RE: serious stuff

October 23, 2004

It is very alarming. The NSF for children, in the Maternity bit has a paragraph siting a study, questioning mothers about the support they received around breastfeeding. It claims that mothers do not get much support between day 11-30 following the birth of their baby. My personal experience is that quite a few breastfeeding mothers are seriously thinking about giving up by the time I go in at 11-14 days post-natal. Which would indicate to me that they are not supported enough prior to this. I think somebody somewhere is trying to pitch Health Visitor against Midwife. I am able to work quite closely with my Midwifery colleagues, they actually come to me for advice and vice versa. Who are these antagonists? Kathy Soderquist

October 24, 2004

Have followed the last few messages with interest.

First of all , it was good to meet up with you and other Senate colleagues at conference.

, I am sorry that you felt my reply to the client complaining in the Journal was 'defensive', she did have some justification in complaining and have to say that if I was an HV in the area where she lives I would be mortified. However, I really do get angry when the whole HV profession is condemmed because of a mother's experience with a few. Most of my clientele breastfeed but I feel strongly about self-rightous mums who, because they can fully breastfeed without introducing solids for 6 months expect others to do the same, and condemn those who can't. I still think imposing this 'no solids before 6 month recommendation' on every baby is a load of bollocks thought up by men in suits, puts mothers off breastfeeding or exhausts them if they are breastfeeding several times in the night when the baby is 5 months old. Mothers and babies are individuals so if necessary I have no qualms about telling them for God's sake start solids, get a good night's sleep, and carry on breastfeeding during the day. Although in this mother's view that would make me a useless HV.

Secondly, like Kathy I find it is both the hospital and community midwives who are not offering breasfeeding support, and I have recently complained to my manager that at the last 4 new birth visits I did, none of the mums knew how to latch on properly as they had not been shown. It is still common for babies to be given formula or glucose water in hospital on the grounds that they are not breastfeeding properly and one mum recently told me that at UCH her baby was given formula for 2 days as the staff told her they had no time to help her breastfeed. Like Kathy too, I have a good relationship with our community midwives who will notify us of social concerns etc, but help with breastfeeding seems to be a no no.

That's my rant for the week.

June

October 24, 2004

June, I had not registered the names on the letters: apologies for being

unclear and seeming to point the finger! Actually, I agree with all the

points you made and felt your letter was a well reasoned response to

what (as is usually the case when someone feels sufficiently hurt and

angry to write a letter of complaint) was a bit of an undirected rant.

I would defend her right to make the complaint though, if that is how

she felt; it was the suggestion that Community Practitioner should not

have published the letter because it was 'health visitor bashing' that

I felt was unhelpful. Perhaps the person who wrote that letter, too,

felt hurt and angry and at the end of her tether and I don't want to add

to her sense of exasperation by casting any more stones. Personally,

though, I would rather hear the complaints than have them only made

about us, not to us. At least then we can try and do something about

the problems and, hopefully, ensure they are only isolated instances. I

recognise, too, that when we hear only one side of a complaint, as in

the AIMS article, we cannot make reasoned decisions about exactly what

happened; the story might sound very different if told by the health

visitor concerned. It is just very worrying that the level of

discontent amongst our clients, collectively, seems to be getting

greater; moving beyond the occasional isolated case.

best wishes

junet579@... wrote:

> Have followed the last few messages with interest.

> First of all , it was good to meet up with you and other Senate

> colleagues at conference.

> , I am sorry that you felt my reply to the client complaining in

> the Journal was 'defensive', she did have some justification in

> complaining and have to say that if I was an HV in the area where she

> lives I would be mortified. However, I really do get angry when the

> whole HV profession is condemmed because of a mother's experience

> with a few. Most of my clientele breastfeed but I feel strongly about

> self-rightous mums who, because they can fully breastfeed without

> introducing solids for 6 months expect others to do the same, and

> condemn those who can't. I still think imposing this 'no solids before

> 6 month recommendation' on every baby is a load of bollocks thought

> up by men in suits, puts mothers off breastfeeding or exhausts them

> if they are breastfeeding several times in the night when the baby is

> 5 months old. Mothers and babies are individuals so if necessary

> I have no qualms about telling them for God's sake start solids, get

> a good night's sleep, and carry on breastfeeding during the

> day. Although in this mother's view that would make me a useless HV.

> Secondly, like Kathy I find it is both the hospital and community

> midwives who are not offering breasfeeding support, and I have

> recently complained to my manager that at the last 4 new birth visits

> I did, none of the mums knew how to latch on properly as they had not

> been shown. It is still common for babies to be given formula or

> glucose water in hospital on the grounds that they are

> not breastfeeding properly and one mum recently told me that at UCH

> her baby was given formula for 2 days as the staff told her they had

> no time to help her breastfeed. Like Kathy too, I have a good

> relationship with our community midwives who will notify us of social

> concerns etc, but help with breastfeeding seems to be a no no.

> That's my rant for the week.

> June

>

October 26, 2004

, I found these complaints quite shocking to read when I had just

returned from CPHVA Conference and felt so inspired by many of the

practitioner presentations which highlighted some amazing practice. This

article seems very unbalanced and appears to have only searched for bad

examples without looking at examples of good practice as well. Certainly

there is room for improvement from all practitioners in all areas of

practice and perhaps it would be helpful to consider some collaborative

approaches in order to support improvements rather than picking on and

accusing our colleagues in this very negative way.

Hayward

serious stuff

> Xena, I think I know about the article you are referring to.

>

> I have not seen anything from the RCM (do they have a newsletter?), but

> think it is in the latest newsletter from Association for the

> Improvement of Maternity Services (AIMS). A couple of us met with Jean

> (who wrote it) and Beverley Beech from AIMS a few weeks ago,

> mainly because they had received so many complaints about health

> visitors. Interestingly, they said had always had a certain level of

> complaints about health visitors failing to support breast feeding, but

> over the last eight years or so, they have seen a steady increase in

> complaints of a more serious and far-reaching nature. They wanted to

> know what had happened at that time, to change the nature of health

> visiting. The first thing that came to my mind, was the change in

> training: between 1995 and 1998 was when the Community Health Care

> Nursing framework was implemented, with its emphasis on health visiting

> as " Public Health Nursing, " the reduction in length of training, change

> of content and loss of a requirement for students to learn about things

> that most of us would consider essential, like breast feeding, child

> development and behaviour, understanding family functioning and the

> particular communication skills needed to engage and relate to parents.

