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Attend anywhere

10 January 2022

SCPHN lecturer Bridget Halnan on using digital technology to maintain a Healthy Child Programme service during lockdown and perceptions from service users.

Those working as specialist community public health nurses (SCPHNs) – health visitors and school nurses (SNs) – as well as leaders of the Healthy Child Programme (HCP) are all guided by the four principles of health visiting:

  • Search for health needs
  • Stimulation of an awareness of health needs
  • Influence policies affecting health
  • Facilitation of health-enhancing activities (Institute of Health Visiting, 2006).

As a SCPHN lecturer, teaching on a course validated by the NMC during pre-Covid-19 times, I was interested to gather the views of current student SCPHNs regarding how the families they have been visiting viewed the curtailed service during a time when social distancing and compliance with Covid-19 legislation was inevitably a more important consideration than delivering a traditional ‘face-to-face’ service.

I was interested in what families felt was missing from the service offer, and if there were any advantages in a new way of working with digital technology that may be useful post-pandemic.

This exercise was conducted during a taught module on the evaluation of service provision. How, as student HVs and SNs, were they able to follow the four principles, given that they had very limited face-to-face contact and severely curtailed health-enhancing activities within the community?

Aim of gathering information

SCPHN students at Anglia Ruskin University study six modules at master’s level. Their final double module, ‘Critical policy review’, is about understanding the antecedents of UK health and social care policy, how policies are implemented in this country, their effectiveness, how this is measured, and the impact of such polices on the health outcomes of families.

As nurses or midwives, they have been used to following NICE guidelines prior to the course, and to working within their competencies as per the NMC code. However, as future leaders of the HCP and future influencers of policies affecting health (Public Health England (PHE), 2021), they need to begin to appreciate both the role of political ideology and the influence of service users, health professionals, lobbyists and other interested organisations in implementing and evaluating services.

SCPHNs, as part of the HCP, start with the premise of working with well families, so – unlike many other aspects of nursing – they need to promote their service and build strong relationships before health promotion can happen. Unlike many other nursing or midwifery roles, new families are not always immediately aware of the service until a SCPHN contacts them in the antenatal period and explains the HCP. Very few NHS services proactively seek out clients, which may well account for this lack of awareness.

The exercise, which I asked the students to undertake over two weeks, was to take every opportunity to speak to service users about their experiences of using the service via digital technology. If families had experienced any face-to-face contact, how did this compare with services provided over the internet, and what, if anything, would they like to see added to the current offer of five mandated contacts?  

Social distancing, isolation, loneliness and difficulty in building relationships via a digital platform proved to be some of the emerging themes

Methods

This exercise was conducted entirely anonymously. Students reported their findings during an online teaching session and I noted their main points. The students work in a number of different trusts across the region, and all are working very closely alongside their supervisors and assessors (NMC, 2018). At this stage of their training, none of them are conducting visits on their own, and during the exercise there was a mixture of online and face-to-face contact. Some contacts were conducted in clinic settings, solely via appointments, but no group activity took place and everyone was socially distanced at all times – or using PPE.  

Key themes

Twenty-three students outlined their findings. Unsurprisingly, the impacts of social distancing, isolation, loneliness and an inability – or greater difficulty – in building relationships via a digital platform proved to be some of the emerging themes. There appeared to be only a few examples of families feeling as if they really knew their HV or SN, coupled with an overwhelming number of examples of families not knowing where to turn or how to contact the service for support or guidance.

A further theme that emerged, which had not been considered in the original remit, was how families wanted more contact and support, and how they missed formal groups set within the community. Well baby clinics – where new parents could traditionally socialise – had been suspended, while introduction to solids workshops were cancelled and ‘drop-ins’ for school-age children were not available because of school closures.

One student said: ‘They want you there, particularly around mental health.’ Another said: ‘One mum would walk to the children’s centre every day to look at the timetable – an excuse to get out of the house, which set the agenda for the day.’ The children’s centre wasn’t open, but she nevertheless went every day, craving adult conversation.  

Another student reported that, during a one-year review via a digital platform, one mother said she would have liked a visit between then and the six-week contact, but she didn’t know if she was allowed and also didn’t know if she was ‘doing it right’. Several students reported that service users didn’t appear to understand the concept of open access, or even what the service or the individual health professional could provide.  

However, students themselves did report some positive aspects of the use of digital platforms. They felt their own experience of learning, and the ability to observe many more ‘contacts’ via Microsoft Teams, was beneficial to their learning. This region has many rural areas, where a car journey from base to a family home can take up to 30 minutes. Students appreciated the ease with which they could log on and join different supervisors carrying out HCP contacts, as well as joining other health professionals for multidisciplinary team meetings, for example to discuss safeguarding. They have continued to find that monthly meetings with GPs are much better attended via Microsoft Teams. However, they are mostly at advanced beginner stage (Benner,1982), wanting to know the ‘whats’, rather than the ‘hows’. Instead of starting with the mother’s agenda, some students are still concerned about what information they should relay at each visit. Conducting a visit via a computer enables them to have a checklist out of view from the family and to tick off the subjects that need to be covered for key performance indicators (Latinovic, 2015).

