Future Health Visiting

21st May 2021

Dr Robert Nettleton, Education Advisor at the Institute of Health Visiting, shares some of his thoughts on The Nursing and Midwifery Council (NMC) consultation on shaping the standards for Specialist Community Public Health Nursing (SCPHN) and health visiting.

 

Having a long memory of my career in health visiting should, I suppose, help me to take the Long View looking forward. This is one of those times when health visiting is being asked to do exactly that. The Nursing and Midwifery Council (NMC) invites us to contribute to shaping standards for the future of Specialist Community Public Health Nursing (SCPHN) and health visiting through its review and the Institute of Health Visiting (iHV) is playing its part.

There have been other such pivot points in the development of health visiting. The profession was first recognised in statute in 1909, and even Florence Nightingale[1] – whose bicentenary we have been celebrating – recognised that ‘health nursing’ required its own training as distinct from ‘sick nursing’. When I was in training as a health visitor the ‘principles of health visiting’ were still ‘new’ – published by the Council for the Education and Training of Health Visitors in 1977[2]. They were incorporated into standards of proficiency for SCPHN in 2004 and we now have drafted new standards from the NMC to consider.

Concern for the future of health visiting is not new either. In 1988 Shirley Goodwin[3], a champion of health visiting, put down the challenge to the profession in the question ‘Whither health visiting?’ She gave a hard-nosed stare at the need for the profession to define its purpose and effectiveness. The strong implication was that, without this, the profession could ‘wither’ and be lost.

Presently in the UK, health visiting is flourishing in many ways, with a strong evidence base, and many champions in parliament and beyond. However, in England in particular, after a surge in investment 2011-15 many services and practitioners are withering under the harsh conditions of underfunding and demoralisation. The proposed standards are ambitious, taking a positive view of the power of health visiting to make an impact on the health of young children, families and communities with generation-lasting effects on the persistent inequalities that mark our society.

The standards apply to all fields of SCPHN (health visiting, school nursing and occupational health nursing) but, importantly, they also detail field specific proficiencies. All the standards have regulatory status therefore, although the title ‘health visitor’ is not protected in statute, health visiting is effectively ‘defined’ by the core and field specific proficiencies for the registered SCPHN. So, while the relatively simplicity of the four ‘principles’ may be lost it is, arguably, clearer for all to know what health visitors as SCPHNs are able to do, ‘from the point of registration’.

The focus of the draft standards is on outcomes, not inputs. This leaves more flexibility about how outcomes are to be achieved. The document states:

these standards aim to provide approved education institutions (AEIs) and their practice learning partners with the ‘flexibility to develop innovative approaches’ to education for SCPHN health visitors, occupational health nurses and school nurses (added emphasis).

It could be argued that this aim needs to be balanced against the marked tendency towards unwarranted variation in standards of service delivery across the UK and between local commissioners in England (sometimes called the ‘postcode lottery’ for the public).

Flexibilities include:

• Length of programme – ‘sufficient’ to achieve the outcomes.
• Theory and practice learning – ‘balance’ rather than 50/50
• ‘Protected learning time’ – rather than ‘supernumerary’

There are potential hazards in such flexibility but also opportunities. Significant numbers of my generation, for example, were able to qualify as nurses and health visitors through integrated degree programmes designed to meet nursing and health visiting outcomes. This included relevant obstetric and occupational health teaching and experiences lost to the present approach. Whether the hazards are outweighed by the opportunities of this less prescriptive approach is worth careful consideration and comment from across the profession.

Practice Learning for autonomy and leadership

The new standards raise the bar on what is expected of the SCPHN at the point of registration. The ambition of the proficiencies lies in the level of autonomy, level of strategic thinking, action and leadership, and commitment to justice, human rights and health equity. Of all these, the level of autonomy is most critical. iHV annual surveys of health visitors over the last seven years indicate that in England at least, health visitors have lost much of their autonomy within a commissioned service. Just before COVID, we found:

49% of health visitors reported that they have the professional autonomy to follow up families with additional needs when these are identified at the mandated contacts. However, a worrying 51% reported that they no longer have the capacity or professional autonomy to follow up families with needs identified at the mandated contacts. This suggests that these senior professionals no longer have the capacity or autonomy to prioritise their work, resulting in unmet needs…

This low level of staff autonomy and belief in their capacity to deliver high quality, effective support is a concern given the recruitment and retention difficulties faced by the health visiting profession[4].