>

> Of course, some programmes do still include that content, as we

> know, but not consistently. They are not required in the new NMC3

> standards either. Although child protection is mentioned, learning to

> cope with all the contradictions surrounding it is not a requirement.

> We might get it into programmes by focusing on how to deal with the

> competing public health imperatives, but again, the public health

> standards emphasise risks, assessments, problems and dangers: nothing

> about supporting parents with their ordinary, everyday difficulties, or

> promoting the positive and social aspects of health. No wonder some

> health visitors lack the skills and fall back on the " I am here to help

> you " line that is so welcomed and appreciated when, as nurses, they

> pitch up to offer help to someone who is ill, and has asked for the

> contact. No wonder, too, that they then resent it and panic when the

> person says " but I don't need or want your help. " This was the final

> trigger for the newsletter article (attached in rich text format), which

> describes how a health visitor turned up unannounced to a pregnant

> woman's house, " demanded entry " and threatened to report the woman to

> social services when she refused it.

>

> Apart from their basic training, there are so many other things that

> emphasise to health visitors that it is their job to be judgemental:

> intrusive " needs assessment " instruments, insistence that only people

> with problems be targeted and others not offered support (are we are

> then surprised if the service is seen as stigmatising?),

> staff shortages leading to sneers about focus, suggesting that all that

> health visitors need to do is discriminate more about who they work

> with; lots of official insistence on a targeting " the mad, the bad and

> the sad, " instead of providing a truly universal and supportive service.

> So, there is huge and determined pressure at an organisational level

> that might all have been deliberately designed to make health visitors

> behave in a judgemental way, even though the official line is that this

> is not intended. I guess it might be too much of a conspiracy theory to

> believe it was deliberately engineered by our nursing and midwifery

> colleagues, as a way of ensuring the public turn against health

> visiting, so they can justify making the very changes (i.e., closing our

> register, replacing health visitors with nurses and midwives) that led

> to the public outcry. After all, nobody is complaining about nice

> nurses or midwives, are they?

>

> I was disappointed at the very defensive reaction to the client letter

> in the Community Practitioner a couple of months ago, complaining about

> lack of support and knowledge: another symptom of the situation we have

> got into. Instead, I think we have to work with these consumer

> organisations and get them on our side, helping to improve the service

> and to counter some of these powerful forces that act against good

> health visiting practice. I was invited (and will do that) to write a

> reply for the next issue of the AIMS journal. Beverley Beech told us

> that, when AIMS was first set up, its name (I might have remembered it a

> bit wrong) was something like 'Society for the Prevention of Abuse to

> Pregnant Women,' with dreadful midwifery as the main target. But

> organisations like that have done wonders for the voice, the image and

> the sheer professionalism of midwifery.

>

> Thank you, Xena, for drawing this to our attention. I have known about

> and wondered whether to bring it to the attention of Senate, but did not

> know whether to or not: perhaps a bit of " head in the sand, wish it

> would go away " feeling. Also, although I hope that, by meeting and

> discussing their complaints with AIMS we might get some good out of it,

> I do have an anxiety about it as well, because I fear so many people

> will want to blame the complaining consumer or claim such bad practice

> could not possibly happen in today's health visiting. What do others

> think? Any other ideas about how health visiting as a profession should

> to respond to this?

>

> best wishes

>

> xenadion01 wrote:

>

> >hmmm, we all know MRSA is only about nurses and cleanliness. Perhaps

> >they need to ban visitors, have you seen some of the attire people

> >wear when visiting hospital patients?

> >

> >Meanwhile, just to stir things up a little, it was pointed out to me

> >by a midwife friend, and I have to confess I have not been able to

> >see the article first hand - said friend is in Germany, that the

> >latest RCM newletter/members journal was pointing out to midwives

> >that they needed to explain to women that they (the women) did not

> >have to let their health visitor into their homes. In fact, they

> >were insinuating that it was better not to, as health visitors were

> >all about child protection and very judgemental (is that how you

> >spell it? I got 82% on the national spelling test yesterday but they

> >didn't have that word!!)about their handling of their new child etc.

> >etc.

> >

> >In this day and age of trying to promote greater collaborative

> >working between disciplines and agencies (hah!), I am wondering if

> >others have seen this said article and what their views are. If this

> >is really what is being said by the midwifery fratermity (OK

> >maternity) we perhaps need to be having words.

> >Regards Xena

> >

October 26, 2004

Hear, hear .

I was so taken aback at the tone of the article it's taken me a few days to collect my thoughts and make a rational response to an irrational piece of work. I can't understand why she hates us with such a passion. Is there a personal agenda in all this? She has heard some stories but has only heard one side. I had a client who was featured in a weekly national women's magazine some time ago who related her tragic story and you would think that she was some kind of martyr to the system. Far from it. The family caused deliberate criminal damage to property, lied to professionals and were generally very troublesome. The article made her out to be a saint. There is a element to some women's organisations that seem to feel threatened by the health visiting service and it is hard to know what feeds this aversion. There is a very right and proper debate led by health visitors about the nature of their relationship with clients and the honesty about what we set out to do. Most health visitors are very concerned that we are not some kind of health police. refers to Jan Mitcheson's research into the use of screening tools and their acceptability to clients. Jan was my research supervisor when I did some further research about the perceptions of health visitors about the use of an antenatal screening tool that we use locally and every health visitor I interviewed stated they were concerned about intrusiveness and that trusting relationships are built over a period of time and have to be very sensitively developed. Remarks about 'harvesting of babies by health visitors' is almost slanderous. To which audience is hoping to spread her remarks. I hope it doesn't include vulnerable parents because she could seriously increase the risks they and their children face if they are poisoned against us.

On a general note I think it is worth reflecting that possibly the wider governmental agenda is turning us into quasi social workers and that label does not do the profession any favours. We must stick to our preventative and health promotional role.

