONCLUSIONS: This paper will explicate some of the many elements associated with the processes of identifying and assessing family health needs. It endeavours to unravel some of the complexity and intricacies of these processes and provide insights into health visitors' practical 'know-how'.     

Health visiting and refugee families: issues in professional practice

AIM: This paper reports on the perceptions of experienced health visitors working with refugee families in Inner London. BACKGROUND: Women who are refugees and asylum seekers in the United Kingdom are more likely to experience depression than either non-refugee women or male asylum seekers. Health visitors provide a universal public health service to all women on the birth of a child, or with children aged under five, and as such are well placed to identify emotional and mental health problems of women who are refugees. Despite successive waves of refugees to the United Kingdom in the 20th century, there are no empirical studies of health visiting practice with this vulnerable group. There is also no body of evidence to inform the practice of health visitors new to working with asylum seekers and refugees. METHODS: An exploratory study was undertaken in Inner London in 2001. Semi-structured interviews were conducted with a purposive sample of 13 health visitors experienced in working with women and families who are refugees. FINDINGS: A range of structural challenges was identified that mediated against the development of a health-promoting relationship between health visitors and refugee women. With refugee families, who were living in temporary accommodation, health visitors were prioritizing basic needs that had to be addressed: in addition, they prioritized the needs of children before those of women. Health visitors were aware of the emotional needs of women and had strategies for addressing these with women in more settled circumstances. Health visitors considered themselves ill-prepared to deal with the complexities of working with women in these situations. CONCLUSIONS: This study identifies issues for further exploration, not least from the perspective of refugee women receiving health visiting services. Health visitors in countries receiving refugee women are framing their work with these women in ways that reflect Maslow's theory of a hierarchy of needs. This study suggests ways that public health nursing practice could be improved, and identifies issues for further study.     

Health visiting in a well-baby clinic.

This article highlights the changes that were implemented after research was carried out into health visiting practice in a well-baby clinic. The study was the result of collaboration between practitioners and nurses working in the academic field.     

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study

BACKGROUND: Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK. OBJECTIVES: The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry. DESIGN: A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support. SETTINGS: The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site. METHODS AND PARTICIPANTS: Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place. RESULTS/CONCLUSIONS: The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.     

Quality assurance in UK nursing education: public protection in the era of streamlined assessment

This paper describes recent reforms of quality assurance (QA) for the education of nurses, midwives and health visitors and reports qualitative findings from a study of how they are working out in practice. This study reported whether the stakeholders consider the system to be adequate for the principal aim of public protection. Using a postal survey and interviews, QA in nursing, midwifery and health visiting is compared and contrasted in the four countries of the United Kingdom. Issues of subjectivity versus objectivity in decision making over QA of nursing, midwifery and health visiting education and the extent to which these processes are rigorous arose. There is an inverse relationship between the number of higher education institutions in a country and the extent to which nursing, midwifery and health visiting QA personnel, responsible for conducting QA events, become involved with those institutions in offering advice and support. Generally speaking, where the changes have been greatest, satisfaction with the QA processes is lowest. Dissatisfaction was only expressed with processes and most likely arose from resistance to change but these are early days in the operation of the new QA procedures.     

A literature review of the public health roles of health visitors and school nurses

This paper describes a two-stage review relating to the family-centred public health role of health visitors and the child-centred public health role of school nurses. During the first stage, literature was searched using CINAHL and Medline databases and two models were used to frame the literature analysis. The findings of this analysis were, however, disappointing. Although many policy documents advocate development of the family-centred public health role of health visitors and the child-centred public health role of school nurses, there was no overwhelming evidence of reports of these approaches in health visiting and school nursing practice. The second stage of the review comprised a content analysis of West Midlands community trusts' strategic development plans. Seventeen plans were analysed. Of these, only two were 'formal' plans, the remainder being fragmented documentation related to plans for the development of health visiting and school nursing services. It may be concluded from the analysis that NHS trusts are beginning to adopt ideas from the rhetoric of national policy documents. Additionally, public health practice initiatives form an integrated part of most of the trust strategic development plans that the researchers examined.     

