Some aspects of health visiting

ht. J. NUN. Stud. Vol. 5, pp. 195-203, Pergamon Press, 1968. Printed in Great Britain

Some Aspects of Health Visiting DORIS

MUMFORD,

S.R.N., S.C.M.,

H.V. Cert.

25 High Street, Gargraue, Skifiton, Yorkshire

IN ORDER to understand health visiting and its various facets in England, one must take a look at its inception and the way in which the service has developed over the years and, in particular, over the past nineteen years. Most people know that health visiting, as such, was started in this country by a group of women in Salford, who were concerned about the high infant mortality These “Ladies of Salford” started in a rate and the reasons for this situation. voluntary capacity as early as 1862 and worked diligently in trying to promote cleanliness in the homes and give instruction on the care of children. This they did by the distribution of cleaning materials and pamphlets. The work done by these ladies produced good results, so it was not long before local authorities were convinced that this service should be supported and schemes were organized which eventually led to the appointment of paid workers.

Training

There was no recognized form of training for these workers until 1919 when the This continued until Board of Education made grants to aid professional training. 1925 when the Ministry of Health took over the responsibility for health visitor training and later approved the Royal Society of Health as the examining body. During this time-and, indeed, until the National Health Service Act in 1946the health visitor was mainly concerned with the care of mothers and babies and the prevention of infection. In 1948, the National Health Service Act was implemented and the interest of the health visitor was extended to cover the whole family. This decision on the part of the Government certainly enlarged the horizons of the health visitor and, therefore, gave her a greater variety of work. The next development came in 1953 when, because of a persistent shortage of health visitors, the Ministers of Health and Education and the Secretary of State for Scotland decided in their wisdom to appoint a Working Party to advise on the proper field of work and the recruitment and training of health visitors in the National Health Service and School Health Service. The Working Party made its report in 1956, but the Government could not make recommendations until the report of the Working Party on social workers in the local authority health and welfare services 195

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was submitted and this came out some time later. The first report clarified the work of the health visitor and referred to her as the health educator and social adviser to the family as a whole. It also recommended that much of the work she was doing did not need all her skills, and ancillaries should be employed by the local authority in order to allow the health visitor to use her expertise to the best advantage. The latter report particularly emphasized the complementary nature of the work of health and social workers. Because of the information contained in these two reports, the Government in 1960 announced its intention of introducing legislation to establish Councils for the Training of Health Visitors and Social Workers. In 1962, these two Councils were set up under a joint Chairman. The syllabus was reviewed and a new one was introduced which enabled health visitors to gain a broad vision of the work they were expected to undertake. New methods in relation to practical work were evolved and the new health visitor must now prove that she was capable of handling both normal and problem families and district techniques before she became qualified. In order to fulfil these requirements, the length of the course was extended from one academic year to one full year, the last twelve weeks being spent doing supervised practical work. E$ect of changes on the health visitor

What effect did all these changes have on the health visitor herself? On looking back, it would appear that-between 1948, when the National Health Service Act was implemented, and 1960-the health visitor was overwhelmed by the variety She became “Jack of all trades and master of work she was expected to negotiate. of none”! She was akin to a piece of flotsam or jetsam, floating hither and thither, with some of the work she had been accustomed to doing being taken over by child care officers and social workers. The National Health Service Act, 1946, gave a very broad outline of the function of the health visitor, so broad that it left the way open for many different interThis led to all kinds of work being given to health pretations by local authorities. visitors which had no direct link with her work in the family and which could have been done equally well by someone with lesser skills than those of the health visitor. The care of the whole family was a challenge to the health visiting service and one which this field worker was capable of doing. Unfortunately, there was a dearth of ancillary help so all the responsibility fell on the shoulders of the health visitor. The burden had to be eased in some way and most health visitors chose to do selective visiting-that is, visiting those families which they considered most in need of help. The disadvantage of this method was that she lost touch with other families which may have needed her guidance. Present period

What of the present ? Now that separate training schemes have been established for social workers and health visitors, but often in the same educational institution, it will be possible to build up a team of workers who will understand each other’s work.

