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Empowering health visitors: a multi-faceted approach.

INTRODUCTION

This paper reports an evaluation of a project to empower health visitors. Empowerment is a concept that has been widely used in nursing and health visiting. It emerged in the late 1960s in the context of movements to promote political awareness and self-help among minorities (Manojlovich, 2007). Chandler (1992) stated that 'to empower is defined as to enable to act' (p. 54), distinguishing empowerment from power, which is 'to have control, influence, or domination' (p. 65). Hawks (1992) added that the ability to act requires 'the correct information, support, resources and environment' (p. 609). An empowerment approach is considered to be a key aspect of health visiting practice both with individuals and communities (Cowley and Houston, 2004; Kenyon 2015). Research has demonstrated that empowered nurses experience less burnout and less job strain, while the inability to act creates feelings of frustration and failure (Manojlovich, 2007).

Health visitors working in Tower Hamlets, a deprived inner London borough, face a large and growing under-5 population, and caseloads with disproportionate numbers of vulnerable families and child protection concerns (Tower Hamlets JSNA Reference Group, 2014). The project was designed to empower health visitors working in Tower Hamlets by developing an evidence-based toolkit that would provide some of the information, support and resources that health visitors need to undertake their role effectively. The project was funded by The Burdett Trust for Nursing Empowerment Programme, and was a partnership between Barts Health NHS Trust (the Trust employing health visitors in Tower Hamlets) and City University London (School of Health Sciences) (CUL).

The project was undertaken in two of the four localities in the borough and had four phases. In the first phase, a Delphi technique in two rounds was undertaken to establish the key areas that the toolkit should address (Bryar et al, 2013). These were:

* infant stimulation and speech and language;

* obesity prevention; and

* stressed and unsupported families.

In the second phase, the CUL team conducted a review of published research-based evidence, and established a baseline of health visitor activity in the identified areas by collecting data from observation, from reflective diaries from health visitors and from interviews with staff and service users. The clinical project manager (Barts Health) met health visitors and staff in local NHS departments, Children's Centres and local voluntary organisations, in order to understand current service provision, referral pathways and barriers to effective working.
Box 1: Topic guide for interviews

Which events in the Toolkit project did you experience (training,
networking, supervision, awaydays)?

About each component:

What was most useful?

Have you used what you learnt then since? How?

Has it affected your work? If so, how?

Has the training added to your knowledge and use of evidence in
practice?

Any effects on your colleagues/teams?

General questions:

Do you use the poster/leaflet/website about health visiting when
working with clients/other professions? Do they help? How?

Have you looked at any of the books? Are they useful?


The baseline data showed that health visitors were generally aware of the evidence base, but were not always able to maximise use of their knowledge through skilled communication due to a range of barriers (e.g. pressures of time, feeling stressed). It was therefore decided that a broader concept of a "toolkit" would be more useful. The third phase therefore included the following range of provision:

* physical resources (for staff and client use): e.g. checklists, guidance, forms, leaflets, books, equipment, training packs;

* virtual resources (for staff and client use): web pages (http://www. bartshealth.nhs.uk/health-visiting), links, evidence briefings;

* training (by a variety of local agencies), to enhance staff knowledge, skills and team working;

* networking, to enhance staff's knowledge of the local resources provided by the borough and third sector organisations; and

* support for staff's own wellbeing and morale (supervision and team development, and awaydays, which combined work-related discussions with 'pampering' such as massage and supportive supervision).

These are described in detail in Davis (2014).

In the fourth phase, CUL evaluated phase 3, and it is that evaluation which is reported here.

METHODS

Qualitative semi-structured interviews were chosen as the method of gathering data. The topic guide appears in Box 1. Relevant team leaders were asked to facilitate contact between the evaluator and those health visitors who had taken part in the project. These were contacted by e-mail, and those who responded either straight away or after prompting were interviewed at their workplaces. Interviews were audio recorded. Research ethics committee approval was not necessary as this was an evaluation, but the principles of informed consent, anonymity and confidentiality were observed throughout.