Examining health visiting expertise: combining simulation, interview and observation

BACKGROUND: Resource constraints and the drive towards evidence-based practice are currently prompting the review of health visiting services, which are a costly element of community health services in the United Kingdom. There is a shortage of evidence about effective domiciliary health visiting practice that can inform local and national decisions about developing and reforming this service. AIMS: This paper is based on a study which aimed to articulate the health visiting expertise involved in recognizing and responding to client need during home visits. The paper describes the innovative, multi-method approach used to articulate this expertise, and presents the rationale for this unusual approach. DISCUSSION: The study used the complementary methods of a 20-minute simulated visit to an actress-client, a postsimulation focused interview and subsequent observation of actual home visits with 15 study participants. Data-gathering took place between 2001 and 2002. The rationale, strengths and limitations of the methodology are discussed, and recommendations made for further development based on the work. CONCLUSIONS: The findings confirmed the utility of this unusual combination of methods, with their blend of control and naturalism, for articulating the knowledge and expertise which underpins assessment practice. Further research using a similar approach is recommended for the systematic examination of professional expertise in nursing and multi-disciplinary contexts.     

Supporting and policing mothers: an analysis of the disciplinary practices of health visiting

AIM: This paper draws on the notion of disciplinary power developed by Michel Foucault to discuss whether the professional practices inherent in British health visiting can be understood in terms of support or surveillance. BACKGROUND: The notion of disciplinary power embedded within Foucault's writings has been widely applied to the sociological analysis of health care professions. While a number of studies have focused on nursing practice, there has been little empirical work developing these ideas in the context of British health visiting. METHODS: A qualitative approach using interviews with 24 health visitors and 16 women who had experienced domestic violence was used. For reasons of confidentiality, the women were not matched to the health visitors. Data analysis was continuous with data collection and led to identification of a number of categories. The theoretical framework of feminist poststructuralism underpinned the analysis. FINDINGS: The women who participated in this research described their engagement in a number of disciplinary practices. These included the discursive production of themselves as good mothers, subjects and objects of the health visiting gaze, as well as their practices of resistance to health visiting work. Analysis of the health visitors' interview data provided further evidence concerning the exercise of disciplinary power in their everyday work of providing support and health care to women and children. CONCLUSIONS: The paper highlights tensions within the health visitor's role between welfare and surveillance, as well as differences between lay and professional perspectives.     

Roles and functions of community mental health nurses caring for people with schizophrenia in Taiwan

Aims and objectives. The study aimed to understand the nursing roles and functions of public health nurses and home health nurses in Taiwan and the factors that affect nursing roles and functions of nurses that provide community mental health home visiting services. Background. Although community nurses provide more psychiatric home visiting services than other psychiatric professionals, little research on their roles and functions has been conducted. Design. Nursing roles and functions were developed through use of grounded theory method of Strauss and Corbin. Methods. Data were collected using semi‐structured face‐to‐face in‐depth interviews and unstructured non‐participant observations. The constant comparative analysis continued during the open, axial and selective coding process until data saturation occurred. Participants were selected using theoretical sampling. Final sample size in this study comprised a total of 29 community nurses (18 public health nurses and 11 home health nurses) who provided community mental health home visiting. Public health nurses conducted a total of 16 (eight carers and eight clients) services and home health nurses conducted 16 (eight carers and eight clients) services. Results. Fourteen nursing roles were identified. These roles included assessor, supporter, educator, consultant, counselor, negotiator, harmoniser, collaborator, advocate, placement coordinator, resource provider, care provider, case manager and case finder. Moreover, several factors that affect nursing roles and functions in the community mental health home visiting service in Taiwan were also identified. Conclusion. This is the first study to identify the role of public health and home health nurses caring for people with schizophrenia in the community in Taiwan. Relevance to clinical practice. The recommendations based on the findings of this research can be used as a guide to improve the delivery of psychiatric home visiting services to community‐dwelling clients with schizophrenia and their carers.     

