Citation
Ebeid A (2025) Public Health Nursing, in United Kingdom Known Commonly Known as Health Visiting: An Algorithm for Codifying Normative Public Health Nursing in Inner Cities. SM J Nurs 8: 7.
Little empirical work focuses on understanding and developing community public health nursing [1-4]. Research into medical expertise suggests that clinical reasoning is not acquired independently of medical knowledge, but rather personal and professional knowledge development structures and clinical reasoning go ‘hand in hand’: that ‘structural changes in knowledge result in dramatic changes in problem solving or clinical reasoning’ [5,6]. This indicates the importance of gathering data about families’ needs, and the personal knowledge-base created, drawn upon and used by expert public health nurse practitioners.
In this paper I reflect on my doctoral research into the needs of hard to-reach families and children in need and how they were supported by their health visitor [7]. Research methodologies were focused interviews, reflective journal, narrative analysis, negotiated understanding, grounded theories, comparative perspectives, documentary analysis and case studies.
My academic supervisor at the University of Sussex was the international researcher Professor Michael Eraut, Professor of Education.
Eraut (personal Communication) suggested that expert health visitors might understand the individual client in terms of ‘categories of client’ using memories of broadly similar cases. This highlights the importance of understanding how expert health visitors identify similarities between clients, relate cases and create ‘categories of client’ as a means of structuring their case-specific, experientially developed knowledge.
Such an understanding would inform the educational preparation of public health nurses/health visitors for work with a variety of ‘typical clients’ and help to facilitate and maximise the development of expertise during practice placements.
Research suggests that public health nursing experts readily identify key information, ‘triggering cues’ or ‘forceful features’ in a situation, perhaps due to their more cohesive and comprehensive knowledge frameworks [8,9].
Eraut [10], explains that memories of cases are aggregated unconsciously and activated intuitively when apparently similar cases are encountered. Then beyond those are the ‘ill-defined problems’, which are very demanding and require people to look at them from different perspectives, then somehow combine these perspectives to come up with a holistic decision. Eraut explains key advantages of a more routinised, recognition-primed approach is a reduction in their cognitive overload, more rapid access to usable information and a reduced need for deliberation. The corresponding disadvantage is inflexibility.
Problem solving and decision making in public health nursing relies on a range of practice-based evidence and the pattern recognition created by piecing together disparate types of information from the client’s narrative, observation, discussion with others and documentary analysis, all of which needs interpretation by the health visitor
1. The first dimension of needs assessment analyses practice in terms of four key elements:
• Assessing clients, and situations (sometimes briefly, sometimes involving a long process of investigation) and continuing to monitor them.
• (Data collection)
•Deciding what, if any action to take, both immediately and over a longer period (either individually or as a team member). (Plan intervention)
• Pursuing an agreed course of action, modifying, consulting and reassessing as and when necessary.
• Meta-cognitive monitoring by individuals or collective monitoring within groups involved, whether agents or clients, and the general progress of the problem or situation; and sometimes also learning through reflection on the experience.
2. The second-dimension concerns key features of the contexts in which the practice takes place:
• Human and Physical environment (individual and family data, child development and childcare, family dynamics, income, quality of home and local environment, family and social networks).
• Relationships dysfunctional, abusive).
• (enabling, supportive, constraining, Patterns and conditions of work (individual or corporate caseloads, attached to GP or geographically based, time available for analysis and discussion, dysfunctional ITC systems).
• granted Culture, Discourses, Knowledge (including the taken for assumptions, beliefs and practices of practitioner and client, practitioner’s skills in eliciting and interpreting client’s narrative and making sense of situations holistically in the context of a client’s personal resources and available community resources).
• Learning opportunities (for professionals and for clients).
•Agency (including characteristics in professionals such as empathy, understanding, motivation and competence and client characteristics such as insight and motivation to change).
