The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need

The role of the school nurse in protecting children and young people from maltreatment: An integrative review of the literature

OBJECTIVES

This review aims to describe the role of the school nurse in protecting children and young people from maltreatment by examining the international literature. Child maltreatment is a prevalent issue in global society today and includes physical, emotional and sexual abuse, neglect and exploitation. School nurses are ideally placed to identify and work with children and young people who are at risk of maltreatment through their regular contact with the school community.

DESIGN

Integrative literature review incorporating thematic analysis.

DATA SOURCES

Electronic databases British Nursing Database, Cumulative Index of Nursing and Allied Health Literature, Medline, PsycInfo, Cochrane Library Database for Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL).

SEARCH TERMS

Role, School Nurse, Child Maltreatment.

REVIEW METHODS

Initial title and abstract review of 444 studies resulted in 78 studies for full text review. Additional search strategies identified one relevant study. Inclusion and exclusion criteria were employed as follows; (1) study published in the English language, (2) peer-reviewed, (3) primary research, (4) inclusion of school nurses (or equivalent role internationally) in the study sample, and (5) a focus on the role of school nurses in preventing child maltreatment. Studies were appraised using the Critical Appraisal Skills Programme tool for qualitative studies and the Strengthening the Reporting of Observational Studies in Epidemiology checklist for mixed-methods and quantitative studies. Findings from the studies were identified, summarised and organised into a summary table, before being analysed thematically.

RESULTS

21 studies met inclusion and quality criteria and were included in the review. Key themes that emerged from the analysis were; supporting the child and family, detective work, working with other professionals, training and supervision, barriers to protecting children and young people from maltreatment and trust.

CONCLUSION

International literature highlights the variety of activities that school nurses may undertake in daily practice to protect children and young people from maltreatment. Several challenges to this role are identified, including time management and building relationships with children and young people. Recommendations for practice and further research are made.

Characteristics and related factors of Japanese mothers who have faced difficulties with childrearing

OBJECTIVE

To identify characteristics of mothers who face difficulties with childrearing.

DESIGN AND SAMPLE

Cross-sectional study. During 2014, 221 mothers and 248 children living in City A within the Tokyo metropolis were registered as requiring help with childrearing. Nursing records of 205 mothers (92.8%) and their 227 children (91.5%) were available. We excluded 29 mothers and children owing to incomplete data for a final sample of 176 mothers (79.6%) and 198 children (79.8%).

MEASURES

Difficulties with childrearing were assessed by self-reported questionnaires at the newborn child's 4-month health checkups. Data on maternal and child variables were collected from nursing records.

RESULTS

The "Difficulties group" included 59 mothers (35.4%) and their 70 children. Logistic regression analysis showed that mothers who were aged 40 years or older, who had a total score on the Edinburgh Postnatal Depression Scale of 9 or greater, who used more child-care support services, and who were monitored more frequently by public health nurses had a high risk of facing difficulties with childrearing.

CONCLUSIONS

Periodic monitoring by PHNs is a key strategy to improve the impact of the difficulties of childrearing for mothers of yoshien jido and their children.

Collaboration: A critical exploration of the care continuum

The purpose of this research was to explore the concept of collaboration within a specific healthcare context and to include the perspectives of healthcare users, a position largely lacking in previous studies. In applying a critical theoretical approach, the focus was on, as an exemplar, mothers with newborn babies who had spent more than 48 hr in a special care nursery. Semistructured interviews were undertaken with child health nurses, midwives and mothers. The three key theoretical findings on collaboration generated in the study point to layers of meanings around identity, knowledge and institutions of care. Findings from the interview data analysis were further examined through the lens of key policy documents. The research outcomes indicate that the concept of collaboration serves an important function in healthcare in obscuring the complexities and ambiguities that characterise the care continuum. The study concludes the need for a more critical approach to the assumptions that underlie the language of collaboration and the implications for practice in healthcare.

Street-level bureaucracy and policy implementation in community public health nursing: a qualitative study of the experiences of student and novice health visitors

Aim To explore the experiences of student and novice health visitors in implementing health visiting policy reform pre- and post-qualification.

BACKGROUND

In England, public health nursing has been subject to major policy reform. The Health Visitor Implementation Plan (2011) set out a plan to recruit increasing numbers of nurses and midwives to the profession to deliver an expanded and refocussed health visiting service. Exploring this policy change from the viewpoint of those new to health visiting offers a unique perspective into how a specific policy vision is translated into nursing practice.