Lund-Lack

serious stuff> Xena, I think I know about the article you are referring to.>> I have not seen anything from the RCM (do they have a newsletter?), but> think it is in the latest newsletter from Association for the> Improvement of Maternity Services (AIMS). A couple of us met with Jean> (who wrote it) and Beverley Beech from AIMS a few weeks ago,> mainly because they had received so many complaints about health> visitors. Interestingly, they said had always had a certain level of> complaints about health visitors failing to support breast feeding, but> over the last eight years or so, they have seen a steady increase in> complaints of a more serious and far-reaching nature. They wanted to> know what had happened at that time, to change the nature of health> visiting. The first thing that came to my mind, was the change in> training: between 1995 and 1998 was when the Community Health Care> Nursing framework was implemented, with its emphasis on health visiting> as "Public Health Nursing," the reduction in length of training, change> of content and loss of a requirement for students to learn about things> that most of us would consider essential, like breast feeding, child> development and behaviour, understanding family functioning and the> particular communication skills needed to engage and relate to parents.>> Of course, some programmes do still include that content, as we> know, but not consistently. They are not required in the new NMC3> standards either. Although child protection is mentioned, learning to> cope with all the contradictions surrounding it is not a requirement.> We might get it into programmes by focusing on how to deal with the> competing public health imperatives, but again, the public health> standards emphasise risks, assessments, problems and dangers: nothing> about supporting parents with their ordinary, everyday difficulties, or> promoting the positive and social aspects of health. No wonder some> health visitors lack the skills and fall back on the "I am here to help> you" line that is so welcomed and appreciated when, as nurses, they> pitch up to offer help to someone who is ill, and has asked for the> contact. No wonder, too, that they then resent it and panic when the> person says "but I don't need or want your help." This was the final> trigger for the newsletter article (attached in rich text format), which> describes how a health visitor turned up unannounced to a pregnant> woman's house, "demanded entry" and threatened to report the woman to> social services when she refused it.>> Apart from their basic training, there are so many other things that> emphasise to health visitors that it is their job to be judgemental:> intrusive "needs assessment" instruments, insistence that only people> with problems be targeted and others not offered support (are we are> then surprised if the service is seen as stigmatising?),> staff shortages leading to sneers about focus, suggesting that all that> health visitors need to do is discriminate more about who they work> with; lots of official insistence on a targeting "the mad, the bad and> the sad," instead of providing a truly universal and supportive service.> So, there is huge and determined pressure at an organisational level> that might all have been deliberately designed to make health visitors> behave in a judgemental way, even though the official line is that this> is not intended. I guess it might be too much of a conspiracy theory to> believe it was deliberately engineered by our nursing and midwifery> colleagues, as a way of ensuring the public turn against health> visiting, so they can justify making the very changes (i.e., closing our> register, replacing health visitors with nurses and midwives) that led> to the public outcry. After all, nobody is complaining about nice> nurses or midwives, are they?>> I was disappointed at the very defensive reaction to the client letter> in the Community Practitioner a couple of months ago, complaining about> lack of support and knowledge: another symptom of the situation we have> got into. Instead, I think we have to work with these consumer> organisations and get them on our side, helping to improve the service> and to counter some of these powerful forces that act against good> health visiting practice. I was invited (and will do that) to write a> reply for the next issue of the AIMS journal. Beverley Beech told us> that, when AIMS was first set up, its name (I might have remembered it a> bit wrong) was something like 'Society for the Prevention of Abuse to> Pregnant Women,' with dreadful midwifery as the main target. But> organisations like that have done wonders for the voice, the image and> the sheer professionalism of midwifery.>> Thank you, Xena, for drawing this to our attention. I have known about> and wondered whether to bring it to the attention of Senate, but did not> know whether to or not: perhaps a bit of "head in the sand, wish it> would go away" feeling. Also, although I hope that, by meeting and> discussing their complaints with AIMS we might get some good out of it,> I do have an anxiety about it as well, because I fear so many people> will want to blame the complaining consumer or claim such bad practice> could not possibly happen in today's health visiting. What do others> think? Any other ideas about how health visiting as a profession should> to respond to this?>> best wishes>> >>> xenadion01 wrote:>> >hmmm, we all know MRSA is only about nurses and cleanliness. Perhaps> >they need to ban visitors, have you seen some of the attire people> >wear when visiting hospital patients?> >> >Meanwhile, just to stir things up a little, it was pointed out to me> >by a midwife friend, and I have to confess I have not been able to> >see the article first hand - said friend is in Germany, that the> >latest RCM newletter/members journal was pointing out to midwives> >that they needed to explain to women that they (the women) did not> >have to let their health visitor into their homes. In fact, they> >were insinuating that it was better not to, as health visitors were> >all about child protection and very judgemental (is that how you> >spell it? I got 82% on the national spelling test yesterday but they> >didn't have that word!!)about their handling of their new child etc.> >etc.> >> >In this day and age of trying to promote greater collaborative> >working between disciplines and agencies (hah!), I am wondering if> >others have seen this said article and what their views are. If this> >is really what is being said by the midwifery fratermity (OK> >maternity) we perhaps need to be having words.> >Regards Xena> >> >> >> >> >

October 27, 2004

and , like you I was deeply upset when I first read the AIMS article.

It reminded me of the one and only time that, as practitioner, I had a client

who had never met me, refuse to have a health visitor. I did think that

the mixture of rejection, injustice and grievance that I felt at the time

was probably the nearest I would ever to get to an insight about how awful

it must feel to be on the receiving end of racism: I was desperate to say:

but you don't even know me, I'm not like you think I am, and health visiting

is not what you think, either. But of course, I did not know what she thought,

or what had happened in her life to make her reach (what seemed to me) to

be a very negative conclusion. It was her right to refuse the service.

I eventually met her, briefly, when she brought her (very healthy) child

to be weighed at a baby clinic many months later, but did not revisit the

issue. People reach the conclusions they do precisely because they are looking

at things in a way that is unique and individual to them. Sometimes, when

we have an insight into that way of thinking, we are in a position to say:

"I had never thought of it that way. Have you ever considered this or that

way of looking at it?" At other times, we have to accept that people all

have very different perspectives on issues. Generally they have that right;

we may profoundly disagree, but it may be how they survive difficult situations.

Very occasionally, as a profession, we can take heed of warnings about misunderstandings

that we might avoid and I think this such a warning.