3. The third dimension focuses on how the professional is thinking i.e. their mode of cognition, which depends on their experience and on the time available (Table 1). Eraut divides the time-continuum into three columns, whose headings describe the distinctive modes of cognition used by the practitioner. Hence their timescales differ according to the way practitioners work. For example, in one context rapid/intuitive might refer to a minute, while in another context it might include periods of up to half an hour. The critical feature is that practitioners have limited time to deliberate or think in any depth. The instant/reflex column describes routinised behaviour that at most is semi-conscious. The rapid/intuitive column indicates greater awareness of what is going on and is often rapid decision-making within a period of continuous semi-routinised action. Typically, it involves recognition of situations by comparison with similar situations previously encountered, then adding to them with already learned responses. The rejection of familiar actions based on prior experience leads to deliberative problem solving and hence to a more time-consuming approach. As practitioners become more experienced, they acquire a wider range of precedents and recognise them more quickly and accurately. The deliberative/analytical column is characterized by explicit thinking by individuals or groups and involves the conscious use of different types of prior knowledge, and their application to new situations. Eraut points out that the relationship between time and cognition is probably interactive:
Crowded contexts also force practitioners to be more focused and process information quickly. As time becomes available the role of meta processes becomes more complex, expanding beyond self-awareness and monitoring to include the framing of problems, thinking about the deliberative process itself and how it is being handled, searching for relevant knowledge, introducing value considerations etc. However, in overcrowded or time pressured practice situations, or when clinical supervision is inadequate the quality declines, clinical risk is higher, job morale falls and the practitioner’s health may deteriorate.
Eraut [11], explains that both knowledge and learning can be examined from two perspectives: the individual and the social. An individual perspective on learning enables us to explore differences in what and how people learn and differences in how they interpret what they learn. A social perspective points out the social construction of knowledge and of contexts for learning and the cultural practices that provide knowledge affordances.
Eraut explains that three distinct definitions of knowledge are in common use. Codified knowledge, defined by publication in books and journals and subject to quality control by editors, peer review and debate including policy documents, local audit reports. The main feature is acceptance and truth. Cultural knowledge which is not codified plays a key role in most professional practices and often “taken for granted” so that people are unaware of its influence on their behaviour. Eraut points out that all people are influenced by assumptions about others of which they may not be aware and some of these arise from their own tacit cultural knowledge. Understanding of client’s meanings is constructed through dialogue and requires self-reflexivity and/or engagement with clients in a more open manner. Greater awareness and understanding of the cultural knowledge of their clients is very important in health visiting and community nursing.
Personal knowledge is the individual centred counterpart of cultural knowledge, which Eraut [12], defined as what individuals bring to situations that enables them to think, interact and perform. It includes practical knowledge, judgments and tacit knowledge, personal versions of codified knowledge, everyday knowledge of people and situations, know how in the form of skills and practices and memories of cases and events.
It also includes aspects of self-awareness, attitudes and emotions.
The evidence of tacit personal knowledge comes mainly from observations of performance. He explains that two aspects of making tacit knowledge explicit are to raise the person’s awareness of his or her tacit knowledge through self-reflexivity and to learn how to represent it in codified form. Eraut points out that even when knowledge is capable of being explicitly described it might be used tacitly because it is usually quicker. He also points out the limits to how far tacit knowledge can transform in this way when “people do not know what they know”. Eraut also argues that knowing how to apply theoretical knowledge and policy in practice has a strong tacit dimension, which can only be learned from observing behaviour and reflection on those observations and experiences.
Eraut [13,14], explains that skills can be considered as both a form of cultural knowledge and a form of personal knowledge. On one level skill is used to describe actions, although the knowledge needed to decide when to use that skill will include situational understanding. The other usage refers to processes for example teamwork, leadership or problem solving which includes multi-cultural awareness and negotiated understanding. Eraut points out that experts identify key features in a situation rapidly through recognizing a familiar pattern, often created from the unconscious aggregation of memories of previous events as Bryans study of health visiting expertise illustrates. Eraut developed a typology of learning trajectories from observations and interviews of nurses.
Fiqure 1 is a model of public health nursing / health visitor practice I devised, which can be used for analysing the nature of health visitor expertise. The model is not necessarily used in a linear way, because new information may indicate a need for the health visitor to revisit earlier step(s).
Applying Eraut’s notion of modes of cognition and learning trajectories to Figure 1 gives examples of health visitor implicit skills in use. Comparing examples of novice and experienced health visitors makes it possible to analyse performance and modes of cognition.
Step 1. Engage client in a therapeutic relationship.
