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Steering through change: a personal perspective on the many changes in community practice and the lessons from having been there.

With over a year of retirement from health and education under my belt, and listening to another government discussing changes to practice, I have been reflecting on how policy changes informed and influenced my practice.

This article aims to show that throughout change, if we have good management, support within our team and are willing to learn from our experiences, then we can continue to develop and provide best practice.

Best able for change

After entering nurse training with 10 years' experience as a mother, first aid volunteer, teacher and a successful business in selling, I was surprised to find that the training of all medical staff was centred around a model of patch or manage, especially as hospital admissions were a known disruption to people's lives, and a drain on the economy. I also learned that the profession best able to change this, was health visiting.

Consolidating my nurse training on a professorial unit taught me how team discussion of embryonic ideas could provide revolutionary thinking that could then be debated nationally, through unions and associations, and contribute to best practice. Politically, this was post-Salmon--all staff rotated onto nights maintaining a continuity of care, and volunteers supported staff through making beds and befriending patients.

Importance of support

Health visitor training required the completion of a 12-week obstetric course, where I was joined by other staff nurses, specialist nurses, sisters, midwives and nurse teachers, who provided dynamic discussions and innovative project presentations.

The health visitor course was the toughest I ever encountered and demanded continual self-analysis--52 weeks long with no holidays was a trial on any relationship and our group experienced enough stress to last a lifetime. However, we also learned the importance of peer support and I was grateful for the calm presence of my clinical practice teacher.

Sharing and training

Over the next three years, I experienced high standards of professionalism and life events that would ground me for many years. These were the days of large health centres shared by GPs, midwives, school nurses, district nurses, dieticians, physiotherapists, speech therapists, community psychiatric nurses and dentists.

Colleagues who job-shared overlapped at 'baby clinics' that our community paediatrician attended to discuss best practice. I believe he was one of the first to perform peripatetic immunisations to the travelling community. Health visitors had backgrounds in special care baby units, registered sick children's nursing, midwifery, family planning and management, and all took on an area of special responsibility.

It was a time of change in politics, immigration and employment, but we had a strong HVA (the predecessor of Unite/CPHVA) section and I was lucky to rub shoulders with some of the greatest thinkers of our time.

Management advised all newly qualified health visitors to complete the first-line management course, and encouraged individual development through City and Guilds 7307.

Community psychiatric nurse support, practice discussion groups and three-month exchanges for city and rural health visitors encouraged an environment of respect, reflection and responsibility, where we found funding to produce teacher-practitioner posts and research-led practice.

Management arranged training days with guest speakers and encouraged attendance of the HVA conference, and we all gratefully accepted the resources supplied by infant formula and food companies.

Changing workloads

My next post sat in the context of the Community Care Act. Practice nurses were medicalising many of the roles of the health visitor, leaving child protection as a disproportionate amount our workload. We looked at different opportunities for health promotion, attending market stalls and established groups.

Departments of health and social care divided, and as managers tried to find a working definition of health care, health visitors saw the reality as the lack of money to support social workers further increased our workloads. Voluntary groups took on more and more skilled work and skill mix, together with regular collection of statistics and the ability to use a computer, became a financial necessity. These influences meant that practitioners had to contribute to their own training, managers were encouraged to accept free or cheap work environments for their staff, mileage allowances fell further behind petrol prices and registration costs continued to rise.

Diverse health information confused individuals and health visitors stopped giving out samples at a time when unemployment and prescription costs rose. I took on the role of health and safety representative and found the MSF (the union that the HVA merged with in 1990) to be an excellent source of training.

However, I felt frustrated with the 'hot desking' and the loopholes that allowed my colleagues to work in cramped environments. The poor, obese and smokers were seen as victims of their own ignorance, or choice. I no longer felt comfortable in my role, and so I returned to teaching.

School nursing

After 10 wonderful years of working as a freelance trainer and assessor in child health and social care settings as well as in a Category C prison, I accepted the opportunity to work as a school nurse. The remit was based on the government document Looking for a school nurse and followed pertinent recommendations that bought practice up to date. I felt the years in teaching had provided me with very relevant skills and understanding, not only of the teacher's role, but also that of the support workers and parent of the older child.

Once again, I was surrounded with dynamic practitioners in education, social services and health. Primary children, ripe and eager for information, were willing to take health messages home, and parents demonstrated a desire to get their school on the Healthy Schools agenda.

Busy, busy, busy

However, instead of the multi-skilled teams that we had dreamed of in the 1990s, many localities had placed the health visitor as manager of band 5s and 4s who were doing much of the routine work. Health visitor time was spent increasingly on staff appraisals and reviews, and an increasing number of strategic, children in care reviews, and case conferences on families they hardly knew.

Records and meetings became essential in order to keep hold of the picture, which fuelled the discontent of band 4s who saw health visitors doing less and less 'work'. The growth in community groups and sharing information seemed to compound this and health visitors found their capacity continually reducing. Resources now seemed so scattered that practitioners were using increasing time collecting them and often used their own holidays for personally financed training.

Some primary care trusts (PCTs) combined the teams, further reducing the number of band 6s while giving health visitors responsibility for children in primary schools. Although this enabled school nurses to focus on the increasing health issues in secondary schools, many health visitors did not feel they had the knowledge or skills to work in schools.

Teachers also appeared to be in resource poverty and desperate for our personal, health, citizenship and social education input, but there were fewer staff with school health and education diplomas available for the primary children. Families moving across PCTs were confused by the different services that community health teams provided, and community practitioners were continuing to struggle to maintain the role that they knew worked. Staff meetings became a platform for information giving and target setting, training opportunities decreased, conference costs rose, the letters page disappeared from the journal, and colleagues found fewer opportunities to share. It began to feel like innovative practitioners were a dying breed.

A culture of 'I work harder than you' developed and everyone was 'busy'. Public holidays, marriages, births and departing colleagues passed without celebration. We discovered a colleague had been in hospital and didn't even manage to send a card. Christmas parties disappeared as December and January became the time to take holidays that had been impossible to take earlier.

Back to sharing

With two years left to retirement I decided to go back into freelance, and found a community health team who worked a corporate caseload providing health promotion.

Weekly case discussion provided time to share best practice and identify resource requirements, which their manager prioritised. They all attended a monthly clinic, held over a whole day, and arranged a shared lunchtime where they caught up on each other's lives. This enabled the team to grow in a supportive environment.

The right questions

Over the years I have been invited into many homes, schools and work environments working with many different families and professionals, learning how life events are affected by various cultures and rituals, and how cultures and rituals influence the development and implementation of policies and practice.

Through these families I have experienced joy and success, sorrows and tragedies and been able to facilitate the creation and interpretation of policies.

Health visiting and school nursing taught me to ask the right questions, that you can't judge a book by its cover and neither book nor religion will tell how a person will live, learn or develop because each person develops through their interpretation of their experiences, making each family unique. That is why it's been a privilege.


O'Dowd A. (2008) Nursing in the 1960's: 'The ward sisters were pretty fierce'. See: nursing-in-the-1960s-the-wardsisters-were-pretty-fierce/ 577485.article (accessed 5 May 2011).

Evans E, Lloyd-Jones C. (2006) Child care and the law. Cardiff: UWIC.

Department for Education and Skills, Department of Health (DH). (2006) School nurse practice development resource pack 2006. London: DH.

Jacqueline Mountford-Green

Retired health visitor and school nurse
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Author:Mountford-Green, Jacqueline
Publication:Community Practitioner
Article Type:Column
Geographic Code:4EUUK
Date:May 1, 2011
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