The guideline contradiction: health visitors’ use of formal guidelines for identifying and assessing families in need

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Abstract

The aim of this paper is to examine health visitors’ use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support. With the increasing emphasis on targeted health visiting, a case study was used to explore the extent to which health visitors in three case sites use needs assessment guidelines in the assessment of family health need. The findings indicate how the presence of core visiting protocols hints at elements of control by managers, leading to conflicts in the relationship between professional judgements and official guidelines. Despite a management ethos of guideline formulation, several contradictions exist for which these guidelines are a focus. These include: little involvement of health visitors in guideline development, some staff not informed about the existence of formal guidelines, little evidence of guidelines contributing to improved client outcomes and their limited use by many health visitors in practice. Thus, even when guidelines exist, no accurate predictions can be made about health visitors’ knowledge of or use of such guidelines in practice.

Introduction

The potential for health visitors to accurately identify children and families in need, to promote family health and well being and to protect vulnerable children is acknowledged in current health and social policy (Home Office, 1998; Department of Health, 2000). Health visitors are in a unique position to identify parents and children experiencing stress and to undertake short-term preventative work with families because of their current, albeit often limited, universal access to families (The National Society for the Prevention of Cruelty to Children, 1996; Department of Health, 1999). As such, assessment of family health and social need is a central feature of the health visitor's role in which a range of skills and knowledge are used. These assessments are crucial in identifying children and families in need and in determining levels of health intervention to be offered. Drawing on recent empirical research, this paper examines health visitors’ use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support.

Section snippets

Universal vs. targeted service

Health visiting is a health-promoting service offered to all families with pre-school children. Health visitors are registered nurses who have undergone post-registration specialist training which focuses specifically on health promotion and disease prevention amongst all population groups. Most health visitors work in the community and through a combination of home visiting, clinic work and community-based activities are well placed to identify and work with vulnerable groups.

Despite the

Identifying children and families in need

Child health promotion work forms the basis for assessment and targeted work with children and families in need. Health visitors have traditionally adopted a number of approaches to identify children and families requiring extra health visiting. These include risk assessment screening, the use of guidelines and a reliance on health visitor professional judgement. These approaches are reported in more detail elsewhere (Appleton, 2002a). However, there is a dearth of research evidence exploring

Study design

A case study strategy (Stake (1994), Stake (1995); Appleton (2002a), Appleton (2002b)) guided by a constructivist methodology (Guba and Lincoln, 1989) was used to undertake an in-depth examination of how health visitors identify families deemed to require additional support. Insights from the preliminary survey work influenced the purposive sampling strategy to select three main study Trusts and one pilot site where contrasting guidelines were issued to health visitors to assist in the

Findings and discussion

A feature of the analysis was the variety and range of criteria available for the identification of families needing increased support. Table 2 illustrates the formal guidelines existing in the case sites. The following sections will describe in more detail the characteristics of the guidelines existing in each site.

Conclusion

The requirement to target health visiting interventions to those families with increased health needs has led to a rapid growth in the development of formal guidelines to assess families in need (Appleton, 1997). While it is acknowledged that extra health visiting support should go to those children and families with most demonstrable need, there seems to be a view that equity in access to scarce health-care resources can be addressed by the development of such guidelines. This paper has

Acknowledgements

We would like to express our sincere appreciation to the research funders and to all the participants who gave up their time so willingly to take part in this research and made the study possible. Smith and Nephew Foundation Nursing Research Fellowship and Department Health/CPHVA Centenary Scholarships funded this research.

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