Health Visiting

Preparation for Practice

Karen A. Luker, Gretl A. McHugh, Rosamund M. Bryar, Karen A. Luker, Gretl A. McHugh, Rosamund M. Bryar

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781119084556
• Edition: 4
• Topic: Medicine
• Subtopic: Nursing

The fourth edition of this seminal text retains its focus on placing the health visitor at the forefront of supporting and working with children, families, individuals and communities. Health Visiting: Preparation for Practice has been fully revised and updated to reflect the changes and developments in health policy, public health priorities, and health visiting. It considers the public health role of the health visitor, and the important role and responsibilities the health visitor has with safeguarding children to ensure the child has the best possible start in life.

Key features:

• Fully updated throughout, with new content on practice and policy developments
• Takes into account the challenges and changing role of the health visitor, and the need to ensure that their practice is evidenced-based
• Includes an additional chapter on working in a multicultural society with a discussion on some of the challenges faced by health visitors
• Discusses and debates the practice of public health and working with communities
• Examines the role of the health visitor with safeguarding and child protection, as well as working within a multi-professional team
• Features case studies and learning activities

Health Visiting: Preparation for Practice is essential reading for student health visitors, public health nurses, and those on community placements, as well as other health practitioners working with and in the community.

Chapter 1
Managing Knowledge in Health Visiting

Kate Robinson

University of Bedfordshire, Luton, UK

Introduction

The mantra of evidence-based practice (EBP) is now heard everywhere in healthcare. This chapter will explore what it might mean, both theoretically and in the context of everyday health visiting practice. Is it a way of enhancing the effectiveness of practice or yet another part of the new managerialism of guidelines, targets, and effectiveness? Why might EBP be an important ideal? When a practitioner intervenes in a client's life, the outcome should be that the client is significantly advantaged. In health visiting, that advantage can take many forms: the client can have more and better knowledge, they might feel more capable of managing their affairs, they might better understand and be able to cope with difficult thoughts, feelings, and actions – the list is extensive. Later chapters will detail the ways in which health visiting can lead to better outcomes for clients and communities. However, the proposition that there should be an advantage derived from the practitioner's intervention is particularly important in the context of a state-financed (i.e. taxpayer–funded) healthcare system. If an individual wishes to spend their money on treatments or therapies of dubious or unexplored value offered by unregulated practitioners, then that is entirely a matter for them, provided that they have not been misled or mis-sold! However, when the state decides to invest its resources in the provision of a particular service and associated interventions then arguably there has to be some level of evidence or collective informed agreement which gives confidence that the choice is justified. In addition, of course, every health visitor must be able to account for what she does and doesn't do to the Nursing and Midwifery Council (NMC), if required.

Chapter 7 explores how health visiting might be assessed, measured, and evaluated. The emphasis in this chapter is on how we choose, individually or collectively, to develop particular services and perform particular actions which we know with some degree of certainty should lead to better outcomes for the client. But how do we know things with any certainty? What sort of knowledge do we need to make good choices? Although there are very many different ways of categorising or describing forms of knowledge, for our purpose here it will be sufficient to make some simple distinctions. We might categorise knowledge by type. For example, Carper's (1978) categorisation of knowledge as empirical (largely derived from science), aesthetic (or artistic), ethical, or personal is well known and is used in nursing. Or we might categorise it by source, and ask where it comes from (books, journals, other people, personal experience, etc.). Or we might use the simple but important distinction between knowing that and knowing how (McKenna et al., 1999). For example, I can know that swimming pools are places people go to engage in swimming and other water sports without ever having been to a swimming pool, but I can only say I know how to swim if I can do so. In the former case, I can probably explain how I came by the knowledge, but in the latter, I may not be able to explain how I know how to swim or what I am doing when swimming; the knowledge statement I know how to swim is dispositional: its truth is determined by my ability to swim. Such ‘knowing how’ knowledge is sometimes called ‘tacit knowledge’, in contrast to ‘explicit knowledge’ or ‘knowing that’. Our concern here is less about how theoretically we might define knowledge than about the question of what sort of knowledge health visitors could and should be using – and who says so – and what sort of knowledge they are using. There is substantial controversy here, as various factions argue that their type or source of knowledge is the most important. And the outcome of what might be argued to be a fight to define the ‘proper’ knowledge basis for practice is important as it has the potential to impinge directly on the health and safety of the client and on the degree to which health visiting can be said to ‘add value’ to clients.

