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Open access fifty years on: reflections on research on the role of the health visitor, june clark dbe, frcn, faan, professor emeritus, swansea university, wales.

The 1960s and 1970s were exciting times for me on a personal and professional level. My personal and professional lives became inextricably intertwined. In 1962, I graduated with a degree in classics from University College London. I had already decided, much against my parents’ wishes, that I wanted to be a nurse.

Nursing Standard . 35, 10, 15-18. doi: 10.7748/ns.35.10.15.s23

Published: 30 September 2020

As a student nurse I was already regarded as ‘a bit of a troublemaker’ and I became active in the RCN. In 1966 I got married and our children were born in 1969 and 1972. In 1967, I qualified as a health visitor and went to work in Berkshire, where my husband held a university post and we lived on the campus in a university flat. These seemingly irrelevant factors determined the next ten years of my career including, in particular, the development of my research into health visiting.

This study of health visiting in Berkshire was my first attempt at research and was also one of the earliest studies undertaken by any nurse in England. This early study is the focus of my contribution to this RCN Fellow’s 2020 publication, nearly 50 years later.

The role of the health visitor: a study conducted in Berkshire, England

A study of 1057 home visits undertaken by health visitors in Berkshire in 1969 showed that the range of the health visitor’s work was much wider than the stereotype which portrays health visiting as an activity limited to maternal and child welfare and concerned mainly with physical care. The sample was the population of health visitors, 82 in all, employed by Berkshire County Council. The health visitors completed a questionnaire, were interviewed, and recorded their home visits for one week. Seventy per cent of the visits were to households containing a young child, 18% were to the elderly, and 12% to other households. The content of the visits was recorded in terms of the topics discussed. Some topics were essentially medical, and some were within the scope of the stereotype, but many were topics not traditionally associated with health visiting and there was a considerable psychosocial content. Differences were found between visits recorded by younger and recently qualified health visitors and visits recorded by other health visitors.

Clark J ( 1976 ) The role of the health visitor: a study conducted in Berkshire, England. Journal of Advanced Nursing. 1, 1, 25-36. doi: 10.1111/j.1365-2648.1976.tb00425.x

onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.1976.tb00425.x

Introduction and background

The 1970s were turbulent or exciting times, whichever way you looked at them. The National Health Service (NHS) was embroiled in preparations for its major reorganisation in 1974 which involved the transfer of community health services, including health visiting, from local government to the newly created health authorities. I was appointed as the nurse member of the Berkshire Area Health Authority, which enabled me to become deeply involved in the development of health and social policy, working with many of the leaders in health care of the day. In 1962, the Health Visiting and Social Work (Training) Act had established the Council for the Training of Health Visitors (CTHV), later extended to include education (CETHV) as the new regulatory body for health visiting. The council established several working parties that attempted to define the future role of the health visitor, and in 1966 a training programme with a new curriculum had been introduced, designed to produce a ‘new breed’ of health visitor with a much broader role ( Clark 1968 ).

I was one of the first to qualify under the new regime. The decade also included the Committee on Nursing (Briggs report) ( HMSO 1972 ) and the 1979 Nursing, Midwives and Health Visitors Act, which replaced the General Nursing Council with the UKCC and abolished the CETHV. The NHS, nursing, and nursing education were turned upside down. Other issues of the day were the development of the primary care team and the attachment of health visitors to general practice, both of which were controversial and were seen by some as a challenge to the autonomy of health visitors. There was tension between health visitors and social workers and the role and status of health visiting was continually challenged.

Already active in the RCN, I found myself involved in numerous working parties and a speaker at numerous conferences. At home with two babies I had the flexibility to serve on lots of committees and task groups. I published articles in the professional press with titles such as That uncertain knock on the door, No new type of visitor, What do health visitors do? The dilemma of identity in health visiting.

I became the health visiting consultant to a popular newsstand publication called Mother and Baby, even acting for several years as the magazine’s ‘agony aunt’. I often thought that I did more and better health visiting in this role than I ever did by knocking on doors – it certainly shattered my complacency about how wonderful health visitors were. I was becoming well known as a ‘champion’ of health visiting.

The trigger for action was the publication of the Report of the Committee on Local Authority and Allied Personal Social Services, The Seebohm Report, in July 1968 ( HMSO 1968 ). The report specifically excluded health visitors from its membership and considerations and stated: ‘In our view the notion that health visitors might further become all-purpose social workers in general practice is misconceived’. It recommended that a new Social Services Department should be set up in each local authority which would undertake the existing work of the children’s department, the welfare department, and parts of the health department. Functions that health visitors had traditionally regarded as theirs were transferred to social workers who would exercise a central role in the new system.

