Resources

Research: the role of the HV in accident prevention

07 December 2018

Ruth Rushton, Mike Bellis and Deborah Haydock carried out a study to highlight health visitors’ training, knowledge, attitudes and practice in preventing accidents. 

Author

Ruth Rushton, Health Visitor

0-19 Service, Victoria Central Health Centre, Mill Lane, Wallasey, Wirral, CH44 5UF

T: 0151 604 7320

E: ruthrushton@nhs.net

 

2nd author:

Mike Bellis, Senior Lecturer, Interprofessional Education / Faculty Coordinator for Technology Enhanced Learning

Riverside Campus, University of Chester
, Castle Drive, Chester, CH1 1SL

T: 01244 512276

E: m.bellis@chester.ac.uk

 

3rd author:

Deborah Haydock, Senior Lecturer, Public Health and Wellbeing

Riverside Campus, University of Chester
, Castle Drive, Chester, CH1 1SL

T: 01244 512176

E: d.haydock@chester.ac.uk

 

Ruth Rushton, a health visitor based in the North West of England, with Mike Bellis,

Senior Lecturer in Interprofessional Education/Faculty Coordinator for Technology Enhanced Learning, and Deborah Haydock, Senior Lecturer, Public Health and Wellbeing, both at the University of Chester, carried out a study to highlight health visitors’ training, knowledge, attitudes and practice with regards to accident prevention. Their research found little published evidence on the matter, despite the importance of preventing childhood accidents being addressed in policy and guidance, and recommendations that those working with children are trained accordingly.


 

Introduction

Accidents are a way of life for children. A realistic parent knows that minor accidents, scrapes and bruises are inevitable and usually easily treated, indeed they are a normal part of a child’s development.

However, accidents are also a major health problem throughout the United Kingdom (UK). They are most common preventable cause of death in pre-school children, and leave many others permanently disabled or disfigured (Royal Society for the Prevention of Accidents, 2016).

The personal costs of an injury can be devastating; significant lasting physical and emotional effects can impact on education and learning, employment opportunities and family relationships (Public Health England, 2014). Accidental injuries also place a large burden on the health service in terms of A&E attendance, hospital admission, as well as treatment and rehabilitation.

To establish the true, long term cost of treating childhood accidents is difficult and complex, however the short-term costs alone are substantial; with an estimated £131 million per year spent on emergency hospital admissions because of childhood accidents (Child Accident Prevention Trust, 2013b). The short-term average health care cost of an individual injury (all types) is around £2,500, while the wider costs of a serious home accident for a child aged 0 to 4 has been estimated at £33,200 (Walter, 2010). The costs are both acute and long term, for example, the total lifetime costs for a three-year-old child who suffers a severe traumatic brain injury is estimated at £4.89m (Child Accident Prevention Trust, 2013a).

Health visitors (HVs) have traditionally been regarded as having an important role in accident prevention due to their frequent contact with children and parents/carers, their access to family homes, and knowledge of child development which is recognised in the Healthy Child Programme (DoH, 2009). This unique position facilitates an opportunity to raise the profile of accident prevention at all levels (Whelan, 2015). This research article examines the role of health visitors in childhood accident prevention exploring their training, knowledge, attitudes and practice.

Health visitors’ role in accident prevention

There is limited literature to be found on the role of HVs in accident prevention. A Canadian study looking at home visits with a specific home injury education and information package found they can have an effect, demonstrating a sustained, modest reduction in injuryed (King et al, 2005). The effectiveness of the intervention did diminish over time, with injury rates increasing in the intervention group, but still remaining less than the control group.

UK studies present key factors in the prevention of accidents, (Ablewhite et al, 2015; Anderst and Moffatt, 2014; Khanom et al, 2013). Factors include: not anticipating risk, inadequate supervision and provision of safety information.

Papers highlight that accident prevention messages do not always involve professionals – social networks including other parents are an important source of safety information (Beckett et al, 2014; Watson et al, 2014). Injuries are strongly associated with socio-economic circumstances, with the social class gradient steeper for injuries than for any other cause of death in childhood (Roberts et al, 1998,  Orton et al, 2014). A study undertaken by Watson et al (2007) focused on the role of HVs and nursery nurses working in deprived areas. It concluded that whilst staff did focus on injury prevention, this was using an individualistic approach to injury prevention rather than a broader public health approach, with many commenting on the barriers or constraints placed upon them.