It is not in the scope of the NMC as a standard-setting regulator to take responsibility for the conditions that give rise to this reduced autonomy in England. The Council’s standards apply to the whole of the UK and the other three nations have better resourced services that are not subject to localised and variable commissioning. Nevertheless, standards for Practice learning must provide a vision for what ‘autonomy’ can look like. This relates to the overarching issue of the SCPHN as leader, a cross-cutting theme for all the proposed proficiencies.

Taking together the NMC’s Standards for Student Supervision and Assessment (SSSA) together with the proposed programme standards for SCPHN, in my view:

• The SSSA standards need to be applied in ways that give full recognition to the high level of autonomy expected of registered SCPHNs and the need for students to be assessed for their capability in functioning with increasing autonomy in unregulated environments, highly indeterminate practice situations, without supervision or direct access to support.
• This level of autonomy combines with the complexity of the SCPHN role whereby students have to deal with multiple clinical, social, interpersonal and interagency issues simultaneously. Practice Assessors (PA’s) need to be prepared and supported to facilitate students to recognise and analyse complexity and the judgments, decisions and actions required for practice at increasingly high levels. This makes more demands on the PA’s own level of practice as they combine their teaching and assessing roles with their own clinical and leadership commitments.
• At the same time for SCPHN-HV students, there is substantial new knowledge and practical skills (e.g. supporting breastfeeding and promoting its duration) much of which will be unfamiliar to them from their prior experience that requires active teaching in the practice setting not covered by the ‘theory’ taught by university partners. The SSSA standards make no reference to the verb ‘teach’ or its cognates. The term ‘learning experience’ does not capture sufficiently the need for active teaching alongside supervision and assessment.
• The lack of differentiation between the expectations of PA’s for SCPHN programmes and pre-registration students does not match the higher demands of working with a SCPHN student. Many PTs / PA’s express the view that this effectively devalues the Practice Assessor for SCPHN and that this is reflected in employers’ lack of readiness to recognise this by adjusting workload and/or providing additional financial recognition. As a consequence, many will elect to limit themselves to pre-registration students, threatening the viability of the implementation of the proposed new post-registration standards.

 

Implications for Standards and implementation

There is evidence at least in England that health visitors acting as Practice Assessors and Supervisors are restricted in their capacity to function at the level of autonomy and leadership for which the new standards provide a vision. It, therefore, follows that the preparation and support that they will need to implement the SSSA standards in a manner that is fit for purpose will need to be tailored to the SCPHN programme and to exceed that required for supporting and assessing pre-registration nursing students.

 

How you can add your voice

The NMC has provided opportunities for all SCPHNs to be informed about the standards, ask questions and add their own voice. Professional organizations have also been hosting their events, iHV included. This week we hosted our Networking Event for Student SCPHNs and on June 16^th iHV members can join our Practice Education Networking event. Finally, before 2^nd August, do give yourself time to complete the NMC’s online survey to have your voice heard!

[1] Bryar, R. (2020) Florence Nightingale: Public Health Nursing Pioneer. Institute of Health Visiting. https://ihv.org.uk/news-and-views/news/florence-nightingale-and-health-visiting-on-international-nurses-day/

[2] Council for the Education and Training of Health Visitors (1977) An Investigation into the Principles of Health Visiting. London: CETHV.

[3] Goodwin, S. (1988) Whither health visiting. Health Visitor. Dec:61(12): 379-383.

[4] https://ihv.org.uk/wp-content/uploads/2020/02/State-of-Health-Visiting-survey-FINAL-VERSION-18.2.20.pdf

 

Dr Robert Nettleton, Education Adviser for the iHV.