Elkan et al’s review of health visiting points out that very little is known about the micro-processes in public health nursing/ health visiting but what appears to work for clients (p229) is an approach that is neither controlling nor judgemental but allows the client to set her own agenda. They point out that this approach might create tension as health visitors are increasingly expected to work to pre-determined managerial and medical agendas. It may take several visits before a health visitor is trusted and a client engages in open and meaningful communication [15]. A theoretical framework underpinning my approach to entry work includes standpoint theory, symbolic interactionism [16], and Rogerian non-directive counselling [17].
The first example of health visiting practice is of a novice health visitor reflecting on a developmental check. It demonstrates rigid adherence to guidelines, a narrow task orientation and deliberative-analytic cognition (personal correspondence 2001).
Initially I felt anxious regarding performing the review. Having only previously observed my practice teacher conduct the assessments, I didn’t feel confident that I had sufficient knowledge when asking Sarah’s mother questions, let alone answering her questions. I also wanted to appear competent to Sarah’s mother, this probably created the most anxiety. I felt pleased I was able to remember the format of the 18-month review.
Step 2. Elicit information on child and family history, culture, health beliefs and health-needs through conversation and open questions,observation, screening tests, previous records and discussion with others. Skills include:
• Accessing relevant knowledge/information from health and medical records
• History taking.
• Child developmental screening.
• Dealing with complexity whilst prioritising the needs of the child and gaining the co-operation of the parent.
• Handling ethical issues.
• Speed and fluency.
The next example describes a routine visit made by an experienced health visitor (Ling et al 2000 p9) and demonstrates how intuitive cognition defamiliarises the familiar rapidly, recognises deviation from the norm and sees what is important in a situation.
The health visitor had been told at the clinic that the teenage couple that had recently moved in had a three-month-old baby; and made a home visit. Initially the health visitor assumed that the baby was ‘upstairs’ because he was sleeping, and that the lack of toys or ‘baby things’ could be explained by either their lack of resources, or the confusion associated with a new house. The health visitor described how, although she had indeed identified what could be described as ‘non-ideal’ conditions within the house; the situation was in no way atypical of what she had seen in many other homes. She described how she went on to feel more and more uneasy, despite the apparent normality of the situation. She therefore asked to see the baby. The health visitor found the infant in a cot covered completely with a blanket so that according to the parents ‘the baby wouldn’t be disturbed by anything’. Apparently the couple saw this as appropriate and normal treatment of a child.
Compare this with a novice health visitor’s description (personal correspondence 2001) and the effect of cognitive overload on her hesitant practice:
I’m not sure if I would have coped so well if Sarah’s mother hadn’t been as well informed. Her compliance with me asking her questions and her readily offering information indicated that she was happy to have me performing the review. During the review I was aware that I occasionally lost my trail of thought and was quickly put back on track by my practice teacher who would occasionally add helpful information. This gave me time to collect my thoughts and think of relevant questions I had not yet asked. I was also conscious that I spent time looking at the child health records and tried to record the information as it was being discussed and this meant I lost the flow of the conversation easily and was aware of being a novice in this field.
Step 3. Reflectively analyse and synthesise information, making sense of the whole situation from the client’s standpoint and preferences. Skills include:
• Disposition to critical holistic reflexivity.
• Disposition to learn from reflection.
• Disposition to group reflection (clinical supervision).
This student health visitor’s reflection demonstrates deliberative analytical cognition and a degree of self-awareness, but her attention is confined to the screening procedure (personal correspondence 2001).
The experience highlighted that despite reading around the area of the 18-month development assessment there were areas that I lacked knowledge. It also emphasized my need for further experience, in order to help the giving and receiving of information flow smoothly, as well as increase my exposure to potential problems to enable me to identify and deal with them. I was able to recognize my own limitations by my increased awareness regarding my lack of knowledge.