AIMS is renowned for being a radical campaigning organisation, on behalf

of pregnant women and mothers, which does mean they put their clients (members)

views ahead of those offered by professionals. I cannot say, when we met

and Beverley, that they seemed either deeeply antagonistic to health

visitors, or to be generally at all unreasonable. Nor were they reacting

to a single or small number of complaints: it was a long litany, with a

marked increase in recent years. We had a long discussion about the different

perspectives that arise within child protection, and the great difficulties

that arise when parents deny that their behaviour is damaging to children.

We talked at length about the recent tragedies: Climbie at the

top of the list, whose carers successfully assured professionals that the

child was the problem. But, set against that, we only have to look at the

recent court decisions around infant deaths (Sally e, Trupti Patel etc)

to see that this is not a one sided story: professionals get it wrong in

both directions. The challenge in health visiting is that we have to get

bioth directions right. We are, in effect, social police, even if we hate

that description. How else are vulnerable children, victims of domestic

abuse etc., to be protected or to get a voice? But we are also there to

support and help, not to judge or blame. It is very difficult to achieve

a positive balance and a very hard job that needs enormous skill.

and Beverley were mystified about what had happened to change health

visiting over the last seven to eight years, and the only explanation they

could reach, faced with a long list of people who had faced both ignorance,

and intrusive, unpleasant questioning by health visitors, was the 'harvesting

babies' one. They said they had had no success in contacting professional

organisations (RCN, CPHVA and NMC): perhaps they did not reach the right

people or try hard enough, or perhaps those they contacted refused to engage

with them, believing them to be troublemakers. Who knows? We said very

clearly that we did not think that any health visitor would be engaged,

even unconsciously, in any activity designed to increase babies available

for adoption, but it was the explanation they had reached in their minds.

It allowed them to make sense of what seemed to them, otherwise, to be inexplicable

behaviour on the part of the professionals.

We also know from masses of research with women who have been on the recieving

end of questions from health visitors, that they commonly ask: why is she

asking me that? What have I done to make her think she needs to ask me that

question? What is she going to do with that information? There has also

been a long standing fear, reported in the literature, that "they will take

their baby away from you, if you don't toe the line". The 'harvesting babies'

terminology is just a new (and extreme) manifestation of this anxiety. The

idea of health visiting being like an offer of help from the Mafia, because

you cannot refuse it, rang horrible bells with me, too. In all the (masses!)

of needs assessment research I have done, even where it is explicitly Trust

policy that clients do not have to participate, they are either not told

of that choice, or not told their needs are being assessed, so they are denied

any effective choice. Of course, effectively health visitors cannot give

a choice, because the whole service is based on the assumption of needs assessment,

now, not of universality!

I think (and have posted masses of papers to about this) that

most health visitors do, as you indicated , try to be very sensitive

and avoid intrusive and unpleasant questions. I think they also try to provide

a universal service, to avoid the stigma, anxiety and misunderstandings caused

by 'singling out' individuals for a service. But it is an uphill battle

in the face of insistence on use of explicit needs assessments schedules

and the 'targeting tools' beloved of management. The paper that Jan Mitcheson,

Houston and I had published in Sociology of Health and Illness is the

only one, as far as I am aware, that specifically documents any resistance

to these techniques by health visitors, although Jane Appleton has also recorded

that health visitors largely ignore the official guidance, so they can make

more sensitive, individually focused and personally tailored professional

judgements (which are very complex and difficult: back to my gripe about

inadequate training!). But even though we have grumbled a lot in private,

as a profession, we have not made a habit of making public our concerns about

the stigmatising impact of of non-universality, or of targeting procedures.

Perhaps we should. But how would we do that?

Or, do we just ignore the complaints as unreasonable, and carry on as if

they have not happened? best wishes

Tom Lund-Lack wrote:

Hear, hear .

I was so taken aback at the tone of the

article it's taken me a few days to collect my thoughts and make a rational

response to an irrational piece of work. I can't understand why she hates

us with such a passion. Is there a personal agenda in all this? She has

heard some stories but has only heard one side. I had a client who was

featured in a weekly national women's magazine some time ago who related

her tragic story and you would think that she was some kind of martyr to

the system. Far from it. The family caused deliberate criminal damage to

property, lied to professionals and were generally very troublesome. The

article made her out to be a saint. There is a element to some women's

organisations that seem to feel threatened by the health visiting service

and it is hard to know what feeds this aversion. There is a very right and

proper debate led by health visitors about the nature of their relationship

with clients and the honesty about what we set out to do. Most health visitors

are very concerned that we are not some kind of health police.

refers to Jan Mitcheson's research into the use of screening tools and their

acceptability to clients. Jan was my research supervisor when I did some

further research about the perceptions of health visitors about the use

of an antenatal screening tool that we use locally and every health visitor

I interviewed stated they were concerned about intrusiveness and that trusting

relationships are built over a period of time and have to be very sensitively

developed. Remarks about 'harvesting of babies by health visitors' is almost

slanderous. To which audience is hoping to spread her remarks. I hope

it doesn't include vulnerable parents because she could seriously increase

the risks they and their children face if they are poisoned against us.

On a general note I think it is worth

reflecting that possibly the wider governmental agenda is turning us into

quasi social workers and that label does not do the profession any favours.

We must stick to our preventative and health promotional role.

Lund-Lack

Re: serious stuff

, I found these complaints quite shocking to read when I

had just

returned from CPHVA Conference and felt so inspired by many of the

practitioner presentations which highlighted some amazing practice. This

article seems very unbalanced and appears to have only searched for bad

examples without looking at examples of good practice as well. Certainly

there is room for improvement from all practitioners in all areas of

practice and perhaps it would be helpful to consider some collaborative

approaches in order to support improvements rather than picking on and

accusing our colleagues in this very negative way.

Hayward

October 27, 2004

From Lund-Lack

I understand what you are saying but it still doesn't excuse the viperous tone of the article which was written by someone who one hopes understands her position of influence and responsibility.

Re: serious stuff>> , I found these complaints quite shocking to read when I had just> returned from CPHVA Conference and felt so inspired by many of the> practitioner presentations which highlighted some amazing> practice. This> article seems very unbalanced and appears to have only searched> for bad> examples without looking at examples of good practice as well.> Certainly> there is room for improvement from all practitioners in all areas of> practice and perhaps it would be helpful to consider some> collaborative> approaches in order to support improvements rather than picking on and> accusing our colleagues in this very negative way.> Hayward>Professor Liz MeerabeauHead of the School of Health and Social CareUniversity of GreenwichAvery Hill CampusSouthwood SiteAvery Hill RoadLondon SE9 2UG020 8331 9150020 8331 8060 (fax)E.Meerabeau@...

