Exploring the support mechanisms health visitors use in safeguarding and child protection practice.
Safeguarding and child protection practice has been acknowledged as having a fundamental role in the health visiting service (DH, 2011). Being a universal service, health visiting is ideally placed to identify vulnerable children and those at risk of abuse (DCFS, 2008). Recent socio-political influences affecting health visiting (DH, 2011) as well as recommendations from reports such as Laming (2009) have suggested health visitors require good support to fulfil their role. Further recommendations (Munro, 2011) advocate that safeguarding practice should be based on sound professional judgements and partnership working with families. The Munro Report (2011) particularly criticised the procedural and task orientated systems entering child welfare services. If health visitors are to use their professional judgement and remain responsive and attuned to the needs of children then support is essential. It is also important to gain knowledge and understanding on this support and how it occurs in practice.
Health visiting has been acknowledged as a profession which is exposed to high levels of stress and anxiety (Wallbank and Hatton, 2011). Anxiety has been acknowledged to run throughout the safeguarding role (Morrison 2006). If health visitors are not supported, especially with the emotional aspects of their work, they can 'burnout'. Burnout is characterised by fatigue, negative attitude and poor performance (Atkinson, 1996). Burnout can also impact on a professional's ability to safeguard and protect.
DEFINITIONS OF SUPPORT
Support is defined by the Oxford dictionary as;
'To keep something from falling, to give strength, help and encouragement' (Oxford Dictionary 2011 p595). Cohen and Willis (1985) acknowledge support as having two main functions, that of providing another with strength and connection, and increasing self-efficacy or the belief in one's ability to cope. Plews et al (2005) illustrate a taxonomy of support and its benefits in Box 1;
The specific aims of this study:
* To examine the experiences of health visitors who work in child protection and safeguarding.
* To discover what health visitors view as supportive in their role.
* To understand the impact of support on health visitors.
The study used a qualitative approach to collect data from a sample of health visitor participants. Participants were emailed and asked to express an interest in taking part. Ten health visitors expressed interest, so two focus groups were compiled with five participants in each. The participants were a homogenous group of white British women. Diversity occurred in terms of their age and the length of their practice experience, this ranged from very experienced to newly qualified.
Box 1 Taxonomy of support Plews et al (2005) Taxonomy of Support Emotional support allowing the person to feel cared for Social integration or being part of a network. Bolsters self-esteem. Offers advice. Provides information as part of a network of reciprocal help. Instrumental aid.
Focus groups were chosen as the method of data collection as these are known to facilitate discussion on feelings, experiences and opinions (Denscombe, 2012). Data was collected by asking open questions and then analysed using a thematic approach which included recording, transcribing and coding the 'raw data'. The results were later checked with the participants for accuracy.
Ethical approval was gained from the university's ethics approval panel and Trust research governance agreed and followed. The ethical issues relevant to this study were to protect the psychological well-being of the health visitor participants and to ensure no harm was done whilst undertaking the study. Self-disclosure was a large part of the study and efforts to ensure safety were maintained by following professional guidance and the Nursing and Midwifery Council (2008) Code of Professional Practice. A debrief session was used to discuss emotive issues raised in the focus groups.
The results suggest that health visitors gain support through both formal and informal mechanisms of support. Box 2 describes a thematic analysis of the transcriptions that the participants viewed as supporting their child protection and safeguarding role. These are broken down into themes and sub themes.
SUPPORT FOR MANAGING EMOTIONS
The results suggest that health visitors gain the majority of their emotional support through contact with their colleagues. This occurs in both day to day interactions and through organised supervision forums. Anxiety was noted to increase for health visitors when clinical risk increased or isolation occurred, and more so if both occurred together. Health visitors' anxiety was reduced by having contact with someone who could talk through their safeguarding concerns. Health visitors felt supported by speaking to experienced colleagues, the Safeguarding Children team, and social workers if involved.
Box 2. Factors which health visitors identified as supporting their child protection and safeguarding role Support to manage emotions * Access to peer support * Debriefing after traumatic incidents * Ability to release tension * Clinical and restorative supervision * Access to timely advice when risk increases Support to deliver safe and effective practice * Access to peer support * Training and development * Challenge and authoritative practice * Gaining feedback on casework * Reduction in hierarchy * Access to timely advice when risk increases Time to evaluate casework and for development * Protected time to reflect on casework * Training and development
"There is nothing worse than needing help and it not being there. You think to yourself what am I going to do now?' (HV6). 'it makes your practice different when you have spoken to someone. More clearer in your mind (HV6).