The HVs’ role in reducing unintentional injury in the under-5s was considered by Whelan (2015). The paper emphasised that HVs are in a position to raise the profile of accident prevention, and concluded that they are responsible for ensuring they are skilled and adequately trained. In addition to this, a systematic review, of the relatively small number of studies, examining the role of health professionals in injury prevention (Woods, 2006), concluded that training may be effective in increasing health professionals’ knowledge and attitudes, however evidence was needed to establish if this would reduce injuries.

Policy 

Childhood accident prevention has long held prominence as a major public health issue, both internationally and in the UK. International bodies, having highlighted the problem, called on countries to investigate child injuries and prepare appropriate preventive programmes (WHO and UNICEF, 2008; WHO and UNICEF, 2005). Over a number of years UK policy has raised the significance of child accidents with Saving Lives: Our Healthier Nation (DoH, 1999), setting injury prevention as a priority, and recognising unintentional injuries as the greatest single threat to the lives of children. Continuing with this, The Healthy Child Programme has injury prevention as one of its key aims (DoH, 2009), incorporating the five key outcomes of Every Child Matters (HM Treasury, 2003). The National Institute for Health and Care Excellence (NICE) made recommendations that HVs should provide information and undertake risk assessments in homes (NICE, 2010a; NICE, 2010b; NICE, 2010c).

In 2014 with the reorganisation of responsibility for children’s services, six Early Years High Impact Area documents were developed to aid the transition of commissioning to Local Authorities. These inform the decisions around the commissioning of the health visiting service and integrated children’s early years services (PHE, 2014b). High Impact Area 5: “Managing minor illness and reducing accidents (reducing hospital attendance/ admissions)” incorporates reducing accidents (PHE, 2014a). The importance of unintentional injuries is recognised in domain 2 (health improvement) of the Public Health Outcomes Framework: “2.07 Hospital admissions caused by unintentional and deliberate injuries in children and young people under 25” (DoH, 2016). Public Health England, in conjunction with the Child Accident Prevention Trust and the Royal Society for the Prevention of Accidents have set out actions Local Authorities can take to reduce the number of children injured or killed (Public Health England, 2014). This is echoed by NICE’s guidelines for service providers concerning training (NICE, 2014), which recommends action should be taken to:

“Provide access to appropriate education and training in how to prevent unintentional injuries for everyone who works with (or cares for and supports) children, young people and their families.

Prioritise those who work directly with children, young people and their families. Ensure the education and training:

  • supports the wider child health remit (for example, the promotion of children and young people's development)
  • helps develop an understanding of the importance of preventing unintentional injuries and their consequences and the preventive measures available. 

Ensure specialist education and training is monitored and evaluated to see what effect it has on practitioner performance. Revise approaches that are found to be ineffective.”

This remit directly applies to HVs with their unique position, access and skill set.

Training

Government bodies (Public Health England, 2014; NICE, 2014; NICE, 2010a) recommend that HVs should receive training which includes the identification, assessment and facilitation of safe home environments. The Nursing and Midwifery Council (NMC, 2004) stipulates that practicing HVs develop and expand their knowledge post-registration, and this is supported by the Health Visiting core service specification (NHS England, 2014), which calls for providers to promote a workforce development plan based on the learning needs of the workforce.

Despite these recommendations there is limited literature concerning training. This was identified back in 1995, (Marsh et al, 1995) in a study which found only a third of HVs had attended a course or lecture on accident prevention within two years.

Accident prevention training is not explicitly covered as part of the taught curriculum of the Specialist Community Public Health Nursing (SCPHN) qualification for a career in health visiting. This element of preventive work would fall under the practice teachers’ remit as they socialise student HVs to the principles of health visiting and the healthy child surveillance programme.

Nationally the Royal Society for the Prevention of Accidents’ (RoSPAa, 2016b; RoSPA 2016c) and the Child Accident Prevention Trust (CAPT, 2016) provide resources and training on child accident prevention and home safety training relevant to HVs and allied professionals. The institute of Health Visiting (iHV) now provides e-learning modules on child accident prevention specifically for HVs. It is suggested that the modules should be undertaken with colleagues to share ideas and get support.