October 27, 2004

I may have missed something here, but has the issue of the

requirement to do structured needs assessment been overtly

discussed with AIMS? If it hasn't then it could have some mileage.

Ditto the change in the curriculum. An informed critique of these

issues by a user group and HVs together could be very helpful and

powerful. What do others think?

From: Cowley <sarah@...>

Date sent: Wed, 27 Oct 2004 16:26:48 +0100

Subject: Re: serious stuff

Send reply to:

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and , like you I was deeply upset when I first read the AIMS

article. It reminded me of the one and only time that, as practitioner,

I had a client who had never met me, refuse to have a health visitor.

I did think that the mixture of rejection, injustice and grievance that

I felt at the time was probably the nearest I would ever to get to an

insight about how awful it must feel to be on the receiving end of

racism: I was desperate to say: but you don't even know me, I'm not

like you think I am, and health visiting is not what you think, either.

But of course, I did not know what she thought, or what had happened in

her life to make her reach (what seemed to me) to be a very negative

conclusion. It was her right to refuse the service. I eventually met

her, briefly, when she brought her (very healthy) child to be weighed at

a baby clinic many months later, but did not revisit the issue. People

reach the conclusions they do precisely because they are looking at

things in a way that is unique and individual to them. Sometimes, when

we have an insight into that way of thinking, we are in a position to

say: " I had never thought of it that way. Have you ever considered

this or that way of looking at it? " At other times, we have to accept

that people all have very different perspectives on issues. Generally

they have that right; we may profoundly disagree, but it may be how they

survive difficult situations. Very occasionally, as a profession, we

can take heed of warnings about misunderstandings that we might avoid

and I think this such a warning.

AIMS is renowned for being a radical campaigning organisation, on behalf

of pregnant women and mothers, which does mean they put their clients

(members) views ahead of those offered by professionals. I cannot say,

when we met and Beverley, that they seemed either deeeply

antagonistic to health visitors, or to be generally at all unreasonable.

Nor were they reacting to a single or small number of complaints: it

was a long litany, with a marked increase in recent years. We had a

long discussion about the different perspectives that arise within child

protection, and the great difficulties that arise when parents deny that

their behaviour is damaging to children. We talked at length about the

recent tragedies: Climbie at the top of the list, whose carers

successfully assured professionals that the child was the problem.

But, set against that, we only have to look at the recent court

decisions around infant deaths (Sally e, Trupti Patel etc) to see

that this is not a one sided story: professionals get it wrong in both

directions. The challenge in health visiting is that we have to get

bioth directions right. We are, in effect, social police, even if we

hate that description. How else are vulnerable children, victims of

domestic abuse etc., to be protected or to get a voice? But we are also

there to support and help, not to judge or blame. It is very difficult

to achieve a positive balance and a very hard job that needs enormous skill.

and Beverley were mystified about what had happened to change

health visiting over the last seven to eight years, and the only

explanation they could reach, faced with a long list of people who had

faced both ignorance, and intrusive, unpleasant questioning by health

visitors, was the 'harvesting babies' one. They said they had had no

success in contacting professional organisations (RCN, CPHVA and NMC):

perhaps they did not reach the right people or try hard enough, or

perhaps those they contacted refused to engage with them, believing them

to be troublemakers. Who knows? We said very clearly that we did not

think that any health visitor would be engaged, even unconsciously, in

any activity designed to increase babies available for adoption, but it

was the explanation they had reached in their minds. It allowed them to

make sense of what seemed to them, otherwise, to be inexplicable

behaviour on the part of the professionals.

We also know from masses of research with women who have been on the

recieving end of questions from health visitors, that they commonly ask:

why is she asking me that? What have I done to make her think she

needs to ask me that question? What is she going to do with that

information? There has also been a long standing fear, reported in the

literature, that " they will take their baby away from you, if you don't

toe the line " . The 'harvesting babies' terminology is just a new (and

extreme) manifestation of this anxiety. The idea of health visiting

being like an offer of help from the Mafia, because you cannot refuse

it, rang horrible bells with me, too. In all the (masses!) of needs

assessment research I have done, even where it is explicitly Trust

policy that clients do not have to participate, they are either not told

of that choice, or not told their needs are being assessed, so they are

denied any effective choice. Of course, effectively health visitors

cannot give a choice, because the whole service is based on the

assumption of needs assessment, now, not of universality!

I think (and have posted masses of papers to about this)

that most health visitors do, as you indicated , try to be very

sensitive and avoid intrusive and unpleasant questions. I think they

also try to provide a universal service, to avoid the stigma, anxiety

and misunderstandings caused by 'singling out' individuals for a

service. But it is an uphill battle in the face of insistence on use

of explicit needs assessments schedules and the 'targeting tools'

beloved of management. The paper that Jan Mitcheson, Houston and I

had published in Sociology of Health and Illness is the only one, as far

as I am aware, that specifically documents any resistance to these

techniques by health visitors, although Jane Appleton has also recorded

that health visitors largely ignore the official guidance, so they can

make more sensitive, individually focused and personally tailored

professional judgements (which are very complex and difficult: back to

my gripe about inadequate training!). But even though we have grumbled

a lot in private, as a profession, we have not made a habit of making

public our concerns about the stigmatising impact of of

non-universality, or of targeting procedures. Perhaps we should. But

how would we do that?

Or, do we just ignore the complaints as unreasonable, and carry on as if

they have not happened? best wishes

Tom Lund-Lack wrote:

> Hear, hear .

> I was so taken aback at the tone of the article it's taken me a few

> days to collect my thoughts and make a rational response to an

> irrational piece of work. I can't understand why she hates us with

> such a passion. Is there a personal agenda in all this? She has heard

> some stories but has only heard one side. I had a client who was

> featured in a weekly national women's magazine some time ago who

> related her tragic story and you would think that she was some kind of

> martyr to the system. Far from it. The family caused deliberate

> criminal damage to property, lied to professionals and were generally

> very troublesome. The article made her out to be a saint. There is a

> element to some women's organisations that seem to feel threatened by

> the health visiting service and it is hard to know what feeds this

> aversion. There is a very right and proper debate led by health

> visitors about the nature of their relationship with clients and the

> honesty about what we set out to do. Most health visitors are very

> concerned that we are not some kind of health police.