Social workers were delighted but health visitors were furious. They complained that they had been misunderstood, misrepresented, and undervalued. I agreed and stood up on several conference platforms to say so. But I argued that if people did not understand what health visitors did, it was probably because health visitors had not told them. There was a plethora of opinions and recommendations about what the role of the health visitor should be, but a dearth of factual information and evidence about their actual practice. What was needed, I argued, was some proper research.

But who could do the research? At the time, nursing research in the UK was embryonic. There were a few studies using work study methods undertaken by researchers who were not health visitors, which health visitors rejected as contributing to the misunderstandings. Very few nurses or health visitors had a first degree, which was the normal university requirement for undertaking post graduate research.

Almost none had a doctorate, which meant it was very difficult to find nurses who could supervise nursing doctoral students. My husband’s job precluded a move to one of the developing epicentres of academic nursing such as Manchester University. I knew nothing about research methods, and I searched in vain for some kind of course that my family commitments would allow. The mantra of the Briggs Committee on Nursing that ‘Nursing should become a research-based profession’ was still four years in the future ( HMSO 1972 ).

But I did have a first degree, I was living on a university campus, and I was ‘unemployed’ because I was pregnant or occupied with babies. My RCN involvement brought support and mentorship from some wonderful nurse leaders such as Marjorie Simpson, Jean McFarlane, and Grace Owen, who were planting the ‘little acorns’ of nursing research which later grew into oaks. I obtained a grant from the King’s Fund – the first one ever awarded to an individual nurse. I joined the fledgling RCN Research Discussion Group. Professor Peter Campbell, Professor of Politics, and Dr Viola Klein from the sociology department at Reading University agreed to take on the formalities of my registration for a MPhil. At the time, most master’s degrees were research-based degrees rather than taught programmes.

I was introduced to Professor Margot Jefferys, one of the founders of the developing discipline of medical sociology, who encouraged me and became my external examiner. And there were other benefits. I had tremendous goodwill from the health visitor interviewees, and I discovered that being accompanied by a breast-fed baby established an immediate rapport in interviews! I sent a questionnaire to every health visitor in Berkshire, achieving a response rate of 89%; I interviewed 79 health visitors and persuaded 72 to record all their home visits for a week using a recording form that I devised, amounting to 2,057 visits in all.

The interviews were recorded on a reel to reel tape recorder the size of a suitcase. The data was analysed using the (then) new Reading University computer which filled a whole building. The thesis was typed on an old-style typewriter with carbon copies – it was more than a decade before computers and word processing came into common use. In 1972 I graduated with the degree of MPhil. The thesis, suitably edited, was published in book form in 1973 under the title A Family Visitor ( Clark 1973 ) – the first in the series of research monographs published through the 1970s by the RCN in conjunction with the Department of Health and Social Security (DHSS). I participated in a BBC series of television programmes about primary health care ( Bloomfield et al 1974 ), and I spoke at many conferences at which my study was referred to. The study was also published as a series of three occasional papers in the Nursing Times, the newest outlet at the time for academic articles about nursing. The 1976 paper revisited for this article was published in the first issue of the Journal of Advanced Nursing.

Impact and influence

This study was undertaken nearly 50 years ago. The health visitor of the 1960s would hardly recognise health visiting as it is today. The ‘family visitor’ with a caseload that includes people of all ages appears to have become nowadays largely a protocol-driven system of developmental checks on young children – an important function, but not the only one. Health visitors no longer visit older people, and family support is seen as the function of the social worker.

In 1999, I was commissioned by the Welsh government to undertake a review of health visiting in Wales The review found that the number of health visitors in Wales had declined dramatically during the previous decade, that the introduction of general management following the 1983 Griffiths report had diminished the position of the heath visitor in the organisational structure and led to the loss of professional leadership ( Clark et al 2000 ).

The review contained several recommendations, but the report was quietly shelved. The good news, however, was that some of the local directors of nursing supported the report and quietly implemented several of the recommendations within their own management arrangements. Fortunately, during the past decade, perhaps as a result of the renewed importance of public health in government policies, health visiting appears to be experiencing something of a resurgence.

My increasing profile in health visiting and primary health care during the 1970s led directly to my representing the UK in work with the International Council of Nurses and the World Health Organization (WHO) following the WHO Declaration of Alma Ata on Primary Health Care in 1978 and the WHO Global Strategy for Health for All by the Year 2000. My search for others who were researching in the same field led me to Professor Sirkka Lauri in Finland, which I visited on a Council of Europe Fellowship in 1981 and several times subsequently. What I saw in Finland revolutionised my ideas about health visiting and primary health care. I published more articles and spoke at more conferences, but sadly, my proposals – such as visiting by appointment, structured documentation, sharing records with clients, seemed ahead of their time. At that time, they were not popular with UK health visitors.

