Universal Health Visiting Pathway evaluation - phase 1: main report - primary research with health visitors and parents and case note review

5. Health visiting workforce

Training, supervision and support

Two thirds (64%) of health visitors reported having informal discussions (e.g. a chat with colleagues) about delivering the UHVP and 41% had discussed the delivery of the UHVP in their supervision.

During the pathway implementation, continuing professional development courses were rolled out to all health visitors in post. Forty-one percent of health visitors reported they had undertaken UHVP training as part of a UHVP health visiting course. A further fifth (19%) had completed online training, 2% had done another form of training, while 2% said they had not undertaken any training on UHVP.

Participants who had recently joined the profession were most likely to have undertaken UHVP training at university (87% of those who had been practicing less than a year, compared with 41% overall). While those who had been in post for longer were more likely to have attended formal training course while in practice (64% compared with 52% overall).

Although the vast majority of health visitors said they felt confident (90%) and skilled (91%) in their roles, only 59% felt they had sufficient opportunity to participate in relevant training. Twenty-two per cent said they had not had enough opportunity, while 18% were unsure. Those who had been delivering the UHVP for the longest time were most likely to feel they had sufficient opportunity for training (69%).

In the qualitative interviews and focus groups, health visitors across the case study Health Boards stated that they did not receive any formal pathway training prior to the introduction of the pathway as the pathway was mainly introduced through informal briefing and team discussion. Some health visitors noted receiving training specific to the Ages and Stages Questionnaire (ASQ), the nationally recommended tool for use at all child health reviews across Scotland around the time of implementation but not specifically around the pathway itself.

There were mixed views on the lack of pathway specific training as practitioners with more years of service felt this was not necessary as it aligned with their prior role, however, a few newly qualified health visitors in two Health Boards felt that their university training did not equip them well for delivering the UHVP. This is contrary to the survey findings however, which used much larger sample.

The pathway just came from above and that’s where it was. There wasn’t an awful lot of training around this pathway. There were masters classes for things but there wasn’t much on the actual pathway (Health visitor).

From the point of view of the placement side of it, yes. But I don’t think the university side of it focused very much on the actual pathway. It was expected that our practice educators would show us that (Health visitor).

In terms of support from peers and supervisors, health visitors in two Health Boards frequently reported that they felt well supported by their team leaders and managers. Many of them also discussed that they were part of cohesive and supportive teams, which positively contributed to their working environment. Peer-support within teams was commonly referenced with regard to caseload management with many health visitors identifying that support could be gained in this way before escalating a caseload issue to management.

A number of health visitors described the importance of team working when asked about the support they receive in terms of caseload management. Regular clinical supervision meetings between health visitors and their team leaders positively contributed to caseload management.

I think we support one another, within the teams. I think it’s down to the team, and the relationship you have as a team, and we have weekly meetings and discuss, at a team level, the management of the caseload. How we’re going to work out reviews, if somebody has got maybe more than their share, if you like, if they’ve got a lot of antenatal, and they’re going to be having two weeks annual leave in the middle of that, you know, we’ll share that all out (Health visitor, Focus Group).

On the whole, clinical supervision is pretty much embedded now. And it didn’t really exist before. Particularly in the last two years, clinical supervision’s become a regular occurrence; it’s about every six to eight weeks. And the training opportunities are coming in more regular now. There’s a lot of [training] programmes here. Particularly with the social care side of things and child protection (Health visitor).

The survey data showed that health visitors who were most likely to feel they had enough clinical supervision included: those working in the West and North Regions (73% and 71% compared with 46% in the East), and those who had been practicing for 1-2 years (78%, compared with 67% overall).

A large proportion of health visitors noted that they knew where to seek support, if necessary, to manage their workload and caseload complexity.

I would know the channels to go through if I was concerned. I think if you’re working as part of teams then if you’re in a supportive team then that kind of support is always ongoing, i.e. if you were really struggling, you’ve got colleagues there that you can have a conversation and review (Health visitor).

Although attention was drawn to team working and peer-support, many health visitors noted that they viewed themselves as autonomous practitioners with a number of responsibilities, including organising and managing caseloads.