> refers to Jan Mitcheson's research into the use of screening tools and

> their acceptability to clients. Jan was my research supervisor when I

> did some further research about the perceptions of health visitors

> about the use of an antenatal screening tool that we use locally and

> every health visitor I interviewed stated they were concerned about

> intrusiveness and that trusting relationships are built over a period

> of time and have to be very sensitively developed. Remarks about

> 'harvesting of babies by health visitors' is almost slanderous. To

> which audience is hoping to spread her remarks. I hope it doesn't

> include vulnerable parents because she could seriously increase the

> risks they and their children face if they are poisoned against us.

> On a general note I think it is worth reflecting that possibly the

> wider governmental agenda is turning us into quasi social workers and

> that label does not do the profession any favours. We must stick to

> our preventative and health promotional role.

> Lund-Lack

> Re: serious stuff

>

> , I found these complaints quite shocking to read when I had just

> returned from CPHVA Conference and felt so inspired by many of the

> practitioner presentations which highlighted some amazing

> practice. This

> article seems very unbalanced and appears to have only searched

> for bad

> examples without looking at examples of good practice as well.

> Certainly

> there is room for improvement from all practitioners in all areas of

> practice and perhaps it would be helpful to consider some

> collaborative

> approaches in order to support improvements rather than picking on and

> accusing our colleagues in this very negative way.

> Hayward

>

Professor Liz Meerabeau

Head of the School of Health and Social Care

University of Greenwich

Avery Hill Campus

Southwood Site

Avery Hill Road

London SE9 2UG

020 8331 9150

020 8331 8060 (fax)

E.Meerabeau@...

October 27, 2004

Thank you . I have known for some time there are unpleasant home truths Health Visiting has to face regarding our public image. A straw poll amongst my colleagues recently elicited the following, five out of six in the team have been consumers of health visiting over a period of 25years. All of us have had poor experiences including myself. four of us have taken action to avoid the Health Visitor. This totally unscientific lunchtime conversation is familiar.

The three greatest influences on my practise have been 1. Becoming a mother myself. 2 The media training I recieved and practised whilst working as a professional officer at the Former HVA. It is extrordinary how often we speak in a language made up of medicalese, psychologese and sociologese. I was thought to give answers in soundbites in plain english. The marketing training I received whilst working in industry really focused my attention on the customer, One of my responsibilities was to oversee the free-phone line. That was also a sobering experience. When it was suggested to customers they contact their health visitor a common response was "I know more about nutrition than she does that is why I have called you ".

We need to humbly ask ourselves what it feels like to be on the receiving end of an EPDS or the other needs assessment tools . I observed my husband squirm with embarassment recently when confronted with a needs assessment tool his embarassment was reflected on the face of the unfortumate nurse conducting the interrogation. Families especially are unclear about how much power we have and what risk we pose to them at a time of great vulnerability and stress for them.

On the other hand I have been looking at what happens to families who get by-passed by the health visiting service and it is not difficult to demonstrate that we are the core service, and that children suffer in a measurable way if we are not there for them. In another completely unscientific survey I have looked at the amount of DLA lost by children who received poor or inadequate health visiting. Amounts up to £40,000 pounds were lost. There is no other worker to helicopter manage the complex needs of families, without the health visitor services are fragmented and families left to chance.

Our profession is a delicate balance of support and supervision we must listen to our clients and retain their trust. We must also deliver to them by addressing their expressed needs and working alongside them as they find solutions I like the idea I read somewhere recently of the Health Visitor as Family Coach. I sometimes think we a re a bit like Marks and Spencer solid but not so customer focused, lots of good things but they are difficult to find under the mountains of elastocated trousers. but totally capable of transferring itself into a 21st Centuray company with a lfirm focus on customer aspirations