Now, they are recognised as central to good practice. The Department of Health’s continuing search to understand health visiting practice ( Clark 1982 ) led to a new research project to develop a model for explaining health visiting practice which eventually became my PhD ( Clark 1985 ), and a project to identify the outcomes of health visiting practice ( Clark and Mooney 2001 ). Citations in other people’s work continued well into the 1990s. In 1982, when I was elected Fellow of the Royal College of Nursing, the citation said, ‘for her contribution to the art and science of nursing in the field of health visiting’.

But I can hardly claim that the study itself had any influence on the developments in health visiting in the 1970s, which were largely determined by the introduction of legislation and other external events over which the profession could exercise little control. In particular, the absorption of health visiting into the new framework of the 1979 Nurses, Midwives and Health Visitors Act moved health visitors from having a unique title and professional registration which was mandatory for practice, to recordable with the Nursing and Midwifery Council as ‘specialist community public health nurses’ alongside a variety of other nurses with no such requirements. Midwives retained their specialist identity; health visitors lost theirs. With hindsight, the legislation of the 1970s could be considered as marking the beginning of the demise of health visiting as I had known it.

Current and future relevance

It is hard to think that my research of some 50 years ago might have relevance to current and future researchers or practitioners, but it continues to be cited from time to time. Perhaps, however, any influence I might have had applies more to individuals than to big changes in policy. The outcome of which I am most proud is the number of individuals whose careers I was able to help, many of whom are now the leaders of the profession, just as the great nursing leaders of the 1960s and 1970s supported me. Health visitors I meet at conferences and other meetings often recognise me, and the older ones, that is, my contemporaries in health visiting, who are now, like me, approaching their eighties, often refer to my work in health visiting and in particular to this study. I did not know whether to be flattered or horrified when I discovered quite recently that A Family Visitor was still included in some students’ reading lists!

As my children grew up, I expanded my interests into other fields of nursing – care of older people, nursing education, and standardised nursing terminology for electronic patient records. I am no longer directly involved in health visiting, but with hindsight I can see some relevance of this study to my and others’ later work in other fields. I have been fortunate to be able to combine practice, research, and teaching in my long career ( Clark 2016 ). With hindsight I can see that the methodological approach of trying to capture the essence of health visiting practice through identification and recording of the topics discussed in the home visit, as described in this paper, led directly to my work on the development of a standardised terminology to capture the essence of nursing, the International Classification for Nursing Practice ( Clark and Lang 1992 ), and to make nursing and health visiting visible in electronic patient records. Only now in 2020 do I see the beginnings of understanding among nurses why the use of standardised terminology and structured documentation for nursing practice is important.

Fifty years later I still carry and promote the attitudes and ideas that were born in my health visiting days – the focus on prevention and early intervention, the social determinants of health, public health as opposed to individualised ‘treatment’. The principles of health visiting which were set out in the 1970s ( CETHV 1977 ) apply equally today and to every field of nursing:

» The search for health needs

» Stimulation of awareness of health needs

» Influence on policies affecting health

» Facilitate health enhancing activities.

Health visiting still has much to offer in meeting society’s health needs.

Correspondence

[email protected]

Open Acesss

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/ ) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

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Evidence-based practice and health visiting: the need for theoretical underpinnings for evaluation

Affiliation.

• 1 Research Fellow, School of Nursing - Postgraduate Division, Medical School, Queen's Medical Centre, University of Nottingham, Nottingham, England. [email protected]
• PMID: 10849142
• DOI: 10.1046/j.1365-2648.2000.01423.x

In this paper we argue that evidence-based practice, which is being introduced throughout the British National Health Service to make decisions about the allocation of limited resources, provides a welcome opportunity for health visitors to demonstrate their efficacy, skills and professionalism. However, the paper argues that to view health visiting as evidence-based is not to reduce health visiting merely to a technology through which scientific solutions are applied to social problems. Rather, health visiting needs to be viewed as a political movement, based on a particular model of society, which shapes the goals which health visitors pursue and influences the strategies they adopt to achieve their goals. The paper describes various models of health visiting as a way of showing how the goals of health visiting are always framed within a particular set of assumptions and causal explanations. The paper then turns to look at the issue of evaluating health visiting services. It is argued that evaluation should properly take account of the models which shape health visitors' goals and intervention strategies, and in turn, health visitors need to be explicit about the theoretical frameworks underpinning their interventions. Finally, it is argued that health visitors' knowledge and understanding of a range of models of society enables them to move between the various models to choose the most appropriate and effective means of intervention. Hence it is concluded that the emphasis on evidence-based practice provides health visitors with a valuable opportunity to show that their unique, professional skills and understanding are the preconditions for effective intervention.

Publication types

• Research Support, Non-U.S. Gov't
• Community Health Nursing*
• Evidence-Based Medicine*
• Models, Nursing*
• National Health Programs
• Nursing Theory*

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The variety is one of the nice things that I like about health visiting; it is never the same. Also, you get to build relationships with families and feel them grow.