Staffing level and resources

Staffing was seen as one of the key challenges affecting the pathway from being fully delivered in relation to workload implications. In fact, in the survey, workload was a concern for three in five (60%) participants, with 18% describing it as ‘far too high’ and 42% ‘a bit too high’. Thirty-eight per cent felt it was about right, 1% that it was too low and a further 1% did not know/preferred not to say. Full-time professionals were more likely than those who worked part-time to feel their workload was ‘far too high’ (22% versus 13%).

During a focus group, one health visitor explained that although staffing levels had improved, it still posed the greatest challenge to the pathway, and all participants in the focus group appeared to agree with this.

On the whole, it's being delivered, but there are times that it's difficult to do that. And I wouldn’t say that it's a hundred per cent being delivered, but there are various factors that contribute to that, which will depend on staffing, primarily. It has improved significantly, the past year, but it is still a challenge in certain places, for various reasons (Health visitor, Focus Group).

Health visitors felt equipped to deliver the pathway in terms of identifying concerns in children and families because of their training, experience and available support. However, they felt that in terms of delivering adequate support to families, their capacity to do this in some cases was limited due to caseload sizes, resource constraints and external barriers such as waiting lists or limited availability of wider services.

Health visitors in one Health Board felt that staffing increases were insufficient as they were counteracted by other changes in the workforce such as retirements and maternity leave. In addition to this, there was agreement amongst health visitors that any fluctuations to staffing levels caused by temporary changes such as holiday leave, maternity leave and sick leave placed a considerable burden on teams because they had to accommodate additional caseloads.

Reassuringly, in areas where health visitors felt they have adequate staffing, it was reported that delivering the full pathway and additional visits was manageable.

If you had asked me that question [whether I feel equipped to deliver the pathway] months ago when our caseloads were a lot higher, I would have said yes but it put us under a lot of pressure. However, now that we have got a new staff member, I certainly feel equipped, yes (Health visitor).

Health visitors in one Health Board, reported that uplift and staffing changes lacked consistency across the Health Board region. Some health visitors commented that staffing uplifts were prioritised to areas with higher additional need rather than areas with very high caseloads and a smaller proportion of additional need in comparison.

Often health visitors reported that the administrative part of the pathway considerably increased their workload. It was clear that the need to provide targeted support to families identified as requiring additional support adds significant workload pressure to the delivery of the pathway.

So I’ve found that my caseload is quite a vulnerable caseload and I need to go out and see the families more frequently than the pathway says and I’m having a lot of Team Around The Child meetings called either by myself or by nursery or by social work which takes up a lot of my time as well. And then if I’m doing a Team Around The Child if I’ve called it I have to sort out the child’s plan, so that can take up quite a lot of my time as well (Health visitor).

When asked whether they have the necessary resources to carry out their role and work in the survey, health visitors were, less likely to feel that they had sufficient resources available to them.

Three in five (60%) agreed (15% ‘strongly’ and 44% ‘tended to agree’) that they had the necessary resources to help them meet the needs of the families (e.g. leaflets, materials) while slightly fewer (55%) said they had access to the IT systems required to carry out their health visiting role effectively (18% ‘strongly agreed’ and 37% ‘tended to agree’). Health visitors working in the North Region were more likely than those in the West to agree that they had the necessary resources (71% compared with 55%).

Responsibilities outside UHVP

In the survey, health visitors were also asked whether they were carrying out any tasks that were not a part of the UHVP. This was intended, primarily, to identify whether they were still delivering services that were not part of the pathway, such as drop-in clinics (14% were delivering these) and immunisations (4%). Participants were also able to write in other responses. The most common were: additional family visits (9%), breastfeeding support/groups (8%) and child protection (6%). Half (53%) said they were not delivering anything that was not part of the UHVP.