Compare this with an assessment of the situation by a more experienced health visitor (personal Correspondence 2003):
Health visitor X made weekly visits to young families in Bed and Breakfast Hotel accommodation to offer help, advice, support and child health surveillance. During a conversation with Mother Y she mentioned that she was concerned about the safety of a friend’s baby whom she had seen at the Hotel a few days earlier. Her friend had disclosed to her that her partner (whom she alleged was a hard drug user) had hit the baby. Mother Y said she saw a bruise on the baby’s forearm, and named mother and child to the health visitor. She said she was worried about the baby’s safety but was frightened to report the incident for fear of reprisal. Health visitor X recognised the mother and child’s names as they were previous tenants at the Hotel and confirmed the identity of mother and baby with Mother Y. Health Visitor X informed Mother Y she would inform Social Services of the above concerns. She telephoned Social Services and relayed the information and gave the child’s last address from health visiting records. Social Services were unable to locate the family and informed the Police child protection unit of their concerns. The child was located and examined by a Paediatrician in the local hospital some days later and discharged home. Unfortunately the child died ten days later.
Step 4. Co-constructed problems and family needs. Prioritise problems and child’s needs with client. Discuss healthy choices and co construct care plan. Client co-drives decision-making processes. Skills include:
• Prioritising the short and medium-term problems and needs of the child.
• Formulating and evaluating healthy options with clients.
• Planning action, step objectives and goals with client.
• Decision- making under pressure.
• Appropriate and timely referral to other agengies and experts.
• Applying relevant theory and policy in a range of practical situations.
• Managing the process within an appropriate time-scale.
• Identifying clinical and non-clinical problems and risks.
• Identifying risk management strategies.
The example below compares two health visitors responses to a simulated client’s presenting problems and needs. It compares a professional agendaled approach that is rigid in adherence to taught plans and narrowly task focused with an approach that is client centred and needs led. The latter approach demonstrates intuitive cognition, and the practitioner rapidly recognises or senses what is important in a situation and deals with complexity effortlessly.
Health visitor X consistently but selectively focuses on verbal cues and pursues more factual elements of the client’s presentation. She does not appear responsive to verbal or non-verbal cues about the client’s current mental and emotional state. The effect of this early focus and failure to pursue cues about emotional and psychosocial needs is that the client stops presenting cues of this type. Exploration of these areas of need is subsequently limited and the visit remains heavily focused on infant needs, rather than the mother’s psychosocial and emotional needs.
Health visitor Y consistently responds to verbal and non-verbal cues about the client’s current mental and emotional state while also pursuing more factual elements and addressing the breast-feeding issue in a positive and constructive manner. Her use of cues about emotional and psychosocial needs encourages the client to elaborate and express her feelings about her difficulties. Opportunities to explore these areas of need are subsequently increased. This visit as a whole achieves a balance in accurately identifying and addressing infant and maternal needs, including the mother’s psychosocial and emotional needs.
Step 5. Check out client’s understanding of expectations and outcomes.
Identify personal and family resources. Skills include:
• Knowing when to seek expert help.
• Locating resource people.
• Identifying how to access services and resources.
• Self-management in handling emotions and evaluation.
• Coping with unexpected problems.
• Crisis management.
• Value issues.
The next example demonstrates family health needs assessment and a team approach to service provision (personal correspondence 2002).
Health Visitor S saw the way to help this family was by supporting the mother – to address some of her emotional, physical and social needs so that she could more effectively cope with her children’s needs, within a concerted multiprofessional team effort. S suggested exercise on prescription as a way of stress management, which Mother said she wanted but never accessed in six months. S applied to Social Services for sponsorship with childcare (under section 17) to give Mother some time for her to make their home comfortable, give Mother time for herself, and to give the baby quality time. S encouraged Mother to consider a course or a hobby at the local college that provided free crèche facilities and supported her self-image and self-esteem by reminding her of her personal assets and qualities.
S talked about debt management, and pointed out where further help was available, but Mother never accessed the service. S supported Mother’s effort to quit smoking. S wrote to charities for school clothing and furniture, unfortunately the applications were not successful but she obtained low cost stair gates. The family’s social worker obtained charity money that paid for a new wooden floor in the sitting room, suitable for the baby to crawl on. S discussed the benefits of mother and baby clubs but Mother wasn’t interested in peer support groups. S discussed the older children’s needs- T’s need to attend school regularly and for after school hobbies…
Compare this account to the student health visitor’s reflection:
In this situation I was able to demonstrate the need for prescribing and I was able to access the GP who was able to prescribe. This meant that the client’s needs had been identified and met using an evidence based approach to practice. The opportunity to combine prescribing with health promotion and education as a means of client empowerment was highlighted, enabling Mrs. Wilson to be in control of her son’s health.