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Exploring the professional identity of health visitors

15 June, 2012 By NT Contributor

The health visiting role has evolved, changed and expanded over the years. How has this affected the professional identity of these practitioners?

Citation: Baldwin S (2012) Exploring the professional identity of health visitors. Nursing Times; 108: 25, 12-15.

Author:  Sharin Baldwin is professional lead for integrated children’s community nursing services, Harrow Community Services, Ealing Hospital Trust.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF including any tables and figures

Health visiting is a complex, diverse and varied role. This article reviews the development of the role and how this has affected health visitors’ professional identity.

The profession of health visiting has sparked debate on numerous occasions about what constitutes its professional identity, and whether indeed it has one. Health visitors have, through the years, been referred to as “the mother’s friend”, “mini social workers” and “public health nurses”, to name but a few. Although it “dips into” a number of related professions, such as nursing, education and social work, the role of health visitors has been in flux since its conception in the mid-19th century. This is still the case, as the current coalition government has pledged to create an extra 4,200 health visitors, an improved training programme and a new vision and identity for the profession (Department of Health, 2011; Milton, 2010).

This article explores health visitors’ identity from the start of the profession and how the role has evolved, and considers what the future may hold.

Historical perspective

Health visiting originated from the Ladies Sanitary Reform Association, formed in 1862 in Manchester and Salford in response to the high infant mortality rate in the poorer districts (Abbott and Wallace, 1998). “Respectable working women” were recruited to visit the homes of “the poorer classes of the population”, to teach in a range of different areas including hygiene, child welfare, mental health and social support (While, 1987; McCleary, 1933), tasks that still resonate with the health visitor role today.

Although these “health missioners” are the predecessors of health visitors, there is some debate around when the first health visitors were employed (Dingwall, 1977). The title of “health visitor” was first used in Manchester and in 1890 health visitors were paid salaries by the local government (Heggie, 2011; Davies, 1988). From this point onwards other councils across the country began to employ health visitors. By 1917, these practitioners were expected to visit all mothers as soon after a baby’s birth as possible, to advise on hygiene and infant care. Their duties were also being extended to include visiting pregnant women, and children until they reached school age.

After 1945 a number of significant changes took place. Nursing registration became a requirement for health visitors in 1945. After the NHS was formed in 1948, the widening of the health visiting role caused confusion about whether their main professional relationship should lie with GPs or medical officers of health (Malone, 2000). The Jameson Report (Jameson, 1956) emphasised the importance of maternal mental health, which became a key part of health visitors’ role (Kelsey, 2000; Abbott and Wallace, 1998). This led to further confusion about health visitors’ roles and those of social workers.

To address this confusion, Jameson (1956) made a clear distinction between these two groups (Kelsey, 2000). Health visitors were described as generalist “case finders” (through their universal access to all families), while social workers were identified as “case workers” (to work with families with identified problems) (Malone, 2000). The lack of clear boundaries between the two roles continued to be problematic, especially in cases of safeguarding children (Malone, 2000).

Health visiting was gradually incorporated into the new NHS structure by “attachment” to general practices. This change also meant health visitors became more involved with individualised medical practice rather than the more community-based public health approach (Symmonds, 1997). In 1974 health visiting was moved from local authority control into the NHS. In 1977, four principles for health visiting practice were published:

• Search for health needs;
• Stimulate an awareness of health needs;
• Influence policies affecting health;
• Facilitate health-enhancing activities (Council for the Education and Training of Health Visitors, 1977).

Public health became a national focus from the 1990s, when government policies recognised health visitors’ vital role in improving health and tackling inequalities. The need to strengthen health visitors’ public health role and work in new ways was highlighted in a number of documents (DH, 2001; 1999a; 1999b). Public health thus became a major component of the role once again, while health visitors were also expected to work with individuals, be the lead nurse for safeguarding children and lead on the delivery of the healthy child programme (DH, 2009a).

The health visitor’s role

Hunt (1972a) suggested that “there seems to be a common feeling among health

visitors that their role is difficult to interpret to others, and that it is not well understood or agreed upon by those with whom they work”.

Almost three decades later this has not changed. As health visiting does not fit neatly into just one category like some other professions, these practitioners have often been referred to as “jacks of all trades” (Hunt, 1972a; 1972b).

Vague job titles and uncertainty over the associated roles potentially create ambiguity and confusion about professional identity (McGillivray, 2008). The title “health visiting” has been criticised for not being explicit in describing what the title-holder does (Hunt, 1972a), unlike other professional groups where the roles are clearer, such as nurses and teachers. However, Cowley (2002) argued that the title does explain what they do - “health visitors do health visiting”, an umbrella term encompassing a range of different activities. Although social workers, community nurses, public health workers, children’s centre workers and outreach workers may all be involved in providing a range of different activities, it is the combination of tasks that makes health visiting a unique profession (Malone et al, 2003; Cowley, 2002).

