26th September 2021
On 24 September, we published a brilliant voices blog by Toby Lowe who is a leading expert on complex systems thinking, highlighting how health visiting is the infrastructure for achieving positive outcomes. Toby challenged us to move away from the outdated ‘cause and effect’ service design and to think differently to maximise the chance of creating a positive outcome. We are flooding our website and social media with case studies written by leading experts, health visitors and parents to make the case for investing in health visiting alongside the #TurnOffTheTaps campaign.
We are delighted to share a case study written by Vanessa Wright who is a health visitor at Solent NHS Trust in Portsmouth. Vanessa’s case study demonstrates how she used her specialist public health nursing skills to #TurnOffTheTaps and reduce the burden on the NHS.
Prevention is better than cure. Vanessa’s case study captures how health visitors provide so much more than a single task, or an intervention, but are instead a vital infrastructure for improving health and reducing inequalities in the earliest years of life. Through her ‘whole family’ approach, Vanessa was able to stop repeated A&E admissions by working in partnership with a parent of a young child with challenging behaviour to address the underlying issues. Vanessa was able to build a trusting relationship with the family which helped to improve the parent and child relationship, this in turn, supported early years education and prevented the child from escalating into children’s social care.
This case study describes how a health visitor stopped repeated A&E admissions by working in partnership with a parent of a young child with challenging behaviour to address the underlying issues. This intervention improved the parent and child relationship which supported early years education and prevented escalation into children’s social care.
For the purpose of this case study the child’s name has been changed to Alfie and Alfie’s mum’s name has been changed to Sally.
‘When a child feels secure in their attachment to their parents, their behaviour is extremely likely to remain within acceptable social boundaries.’
From the ‘Parent and Child Game’ by Jenner (1999)
Alfie was born healthy and well and he was achieving his developmental milestones. Alfie’s dad was not involved in his life and he lived with his mum and 2 older sisters. When Alfie was two, he became unwell with scarlet fever and started suffering from recurrent tonsilitis. This is when Alfie’s mum, Sally, noticed a change in his behaviour.
At around the same time, Alfie’s GP contacted me, the family’s health visitor, because the A&E department had shared a cause for concern report due to Alfie attending A&E on a very frequent basis over a short period of time. Alfie’s admissions were all related to accidental injuries.
I contacted Sally and explained that I had received a notification from the A&E department. Sally said that she was expecting my call as the nurse in A&E had explained that the health visitor could help to support with managing Alfie’s behaviour. Sally sounded very worried on the phone. I listened to her concerns and explained that I could offer Sally and Alfie support in the home. Sally thought that this would be ‘really helpful’ as she said she was at ‘breaking point’ and ‘didn’t know what to do’.
I could see from the first time I met Sally how much she was struggling, from her nonverbal cues and body language. I also observed Alfie’s behaviour and it really worried me, as he was jumping off surfaces and smashing his toys. I could see why Alfie was presenting in A&E so frequently with accidental injuries. I knew it would take some time to unpick the root cause of Alfie’s behaviour and, to do this, I needed to complete a holistic assessment of Alfie in his own home, observing Alfie’s interactions with Sally – and this would be competed over a couple of visits.
Over the weeks that followed, I was able to build up trust and confidence with Alfie and his mum, whereby she felt able to share more about how she was feeling and the things that mattered to her. Sally said that she ‘didn’t like Alfie sometimes’ and that she felt ‘guilty’ about this. Sally explained how she felt ‘frustrated’ and ‘angry’ that everyday activities were so ‘stressful’ with Alfie. Sally also disclosed that she was really worried about taking Alfie to A&E again, because she thought that social services would take him away from her. She said she felt ‘on the edge’ with no one to turn to.
Alfie was attending pre-school, and this was not a positive experience for Alfie or Sally. Alfie’s name was constantly being recorded in the accident book and he was not able to walk to the football field with his friends because he required extra supervision from staff due to having frequent accidents. The staff ratio per child was not high enough at the nursery to keep Alfie safe. Alfie was slowly becoming more and more excluded.
Sally was worried about keeping Alfie safe. Not only was Alfie jumping off surfaces, but he was hanging out of the windows, hurting his sisters, and he would unbuckle his seat belt when the car was moving.
Sally also felt her two older children were missing out on her attention because all of her time and energy was focused on Alfie.