METHODS

A descriptive qualitative study in which participants were enrolled on a one-year post-graduate health visiting course at a University in South West of England. Qualitative data were collected pre- and post-qualification. A total of 16 interviews and a focus group were conducted with nine participants between September 2012 and March 2013. Findings Descriptive data were interpreted using Lipsky's theoretical framework of street-level bureaucracy. Three themes emerged which relate to this 'bottom-up' perspective on policy implementation; readiness to operationalise policy, challenges in delivering the service vision; and using discretion in delivering the vision. Community public health nurses operate as street-level bureaucrats in negotiating the demands of policy and practice, and by this means, attempt to reconcile professional values with institutional constraints. Barriers to policy implementation at a local level mediate the effects of policy reform, ultimately impacting upon outcomes for children and families.

Public health nurses’ concerns in preschool-aged children’s health check-ups

The aim is to describe Finnish public health nurses’ concerns during regular health check-ups of preschool-aged children. In 2011, focus-group interviews were conducted with 12 public health nurses. The data were analysed using inductive content analysis. Public health nurses’ concerns dealt with the healthy growth and development of children and their ability to cope with difficult family situations, as well as the everyday reality of parenting. The concerns of public health nurses related to children’s health focused on their psychosocial development. Concerns also focused on the interaction between mother and baby, children’s behavioural problems and their cognitive development, parents’ mental health problems and families’ social circumstances. The everyday reality of parenting caused concern, including the lack of sufficient family time and conflicting parenting roles. Based on the available evidence, the role of public health nurses in child health care has broadened remarkably from the traditional physical follow-up of growth and development to support the well-being of the entire family. Children’s psychosocial problems and families’ difficult circumstances increasingly represent the challenges faced by public health nurses during preschool-aged children’s health check-ups. Public health nurses’ concerns revealed that, in order to respond to the needs of families, they may need to increasingly rely on multi-disciplinary cooperation with other professionals.

Moving from a universal to targeted child health programme: which children receive enhanced care? A population-based study using routinely available data

BACKGROUND

There is a current emphasis on 'progressive universal' delivery of the UK child health programme, with a core universal service complemented by enhanced support provided according to need. In Scotland, a three-category indicator of need, the 'Health Plan Indicator' (HPI) is used to identify children requiring enhanced support from the child health programme to facilitate this.

METHODS

Routine child health programme and hospital delivery records for a cohort of 36 871 Scottish children were used to explore the factors associated with being identified as requiring enhanced child health programme support using multilevel logistic regression modelling.

RESULTS

The following factors were all independently associated with an increased likelihood of being assessed as requiring enhanced support: (i) deprivation; (ii) young maternal age, maternal smoking and drug misuse; (iii) a previous stillbirth; (iv) prematurity; (v) being small for gestational age; (vi) no breastfeeding, admission to a special care baby unit; and (vii) medical, social or developmental concerns about the baby. There was a tendency for children living in areas with higher Health Visitor staffing levels to be more likely to be assessed as requiring enhanced support but this effect was not statistically significant. There was significant residual variation between areas in the likelihood of children being assessed as requiring enhanced support.

DISCUSSION

This study suggests Health Visitors take a complex range of factors into account when assessing which children require enhanced support from the child health programme. Health Visitors' workload may influence the likelihood of them identifying children as requiring enhanced support but this requires further clarification. There are clear differences between areas in allocation of the different HPI categories. Further work is required to explore the relationship between being identified as in need of enhanced support, the care actually provided to children, and their outcomes.

Negotiating policy in practice: child and family health nurses' approach to the process of postnatal psychosocial assessment

Background

There is growing recognition internationally of the need to identify women with risk factors for poor perinatal mental health in pregnancy and following birth. In the state of New South Wales, Australia the Supporting Families Early policy provides a framework of assessment and support for women and families and includes routine psychosocial assessment and depression screening. This study investigated the approach taken by Child and Family Health Nurses (CFHNs) following birth to assessment and screening as recommended by state policy. This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Methods

This was a qualitative ethnographic study that included 83 CFHN and 20 women. Observations occurred with thirteen nurses; with 20 women, in the home or the clinic environment. An additional 70 nurses participated in discussion groups. An observational tool (4D&4R) and field notes were used to record observations and analysed descriptively using frequencies. Field notes, interview data and discussion group transcripts were analysed thematically.