Some students did say that, due to the ease of visiting via ‘attend anywhere’, they were able to follow up families more frequently – for example for feeding support – and (although supernumerary) would not have been able to offer weekly support visits in pre-Covid times but could now do so using digital technology. Another student added that, in this environment, with so many SCPHNs working from home, she felt that she could more easily access a supervisor for advice than if they were out on the road visiting homes.  

What emerged through the group discussion was a dissatisfaction felt by students as well as service users with the inability to build effective relationships

Discussion

Although I was interested in families and how they perceived the service during lockdown, what emerged through the group discussion during my teaching session was a dissatisfaction felt by students as well as service users with the inability to build effective relationships – and thus deliver an effective HCP. The strongest theme – in the week that the National Food Strategy was published (National Food Strategy, 2021) – was the very long gap between the six-week contact and the one-year review.

The student group and the families they had contacted all felt that a further contact – similar to that in the other UK nations – would be helpful. Not only would this be beneficial at a time when parents were thinking about introducing solids, but also this would allow the six-week check to focus on more appropriate matters for a family at that time, such as mental health issues and the promotion of breastfeeding. Families tended to forget much of the information about introduction of solids at around six months that they’d been given at the six-week contact. A good example of this came from a student who visited a mum at one year whose child was still taking manufactured purées and infant formula, and was already overweight. This is further evidence of why the newly published review of health visiting and school nursing is timely (PHE, 2021).

Limitations

The students were given a very informal remit, and as such, did not always stick to the brief. They had different amounts of exposure to families during the two weeks, and some students took the opportunity to speak to friends who had young children to gain more insight.

Most of the current students have friends with young children and have used these connections to gain more insight into, for example, breastfeeding; sadly, this student cohort reported that the SCPHN service was sometimes seen as an irrelevance. These friends, when having difficulty feeding, for example, consulted their GP – or even went back into the clinical environment where they used to work – in order to weigh their baby.

Well baby clinics are no longer ‘walk-in’ and gaps between mandated contacts can be months, so students’ friends reported that they hardly ever saw an HV. Students reported that their supervisors might perceive this as a good thing, as it suggested there were no parental concerns – but this does not appear to be the perception of service users.

One friend told a student that she felt she’d been left to fend for herself. Another didn’t understand why there was no weekend service and had had to rely on contacting A&E for advice. The students see their ability to prescribe as an opportunity to address high-impact areas (PHE, 2021), and this cohort at least would welcome an expansion of the service to include out of hours and weekends. I too have advocated this (Halnan, 2017).  

A further telling feature of lockdown was the matter of staff retention. Students reported that some staff had left the service altogether, in fear of their registration. They reported that they did not feel they were offering a safe service because they did not have ‘eyes on the baby’. An appointment-only clinic service of 30-minute slots was cut down to 15-minute intervals to accommodate more families, while at the same time a ‘self-weigh’ service was instigated. Some students reported that service users found this unsatisfactory as they still could not consult an HV or SN in a timely manner. For the self-weigh service in particular, they said, families were not always able to seek immediate help and support over concerns following weighing their infant.

Conclusion

As a SCPHN lecturer, not working directly with families during this unprecedented time, I can’t fail to appreciate the difficulties – and sometimes even personal risk – that frontline staff have faced. Supervisors and assessors of student SCPHNs have striven to maintain a service for all families, while at the same time helping our students to get the best learning experience possible. There are many concerning issues in this report, but these do not reflect the care, compassion and commitment of the trained staff I see every time I conduct a link visit – albeit via Teams – in practice. The replacement of the 4:5:6 model should be welcomed; this need for change is evident from the student’s current experience in practice (PHE, 2021).

Staff have embraced digital technology to keep families (as well as themselves) as safe as possible. However, in order to allow for the most effective service to proceed post-pandemic, issues such as effectiveness of the HCP mandated contacts need to be commissioned and embedded in practice. Inequalities of service between the four nations, as well as inequalities of health outcomes across the social divide – particularly in the rising rates of childhood obesity – must be an urgent priority.


References:

Benner P. (1982) From novice to expert. American Journal of Nursing 82(3): 402-7.

Halnan, B. (2017) Should health visitors have a regular rotation in A&E?. Journal of Health Visiting 5(7): 326-28. 

Institute of Health Visiting (2006) Principles of health visiting. See: ihv.org.uk/about-us/principles-of-health-visiting/ (accessed 24 November 2021).

National Food Strategy. (2021) Henry Dimbleby. See: nationalfoodstrategy.org/henry-2021/ (accessed 24 November 2021).    

NMC. (2020) The code. See: nmc.org.uk/standards/code/ (accessed 24 November 2021).  

NMC. (2018) Standards for specialist community public health nurses. See: nmc.org.uk/standards/standards-for-post-registration/standards-of-proficiency-for-specialist-community-public-health-nurses/ (accessed 24 November 2021).  

NMC. (2016) Approved programmes. See: nmc.org.uk/education/approved-programmes/ (accessed 24 November 2021).     

Public Health England. (2021) Health visiting and school nurse service delivery model. See: gov.uk/government/publications/commissioning-of-public-health-services-for-children/health-visiting-and-school-nursing-service-delivery-model (accessed 24 November 2021).  

Latinovic R. (2015) Key performance indicators: what are they all about?. Public Health England. See: https://phescreening.blog.gov.uk/2015/07/10/key-performance-indicators-what-are-they-all-about (accessed 24 November 2021).   

Image credit | Shutterstock

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