Step 6. Implement care plan, working with parents and other agencies as necessary. Skills include
• Ability to inspire and motivate and give realistic feedback.
• Discussing client’s concerns and perspective.
• Using knowledge resources (human, paper-based, electronic).
Steps 7/8/9. Review and evaluate outcomes and client benefits. Change plan as necessary. Skills include:
• Evaluating input, output, outcomes and health gains.
• Involving clients and others in review and evaluation processes.
• Supporting clients learning from reflection on experience.
• Learning from experience to improve one’s practice.
• Cost-benefit analysis. The skills that occur in three or more steps are listed below:
• Client needs-led orientation. • Presenting oneself in a culturally acceptable way.
• Communication with a wide range of multi-cultural clients.
• Working in partnership with parents.
• Asking the client about their own ideas, concerns and expectations.
• Giving and receiving information. • Identifying client’s pre-suppositions, beliefs and values.
• Assessing the needs of the family as well as the child.
• Attending to wider determinants of health.
• Discussing problems and needs openly with client.
• Check out own and client’s understanding of the situation.
• Active listening. • Facilitating and maintaining trusting relationships.
• Non directive counselling.
• Empathy.
• Positive regard.
• Non-judgemental attitude
• Asking open-ended questions.
• Observational skills.
• Attending to other perspectives of the problem/situation.
Given their importance, my research seeks to find out the extent to which skills like these are critical for providing appropriate support for hard to reach families. Meanwhile I will briefly assess how they might best be acquired. Is it just practice or does it require particular kinds of learning support?
Eraut’s [18], research into workplace learning concluded that reflexivity; flexibility and creativity including critical self-reflection are significant features of intuitive practice. He pointed out that in the Dreyfus [19], model of learning, experts are depicted as the fifth and final step on the pathway and explained that the proficiency track leads to the confident, fluent and productive handling of well-defined problems but does not prepare people to tackle ill-defined problems. While tackling well-defined problems may be acquired by practice with appropriate feedback, addressing ill-defined problems requires a more critical approach, a willingness to go back to first principles, analysis, judgement and the ability to recognise and develop multiple representations of complex problems: it may also involve being able to work with other, different types of expertise. Eraut explains that the cultivation of such expertise requires a very different learning context from that needed for the development of proficiency.
Eraut [18], concluded that the majority of professional learning and development was informal learning within the workplace itself and largely due to 1) discussion and collaboration within the work group and 2) discussion and collaborative working with significant others. He pointed out that learning processes external to the workplace included visiting other sites, conferences, short courses, working for a qualification and independent study.
Eraut [20], explains that professional learning and development is promoted by working alongside an experienced colleague for a period of time in supervised practice or shadowing colleagues. This enabled one to learn by asking questions and receiving feedback about shared activities as and when they happen, and also to pick up aspects of their reading of situations and ongoing monitoring and decision making, that are largely tacit and beyond their powers of explanation. Working in groups with people who have different kinds of expertise helps one to understand the nature of that expertise and make better use of it, and characterize an analytic mode of cognition.
Eraut concluded that: Support and feedback for professionals are critically important for learning, retention and commitment, especially during their first few months when they are best provided by the person on the spot.
Clark et al’s [21], review of health visiting and school nursing in Wales points out that few student and newly qualified health visitors and school nurses have access to this kind of support in practice.
An important alternative, or rather addition to workplace learning is ‘clinical supervision’. This was described a in the DH document ‘A vision for the future’ (DH 1993) as: “A formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations”(p15).
DH [22], Platzer et al [23], Hannigan [24], Holstrom et al, pointed out that systematic clinical supervision could decrease practioners stress, increase creativity, improve nurse-patient relationships and raise nurses awareness of the patient’s issues. Blumer points out that effective supervisor skills and attributes include: trust worthiness, being open and honest, good listening and analytical skills, being supportive, giving constructive feedback, facilitating rather than directing and being non judgemental. Asking the right questions facilitates reflection.