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VISIl-ING

Function of the Health Visitor

Many members of the profession have felt that agreement should be reached, in principle, on the function of the health visitor and this should be printed in detail. The Council for the Training of Health Visitors has done just this and it defines her work as follows: 1. “The prevention consequences.”

of mental,

physical

and

emotional

ill health

and its

In the past, the prevention of mental ill health has been a secondary consideration, the health visitor’s chief concern being with the prevention of physical illness, particularly in relation to infectious diseases through early detection of symptoms and prophylactic treatment. During the past few years, it has become widely recognized that mental, physical and emotional ill health go hand in hand and The health visitor performs this function by being a regular cannot be separated. visitor to the homes and by establishing a good and friendly relationship with the families in her area. Again, she can only do this if she is given sufficient ancillary and clerical help. To know the family well, the health visitor must be aware of the interactions between each member; without this knowledge, she will not be able to assess their needs with any degree of accuracy. A great deal of thought has been given to the needs of the young child, particularly from the emotional point of view. The first few years are the most important and, through research, knowledge has been gained which the health visitor can successfully use in the assessment of a child’s emotional development and its needs. This can be done by watching a child in play and its reactions in its home life. Autism, mental retardation and subnormality can so be detected at an early age by the diligent health visitor. 2. “Early detection

of ill health and the surveillance

of high risk groups.”

This has always been one of the main functions of the health visitor. Science is now making rapid strides in developing different tests for diagnosing diseases and handicaps. The tests which the health visitor is wholly or partially responsible for at present are (a) the phenylketonuria test on urine, (b) the Ortolani test for congenital dislocation of hip, and (c) the early ascertainment of deafness. These tests are all done in the first year of a child’s life and the first two in the first six weeks. This part of the health visitor’s work could become one of her most important and worthwhile tasks. The health visitor is expected to give special attention to high-risk groups, following up after information from the midwife or hospital of birth injuries and malformations, small or otherwise. Included in the high-risk group are children of parents with a history of ill health; it also includes those children who may, through illness or accident, have to be put in the high-risk group. 3. “Recognition and identification resources where necessary.”

of need and mobilization

of appropriate

In her general training, the nurse learns to observe and evaluate disease. In health visitors training, she is taught to recognize social and environmental problems and learns that no one person is capable of solving a difficult family problem. The health visitor, with her nurse-training background, is able to assess when to call in other help and the type of help needed. This means she must be aware of the

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resources at her disposal. One of the first things a health visitor does when she takes over a district is to find out what agencies, both voluntary and statutory, apply in her area, where they are, and how to approach them. 4. Health teaching. Health education is a component feature of the health service and can be given in many different ways. The health visitor is well versed in the many approaches to health education, but her most important is individual teaching within the client’s own environment. In the home, the health visitor will be required to teach on the needs which are uppermost at the time of her visit and not according to any set formula. The child health centres are also a good base for teaching, in particular, by group discussions or using visual aids-mothers participating too. Some centres have a library of books for lending out to mothers. The schools are also used for teaching. Some health visitors have regular classes in the curriculum, whilst others are used as consultants to advise on new trends in health. There is also a great deal of health education done in mothers’ clubs, church groups, youth clubs, to name only a few. 5. “Provision of care; this will include support during periods of stress and advice and guidance in cases of illness as well as in the care and management of children. The health visitor is not, however, actively engaged in technical nursing procedures.” This final point is probably the most important lead into the future role of the health visitor in general practice. Health visitors have not been fully aware of the duties of giving advice and guidance in cases of illness, probably because of the efficient home nursing service in this country and, in some cases, because health visitors have given little emphasis to their practical nursing background as they considered themselves in the role of social worker only. There has, however, been a change in the nature of illness. People live longer and, due to drug therapy, they do not need to stay in bed as they used to do. Acute illness is treated in hospital ; therefore, most nursing in the home is of the chronic variety or injection therapy. In the light of this, it does not seem necessary for a state registered nurse to be doing this work as it is a waste of her nursing skills, but someone has to decide whether the person to do this particular job is to be a state registered nurse or a state enrolled nurse or a lay worker. It is here where the health visitor, with her experience of the whole family, is so well equipped to cope with it. Support to the family may be given by the health visitor or by a team of workers, It is true to say, however, that the health depending on the extent of the problem. visitor is the main person giving support in times of stress, particularly in relation to the elderly, mothers with handicapped children, liaison with hospitals when children from her families are admitted, etc. One of her chief supportive roles is that of helping the problem family, assisting with their budgeting, obtaining help Support for this type of family is time-consuming because from available resources. they are always in need of help and seldom reach the stage of being able to manage independently. Although the health visitor is not actively engaged in bedside nursing, she canas I have already stated-assess the needs and mobilise the right member of the team.

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Planning for the future In this country, one must consider the best service for the community and the way in which it could work; the health visitor is an integral part of a team which should be caring for all families and not just those in need of physical care. Many people do not realise that preventive medicine cannot be separated from curative because social problems produce sickness and sickness produces social problems. Over the past few years, this aspect has been emphasized in three reports-“A Hospital Plan for England and Wales”, “Development of Health and Welfare Services”, and “The Field Work of the Family Doctor”. All these reports stressed that all services needed to work together in order to achieve maximum output and give the best service to the people. These reports have influenced the trend towards team work with general practitioners and other workers.