In later sections of this chapter, we will look more closely at EBP, which is currently the dominant knowledge protocol in the National Health Service (NHS), and try to establish what forms of knowledge it valorises – and what forms it discounts – and why. The chapter will also look at reflective practice (an alternative protocol for generating and managing knowledge about practice that is supported by many institutions and individuals within nursing) and at the idea of knowledge being generated and managed within communities of practice (CoPs) (an idea that is popular in education and some other public sector areas); each of these can be viewed as a social movement, with enthusiastic advocates trying to ‘capture’ the support of key health organisations and institutions, as well as the hearts and minds of individual practitioners. We will also look at what is known about the types and sources of knowledge that healthcare practitioners actually use in practice – which prove to be somewhat different from any of the ‘ideals’ promoted by these social movements.

But before examining any of these ‘ideal’ types of knowledge management, it will be useful to remind ourselves about the practice of health visiting. For evidence-based health visiting or reflective health visiting or any other imported concept to be a reality, it must be integrated into the taken-for-granted, existing ways in which health visitors go about their business. But defining or describing health visiting is not simple. If we start by looking at what the government thinks it is, then we must recognise that, in the UK, health visiting is practised in four nations (involving two assemblies and two parliaments), each of which has a different idea of what health visitors should do, and to what ends. We then have the view of the profession as a whole, which is expressed through various collective means. But when we try and look at the actual practice of health visiting, we find that there is a lack of shared knowledge about what goes on in the very many interactions which lie outside of the public domain of hospitals and clinics. Despite these difficulties, the next two sections will look briefly at the contexts in which health visitors manage knowledge.

Defining health visiting practice

The Department of Health commissioned a review of health visiting, Facing the Future (DH, 2007), aimed at highlighting key areas of health visiting practice and skills. This is not a wholly research-based document – and makes no claims to be – although there are some references to research. Rather, ‘this review is informed by evidence, government policy and the views of many stakeholders’ (DH, 2007: §1). Decisions about what health visiting should be about are therefore largely presented as decisions for the community of stakeholders in the context of stated government priorities. Key elements of the decision-making process can be seen as pragmatic and commonsensical – in the best sense. For example, the review argues that the health visiting service should be one which someone will commission (i.e. pay for), one that is supported by families and communities (i.e. acceptable to the users of the service), and one that is attractive enough to secure a succession of new entrants (i.e. it has a workforce of sufficient size and ability).

In terms of the future skills of health visitors, the review is clear that they will be expected to be able to translate evidence into practice – although it is less specific about what sort of evidence will count and how the process will be managed. However, at the national level, it recommends that the relevant research findings to support a 21st-century child and family health service be assembled. There is also some indication that future practice will be guided by clear protocols: ‘Inconsistent service provision with individual interpretation’ will be replaced by ‘Planned, systematic and/or licensed programmes’ (DH, 2007: recommendation 8). As we shall see, the reduction in variations in practice is one of the key aims of the EBP movement. In terms of evidence underpinning practice, the document also draws specific attention to the expanding knowledge base in mental health promotion, the neurological development of young children, and the effectiveness of early intervention, parenting programmes, and health visiting. Clearly, this is a very broad base of evidence, derived from a range of academic and practice disciplines.

So, while the review is not specifically about the evidence or knowledge base of health visiting and how it might be used, many of the relevant themes in debates about EBP begin to emerge. For example:

• What is the role of the practitioner in assembling and assessing evidence?
• How can evidence be translated into practice?
• What counts as evidence?
• How can other bodies support the practitioner by generating and assembling evidence?
• How can any practitioner be conversant with developing knowledge bases in a wide variety of other disciplines?
• What will be the role of protocols, guidelines, and ‘recipes’ for practice?

These questions all remain relevant, and health visiting commissioners, managers, and practitioners attempt to answer and reconcile them at all levels of practice. However, at the highest level of government, where the health visiting service is created and defined, significant changes in the knowledge base have been used to refocus the purpose and practice of health visiting. The new knowledge largely stems from the neurosciences and developmental psychology, and not from within health visiting itself, and is concerned with how and when brain development occurs. It underpins the premise that early intervention in every child's life – starting from conception – to optimise brain development is a key plank in strategies aimed at improving educational attainment, reducing crime and antisocial behaviour, reducing obesity, and improving health. Perhaps the most robust expression of what might be called the ‘early intervention movement’ is the first of two government reports by the Labour MP Graham Allen: Early Intervention: The Next Steps (Allen, 2011a). The context of Allen's report is the UK fiscal deficit and the Conservative/Liberal Democrat coalition government's agenda of addressing this deficit by making substantial reductions in public spending. Indeed, Allen's second report (Allen, 2011b) is entitled Early Intervention: Smart Investment, Massive Savings. In order to emphasise the need for early intervention, his first report starts with two images of a child's brain: one from a ‘normal’ child and one from a child who has suffered significant deprivation in early childhood. The differences in neurological developme...