In Hampshire (DoH, 2015), a project aimed at reducing unintentional injuries in the under 5s utilised Health Visitor Champions who supported education and practice for all team members, including skill mix staff, with iHV resources. According to the report these strategies affected change.


Study aim/ purpose

Numerous government reports and recommendations have identified the importance of child injury prevention, and the burdens injuries place on families and services. To address child accident prevention, they emphasise the utilisation of existing staff, programmes and cross-partnership working.

There is very little up to date evidence exploring the role of HVs in accident prevention. Despite the recommendation for training, no current evaluation of HVs’ accident prevention training was found. While identifying the need for an accident prevention programme, and associated recommendations, is extremely valuable, there remains a gap in the knowledge of the current role of HVs in delivering accident prevention.

This study was undertaken to highlight the HVs’ training, knowledge, attitudes and practice with regards to accident prevention.


 

Method

Research Design

The research design used a descriptive, non-experimental survey, utilising a questionnaire with predominantly quantitative questions to collect information on demographics, attitudes, knowledge, beliefs, opinions, experiences and behaviour of HVs in relation to accident prevention.

A survey design was considered appropriate as it facilitates data collection from wide ranging, large representative samples (Parahoo, 2006), and would additionally facilitate the exploration of knowledge, attitudes and behaviours towards a given topic area (Everitt and Skrondal, 2010).

Several open questions were included to enhance interpretation, generating some qualitative data, but of far less depth than would be obtained from an unstructured interview.

Research methods

Data was collected through a structured questionnaire as described in Table1. The questionnaire was subjected to face validity and a pilot study using four participants, which helped to refine the questions and make minor amendments accordingly, predominantly around safe sleeping, which was not within the remit of this study.

Table 1 Questionnaire structure

STUDY QUESTIONNAIRE

Section 1

Demographic data / training / personal experience

Section 2

Factual knowledge on epidemiology of childhood accidents

Section 3

Attitudes towards accident prevention

Section 4

Accident prevention delivery and perceived needs

 

Participants

An area in the North West of England, where the researcher is based, was chosen (non-probability, convenience sampling). This setting has both areas of high socioeconomic deprivation and some affluent divisions.

Inclusion / Exclusion criteria

All practising HVs (that is those that visit families) working for the chosen NHS Trust were invited to participate. HVs in a managerial role with no caseload were excluded to avoid any potential bias from managerial agendas. HVs in a specialist role without a standard caseload were excluded as they may not reflect standard attitudes and practice. Student HVs, nursery nurses and school nurses were all excluded as the aim of this study is to examine the role of practising HVs.

Ethics

The research proposal was submitted and approved by Chester University and local NHS ethics committees in line with research governance. A covering letter and participant information sheet were provided with each questionnaire, and guarantees of anonymity, confidentiality and the ability to withdraw without obligation were assured.

Returning a completed questionnaire was considered to be implied consent.

Data analysis

Questionnaire data was manually transferred into an Excel spreadsheet, checked for accuracy of transcription, coded, and then entered into the SPSS statistical package.

Descriptive statistics were used for section one of the questionnaire and the Mann-Whitney U Test applied to test for statistical difference in participant’s knowledge between those trained and untrained for section 2. Section 3 (attitudes) collected ordinal data in the form of a Likert scale, and each question related to a question in Section 4 (practice). Analysis using Chi squared / Fisher exact test was used to determine if those groups tend to rank their attitude the same.

To clarify some responses and allow participants to convey additional thoughts, four open questions were included and were examined using Thematic Analysis, which is used widely in qualitative research (Guest et al, 2012). All narratives from the open questions were copied and input onto an Excel spreadsheet, manually coded and categorised according to themes and analysed using the six phases as described by Braun and Clarke (2006).


 

Findings / Results

A total of 51 usable questionnaires out of 63 were returned (response rate of 81%) with the demographics summarised in Table 2.

TABLE 2 Characteristics of respondents

Age (years)

No.

(%)

Years in Health Visiting practice

No. *

(%)*

Under 25

1

(2)

Under 5

20

(40)

25 – 34

8

(15.7)

5 – 10

9

(18)

35 – 44

18

(35.3)

11 – 15

8

(16)

45 – 54

12

(23.5)

16 – 20

3

(6)

55 – 64

11

(21.6)

Over 20

10

(20)

65 and over

1

(2)

 

 

 

*One respondent did not indicate years in practice.