Results

CFHNs demonstrated a range of approaches to assessment and screening. Psychosocial assessment was conducted in 50% (10 out of the 20) of the interactions observed; however, all the women were screened using the Edinburgh Depression Scale. Four major themes that represent the approach taken to the assessment process were identified: ‘Engagement: getting that first bit right’, ‘Doing some paperwork’, ‘Creating comfort’ and ‘Psychosocial assessment: doing it another way’. Nurses utilised other skills such as observing the women interacting with their baby, taking note of non verbal communication and using intuition to develop a clinical decision.

Conclusion

Overall, nurses’ took a sensitive and caring approach to assessment and screening, however, there were differences in interpretations of the policy recommendations across the two sites. Nurses adopt a flexible, relationship-based approach to the assessment process; however, they experience tension when required to incorporate structured psychosocial assessment processes. To undertake assessment and screening effectively, CFHNs require ongoing support, training and supervision to maintain this sensitive and emotionally challenging work.

Approaches used in investigating family support in transition to parenthood

Early support has been acknowledged to be needed in the phase of transition to parenthood, and increasing knowledge is available on the factors enhancing this transition. The issue is to translate the knowledge into practices of preventive care. In this article, our aim is to map out recent research on supporting parents in maternity and child health care and to analyse how the subject of family support has been studied. The data consist of 98 scientific articles published in peer-reviewed journals during 2000-09. Most of the reported research was Anglo-American, and fell within the academic fields of nursing studies, medicine and public health. The studies were categorized into three groups according to the epistemic perspective that was taken on the subject of family support, the studies focusing on (i) views and perceptions on family support of both clients and professionals (63 studies), (ii) the effectiveness of interventions (27 studies) and (iii) activities in the practices and processes of MCH (8 studies). First, the groups were described with regard to the study participants and the data and methods used. A bias towards the perspectives of risk groups and mothers was detected. Second, we examined the potential of different epistemic perspectives to describe care practices. The article contributes to the discussion about how to examine the practices and processes of health promotion and preventive care in such a way that the 'good practices' identified could be implemented in other contexts than the one studied.

Sustainable practice change: professionals' experiences with a multisectoral child health promotion programme in Sweden

Background

New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.

Methods

All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n = 23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for programme sustainability.

Results

The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for programme sustainability.

Conclusions

These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a programme requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.

Does nursing research impact on policy? A case study of health visiting research and UK health policy

The aim of this study was to critically examine the impact of nursing research on the development of health care policy using UK health visiting research as an example. We used established methods to evaluate research impact. This included a documentary review of over 30 policy documents, citation analyses on 19 papers and interviews with health visiting researchers. Although there were examples of policy documents being informed by health visiting research it was not always clear what role research had played in the development of recommendations. Information from researchers provided examples of local, national and international impact, although the extent to which papers may have impacted upon policy was less clear from the citation analyses. Many of the UK studies cited in policy documents were qualitative, observational or reflexive and a lack of evaluative research, in particular randomised controlled trials and other controlled evaluations, may limit the impact of health visiting research on health care policy in the UK. There is evidence that health visiting research has influenced health care policy but this has been limited and there is a need for more research to underpin and inform the role of the health visitor.

Exploring understanding of the term nursing assessment: a mixed method review of the literature

BACKGROUND

Much skilled nursing practice is described by words that at face value appear low-tech and self-explanatory. Despite being intrinsic to practice, the term "nursing assessment" has few operational definitions. Evidence-based practice and the quality agenda makes it imperative that this term is well understood.

OBJECTIVES

To contribute to the evidence base and facilitate a greater understanding of assessment of patients as carried out by nurses through exploring the research question: How is the term "nursing assessment" used in the current health care literature?

DESIGN

The review process, synthesised from the work of Greenhalgh et al. (2005), Clancy (2002), Egger et al. (2001), identified and assessed the quality of articles, text books, the grey literature, policy documents and databases. Glaser's Grounded Theory (GT) method was utilised to analyse the concept of "assessment" as exemplified within the included studies.