Daly

---- Original Message -----

From: Cowley

Sent: Wednesday, October 27, 2004 4:26 PM

Subject: Re: serious stuff

and , like you I was deeply upset when I first read the AIMS article. It reminded me of the one and only time that, as practitioner, I had a client who had never met me, refuse to have a health visitor. I did think that the mixture of rejection, injustice and grievance that I felt at the time was probably the nearest I would ever to get to an insight about how awful it must feel to be on the receiving end of racism: I was desperate to say: but you don't even know me, I'm not like you think I am, and health visiting is not what you think, either. But of course, I did not know what she thought, or what had happened in her life to make her reach (what seemed to me) to be a very negative conclusion. It was her right to refuse the service. I eventually met her, briefly, when she brought her (very healthy) child to be weighed at a baby clinic many months later, but did not revisit the issue. People reach the conclusions they do precisely because they are looking at things in a way that is unique and individual to them. Sometimes, when we have an insight into that way of thinking, we are in a position to say: "I had never thought of it that way. Have you ever considered this or that way of looking at it?" At other times, we have to accept that people all have very different perspectives on issues. Generally they have that right; we may profoundly disagree, but it may be how they survive difficult situations. Very occasionally, as a profession, we can take heed of warnings about misunderstandings that we might avoid and I think this such a warning.AIMS is renowned for being a radical campaigning organisation, on behalf of pregnant women and mothers, which does mean they put their clients (members) views ahead of those offered by professionals. I cannot say, when we met and Beverley, that they seemed either deeeply antagonistic to health visitors, or to be generally at all unreasonable. Nor were they reacting to a single or small number of complaints: it was a long litany, with a marked increase in recent years. We had a long discussion about the different perspectives that arise within child protection, and the great difficulties that arise when parents deny that their behaviour is damaging to children. We talked at length about the recent tragedies: Climbie at the top of the list, whose carers successfully assured professionals that the child was the problem. But, set against that, we only have to look at the recent court decisions around infant deaths (Sally e, Trupti Patel etc) to see that this is not a one sided story: professionals get it wrong in both directions. The challenge in health visiting is that we have to get bioth directions right. We are, in effect, social police, even if we hate that description. How else are vulnerable children, victims of domestic abuse etc., to be protected or to get a voice? But we are also there to support and help, not to judge or blame. It is very difficult to achieve a positive balance and a very hard job that needs enormous skill.and Beverley were mystified about what had happened to change health visiting over the last seven to eight years, and the only explanation they could reach, faced with a long list of people who had faced both ignorance, and intrusive, unpleasant questioning by health visitors, was the 'harvesting babies' one. They said they had had no success in contacting professional organisations (RCN, CPHVA and NMC): perhaps they did not reach the right people or try hard enough, or perhaps those they contacted refused to engage with them, believing them to be troublemakers. Who knows? We said very clearly that we did not think that any health visitor would be engaged, even unconsciously, in any activity designed to increase babies available for adoption, but it was the explanation they had reached in their minds. It allowed them to make sense of what seemed to them, otherwise, to be inexplicable behaviour on the part of the professionals. We also know from masses of research with women who have been on the recieving end of questions from health visitors, that they commonly ask: why is she asking me that? What have I done to make her think she needs to ask me that question? What is she going to do with that information? There has also been a long standing fear, reported in the literature, that "they will take their baby away from you, if you don't toe the line". The 'harvesting babies' terminology is just a new (and extreme) manifestation of this anxiety. The idea of health visiting being like an offer of help from the Mafia, because you cannot refuse it, rang horrible bells with me, too. In all the (masses!) of needs assessment research I have done, even where it is explicitly Trust policy that clients do not have to participate, they are either not told of that choice, or not told their needs are being assessed, so they are denied any effective choice. Of course, effectively health visitors cannot give a choice, because the whole service is based on the assumption of needs assessment, now, not of universality!I think (and have posted masses of papers to about this) that most health visitors do, as you indicated , try to be very sensitive and avoid intrusive and unpleasant questions. I think they also try to provide a universal service, to avoid the stigma, anxiety and misunderstandings caused by 'singling out' individuals for a service. But it is an uphill battle in the face of insistence on use of explicit needs assessments schedules and the 'targeting tools' beloved of management. The paper that Jan Mitcheson, Houston and I had published in Sociology of Health and Illness is the only one, as far as I am aware, that specifically documents any resistance to these techniques by health visitors, although Jane Appleton has also recorded that health visitors largely ignore the official guidance, so they can make more sensitive, individually focused and personally tailored professional judgements (which are very complex and difficult: back to my gripe about inadequate training!). But even though we have grumbled a lot in private, as a profession, we have not made a habit of making public our concerns about the stigmatising impact of of non-universality, or of targeting procedures. Perhaps we should. But how would we do that? Or, do we just ignore the complaints as unreasonable, and carry on as if they have not happened? best wishesTom Lund-Lack wrote:

Hear, hear .

I was so taken aback at the tone of the article it's taken me a few days to collect my thoughts and make a rational response to an irrational piece of work. I can't understand why she hates us with such a passion. Is there a personal agenda in all this? She has heard some stories but has only heard one side. I had a client who was featured in a weekly national women's magazine some time ago who related her tragic story and you would think that she was some kind of martyr to the system. Far from it. The family caused deliberate criminal damage to property, lied to professionals and were generally very troublesome. The article made her out to be a saint. There is a element to some women's organisations that seem to feel threatened by the health visiting service and it is hard to know what feeds this aversion. There is a very right and proper debate led by health visitors about the nature of their relationship with clients and the honesty about what we set out to do. Most health visitors are very concerned that we are not some kind of health police. refers to Jan Mitcheson's research into the use of screening tools and their acceptability to clients. Jan was my research supervisor when I did some further research about the perceptions of health visitors about the use of an antenatal screening tool that we use locally and every health visitor I interviewed stated they were concerned about intrusiveness and that trusting relationships are built over a period of time and have to be very sensitively developed. Remarks about 'harvesting of babies by health visitors' is almost slanderous. To which audience is hoping to spread her remarks. I hope it doesn't include vulnerable parents because she could seriously increase the risks they and their children face if they are poisoned against us.

On a general note I think it is worth reflecting that possibly the wider governmental agenda is turning us into quasi social workers and that label does not do the profession any favours. We must stick to our preventative and health promotional role.

Lund-Lack

Re: serious stuff

, I found these complaints quite shocking to read when I had justreturned from CPHVA Conference and felt so inspired by many of thepractitioner presentations which highlighted some amazing practice. Thisarticle seems very unbalanced and appears to have only searched for badexamples without looking at examples of good practice as well. Certainlythere is room for improvement from all practitioners in all areas ofpractice and perhaps it would be helpful to consider some collaborativeapproaches in order to support improvements rather than picking on andaccusing our colleagues in this very negative way. Hayward

October 27, 2004

,

You have made me think of my own experience of a health visiting service nearly 24 years ago. This person walked in the door, said you're OK, you're a health visitor, you're fine and walked out again. I had an awful experience of mothering a baby ie had PND which no one recognised, i was isolated and unsupported and I think my husband was as confused as i was.

However i think carrying out a mood assessment appropriately and not dishing out the EPDA willy nilly does make a difference but we must be clear with our clients about our agenda and dsicuss child protection etc and be honest as I know others have said already. I don't want others to share my experience.

But we must be careful, it is argued that Cambridge's disinvestment was on the back of a very powerful person's experience of an HV ie Thornton - judgments that have sweeping consequence can be made.

Ann

Re: serious stuff

, I found these complaints quite shocking to read when I had justreturned from CPHVA Conference and felt so inspired by many of thepractitioner presentations which highlighted some amazing practice. Thisarticle seems very unbalanced and appears to have only searched for badexamples without looking at examples of good practice as well. Certainlythere is room for improvement from all practitioners in all areas ofpractice and perhaps it would be helpful to consider some collaborativeapproaches in order to support improvements rather than picking on andaccusing our colleagues in this very negative way. Hayward

October 27, 2004

Yesterday I e-mailed the chair of AIMS to lodge my dismay at the article. Their web page states that they support professionals!! Kathy

October 28, 2004

I have been giving some careful consideration to the questions raised in the AIMS newsletter which is why I have not jumped in until now. I think it is right and proper that parents complain when they feel abused and let down by the system. I for one have been aware that all has not been well in health visiting for some time as I have been working with groups of health visitors across the UK (training parent advisor/family partnership model).