FINDINGS

Seven health visitors from two localities (all female) were interviewed. They described their responses to many of the components of the project. Table 1 itemises which health visitors had experienced which components of the project. Only those data that relate to empowerment are reported here. Two interviews were not recorded, one because of equipment failure, and one because of the preference of the health visitor interviewed: detailed notes were taken during these interviews, and typed soon afterwards.

Health visitors identified a number of ways in which they felt empowered by the project:

* knowledge;

* materials; and

* psychological support.

They also identified aspects of the project that had tended to make them feel less rather than more empowered.

KNOWLEDGE

Some knowledge gains were reported. Two mentioned that they had been introduced to some new ways of helping families of children with sleep problems, while another who had not previously worked in the locality valued ethnic-specific information relating to speech and language development. Two had been to the networking event and had been introduced for the first time to a number of local third sector organisations that supported families with young children, to which they or their colleagues had since referred clients. Another health visitor had learnt a new and useful technique from the communication skills training.

Generally, however, the health visitors had not themselves acquired significant amounts of new knowledge from the project and its components. Much more commonly, though, those interviewed spoke of the value of the training as a 'refresher', which both reminded them of what they already knew and provided an opportunity to reflect.

It's always good to reflect on practice, acknowledge your skills, restore your self-belief. (HV6)

Others were more specific.

It is always good to refresh with speech and language what is good for a year, fifteen months and so on ... You don't see these children routinely any more ... Suddenly one pops up at say fifteen months and you think, How many words should that child have? (HV2)

The attachment stuff is always good to go over again. It refocuses you and it makes you think about it more. (HV2)

One, who had also particularly valued the day on perinatal health and attachment, added that though for her, the training was more a refresher, this was not necessarily true for her colleagues:

Any study day that you do, you come away and you think, Right, let's really hone our skills back on it again. I think that it is good to get you re-focussed. But certainly for junior members of the team, they thought that it was invaluable. (HV4)

However, another felt that, as more junior colleagues were the target audience for a lot of the training, attendance by more experienced health visitors was not the best use of their time.

MATERIALS

Health visitors were full of praise for the information packs that came as part of the sleep training, and which they could give to families.

We have got like little packets of information about different sleep training techniques, which have been very useful to give out to parents (HV5)

Lots of them [parents] were using the leaflet and they would say: 'I used the leaflet, and I tried this and I tried that, and it is working'. (HV1)

Similarly, all the health visitors were pleased to have the new leaflet (Barts Health, 2014) explaining their role:

I always give out the health visiting leaflet because I think that the general public really don't have a clue about what health visitors are. I always give them a verbal explanation on what a health visitor is, but ... It makes us look a bit more professional I guess, and it validates our role a wee bit. (HV4)

The books provided were thought to be well-selected. Generally, they did not provide the health visitors themselves with new information; rather, they supported them in giving information to others. One who ran a sleep clinic sometimes lent relevant books to clients, and others recommended them to student health visitors on placement with them.

We have students in the office, and if there's a quiet moment before they are waiting for us to go out on a visit, they are always looking at them.... They were very much appreciated. (HV2)

The website was another resource that those interviewed did not use much themselves, but did mention to others, including to student health visitors and to clients.

PSYCHOLOGICAL SUPPORT

Though the training had not exposed the health visitors to much new information or ideas, it had been invaluable in providing affirmation and reassurance.

It was inspiring, and reassuring that the work we are doing counts--empowering: you to believe in yourself a bit more. (HV6)

Sometimes when you work with families where you are struggling with emotional and mental health, it is about recognising that we can't always fix it ... What came out was really that there is no magic phrase that you can say. And sometimes you need to hear that, because you think ... I am not doing something that I should be doing. But actually it is because these are very complex situations, often with very vulnerable families and there is no magic fix, it is about long term work ... That was such a good thing to hear, actually. (HV5)

One talked about being more motivated to pay attention to perinatal mental health at every contact with a mother, whereas before she had tended to do so only at the six-week check. She also felt more motivated to provide follow-up appointments.