Link to nursing

The role has commonly been linked with nursing despite the different origins of the two professions. However, if health visiting as a profession is distinct from nursing then this raises the question of whether it is necessary for health visitors to be qualified nurses before entering the profession. This has been debated by professionals for some time (Brocklehurst, 2004; Malone et al, 2003).

In 2002, this debate was further intensified when health visitor regulation was transferred from the United Kingdom Central Council for Nursing, Midwifery and Health visiting (UKCC) to the Nursing and Midwifery Council (NMC), a regulatory body whose title did not include the phrase “health visiting”. Health visitors moved from having a unique professional registration to being registered with the NMC under “specialist community public health nurses”. Considering the two services’ differences in organisation and purpose, and that health visitors require an additional qualification, categorising health visiting under the broader “nursing” title could be seen as diminishing the significance of health visiting as a profession. Furthermore, there is no research to show any benefits of treating health visiting as a branch of nursing, while there is increasing evidence that it causes harm to health-visiting education, the regulatory process and therefore to practice (Cowley et al, 2000).

Public health

There is a complex relationship between health visiting and public health. In 1999, health visitors were identified as being “pivotal in leading public health practice in communities by developing a wider, family centred public health role, and leading teams of other practitioners” (DH, 1999b). However, there was no clear guidance on what this public health role meant. This led to confusion about which aspects of the role would need to be lost to create capacity for the new (Carr, 2005). McMurray and Cheater (2003) argued that a public health approach requires “more than just a change in role - it requires an altered ethos”.

According to Craig and Smith (1998), there are two theories about the relationship between health visiting and public health. The first is that “health visitors are public health workers in the entirety of their role” (Standing Nursing and Midwifery Advisory Committee, 1995), and the second is that health visitors serve a public health function when they take a population perspective (Billingham, 1994). It has been argued that health visiting was part of public health from the beginning (Lynch, 1997) and that its primary focus on public health makes it unique among the caring professions (Malone et al, 2003). A contrary argument suggests that the focus of modern health visiting is on the individual, not the wider population and therefore quite distant from public health (Caraher and McNab, 1997). This greatly confuses the professional identity of health visiting.

The ambiguity surrounding health visiting and public health is further amplified by the various titles associated with the role (Craig and Smith, 1998), for example, public health nurse (Malone et al, 2003; DH, 1999b). This has led to a variation in the interpretation of health visitors’ public health role, causing inconsistent and diverse approaches to the delivery of health visiting services (Smith, 2004; Craig and Smith, 1998). An exploratory study on the public health role of health visitors found different perspectives, which resulted in confusion over what this part of their role really meant (Smith, 2004).

The title “public health nurse” can be seen as positive for health visiting as it puts health visitors squarely in the public health arena within primary care (DH, 1999a). However, it has been criticised for fragmenting the core function of health visiting by reducing it to a series of task-oriented, routinised approaches that mirror a medicalised model (Smith, 2004; Craig and Smith, 1998). Besides the confusion surrounding public health, health visitors also face an identity crisis over the social aspects of their role. In 1899 the health visitor was described as the “mother’s friend” (Davies, 1988). At the same time health visitors were responsible for reporting to the authorities on matters of vaccination, disease and home hygiene.

Child protection

Child protection is an area where the health visitor’s role often conflicts with that of social workers. Throughout the 20th century there was a lack of clarity between the two roles due to unclear boundaries and little autonomy for health visitors in comparison with social workers (Brooks and Rafferty, 2010). The implication of health visiting practice is made more complex by the difficulty in identifying a body of professional knowledge unique to health visiting, a problem also found in social work practice (Twinn, 1991). England (1986) argued that “the social worker’s ‘practice knowledge’ is his understanding of his clients and it is this unique understanding which informs and determines his helping”. This can also be applied to health visiting practice in terms of personal attributes, interpersonal and observational skills, and equally to other similar healthcare or public health professionals (Cowley, 1995; Hunt, 1972a).

Other overlapping roles

Other community workers and nurses have also been seen as a threat to the role of health visitors. Practice nurses are increasingly involved in health promotion and preventive work. This has caused anxiety among health visitors that their responsibilities are being eroded by practice nurses and that their autonomy (and therefore professional identity) is being diminished through lack of professional networking by being “attached” to general practices (Williams and Sibbald, 1999). Hunt (1972a) highlighted that 68% of health visitor participants chose to be members of the Health Visitors Association rather than the Royal College of Nursing. This was seen as a way to maintain a sense of identification with health visiting through association with colleagues in a professional organisation (Adams et al, 2006; Hunt, 1972a).