Here is an example of the response of a recently trained health visitor. In a seminar on the kind of relationship a health visitor seeks to have with a client where we agreed (I thought) that partnership might be the most effective relationship a health visitor might have, a participant piped up in absolute horror 'but the client might become more powerful than we are!' The very fact that we are seeing this public backlash on health visiting reminds me that an authoritarian approach in parenting brings about the same rebellious and outspoken responses from teenagers. The very fact that as a profession we are being seen as the 'health police' and authoritarian in its approach needs someone to say 'enough is enough!'

Here is another example of a health visitor response to a short listening skills practice, 'I don't do psychological'. These are exact words from a recently trained health visitor. What did that mean? It meant that she felt that listening closely to what the client was saying and responding appropriately was too intense a way of interacting. Another health visitor told me that she was afraid to work too closely with clients as she may detect more problems about which she unable to do anything especially post-natal depression due to lack of time and pressure of work. I found this alarming to say the least.

These sort of examples are balanced however, by some pockets of absolutely excellent practice where the more inexperienced health visitors are well supported by their more experienced colleagues. Some very experienced health visitors who take part in the training do already have very well developed communication skills and are an absolute delight to work with and make me feel proud to be a health visitor. This type of training in core communication skills needs to be a part of every health visitors basic training. How can we make this happen? Any suggestions welcome.

At the CPHVA conference I heard a presentation regarding the introduction of a health needs assessment tool in the North East. I was sceptical at first but as the presentation went on I was impressed by the sincerity of the health visitors and their efforts to evaluate its effect on parents. They insisted firstly that the tool was not used at a first visit, believing that the relationship with the client was the most important thing to get right first. They also insisted that it was not a checklist and that the clients points were important to be responded to. It was also stressed that the tool could not be used without adequate training in its use. It was an aid to a guided conversation with clear explanations being given along the way as to why certain areas might need to be touched on. What bothered me most was that at the end of the presentation the health visitors in the audience descended on the presenters to get a copy of the tool as if it were a magic potion that would allow them to discover what had as yet been undiscovered. I still feel however, that if we train health visitors to communicate adequately we would not need to train them how to ask questions that need to be asked.

Unusually I am going on a bit but I am quite fired up by this discussion that has been ongoing over the last few days. Finally, again at conference I met Sally , Director of Netmums. More positively than all that has gone before in this discussion she would like to work with us (SIG for Parenting and Family Support) to support health visiting. The research carried out by her organisation found that 54% of parents would turn to a health visitor for advice on parenting issues but only 15% would talk to a health visitor if they 'felt down'. This calls into question the use of the EPDS. Is it being used? Is it being used properly? I have heard a health visitor say that she didn't actually believe the high scoring result that she had from one client and thought she was telling 'porkies' to get better housing!

So all in all there are some worrying things going on out there in practice. However, as I know from the SIG group, and Senate there are also many brilliant things and some very skilled practitioners. Like the curate's egg it is good in parts. Somehow we need to get the training right so that we include the core communication skills.

Best wishes,

Re: serious stuff

Yesterday I e-mailed the chair of AIMS to lodge my dismay at the article. Their web page states that they support professionals!! Kathy

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October 31, 2004

Dear All,

We have had several students over the past few years who have struggled with communication skills, which from my discussions with other course leaders is a common problem. We have actually failed two students for just this reason, which in my view is absolutely right. We have therefore been increasing our ways of assessing communication skills and helping students to develop a greater awareness of these within the HV and all other pathways. We have various ways of doing this and this is part of a dynamic process planned and evaluated with Practice Teachers:

The Hyland son Psychological Skills Scale (developed in the past for district nursing) is very useful and students and Practice Teachers find this helpful in developing their skills within health visiting practice. Some CPTs are even assessed by their students.

The Learning Contract focuses on communication skills and students reflect in depth on different ways they are adapting their communication skills for health visiting practice.

Students' reports (written by the CPTs) focus on attitudes as well as knowledge, skills and integration and these are based on generic lists to help the student to see where they need to concentrate. They also use the ASSET model (developed in relation to social work) within the report which includes communication skills and interpersonal awareness.

We have a Student Attitude and Values tool which CPTS again use with students.

We also have a Consumer or Carer Feedback form focusing strongly on communication skills.

We have a Team Feedback form which is used on a uniprofessional or multiprofessional basis as appropriate.

We have a teaching observation feedback form and a student observation form used by CPTS with students when appropriate.

In addition the Competencies include ways in which CPTS and Students can use evidence from consumers and members of the team as feedback about their level of competence.

Most of these tools are shared only between the student and CPT but are used as evidence when the CPT is writing the report. The CPT then has additional evidence if they need to validate their report but generally these remain confidential to the pair of them. The only evidence that goes forward within the Portfolio are the Report and Competencies and Teaching Observation Form (used to ensue that they can fulfil the mentor role on completion of the Programme). We decided that all the tools need to be used at least once to destigmatise the process, but some Student/CPT partnerships use some of these regularly as they find them helpful.

I am sure that other HV and SN programmes have similar ways of concentrating on communication skills as an essential part of the teaching and assessment process and this for me is absolutely essential in ensuring that students practice in a client centred manner and develop communication skills which are acceptable to clients who use our service.

I would be interested to hear of other ways that other institutions are using to address these issues, because this is always so helpful. Barbara Nugent from UCE suggested the Hyland son as a tool and it has been invaluable for us.

ChambersPrincipal Lecturer in Health VisitingSchool of Health and Social CareOxford s UniversityPhone: 07973 617482e-mail: cachambers@...

October 31, 2004

I found your details of what you do at Oxford s in terms of communication skills very interesting.

When I was teaching health visitors which included a spell at Oxford s we always did a great deal on communication skills and used it as part of the criteria before taking students.

When , and myself did the work for the UKCC in 1999/2000 looking at the statutory framework for health visiting we found that the amount of communication skills taught and assessed in the courses to be minimal most course leaders saying there just was not time. That was very worrying.

Like you I have failed students because their CPT and us as lecturers assessed their communication skills not to be satisfactory.

I remember being told once by a senior nurse that all nurses have good communication skills and why did I think I needed to teach them to communicate on a HV course - we know that not to be correct.

It would be interesting to hear what other courses are now doing to teach and assess these skills.

Margaret