If a client has got a problem, it means sitting back and just listening. If I cannot provide a solution there at the clinic, I will actually make an appointment ... When it is a busy clinic what I will do is a follow up home visit, so we can talk about this more. (HV3)

The health visitor who ran the sleep clinic had evidence suggesting that other health visitors, not interviewed as part of the evaluation, were also feeling more confident in their practice.

I am definitely getting referrals for the more complex mothers and not [any more] for the bread and butter sleep management stuff. So that is good, definitely good. (HV4)

Restorative supervision was provided by the local psychology service, and had been useful not just in helping individuals think through how to deal with particular challenges in life or work, but more widely.

Very helpful--it was about boosting self-belief, reminding you that the work is worthwhile. (HV6)

One health visitor spoke of the service providing the supervision as follows:

I always think that having a day with a psychologist is like being wrapped up in a blanket and looked after. Because they are really skilled. They are really skilled and they really understand health visiting. So they are realistic about what we can do and about the reality of our workloads and of the challenges some of our families face, so it is very grounded in reality. We have supervision with them once a month with them and it is by far the highlight of the month. (HV5)

WHAT WAS DISEMPOWERING?

Aspects of some parts of the project were experienced negatively, and these are worth mentioning here as an illustration of how administrative and organisational decisions can sabotage the good intentions behind projects such as this.

First, some awaydays that were designed to make staff feel 'pampered' were perceived to have been badly organised, which had therefore been irritating rather than nurturing.

Second, as already mentioned, some health visitors felt that the training had been more useful for less experienced and qualified members of their teams, and were therefore not the best use of their own time. On the other hand, some valued the sense that teams now knew that they shared the same knowledge base.

Third, although the experience of restorative supervision was very positive, even for those who had been resistant to the idea, the experience was marred by a Trust plan for health visitors to themselves be trained to provide restorative supervision to colleagues. This felt like a cause of additional work and hence of additional stress.

DISCUSSION

The initial motivation behind the Toolkit project was to ensure that health visitors were using evidence-based practice to enable them to provide the highest quality care for families in Tower Hamlets. Once it had been established that in the main their knowledge base was up-to-date, the focus of the project became the support that the health visitors needed. Research on the use of evidence in practice, over many decades, has shown that barriers to research utilisation need to be addressed (Bero et al, 1998; Bryar and Griffiths, 2003). This project has reinforced the evidence that health practitioners may be very skilled and knowledgeable but do not have the time, resources and support to make best use of their knowledge in practice. The wide range of interventions used in the Toolkit Project was shown in this evaluation to have empowered health visitors in their work with families. Refresher training in topics key to health visiting practice, for example, had succeeded in reassuring and motivating them, not least by emphasising the importance of their role. As another example, the provision of relevant and recent materials to give to clients supported them in making effective contact with clients: the materials endorsed the advice that health visitors gave orally and in that way empowered them.

The study had some limitations. The size of the sample was small, and included only experienced health visitors. However, one could argue that if such a group felt empowered by the project, then those with less experience, knowledge and confidence would be as or more likely to feel empowered. Another limitation was that it was not possible, due to limited resources, to test the self-reports of health visitors by observation, consultation with colleagues and clients, etc.

Hawks (1992) argues that a key factor in empowerment is the existence of a nurturing and caring environment. The mixture of relevant materials, refresher training and supportive supervision that the project comprised was successful in helping the health visitors interviewed to feel more supported and thus empowered in their work with families. Evidence from the health visiting early implementer sites (Department of Health, 2013) and other projects which have used innovative methods to develop and sustain health visiting services (for example, James et al, 2015) indicate that empowerment of health visitors through a multifaceted approach is most effective. One thing that those commissioning and managing health visiting services may wish to take from this project is that the value of training is not just the receiving of knowledge and acquisition of skills. Staff may feel more affirmed and motivated by the provision of relevant training and support that might not be indicated by a strict needs analysis. Keeping morale and commitment high may benefit from a more nurturing model of training than is often the case.