Although health visitors’ role overlaps with a number of other professions, which may pose a threat, it is the combination of health promotion, safeguarding children, education, social work, as well as their accessibility, ability to work with individuals, families and communities that gives health visiting its distinctive identity.

Political impact

Change is continuous in the NHS, and with different political agendas and priorities the role of the health visitor has also altered. A number of perceived threats arising from the changes in the NHS in the 1990s have been documented, such as: Project 2000 training (Craig and Smith, 1998); skill mix and practice nursing (Traynor, 1993); evidence-based purchasing strategies (Roberts, 1996); and the conflict between focusing on the individual and working with a community (Craig and Smith, 1998).

However, these threats can also be seen as opportunities for the health visiting profession. Project 2000 training was presented as “a preparation for nursing practice grounded in the philosophy of health and health promotion” (Twinn and Cowley, 1992), which would better prepare health visitors for their public health role. Skill mix and practice nurses would contribute to the public health agenda, with health visitors providing leadership in this area, as ascribed to them (DH, 2001). Through evidence-based purchasing strategies, health visitors could effectively articulate their core mission and make sound business cases to commissioners for continued investment, thus modernising and raising the profession’s profile.

Working with individuals as well as communities makes health visiting unique in the area of public health, providing opportunities for greater creativity in health promotion and prevention.

During the 1990s, the Labour government showed increased interest in the potential of nursing and promoted this in the NHS, through initiatives such as nurse prescribing, NHS Direct and nurse-led walk-in centres (Brocklehurst, 2004). In 2001, a resource pack for health visitors was published, to help develop their “family centred public health role” (DH, 2001). Since then a number of other documents followed, highlighting the importance of the public health and leadership role for health visitors (for example, DH, 2009a; 2009b), culminating in the recent health visitor implementation plan (DH, 2011).

The NHS pay system, Agenda for Change, has also impacted on the profession. A previously attractive prospect to senior nurses, health visiting may now represent a lowering of salary (band 5) during training, which would discourage such qualified staff from considering a move into health visiting. The lower banding on qualification (band 6) has meant that many more junior staff apply but are not experienced enough to meet the entry criteria (Adams, 2009). Furthermore, in many areas midwives are on a higher band level (band 7) than health visitors, again undermining the significance of specialist health visiting training. Inconsistencies in the banding process across the country have also contributed to higher health visiting vacancies in some areas.

Current challenges

The DH (2010) white paper outlined a number of changes that will impact on health visiting. The abolition of primary care trusts; creation of clinical commissioning groups; staff pay determined locally; a new public health service for vaccination, screening programmes and public health emergencies; ringfenced public health funding; and health improvement responsibilities moving to local authorities are all significant changes for health visiting.

The current national shortage of health visitors, highlighted in the recent Laming (2009) review, has also been recognised by the coalition government, which has committed to recruit 4,200 new health visitors by 2015 (Milton, 2010). The DH’s (2011) implementation plan sets out the vision of the new health visiting service and a call to action for stakeholders involved. Although this provides an opportunity for a revitalised health visiting service, the question remains whether this will impact positively and create more opportunities for the profession, or merely expand and change the role yet again, causing further confusion over professional identity.

Since its origin, health visiting has struggled to define its role and has suffered from uncertainty over professional identity. A number of factors have influenced this, such as: its diverse spread across health, education and social care; its link to wider public health functions; its responsibility in child health and protection; and its evolution from 19th-century volunteers into 21st-century professional nurses.

Various political agendas have impacted on health visiting identity, and are the key drivers of change for the profession. The new government proposals herald significant transformations to the NHS in England and especially to the provision of health visiting. It remains to be seen whether these changes impact positively on the profession and give health visitors a stronger identity, both within the NHS and the wider community.

It is clear that professional identity is not static and alters and develops over time in line with changes to professional roles, boundaries and perceptions of the profession. Health visiting is one profession where these changes have been continuous, offering both opportunities and challenges along the way.

• The role of health visitors has been in flux since its conception in the mid-19th century
• Health visitors’ role has changed over the years and this has affected the profession’s identity
• It has been linked with nursing despite the different origins of the two professions
• There is a complex relationship between health visiting and public health
• Agenda for Change has also impacted on the profession

Related files

120619 exploring the professional identity of health visitors.

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Reflections on leadership in health visiting during COVID-19

21st july 2020.

A Voices blog by Maggie Fisher, Professional Development Officer at the Institute of Health Visiting, on health visiting leadership during COVID-19.

Maggie Fisher, Professional Development Officer at the Institute of Health Visiting

During this epidemic, I have had contact with different health visiting service leads in England and the Channel Islands. During these numerous and varied conversations over the last few months, I have been struck by the huge difference good leadership has made to staff morale and services.