Work

in the General

Practice

At the present time, general practitioners cover every aspect of disease but, with the change of emphasis to whole care of the community, the training of medical students for work in general practice is changing. Medical students now have to spend some time in local authority service and with general practitioners, linking these up with the hospital service. In the past, general practitioners and health visitors have never worked together and much of their work, though different, is They have both been individuals in their own services, making complementary. their own decisions and solving their own problems and with different bodies to be responsible to: the health visitor to her medical officer of health and superintendent health visitor, and the general practitioner to his executive council. With the attachment of nursing staff to general practice, there has to be a new approach by both these members of the team more than any other. The advantage for the health visitor of attachment is that her work becomes more interesting. She is able to know a wider group of people needing help than she would working in family groups of mothers, fathers, children and grandparents. She will know from the general practitioner any middle-aged persons who need advice and guidance; this group could easily be missed if the health visitor were working in isolation. Although the health visitor does a tremendous amount of work with the aged needing social advice, unless she is attached she will not know them all. This has been proven on the districts where attachment to general Another important point is supporting a husband or practice has taken place. wife when the other has died. Unless the health visitor is working in close partnership with a general practitioner, she would not be aware of this, whereas, with attachment, she would automatically be drawn in. How does one achieve attachment? This is not easy. At the present time, general practitioners work in a wide geographical area; in fact, in a town he could cover the whole of it. On the other hand, the health visitor has always been responsible for a confined area. Practices cater for small and large areas and range from single-handed practices to larger ones with from two to ten general practitioners in any one practice. In the light of this variation, arrangements have to be somewhat elastic as what may

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satisfy one practice certainly will not suit another. It may be that, in future, the larger groups of general practitioners may confine their practices to certain restricted areas and this would help in planning the service. Although arrangements have to be elastic, there is only one type of attachment which is likely to prove efficient and that is complete partnership of a nursing and social worker team within the general practice. From the administrative angle, this is not easy to achieve for, unless doctors organize their practices within reasonable limits of distance, not all grades of nursing staff are going to be able to function within this structure because, to do so, they must be mobile. Many nurses have reached the age when they do not wish to drive a car. To add to the difficulties, there are some doctors who work in a town and the practice spreads into a country area, the two areas being under two different local authorities. These are difficulties which can be talked out by adjoining authorities; in fact, none of them is insurmountable if everybody wants it to work. District organization I would like to see a group of general practitioners looking after an area with This would be an economic unit and yet of a size 16,000 to 20,000 population. which would enable the staff (both medical and nursing) to retain the personal interest and relationship with clients or patients. In the team with the general practitioner, I would like to see health visitors, fully-qualified district nurses, state enrolled nurses, a mental health social worker and a general social worker, plus lay workers. I would envisage that the health visitor (out of four or five workers) would act as the team leader, doing the work referred to her-assessment of the needs of the family-sometimes relying on reports from field workers, sometimes doing the visit herself. The district nurses will be doing the nursing which requires their skills and supervizing some of the work of the state enrolled nurses. The health visitor is the key worker in any group of this kind, be it large or small, because with her background and training she understands all aspects of treatment. She is the only person who visits every home where there are children; therefore, she is the only person who sees the normal family in health. The other members of the team only see them when there is a crisis. Projects of this kind must be well thought out in advance and nothing is gained One must plan for integration in order to give an by rushing into arrangements. Medical and nursing colleagues must be taken along with the effective service. project every inch of the way. The general practitioner must have a real desire to work with members of a local authority team, and the type of work the health visitor does must be clarified with the general practitioner before commencing. The reason for this is because many general practitioners are still unaware of the training and function of the health visitor. They do know for what the district nurse and the midwife are responsible but the work of the health visitor is still a closed book to many doctors. I would like to emphasise the following points which should be followed if a scheme of attachment is adopted: 1. All members should work as colleagues. 2. It should be stressed that nursing staff are still responsible to their senior personnel in the health department.