Reasons given for undertaking tasks that were not core UHVP included:

• The added value to families of delivering these elements (46% of those delivering tasks that are not core UHVP)
• Lack of capacity among (non-health visiting staff) to deliver them (43%)
• Involvement needed from a safeguarding point of view (40%)
• Parents prefer to receive them from their health visitor (28%)
• Lack of skills among other (non-health visiting staff) to deliver them (20%),
• Health Board asked them to continue delivering them (13%) and
• Health Board has not yet fully implemented UHVP (8%).

In order to understand more about why health visitors were engaging in activities outside the core UHVP, further qualitative research was undertaken. For instance, as a part of the implementation of the pathway, health visitors were no longer required to immunise children as part of their transformed role. Most of the Health Boards mentioned that they have immunisation teams to undertake this role, however, in some areas of one Health Board, health visitors were still involved in immunisation.

Currently we are involved heavily in immunisations. We are responsible for the pre-school booster clinic alongside an immunisation nurse. We are also on the days that we don’t have an immunisation nurse here we would cover for holidays and sickness and things like that, so we’d be caught up in doing immunisations during that period of time as well. When I started last September we were three full time members of staff here. We’re now down to myself and my colleague who work four days a week and my other colleague is still full time, and we have enormous caseloads, so we’re just not physically able (Health visitor).

Health visitors in one Health Board also reported undertaking the 27-30 months and 4-5 year reviews as clinic visits rather than home visits. It became apparent that staffing challenges were highlighted as one of the reasons for undertaking contacts in clinics, especially for core families.

One health visitor explained in the focus group:

For us, when we had a full complement of staff, we were managing the contacts as they should have been done, at home. However, staffing has been an issue for our area, for the last two years, and we've had to change our way of thinking. So although we do the three month, and the four month, at home, we’re having to take children in at 27 months. Unless we are aware that they have got, if they're vulnerable, if they're complex, or if they're going through child protection, whatever. But the ones that we’re aware are core, we’re having to take them into clinic. So it's not ideal. But to manage the contacts, and the assessments, we’re having to do that (Health visitor).

In addition to this, it was mentioned that health and safety issues of carrying weighing scales also necessitated management decision to allow health visitors to carry out the 27-30 months and 4 to 5 years reviews in clinic in this particular Health Board.

Job satisfaction

The survey explored health visitors’ satisfaction with their job. Seventy per cent of participants reported being satisfied with their current health visiting role (17% very satisfied and 53% fairly satisfied), a further 12% said they were neither satisfied nor dissatisfied while 13% were ‘fairly’ and 3% ‘very’ dissatisfied.

The length of time in practice was clearly linked to job satisfaction with those who had been practicing for under a year (86% very/fairly satisfied) and 1-2 years (82%) being most satisfied with their role and those who had been practicing for 10 years or more being the least satisfied (60%). Those that had been practicing for 10 years or more were also more likely than average to say they were very or fairly dissatisfied (22% versus 16% overall).

The vast majority of health visitors felt skilled and confident in their role. Ninety percent agreed (38% ‘strongly’ and 52% ‘tended to’) that they felt confident delivering all parts of their health visiting role. Confidence increased with experience, from 71% among those who had been practicing for under a year to 95% among those with more than 10 years’ experience.

Ninety-one percent of health visitors agreed (40% strongly and 52% tended to agree) that they had the skills they needed to perform their job effectively. Once more, this increased with both overall experience and time delivering the UHVP. Ninety-six percent of those with more than 10 years’ experience agreed, compared with 78% of those practicing for under a year and all (100%) health visitors who had been delivering the UHVP for more than 4 years agreed, compared with 91% overall.

In terms of the recognition and support health visitors receive, half (52%) agreed that they felt valued for the work they do (15% ‘strongly agreed’ and 38% ‘tended to agree’). Some however, did disagree with this – 16% tended to disagree and 8% strongly disagreed. Those who had been in health visiting for 10 years and over were more likely to disagree that they felt valued (30% versus 14% of those who had been in health visiting for 2 years or less). However, there was no significant difference by length of time delivering the new pathway, or between full and part time health visitors.

A number of subgroups were more likely than average to feel valued: those in the North Region (61%), and those who had been practicing as a health visitor for under a year (65%) or between 1 and 2 years (64%).