I noticed some key themes that seemed to emerge in organisations that appear to make a huge difference to staff morale and how they cope with the changes:

• The importance of strong kind compassionate leadership for staff morale.
• The difference that collaborative leadership makes by actively involving staff in the decision-making process which helps to engage and involve staff, so they do not feel ‘done to’ or ‘dictated to’.
• How vital it is that leaders use clear open communication with weekly or daily briefings, so staff are aware of what is happening and feel connected, included and valued.
• The importance of culturally sensitive and inclusive practices, especially around support and recovery. One size does not fit all, and a range of different support needs to be available that is inclusive of male and female staff, as well as culturally sensitive and appropriate.
• That it is OK not to be OK – and it is a sign of courage that you can admit you feel vulnerable, these are tough times.
• Planned recovery for staff from this pandemic, and its effects that have touched everybody’s lives, may take years to recover from the aftermath, and this is normal.
• The need for bereavement and relationship support, and trauma-informed care.
• The attitude of managers and the senior hierarchy appears to make a huge difference to how staff feel and cope. Kindness and compassion are key attributes, alongside listening, and clear communication.

However, the response to the pandemic has required decision-making with incomplete evidence and at a pace and scale that has not been needed before, as safety remained a top priority. Unfortunately, in some instances, this has led to more directive, top-down, command-based models of communication, rather than our preferred person-centred decision-making that lies at the centre of health visiting and nursing practice.  Health visitors have reported examples where staff have not been consulted but told they had to be redeployed, with no preparation for this, or matching of their skills so these could be used appropriately. Because of this autocratic approach, staff have not had time to hand over vulnerable families, or families who they may have had concerns over but did not meet the vulnerability criteria. This has left health visitors feeling anxious and worried about these families and a feeling they have let them down by not being able to prepare these families for their abrupt departure. Below are some direct quotes from health visitors that illustrate this (1).

“The tone of the communication from management has been hostile when questions are asked.”

“With less than a day’s notice, our service was reduced by 50% as half of us were redeployed to other areas, not necessarily ones we had any experience in. There was no opportunity to prepare our caseload or families, or conduct any kind of handover to colleagues left in post.”

“I have found myself suffering high levels of anxiety and uncertainty over the past 10 weeks but have stuck with it and tried to embrace the experience.”

“I have been told by my new manager that I may be (in redeployed role) until October and it feels like my health visiting managers have just accepted this. I miss my caseload and worry about the families I was working so intensively with before lockdown.”

“The sheer lack of communication is staggering. The District Nursing staff don’t know why we are there as there is not enough work, as they have closed a lot of their clinics and care homes are reluctant to allow them in.”

A cornerstone of health visiting practice is health visitors’ ability to build up trusting therapeutic relationships with all families, which they carefully nurture over time. For vulnerable families, this takes even longer and is more fragile, hence the distress of health visitors who had to abandon these families suddenly. The Centre for the Developing Child (2) noted that it can take 10 or more contacts with a vulnerable family to get them to engage as they often mistrust services. The importance of frequent contact underpins the success of intensive home visiting programmes like the Family Nurse Partnership.

The impact of contrasting styles of leadership is very striking, and the effects this has had on staff morale, anxiety and stress levels. Compassionate leadership is needed in a challenging environment where staff may be struggling with new ways of working and fear over the pandemic and their own health, and that of their families. Listening, responding and asking is a much more effective style of leadership.

Valuing staff skills, experience and contributions is so much more nurturing than an autocratic approach, which appears very damaging to a workforce that in many areas already feels overwhelmed, undervalued and fragile. The experience of health visitors who have been redeployed, and those that remained with a greatly increased workload, has been very different and time needs to be taken to reintegrate teams and allow for debriefing and recovery.

The pandemic has also shone a light on the many positive leadership skills of health visitors who have rapidly transformed their service models, maintained the safety of vulnerable children and families by working collaboratively across their local systems, and ensured that their staff were safe, equipped and supported to work in new ways.

There have been some inspirational examples of how the health visiting service has responded with innovative and creative ways of providing a service to families which appear to be highly valued by parents. Leaders have worked collaboratively in a sensitive compassionate way, valuing staff skills, experience and contributions. The Institute of Health Visiting will shortly be publishing some case studies to highlight the numerous ways that health visitors rose to the challenge of managing caseloads under lockdown.