There is a renewed international interested in reflective learning and the role it has to play in the working and learning environments of nurses although there is limited research evidence of its impact on improving practice and patient/client outcomes. Hart and Freeman’s analysis of professional and policy literature in British nursing and health visiting, from the mid 1950s to the late 1990s identified that although much has been written on the subject of reflective learning, there is little evidence of nurses and health visitors critical reflection on practice. Lyth [25], points out the financial costs of universal provision of clinical supervision to nurses.
Eraut points out that the term reflection needs to be treated as problematic rather than taken for granted. He defines reflection as both a process and an activity and points out the main proponents of reflection as a learning tool were Dewey [26], Kolb [27] and Schon [28].
The challenge for professional educators in group reflection is:
To focus attention on extracting key issues and addressing them in a manner that leaves participants better prepared for similar incidents in the future. The likelihood of this kind of outcome will depend on having sufficient time, the quality of the relationships within the group and the expertise of any facilitator(s) (p3)
Eraut also points out that critical theorists such as Mezirow [29], argue that both individual and organisational action are constrained not only by power relations but also by their lack of awareness of those relations and the ways in which they work and argue that this lack of awareness can only be addressed by a process of critical reflection.
Hawksley et al., carried out a two stage review of UK published literature and fifteen West Midland Community Trust Development Plans for health visitors and school nurses, to identify national and local trends concerning the family-centered public health roles of health visitors and the child centered public health role of school nurses. Reviewers framed their analysis of UK literature adapting Brannigan’s and Clark et al’s model of public health intervention. Brannigan’s model is based on three levels of intervention. Level one is at the level of individuals and families; level two is at the level of neighbourhoods and communities and level 3 aimed at local populations. Clark et al’s model describes four key approaches. The medical or disease model focuses on treating individuals, cultural behaviour models focus on influencing behavioural and lifestyle change, ecological models focus on community development and a structural model focuses on factors such as alleviating inequality and poverty.
Hawksley et al’s analysis of UK literature in relation to health visiting showed predominantly Level 1 type interventions using cultural behavioural models of health. Another main category was Level 1 type interventions using medical models of health. The structural model was the least represented. They concluded their literature review found little evidence of a shift in practice to new ways of working as advocated in UK policy.
For the second stage of their review they requested fifteen West Midland Community Trusts to forward information concerning their strategic development plans for future health visitors and school nurses (i.e. thirty development plans). Seventeen responses were received; two were ‘formal’ and the remainder consisted of working group information and ideas that were informing policy frameworks. Another unexpected finding was that Trusts had not separated the development plans of school nurses and health visitors. Content analysis of the seventeen documents indicated the main five themes as practice development (leadership, evidence-based care, managing change), and user participation while less prominent themes were enhancing communication (the only citation involved a public health practitioner working alongside PCG/T’s to commission services), workforce issues, and education. Their review of Trust Development Plans concluded that there was a trend towards developing community initiatives with user participation and attention to vulnerable groups as being key concerns. They point out the Plans they reviewed reveal fragmentation in both health visiting and school nursing. Whilst Hawksley and colleagues acknowledge that development plans analysed may not accurately reflect practice trends and that practitioners may not disseminate practice initiatives related to new roles they were disappointed with the little evidence they found that policy was implemented in health visiting or school nursing services.
The Chief Nursing Officer’s Review of the contribution of nurses, midwives and health visitors to children in need (DH 2004), pointed out that those families at greatest risk do not seek help as they cannot handle the perceived bureaucracy of the healthcare system. The Report concluded that health visitors lacked skills in working with families and children in need. In 2007 the Department of Health (DH) announced a review of the future of health visiting (www.dh.gov.uk). The DH also announced piloting of structured two-year ante and post-natal home visiting to hard to reach groups based on David Old’s work in the US (Olds 1984, 1988, 1992, Olds et al 1986, 1994, 1997, 2004). Target families are low income, young, single, first time pregnant women. Health visitors visit families once or twice a month from pregnancy for two years (http://www.wsip.wa.gov/rptfiles). Old et al’s studies found consistent results across trials including: improvements in women’s prenatal health, reductions in children’s injuries, greater interval between pregnancies, increases in father’s involvement and improvements in school readiness.