METHODS

The focus for this mixed-method review is the health care literature between 1990 and 2005. Studies were identified, screened and assessed for methodological quality and data were extracted and recorded. Analysis of the included studies was facilitated using a GT approach. Possible tensions when using a mixed-method research design are acknowledged and briefly discussed.

RESULTS

Of the 32,602 instances initially identified, 329 articles, policy documents and book extracts were closely read and after further screening, 120 articles and 12 policy documents and book extracts were analysed. Seven overlapping categories were identified, with "judicial" or "judgement making" identified as the core category.

CONCLUSIONS

Hierarchies of nursing practice, government policies and inter-professional agendas cause barriers to meaningful assessment. Informal and formal assessments and screening processes are often conflated, resulting in confusion regarding the scope and nature of the process. Differences between the rhetoric of placing the patient at the heart of the assessment process and practice have been identified.

Supporting nurse decision making in primary care: exploring use of and attitude to decision tools

Nurses are increasingly working more autonomously in extended roles, yet we know little about the nature of the decisions they make. Decisions vary in terms of complexity, ambiguity and presentation, and the nature of the decision task impacts on the process of decision making, such as the likelihood of using a decision tool. Thus, knowledge about the nature of nursing decisions is essential for development of effective decision tools. This article presents an analysis of 410 nurse-patient consultations and interviews with 76 primary care nurses, and explores the nature of the decisions that primary care nurses make and the impact of that on their use of and attitudes towards decision tools.

Health visitors’ assessments of parent–child relationships: A focus group study

BACKGROUND

Health visitors (HVs), also known as public health nurses, in the UK provide a universal community-based service to preschool children and their parents. Since they have ongoing supportive contact with almost all mothers and young children they have opportunities to identify problems in the parent-infant relationship: for example during developmental screening, home visits and immunisation clinics. Research into the role of screening for problems in the parent-child relationship in early childhood is sparse and little is known about how such problems are currently identified in the community.

OBJECTIVE

To explore the approaches taken by health visitors (HVs) to identifying problems in the parent-child relationship.

DESIGN

Focus group study.

SETTING

Glasgow, Scotland.

PARTICIPANTS

24 health visitors sampled purposively.

RESULTS

Multiple sources of information were used by health visitors in assessing parent-child relationships. These include use of known risk factors, knowledge of local norms, direct observations of behaviour, reflection on the relationship between the parent and health visitor, as well as more intuitive reactions. In many cases understanding difficulties in parent-child relationships involved piecing together a jigsaw over a considerable time span. Continuity of relationships appeared to be crucial in this task. Home visits were described as the most informative setting in which to develop an understanding of the parent-child relationship. PARTICIPANTS reported a lack of formal training in the assessment of parent-child relationships and were keen to obtain more training.

CONCLUSIONS

Health visitors use complex strategies to integrate information about parent-child relationships. These strategies are acquired in a variety of ways, but receive little emphasis during basic professional training.

Health visiting assessment processes under scrutiny: a case study of knowledge use during family health needs assessments

BACKGROUND

Accurate assessment of family health need is a core health visiting skill, requiring considerable knowledge and expertise. To date, there has been only limited empirical examination of the types of knowledge and ways of knowing which are likely to influence health visiting practice during family health needs assessments.

OBJECTIVES

This paper will present a detailed analysis of health visiting assessment processes and will explicate some of the many elements associated with the processes of identifying and assessing family health needs.

DESIGN

An in-depth case study was undertaken to explore health visiting practice across three study sites. The focus of interest was to attempt to understand the factors that may influence a health visitor in making a professional judgement to offer a family extra support.

SETTINGS

The study was conducted in three community Trust case sites in England, UK.

METHODS AND PARTICIPANTS

The study was informed by a constructivist methodology. Data collection took place during 56 observed home visits to families receiving increased health visiting support and intervention. Following the home visits separate in-depth interviews were undertaken with the health visitors and the clients.

RESULTS/CONCLUSIONS

This paper will explicate some of the many elements associated with the processes of identifying and assessing family health needs. It endeavours to unravel some of the complexity and intricacies of these processes and provide insights into health visitors' practical 'know-how'.

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study

BACKGROUND

Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK.

OBJECTIVES

The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry.

DESIGN

A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support.

SETTINGS

The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site.

METHODS AND PARTICIPANTS

Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place.

RESULTS/CONCLUSIONS

The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.