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‘01

3. Regular meetings of the team are important and should be held daily whenever possible. Weekly consultations are insufficient and do not hold a team together. 4. Doctors’ records of patients should be available to nursing staff and local authority records to general practitioners. When all these difficulties have been talked out by the team and basic principles have been agreed, then-with a sincere willingness to make the project work-it will be successful. Much depends on the personal element. From my experience, I have found that the work for the health visitor increases when she works within a practice. She is used to full capacity. The work becomes more varied and interesting; the client or patient is cared for by the person with the most suitable skills for doing so. Changes are very necessary in the nursing field as in any other and the ability to be adaptable and change with the times is sometimes difficult. The changes taking place in this country at the moment are the most radical we have had. I am sure they will give a more comprehensive service than ever before, with a greater conservation of the efforts of the staff concerned. General References National Health Service Act, H.M.S.O. (1946). Report of the working parti on the ProPer jield of work and the recruitment and training of health visitors

(“Jam&on

Report”),

Report of working par0

husband Report”),

Chairman, Sir Wilson Jamieson, H.M.S.O.

on the properjeld

H.M.S.O.

(1956).

of work and recruitment and training of social workers (“Young-

(1961).

Hospital Planfor England and Wales, H.M.S.O. (1962). Development of Health and Welfare Services, H.M.S.O. (1963). The Field Work of the Family Doctor (“Gillies Report”), H.M.S.O. (1963). The Function of the Health Visitor, Council for the Training of Health Visitors (1967).

RCeum&L’initiative d’un service d’infirmieres visiteuses fut prise d&s 1862 par les “Dames de Salford”, mais ce n’est qu’en 1925 que le Ministtre de la Sante accepta la responsabilitt de former des infirm&es visiteuses et agrea la Royal Society of Health comme organisme examinateur. La t&he de l’infirmiere visiteuse consistait principalement, b cette Cpoque, a prendre soin des meres et des bebts et a prtvenir les infections. Un groupe de travail fut constitut en 1953 pour inspecter le service d’infirmitres visiteuses. 11 en resulta, en 1962, la creation du “Council for the Training of Health Visitors” et la revision et la refonte des programmes de formation. Des autorites locales ayant interprttt si largement la loi de 1946 sur le Service de la Sante Publique que l’intirmitre visiteuse ttait aussi employee a des tkhes ttrangtres B ses aptitudes professionnelles, le Conseil dtfinit db son installation les fonctions de l’infirmitre visiteuse. 11 a ttC souligne au cows des dernieres an&es que la medecine preventive ne peut &tre dissociee de la medecine curative. L’infirmitre visiteuse doit avoir ceci present B l’esprit et optrer a l’avenir comme membre d’une tquipe et de concert avec l’omnipraticien, l’infirmiiire du district, l’accoucheuse, l’infirmi&e appointee par l’Etat, l’assistante sociale A la Sante mentale et l’assistante sociale en service general, de meme qu’avec l’aide m&rag&e, pour servir le plus efficacement la communaute. Le rattachement P la pratique mtdicale g&&ale Clargit les objectifs de l’infirmiere visiteuse et rend son travail plus intQessant et plus varit, mais ces arrangements ne sont pas aises et les difficult& doivent &tre ttudites par tous ceux que I’entreprise concerne avant qu’un succ?s quelconque puisse ttre obtenu.

DORIS MUMFORD

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Des changements sent aussi ntcessaires dans le domaine du nursing qu’en d’autres. Ceux qui s’accomplissent actuellement dam ce pays sont radicaux, mais devraient aboutir a un service plus comprehensif que jamais auparavant, par une meilleur economie des effortsdu personnel en cause.