Help or hindrance? Single,unsupported mothers’ perceptions of health visiting

Although there have been studies of clients' perceptions of health visiting, the views of single, unsupported mothers about the health visiting service have been under-researched. Therefore, this study investigated their views using semi-structured interviews with 12 single, unsupported mothers identified by health visitors within one National Health Service Community Trust. The data were analysed using Burnard's (1991) thematic content analysis, which enabled a number of identifiable themes to emerge. Findings showed that the participants perceived the health visiting service as being concerned almost exclusively with babies and there was a general lack of understanding about the broader role of the health visitor. Clinics were seen as places to visit to weigh the baby but not as a contact point with a health visitor. Some health visitors were perceived as being judgemental in attitude and not necessarily interested in the clients as individuals. Participants considered that health visitors should be friendly, interested, able to promote their confidence and offer individualized advice. Overall the study suggests that health visitors may not be utilizing all dimensions of their role with single, unsupported mothers and may not be communicating effectively with them about this. The study also shows that single, unsupported mothers wish to be treated in the same way as other mothers but at present some feel that they are stigmatized and treated differently. The paper concludes with an outline of the implications of the findings and recommendations for practice and future research.     

Giving and receiving: an empirically derived theory on health visiting practice

The aim of this study was to uncover how experienced health visitors conceptualize and evaluate their health visiting work. The grounded theory approach to data collection and analysis was used to develop a beginning midrange substantive theory about health visiting practice. The beginning theory provides an explanation and understanding of how health visitors work with clients in the community during their day-to-day visiting practice. Data were gathered from 45 experienced health visitors from 13 health authorities in the north-west of England by means of the conversational interview. The basic psychosocial problem uncovered in the data was health visitors' need to provide a service and clients' need to fulfil personal needs and goals. The unifying theme of giving and receiving integrated the major categories into the key analytic framework in this study. This key psychosocial process was the pattern of interaction between health visitors and clients, in which both parties control the interactions by regulating what they offer and accept from each other. Each party both selectively 'gives' and 'receives' in order to manage the health visitor-client encounters. What gets offered and how the offer is received and acted on is a complex process involving many factors related to the health visitor, the client, and the context in which the interaction takes place.     

Can direct patient referral help the NHS modernisation agenda?

Patient referral systems have a direct impact on the patient experience: reducing unnecessary delays and stages relieves a great deal of anxiety. The NHS benefits from more efficient systems, which ease workload and reduce costs. This paper describes a nurse-to-nurse referral project set up by NHS Direct in one area, working with representatives from the local health economy.     

An empowerment approach to needs assessment in health visiting practice

This paper examines the usefulness of an integrated approach to needs assessment using an empowerment framework, within a health visitor/client interaction, in the home setting. It is intended to demonstrate the existence of a flexible approach to assessing need that is based on research about necessary processes for carrying out health visiting. The design of the tool described in this paper allows the use of professional judgement as well as fulfilling commissioning requirements to address health outcomes. Health promotion and empowerment are central to health visiting practice and should be reflected in the way needs are assessed. Many NHS trusts have introduced a system of targeting and prioritizing health visiting through a system of questioning to assess needs. This may reveal the work that health visitors do, but may also inhibit the open, listening approach required for client empowerment. Different methods of assessing need can be used that do not compromise the commissioning requirements, the health visitor's duty of care or professional accountability. The empowerment approach is key to the philosophy of health visiting. There are ways of approaching needs assessment that do not compromise the ethos of partnership-working in a health promoting way.     

Conflicting paradigms of health visiting: a continuing debate for professional practice

The interpretation of health visiting practice has formed the focus of a professional debate amongst practitioners and those involved in health visiting education for many years. More recently, changes in nurse education, government legislation and general anxiety about the future of health visiting have added to the intensity of the debate. In re-examining the conceptual origins of health visiting, this paper proposes one possible explanation for this phenomenon in which the author describes four conflicting paradigms of practice. The author argues that it is the tendency of practitioners to adopt one specific paradigm of practice which has contributed to the continuing debate and current professional uncertainty experienced by health visitors. The authors goes on to suggest a conceptual framework for practice developed from an epistemology of practice grounded in reflection in practice and the principles of health visiting. It is argued that this approach to practice allows practitioners to reconsider their practice in terms of the values and beliefs underpinning health visiting rather than identified tasks and client groups. It may also provide practitioners with the opportunity of developing and adapting strategies to meet current health needs rather than the traditions of practice.