'Some things are anxiety provoking. We are accountable for what we do and don't do. So if harm comes to a child because of a failure on our part, you've got to take that into consideration' (HV2)
The effects of experiencing negative emotions such as anger, fear, and sadness in child protection cases were identified by all the health visitors. The participants explained they coped with these feelings in a variety of different ways. Coping mechanisms ranging from the use of humour, described within a professional context and as a means of distancing and reframing the experience (Moran, Hughes, 2002), to the need to talk with colleagues, to share feelings and to make contact with the Safeguarding Children Team. The cases described which required the most emotional support were those which left the health visitor feeling powerless to prevent.
Examples included families exhibiting disguised compliance and emotional neglect, or when the health visitor held intuitive feelings for the parent or child and felt unable to evidence their concerns.
It makes you feel overwhelmed for starters, not being able to deal with the issues causing stress' (HV 6).
'At times you're seeing situations that are beyond your control and you can't change it, you can't always make it better' (HV 2).
In contrast the emotional effects of being involved with physical and sexual abuse, although difficult and having an impact created less need for support as these cases were generally prioritised and actioned by Children's Social Care.
SUPPORT TO PROVIDE SAFE AND EFFECTIVE PRACTICE
The results of this theme were dominated by the health visitors' opinions of their own contribution and whether they felt they were providing a quality service which protected children. It is succinctly illustrated by the words of a participant.
'Ultimately you want to know that your practice is good. You could be thinking I may end up in court'. (HV 7)
Day to day interactions with colleagues were again defined as an important and beneficial aspect for delivering safe and effective practice. Discussions with colleagues enabled the health visitors to share learning and advice and make sense of their experiences. Health visitors described the importance of predictable and consistent advice between colleagues to remove uncertainty and doubt in practice.
Being an authoritative practitioner who was able to challenge both families and other professionals, was connected to safe and effective practice. Assistance and support to challenge in child protection work was identified as important for maintaining accountability and improving the assessment process in multi-agency working. Newly qualified health visitors found this aspect of the role more difficult to undertake, especially if their decisions ran at a tangent to other agencies.
'Support to challenge is really key. Newly qualified staff have said to me 'I am glad you went with me [child protection conference], I don't think I could have done that' (HV 3).
Gaining regular feedback on casework and debriefing sessions with an experienced practitioner, was reported to be of benefit to the delivery of safe and effective practice. This was cited as very beneficial to health visitors especially after they had been involved in a critical incident or where a case had escalated or a child had been harmed. The need to contact someone more senior or experienced for immediate support was reported as necessary prior to being able to continue at work.
'You need quite immediate support with stressful things. You need a kind of debrief thing before you carry on and work' (HV 4).
TIME TO EVALUATE CASEWORK AND FOR DEVELOPMENT
Health visitors connected support to being allowed time for training, professional development and supervision. Time away from practice allowed health visitors to think, plan and evaluate cases and it was cited as important to embed learning in practice. Having protected time out was reported to allow space to explore the intuitive feelings and hunches the health visitors associated with the responsive and relational aspects of their practice. When health visitors did not access supervision or training they described feeling caught in a 'spiral of demand' and found it hard to problem solve and think clearly.
Box 3. Recommendations to improve support in child protection and safeguarding practice Opportunities for feedback and debriefing sessions Regular caseload supervision Preceptorship for newly qualified health visitors Training and development Support to challenge Development of peer support forums
'Doing, doing, doing and not taking the time out to think, when do we think what am I doing here? (HV 8).
'It was great to have time out to breathe and it brought up a few issues which I had never thought about, which I could address (HV3).
'It's great, I could not see the wood for the trees, but it has opened up an opportunity to think' (HV6).
Support for health visitors working in safeguarding and child protection was generally required in connection to the management of risk and the containment of emotions. Health visitors required increased support if the children they are responsible for were perceived to be at risk of either harm, significant harm or if their concerns were difficult to evidence, prevent or were ongoing. The anxiety health visitors described came mostly from worries about failing to protect.
Support was accessed from a number of sources. Having access to informal support such as peers, to discuss case work allowed private thoughts, feelings and worries to be aired and processed. Peer support was reported to happen informally, in both an unplanned fashion and within the day to day interactions with colleagues.
'I think my support are my peers and you know you choose your peer support carefully and seek it from who you feel comfortable' (HV 2).
'I'd agree support is from the day to day contact with your colleagues, that's where the bulk of your support is' (HV 3).