Maggie Fisher, Professional Development Officer, Institute of Health Visiting

• Institute of Health Visiting (2020) Health visiting during COVID-19. Institute of Health Visiting
• Center on the Developing Child at Harvard University (2007). A Science-Based Framework for Early Childhood Policy: Using Evidence to Improve Outcomes in Learning, Behavior, and Health for Vulnerable Children http://www.developingchild.harvard.edu
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Anna’s Student Nursing Experience

On Wednesday 2nd September (8pm-9pm UK time) @EBNursingBMJ is co-hosting a twitter chat on student nursing and midwifery with @RCNStudents 

To celebrate the contributions our student nurses/midwives make – we are sharing blogs of their experiences in practice.  Today’s blog is from Anna Jones , a second year student nurse on the children’s branch, from the University of Leeds 

My name is Anna Jones and I am a second year student nurse. I am studying at the University of Leeds and my branch is children’s nursing. I am currently on my summer annual leave and I have to say, I’m enjoying every minute! As much as I enjoy my course, it’s a relief to have a break! To say that second year has been difficult would be an understatement. Continual deadlines whilst working on placement all year has been exhausting, but a challenge I am proud to say that I have overcome. Being a student nurse brings many challenges every day. Whether it’s completing an assignment, frantically trying to get a certain skill signed off or ironing your uniform after a twelve and a half hour shift ready for another the next day. What I would give for my own fairy god mother!

However, these challenges do not compare to the ones many patients encounter daily and I am forever putting my own life into perspective to realise how truly lucky myself and many others are to have good health. Working within the field of paediatrics is incredibly rewarding and a joy to meet and care for so many courageous children and families. The strength and resilience they have to face each day is remarkable and gives me the motivation to deliver the best care I can, because my patient’s deserve nothing less.

Like I mentioned, this year has been a tough one – I thought first year was difficult but nothing can prepare you for the jump to second year. I first worked on a day case surgical ward which I loved. Whilst the no nights and weekends were a bonus, meeting so many children and families every shift was a delight. I was able to accompany patients throughout their short stay in hospital, from their admission and the journey to the anaesthetic room to bringing them back to the ward and saying goodbye as they were discharged. Although this was a short experience for patients and their families, do not underestimate the fear and anxieties that are experienced and how valuable the role of nurses are to lend a comforting smile and words of encouragement as children prepare for their surgery.

Being a children’s nurse means delivering the upmost care to that patient, but also ensuring family centred care is encapsulated within practice because they are also on this journey, experiencing a vast range of emotions. Comforting a parent who was crying as their child had been anaesthetised and taken to surgery, having only known them for a few hours seems a bit of an awkward situation. But when you are in that role, that caring role of a nurse, you pat them on the back, lend them a shoulder to cry on or even give them a hug, all with no hesitation. Because if you cannot show that level of compassion and empathy, how can you truly fulfil your role as a nurse?

The rest of my placements this year have been based in the community, one of which was health visiting. Students often have mixed reactions about health visiting but for me it was very different to life on the ward! 9am starts was one of the best perks, an extra two hours in bed was bliss! Working 9-5 Monday to Friday was also a very different routine, and one which I actually found more tiring than 3 long days on a ward. Community placements were slightly more relaxed compared to the busy pace of a ward, but do not doubt the workload. One baby is born every forty seconds in the UK, and each one needs a health visitor. But I enjoyed the placement and an area of health care I would certainly consider further along in my career. Another placement within the community was based at a SILC school. These are Specialist Inclusive Learning Centres for children with special needs. This was a special placement for several reasons; meeting children with specialist and complex needs was so valuable as a student nurse. To see the small yet significant impact you were making on these children was endearing and a valuable learning experience for future practice. The school was also where my grandma had nursed for 20 years; I had quite literally stepped into her shoes! As you can see, nursing runs in the family…

I found that working in the community was a valuable experience to ascertain the care that is delivered outside of the hospital setting. It was also important to become aware of all the services available for children and families to ensure that you are working as part of a wider team to ensure that the care you deliver is holistic within the context of that patient. I realise I sound like I’m writing an essay but it is so important to deliver effective, person centred care. To put my job into perspective, I always try to imagine if it was my younger sister or brother being cared for which gives me the drive to deliver the care that my patients deserve. If my parents or grandparents had to go into hospital, I would want the best level of care delivered to them, as would everyone. This is why the notion of ‘person centred care’ should resonate throughout the nursing workforce and an aspect I will channel within my career. At the beginning of my nursing programme I discovered a quote by Maya Angelou that encapsulates this well within the context of nursing:

‘People will forget what you said, people will forget what you did, but people will never forget how you made them feel.’

I have one more placement of my second year, 4 weeks on a respiratory ward which I begin in a few weeks time. It’s been nice to relax and have some time off but I am looking forward to being thrown back into the whirlwind that is nursing. I will then continue straight into third year. My final year. With so many assignments and placements, qualifying has always seemed like a lifetime away, but now it’s only 60 weeks away (to be precise!) Am I apprehensive? Yes. I can already feel the huge weight that is third year beginning to rest on my shoulders with the prospect of dissertation and applying for jobs. Am I ready? Sometimes I’m not so sure, but I’ve got this far so there is definitely no turning back now! Am I excited with what the next few years will bring? Absolutely.

Anna Jones @AnnaJones6

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