 

The majority of respondents, 90% (46/51), had had no training in accident prevention in the past two years and only 35% (18/50) regularly accessed accident prevention websites.

KNOWLEDGE OF CHILDHOOD ACCIDENT EPIDEMIOLOGY

The number of correct answers scored by HVs ranged from 6 to 11 out of 14 with a mean of 8.2 and median value of 8.

The first seven questions were on the whole answered poorly, with less than 50% of the sample identifying the correct answer. The exception was question 6 where the majority, 84.3% (43/51), knew that boys had more accidents than girls. Most health visitors (>60%) correctly identified risk factors for accidental injury. HV’s knowledge of the epidemiology of childhood accidents is summarised in Table 3.

TABLE 3 Health Visitors’ knowledge of childhood accident epidemiology

 

QUESTION

No. answering correctly

(%)

answering correctly

  1. How many children aged under-five in England attend A&E each year after being injured in and around the home?

 

5

(9.8)

  1. How many children aged under-five in England are admitted to hospital following an injury in and around the home?

 

20

(39.2)

  1. In the under-fives, which type of injury caused the most hospital admissions?

 

25

(49)

  1. In the under-fives, which type of injury caused the highest number of deaths?

 

17

(33.3)

  1. How many children under-five die each year as a result of an injury in and around the home?

 

9

(17.6)

  1. Do boys have more accidents than girls?

 

43

(84.3)

  1. Where in the house do most accidents occur?

 

5

(9.8)

  1. Which of the following are risk factors for childhood accidental injury?

 

 

 

Maternal age under 20

47

(92.2)

Children living with both natural parents

42

(82.4)

Socio-economic deprivation

50

(98)

Frequent house moves

42

(82.4)

Morning time

34

(66.7)

Maternal alcohol consumption

50

(98)

Visiting friends and relatives housed

32

(62.7)

 

 

ATTITUDES TOWARDS ACCIDENT PREVENTION

Health visitors’ responses to the attitudes section of the questionnaire demonstrated that many hold extremely positive attitudes towards accident prevention activities. HVs’ attitudes to discussing accident prevention at core contacts are shown in Table 4.

TABLE 4 Health Visitors’ Attitudes to discussing accident prevention at core contacts

Accident prevention should be discussed at these core contacts:

No. (%)

 

STRONGLY

AGREE

AGREE

NEUTRAL

DISAGREE

STRONGLY

DISAGREE

Antenatal visits*

31 (62)

11(22)

2 (4)

4 (8)

2 (4)

Birth visits*

35 (70)

10(20)

2 (4)

1 (2)

2 (4)

4 – 8 week contact visits*

37 (74)

11(22)

0 (0)

0 (0)

2 (4)

12 – 16 week contact visits

41 (80.4)

8 (15.7)

0 (0)

0 (0)

2 (3.9)

9 month reviews

44 (86.3)

5 (9.8)

0 (0)

0 (0)

2 (3.9)

2 year reviews

44 (86.3)

5 (9.8)

0 (0)

0 (0)

2 (3.9)

*one respondent did not answer

 

Just over half, 54.9% (28/51), agreed or strongly agreed that accident prevention should be discussed at every Healthy Child Clinic contact. The majority, 62.7% (32/51), strongly agreed / agreed that HVs should run a parents’ group to teach first aid.

 

HVs attitudes to training and resources are presented in Table 5, with nearly all wanting more in each category.

TABLE 5 Health Visitors’ attitudes to accident prevention training and resources

Question:

No. (%)

Do you think that…..

STRONGLY

AGREE

AGREE

NEUTRAL

DISAGREE

STRONGLY

DISAGREE

Health visitors should have training and regular updates to deliver the accident prevention message

 

 

32 (62.7)

 

17(33.3)

 

1(2)

 

0(0)

 

1(2)

You would like further resources / leaflets on accident prevention to give to parents

 

 

37(72.5)

 

12(23.5)

 

1(2)

 

0(0)

 

1(2)

Health Visitor accident prevention champions should be based in each team to support and educate colleagues

 

23(45.1)

 

16(31.4)

 

10(19.6)

 

1(2)

 

1(2)

 

 

CURRENT PRACTICE IN ACCIDENT PREVENTION

Discussion of accident prevention is being prioritised at universal contacts always or most times by 76% (38/50) of the HVs surveyed. If respondents did not always prioritise, they were invited to explain why. Data from this generated four themes:

 

  1. Time; there are other topics to cover.
  2. Parental lead; HVs recognised that their visits can be client led in order for families to engage and benefit from contact.
  3. Child too young; HVs discussed advice in accordance with the child’s development and home observations.
  4. Tailoring their visits; in accordance to the home situation.