Key points

* A project to empower health visitors provided improved resources, training and restorative supervision

* Training had provided affirmation, reassurance and the opportunity to reflect

* New printed and online information about health visiting and child care issues were very helpful for families

* Restorative supervision had provided support for the wellbeing and morale of health visitors

* Overall, health visitors reported feeling empowered by the project

STEPHEN ABBOTT BA, MA (Econ), CQSW Senior Research Fellow

ROSAMUND BRYAR PhD, MPhil, BNurs, RN, SCPHN (HV), NDNCert, SCM, CertEd(FE) Professor of Community and Primary Care Nursing

CORRESPONDENCE: s.j.abbott@city.ac.uk r.m.bryar@city.ac.uk

ACKNOWLEDGEMENTS

We are grateful to those who agreed to be interviewed, to The Burdett Trust for funding, and to Claire Davis, the clinical project manager.

COMPETING INTERESTS

Neither author has any competing interests.

References

Barts Health (2014) Health visiting in Tower Hamlets. Available at: http://www.bartshealth.nhs.uk/media/180774/ Health%20visiting%20in%20Tower%20Hamlets.pdf Accessed August 18, 2015.

Bero L, Grilli R, Grimshaw J, Harvey E, Oxman A, Thomson M. (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ, 317 (7156): 465-8.

Bryar R, Griffiths J (Eds). (2003) Practice Development in Community Nursing: Principles and processes. London, Arnold.

Bryar R, Anto-Awuakye, Christie J, Davis C, Plumb K. (2013) Using the Delphi approach to identify priority areas for health visiting practice in an area of deprivation. Nursing Research and Practice, available at http://www.hindawi.com/ journals/nrp/2013/780315/ (Accessed November 27, 2014). Chandler GE. (1992) The source and process of empowerment. Nursing Administration Quarterly, 16(3): 65-71.

Cowley S, Houston A. (2004) Contradictory agendas in health visitor needs assessment. A discussion paper of its use for prioritizing, targeting and promoting health. Primary Health Care Research and Development, 5(3): 240-54.

Davis C. (2014) Health Visiting Toolkit Project. Project report. London: Barts Health NHS Trust.

Department of Health. (2013) Health visitor programme: early implementer case studies. Available at https://www.gov.uk/government/publications/ health-visitor-programme-early-implementer-casestudies (Accessed 29 June, 2015).

Hawks J. (1992) Empowerment in nursing education: concept analysis and application to philosophy, learning and instruction. Journal of Advanced Nursing, 17 (5): 609-618.

James D, Miller S, Bradford C, Johnston J (2015) Storytelling and Health Visitor Development: A successful outcome for Cumbria and the North East. Workshop Abstract. Faculty of Public Health Conference 23/24 June 2015 available at http://www. fph.org.uk/uploads/Conference%20Program%20 and%20Abstracts%2020.6.15.pdf (Accessed 29 June, 2015)

Kenyon L. (2015) Building Community Capacity (BCC). An Introductory Toolkit for Health Visitors. Department of Health, Health Education England, and Institute of Health Visiting, London.

Manojlovich M. (2007) Power and Empowerment in Nursing: Looking Backward to Inform the Future. Online Journal of Issues in Nursing, 12(1).

Tower Hamlets JSNA Reference Group. (2014) Joint Strategic Needs Assessment Summary Document. Life and Health in Tower Hamlets. April 2014, available at http://www.towerhamlets.gov.uk/lgsl/701-750/732_ jsna.aspx (Accessed 29 June, 2015).
Table 1. Project components experienced by those
interviewed

    Training

    Sleep   Perinatal    Communication   Speech
            mental       skills          and
            health/                      language
            attachment

1   Y       Y            Y               N
2   Y       Y            Y               Y
3   Y       Y            Y               N
4   Y       Y            N               N
5   Y       Y            N               Y
6   Y       Y            N               Y
7   Y       Y            Y               N

    Other

    Awayday   Restorative   Networking
              supervision

1   Y         Y             N
2   Y         Y             Y
3   Y         Y             N
4   N         N             N
5   N         Y             N
6   Y         Y             Y
7   Y         N             N
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Title Annotation:PROFESSIONAL AND RESEARCH
Author:Abbott, Stephen; Bryar, Rosamund
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Oct 1, 2015
Words:3178
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