Peer support was used by both junior and experienced staff alike and was reported to have a significant effect on the role. A participant described the limitations of formal child protection supervision for supporting the emotional aspects of practice,
'When its formal [supervision] I tend to clam up or I tend to think I can't say that. I am not as relaxed thinking what to say in supervision, as I am with my colleagues' (HV1).
The requirement of clear lines of individual accountability and responsibility limit the effect of peer support in risk management.
In practice, as clinical risk increases health visitors contact their Safeguarding Children team to support their decision making and to ensure correct Trust procedures are followed. It was cited as important for health visitors to access this support in a timely manner for it to be beneficial to practice.
Formal supervision mechanisms were reported to be highly effective for supporting child protection and safeguarding practice. Child protection group supervision was reported to provide structure, reflection and guidance on dealing with accountability and risk.
The results did suggest a distinction between the benefits health visitors gained from group child protection supervision and individual supervision. Individual clinical or restorative supervision reported to be more informal and useful for dealing with the emotional elements of the role, whereas, child protection group supervision reported to be beneficial for accountability, outcomes and actions. These results would suggest the need for both types of supervision to continue to adequately support health visitors in practice.
In relation to multi-agency working, health visitors described feeling supported by policies and procedures which helped them to challenge. Challenge was connected to the health visitor being able to articulate assessments of need and escalate concerns. Differing thresholds for intervention were identified as the main barrier to this, with health visitors feeling their preventative role was limited if their referrals were not actioned by Children's Social Care or Children's Centres. Despite evidence of the detection of risk factors improving (Brandon 2005), feedback from other reports (Laming 2009) has suggested that children can be known to agencies prior to harm occurring. When referrals were not actioned, health visitors described feeling responsible for monitoring and continuing to review the child, this subsequently affecting the delivery of the universal functioning of the Healthy Child Programme.
The knowledge gained has informed a number of recommendations to support health visiting practice locally. These are identified in Box 3. They include the development of forums, which allow peers to meet and discuss cases after incidents Peer support sessions would create additional opportunities for learning to take place in practice and may be required more with the onset of mobile working. Looking to the future an integrated approach to training and supervision may also help to overcome the problems attributed to organisational barriers such as thresholds and referral criteria. The support of student and newly qualified health visitors should be given priority. Emotive reports came from the transcriptions of newly qualified health visitors after being exposed to child protection. At times this was reported to make them feel shocked and question whether they wanted to be part of the profession.
'The first meeting I went to I nearly cried. it made me question whether I wanted to be a health visitor' (HV 5).
A robust period of preceptorship is recommended for all newly qualified health visitors teams who have had limited exposure to previous child protection practice work. This transition between qualifying and entering the SCPHN register is now recognised as an extremely sensitive time for practitioners (DH, 2012). Preceptorship is becoming fully embedded in practice and the importance of this is highlighted and recommended to continue.
This study has highlighted the importance of support for maximising the impact health visiting has on outcomes for children. Peer support has been identified as one of the main sources of support in safeguarding and child protection practice. This support is limited, however, in terms of its responsibility and accountability in decision making processes. Support mechanisms therefore, have to be part of a wide network, which include processes for dealing with escalating risk, evidencing professional judgement, and evaluating practice. There is emerging evidence to suggest that supporting staff leads to improved outcomes for children (Glissen and Green, 2011, Hamama, 2012). However, the challenge for the future exists on how health visitors demonstrate to commissioners that support can impact on child health outcomes. Staff support is closely aligned to the ability to safeguard and protect but it is a topic that requires further evidence to substantiate and demonstrate it. Building and evaluating practitioner support is an essential requirement for all organisations employing child protection practitioners.
* Health visitors are exposed to anxiety when working in child protection and this can increase if they work in isolation.
* Health visitors identified their peers as the main source of support for dealing with issues in child protection practice.
* Different support mechanisms are being used for the restorative elements of child protection practice and for the management of clinical risk.
* Health visitors identified a need for additional support in their child protection or safeguarding role when challenging other agencies.
* Newly qualified health visitors should be supported through a preceptorship process
JUSTINE ROOKE FiHV Health Visitor--Practice Teacher Harrogate and District Foundation Trust
I would like to thank my tutors Martin Manby and Sue Peckover for giving me advice and inspiration. My health visitor colleagues who took part in this research, and the members of the Children's Safeguarding team who offered me guidance and support.
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|Title Annotation:||PROFESSIONAL AND RESEARCH|
|Date:||Oct 1, 2015|
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