 

The core contacts at which accident prevention is discussed are shown in Table 6. The percentage discussing accident prevention increases as the infant ages.

 

TABLE 6 Health Visitors practice of discussing accident prevention at core visits.

At which of these core contacts do you discuss accident prevention?

 

No. (%)

Antenatal visits

33 (64.7)

Birth visits

40 (78.4)

4 – 8 week contact visits

44 (86.3)

12 – 16 week contact visits

46 (90.2)

9 month reviews

50 (98)

2 year reviews

50 (98)

 

Just over half of HVs, 54.9% (28/51), reported rarely discussing accident prevention in the Healthy Child Clinic. With regards to the use of accident prevention resources when visiting families, most HVs-  82.4% (42/51) - use leaflets, while 39.2% (20/51) use websites, 7.8% (4/51) use Facebook, and 2% (1/51) the ‘red book’.

Nearly all HVs surveyed, 94% (48/51), thought that their practice would benefit from accident prevention training as it would give them up to date evidence-based information and statistics, and, by reducing the risk to children, it would also reduce the impact and cost on the NHS.

At the end of the questionnaire, participants were asked to provide any further comments with regards to HVs and accident prevention. These are outlined in figure 1.

FIGURE 1. Range of issues identified by participants

Accident Prevention

 

Discussion

The importance of supporting families in preventing childhood accidental injuries has consistently appeared over the years as a key goal. This is echoed in this study, with the majority of HVs agreeing that accident prevention was a priority in their work.

Findings from this study highlighted the need for training in accident prevention, with deficiencies in knowledge concerning childhood accidents suggesting that there is a lack of training opportunities or the ability to access them. This may well be a national issue, as not a single published article could be found with regards to the evaluation of training of HVs in accident prevention. Our results are relevant to the area surveyed. In order to establish if findings could be universally applied a substantially bigger study, encompassing areas of the country with different ways of working and populations, would be required.

This study demonstrated that HVs had extremely positive attitudes towards discussing accident prevention at core contacts. Around half of HVs agreed that accident prevention should be discussed in the Healthy Child Clinic. Any brief intervention possible in the clinic is to be encouraged as part of the ethos of “Making Every Contact Count” (Public Health England, 2016).

Recently there have been increasing concerns over the possible erosion of public health tasks in Health Visiting as a result of general NHS funding constraints and the accompanying service redesign. Respondents raised concerns about aborting the 12-16 week contact due to funding issues, and that accident prevention was no longer discussed at two-year reviews. Almost all HVs (96%) surveyed would like further resources on accident prevention, and three quarters strongly agreed or agreed that accident prevention champions should be based in each team to support and educate colleagues.

As the NHS has limited funds, HVs need to work in partnership with local agencies to ensure that consistent safety messages are given to the population to reduce the incidence of accidental injury.


 

Conclusion

Accident prevention is a public health priority and achievable if parents are educated, understand how accidents are directly related to the developmental age of their child and the environment they are in, and have the resources to help keep them safe.

It is encouraging that many HVs are already undertaking a range of accident prevention work and hold positive attitudes towards the subject. However constraints due to the ‘squeeze’ on public health funding (House of Commons Health Committee, 2016) may limit opportunities.

NICE (2018) recommends the provision of appropriate education and training in how to prevent unintentional injuries for everyone who works with children, young people and their families. This study has highlighted that there is a lack of training opportunities in accident prevention, with a majority of HVs feeling strongly that training would enhance their practice in this area.

 

RECOMMENDATIONS

  • All workforce HVs should be trained in accident prevention to be able to fully deliver the Healthy Child Programme. 
  • Employers should provide subject leadership through identifying and training HV accident prevention champions.

  • The importance of accident prevention would be enhanced if Health Visiting teams participated annually with partners in Child Safety Week. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392794/ (accessed 5 November 2018).


 

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