Resumen-El Servicio de visita sanitaria fuC iniciado por las “Damas de Salford” tan tempranamente coma en 1.862, y hasta 1.925 el Ministerio de Sanidad no acepto responsabilidades para la formacidn de visitadoras sanitarias, admitiendo entonces a la Real Sociedad de Sanidad coma cuerpo examinador. Por aquC1 entonces, la enfermera sanitaria se dedicaba preferentemente a la atencion de madres y bebes, y a la prevention de infecciones. En 1.953 el Partido de 10s trabajadores prepare una investigation sobre el servicio de visita sanitaria, con el resultado de que, en 1962, fut creado el Consejo para la Formacicin de las Visitadoras Sanitarias, y examinado y revisado el programa formativo. La interpretation amplia de1 Acta de1 Servicio Sanitario National, de 1.946, por parte de las autoridades locales, habia permitido a la visitadora sanitaria estar empleada en labores que no requerian sus conocimientos profesionales, pero el Consejo reck% nombrado definio claramente la funcidn de dicha visitadora sanitaria. A lo largo de 10s Gltimos adios mis cercanos, se ha subrayado que la medicina preventiva no puede estar separada de la medicina curativa. Teniendo presente esta idea, la visitadora sanitaria debera trabajar, en el futuro, coma miembro de un equip0 conjunto con el medico de cabecera, la enfermera de distrito, la matrona, la enfermera estatal, la asistenta social para la salud mental, y la asistenta social general, junto con personal auxiliar, para dar el mejor servicio posible a la comunidad. La agregacion a la practica medica general amplia las perspectivas de la visitadora sanitaria, y su trabajo se hate m8s interesante y variado, pero la coordination no es facil, y las dificultades deben ser descartadas por todos 10s relacionados con la corntin tarea antes de que pueda ser alcanzado algun tipo de Cxito. Los cambios son muy necesarios en la profesion de enfermera, tanto coma en cualquier otra. Los cambios que en el moment0 actual se e&n produciendo en este pais son lo mbs dristicos posibles, pero podrian dar lugar a un servicio mis amplio que en ninguna otra epoca, con gran ahorro de1 esfuerzo de1 equip0 dedicado a ello. nOCemeHUZi Ha UOMy 6nno r.,HOJfUmbB~925r. hfUHeCTepCTB0 3npaBOOXparIeHUfIB3UJIO Hace6fI OTBeTCTBeHHOCTb 3ao6y'IenUe 3npaBOOXpanUTeJIbHblX nOCeTUTeJIbHUn U 0~06pUno &poneacKoe o6meCTBO HapOAHOrO 3J(OpOBUR KaK 3K3aMeHyKImyIO OpraHU3anUKJ. B TO BpeMR 3npaBOOXpaHUTeJIbHaU nOCeTUTeJIbHUna6btJIarJIaBHbIM o6pa30M 3aHUTayXOnOM 3aMaTepRMUMHOBOpO?KneHH~IMM UeTbMU c neJIbPJ npe~oTBpan&eHUFI 3apaHteHUU. B 1953 r. 6bma OpraHUaoBaHa pa6o~aarpynna~n~Ucc~e~oBaHU~o6cnymusanUrr3~paBooxpaHUTenbH~xnOCe~eHUi, UBpe3ynbTaTe3TOr06bIJIOCHOBaHB1962r.~OBeTnOo6y~eAUH)3~paBOOXpaHATe~bHbIX noceTUTenbKUn U nporpanwa o6yqetmU 6bmanepecMoTpenan UcnpasneHa. ~UpOKOe UCTOJIKOBaHUe MeCTHbtMU BJIQCTHMU 3aKOHa 1946 r. 0 HanUOHanbHOM 3npaBOOXpaHeHUU naJI0 FJ03MOH(HOCTb 3UpaBOOXpaHUTenbHblM nOCeTUTenbHUJ@M 6brTb npUrnaIneHHbIMU Ha pa6oTy, KOTOpaR: He Tpe6oBana KBaJlUnUpOBaHHOrO TpyUa, HO HeRaaH OnO6peHHbIiZ COReTfiCHO yCTaHOBUJI+yHKnUU 3UpaBOOXpaHUTeJfbHblXnOCeTUTeJIbHUn. B TeqeUUe nocneEaBx HeCKOJIbKUXneT 6nao nOnYepKHyTO,~TOnpe~oxpaHUTeJIbnaR Me~UqUHaHeMO~eT6bITbOT~eJleHaOTJIe~e6Ho~Me~U~UHbI.~pUHIiB3TOBOBHUMaHUe, 3~paBOOXpaAUTeJIbHbIe nOCeTUTeJIbHUnM nOn?KHbI B 6ynymeM pa60TaTb KaK YJIeHbI rpynnbIBMeCTeCO6~enpaKTUKyIorrlUMUBpasaMU,O6naCTHbIMUMeACeCTpaMU,aKymepKaMU, MenCeCTpaMU rOCynapCTBeHHOt cnyw6n, nCUXUaTpUgeCKUMU 06meCTBeHHbIMU pa60THUKaMU A 06munm COnUaJlbHbIMM pa60THMKaMU COBMeCTHO C nOnOnHUTeJIbHOti nowombro, Y~06hI 06eCneWTb Uau6onee a@@eKTUBHOe o6cnyHtaBaKUe 06meCTBa. npUHaJJJIe)KHOCTb K o6meiI MeUMnUHCKO# npaKTUKU paCIIIHpReT BO3MOUCHOCTU 3ApaBOOXpaHUTeJTbHblX nOCeTUTenbHMn U UX pa6oTa CTPHOBUTCU 6onee UHTepeCHOti U pa3HOO6pa3HO#, HO OpraHU30BaTb 3TO He JIerKO U MOryT BOaHUKHyTb TpyUHOCTH JJJIR AHHOTaqH)l

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