To offer an evidence-based parenting intervention, which is child centred, delivered in the home, over six-sessions, using the following principles and techniques:
- social learning theory
- attachment theory
- listening techniques
- positive behaviour management
The intervention aims to improve parents’ confidence and their relationship with their child. Sally was very motivated to change, which greatly supported her engagement with the sessions. I explained the programme to her, and she committed to the sessions and said this was the first time she had felt listened to.
The programme required me to ‘role model’ techniques and observe Alfie and Sally together. I provided strengths-based feedback, which increased Sally’s confidence and helped to improve Alfie and Sally’s relationship.
- I saw Alfie and Sally in their own home, where they were both more comfortable in their familiar surroundings. This helped me to get to know Sally better and understand the things that mattered most to her and Alfie.
- I was able to provide continuity of care.
- As a health visitor, I have been trained to work in partnership with families. Instead of a ‘tick box’ assessment, we work with families to explore the complexities of their life and build on their strengths to find solutions that will work for their individual child (not just any child – as all families are different). I was able to build a trusting relationship with Alfie and Sally. This helped her disclose her deepest fears about social care taking Alfie away.
- I worked through the evidenced-based parenting intervention with Sally who was very reluctant to join any groups or programmes with other parents. So, I continued meeting her where she was, in her own home. The programme consisted of 6 home visits, including a holistic assessment.
- I used detailed observational skills and coaching skills to provide positive feedback to strengthen Alife and Sally’s relationship which fostered improved attachment and bonding.
- During the 6 home visits we regularly discussed Sally’s achievements, as well as any challenges.
- An evaluation was completed at the end of the programme during which I reviewed ‘what had worked well’ with Sally.
Outcome and Impact
Sally reported that:
- She felt ‘listened’ to and that people were ‘on her side’.
- She ‘felt supported’ and ‘felt in control’ again.
- She is ‘more confident’ and says ‘life is less stressful’.
- Alfie stopped having admissions to the A&E department.
- The apparently small things were the ‘big’ things: Alfie was able to walk to the football field with all his friends.
- Alfie was no longer having frequent accidents at nursery and was no longer at risk of exclusion.
- She could enjoy activities with him, such as trips to the park and going shopping.
- The family no longer needed enhanced visiting as they had learnt some new skills to manage things themselves.
- Escalation to Children’s Social Care was prevented.
- The whole family now enjoy Alfie’s company, and they talk about his day at nursery.
Lessons Learned and Recommendation
- Taking the time to listen to parents is key to building trusting relationships, to help them to disclose their fears and underlying issues.
- A strengths-based approach is important for building parental confidence.
- Health visitors are in a unique position to be able to see babies, children and families in their own home which enables more accurate observations of the parent and child relationship. It also provides a safety net for families who are reluctant to join a ‘programme’ or a group with other parents.
- Rather than waiting for things to reach a crisis point, getting help in early can make a big difference.
- Offering empathy, a bit of kindness, care, role modelling and support helps to empower parents like Sally to make sustained changes.
- Providing regular opportunities to reflect and discuss progress, as well as challenges, with Sally supported ongoing evaluation of ‘what was working well’.
- The techniques used during the session provided Sally with a ‘tool kit’ of techniques to manage Alfie’s behaviours in a positive, child-centred way.
- Problems with children’s behaviour cannot be treated in isolation; they need to be understood in the context of the lives of each family that we work with. The clinical Specialist Community Public Health Nursing skills of a health visitor are essential to be able to assess a multitude of needs for both the adult and the child; not only to address the frequent A&E attendances but to work to prevent further accidents by addressing the root cause of Alfie’s behaviour.
Vanessa has been working as a health visitor for 8 years and says that she ‘wouldn’t want to do any other job’. When Vanessa became a new mum herself, she moved to a new area and was far away from her family and friends. Vanessa’s health visitor introduced her to other mums in her local area and she remembers being so grateful to her, so much so that it left a lasting footprint on her life and inspired her train to be a health visitor. Vanessa described her own health visitor as her ‘life saver’.
Vanessa says the best part of her job is searching and identifying health needs and providing early intervention. Vanessa ‘loves seeing the lived experience of babies and young children and building trusting relationships with families’.
We would like to say a heartfelt thank you to Vanessa for sharing her story which brilliantly articulates the important role of the specialist community public health nurse in achieving positive outcomes whilst reducing the burden on the NHS.
Calling all health visitors: We invite you to find your inner warrior and share your stories on social media. How have you made a difference to babies, children and families? Support the #TurnOffTheTaps campaign and raise the profile of health visiting so every baby can get the best start in life. Together we are stronger. #InvestInHealthVisiting