Establishing the validity and reliability of clinical practice guidelines used to identify families requiring increased health visitor support

Does nursing research impact on policy? A case study of health visiting research and UK health policy

The aim of this study was to critically examine the impact of nursing research on the development of health care policy using UK health visiting research as an example. We used established methods to evaluate research impact. This included a documentary review of over 30 policy documents, citation analyses on 19 papers and interviews with health visiting researchers. Although there were examples of policy documents being informed by health visiting research it was not always clear what role research had played in the development of recommendations. Information from researchers provided examples of local, national and international impact, although the extent to which papers may have impacted upon policy was less clear from the citation analyses. Many of the UK studies cited in policy documents were qualitative, observational or reflexive and a lack of evaluative research, in particular randomised controlled trials and other controlled evaluations, may limit the impact of health visiting research on health care policy in the UK. There is evidence that health visiting research has influenced health care policy but this has been limited and there is a need for more research to underpin and inform the role of the health visitor.

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study

BACKGROUND

Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK.

OBJECTIVES

The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry.

DESIGN

A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support.

SETTINGS

The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site.

METHODS AND PARTICIPANTS

Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place.

RESULTS/CONCLUSIONS

The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.

From health surveillance to health promotion: the changing focus in preventive children's services

The shift from surveillance to promotion requires paediatricians to play several roles in a larger multidisciplinary and multi‐agency team

Health Needs Instrument for hospitalized single-living Taiwanese elders with heart disease: triangulation research design

AIM

The aims of this study were (a) to explore the health needs of hospitalized Taiwanese older people with heart disease who live alone in the community; (b) to develop an instrument to assess their health needs and (c) to examine relationships among their health needs.

DESIGN

Three phases were involved in this between-method triangulation design.

METHODS

The first phase explored the contextual content of the health needs from the perspectives of a purposive sampling of 34 subjects by the use of an explorative qualitative method. The second phase developed the Health Needs Instrument (HNI) and established its reliability and validity. The last phase implemented the instrument in a cohort and examined their appraisals of each type of health need as well as the relationships among different types of health needs.

RESULTS

The HNI encompasses the following five types of health needs: help in managing tangible things, psychological support, medical support, obtaining health information and participation in decision-making. In the last phase, a purposive sample of 54 subjects (48 men and 6 women) with an average age of 75.3 years was obtained. Subjects' health needs were ranked as obtaining health information (100%), participation in decision-making (96%), managing tangible issues (87%), medical support (86%) and psychological support (67%). Detailed items for each type of health need were revealed. By examining the relationship between their health needs, the psychological needs in confronting the subjects' physical discomfort had a significant correlation with medical support (r = 0.469, P < 0.01), with tangible needs after surgery or an invasive examination (r = 0.460, P < 0.01), with informational needs (r = 0.393, P = 0.034) and with tangible needs of maintaining daily living activities during the hospitalization period (r = 0.290, P = 0.034). The need for tangible help in maintaining daily living activities during the hospitalization period was significantly correlated with the need for medical support (r = 0.341, P = 0.012), with help in managing admissions and discharge procedures (r = 0.374, P = 0.05) and with help after an invasive examination or in the postsurgery period (r = 0.334, P = 0.013).

CONCLUSION

Finally, a conceptual framework was developed to depict this phenomenon. With the help of this HNI, both Eastern and Western health care providers can be empowered to detect the complex health needs of this particular population earlier and more accurately in order to promote their well-being as well as their health-related quality of life.

RELEVANCE TO CLINICAL PRACTICE

Empowering nurse clinicians to assess health needs of hospitalized single-living Taiwanese elders with heart disease.

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

The aim of this paper is to examine health visitors' use of formal guidelines in identifying health needs and prioritizing 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.

A structured health needs assessment tool: acceptability and effectiveness for health visiting

BACKGROUND

There is, nominally at least, a universal health visiting service in Great Britain, although the frequency of contacts may be severely restricted. Debates about whether home visiting should be universal or selective, therefore, focus on whether health visitors should use professional judgement or structured assessment tools to target attention within their caseload. Research attention has focused mainly on unstructured needs assessments and professional judgment or the development of assessment tools, so that the views of practitioners using structured instruments and their clients are not known.

METHODS

A two-phase qualitative study examined the acceptability and effectiveness of a structured health needs assessment tool (HNAT) implemented in London. Views about the tool were elicited from 30 health visitors through telephone interview, and then 21 assessments were observed and tape-recorded; 19 clients were interviewed after the event. Data were evaluated for adequate coverage of views across the target population and analysed using the framework approach.

FINDINGS

A range of views were expressed, but the HNAT caused anxiety and distress to, particularly, the most vulnerable clients. The structured format of the tool appeared to encourage the health visitors to question instead of listen. It did not help to identify all the needs and intruded into normal practice in an insensitive and unhelpful way.

LIMITATIONS

This study investigated only one form of structured HNAT. These are commonly used to prioritize undifferentiated needs of clients who have been offered an unsolicited, health promoting service. Our findings therefore do not apply to validated instruments used for screening or specific diagnostic purposes where a client has requested help with a problem.

CONCLUSIONS

Given the problems in use and potential for harm, this form of structured assessment tool appears unsuitable for routine use to determine the intensity of health visiting contacts.

Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool

The demand for explicitness in the way health visitors target their services has given rise to a plethora of different health needs assessment tools (HNATs). This paper describes an in-depth conversational analysis of the use in practice of these structured health needs assessment tools (HNATs) in two different NHS Community Trusts in England. These HNATs aimed to enable clients to participate in the assessment of their own health needs, as well as fulfilling the political requirements of justifying the expenditure of health visitor time where needs are identified. However, conversational analysis of 10 interactions showed that use of the instruments was associated with a failure to either identify needs that are relevant to the client or to enable clients to participate in the process. Use of the structured instrument simultaneously emphasises the significance of a professional lead, instead of client participation, and minimises the importance of inter-personal relationships and communication. In one site, a directly controlling style was apparent in the practice of health visitors who were, themselves, explicitly controlled by their managers. In the other site, professional expertise was emphasised, and a covert assessment style acted to disempower clients. The controlling nature of the interactions, the number of missed cues and the possibility of distress caused by the insensitivity of questioning style are all potentially harmful side effects of using structured instruments to assess needs. The problems seem to stem from the use of a pre-determined list of questions that form the basis for assuming that any family's health promotion needs can be categorised and predicted in advance. In conclusion, therefore, it is recommended that health visitors should use the open, conversational style of needs assessment that has been shown to be effective and acceptable, rather than an approach based on a structured instrument.

Preventing filicide in families with autistic children

Autism is a complex neurodevelopmental disorder that affects social behaviors and parent-child interaction. It has been associated with an increased risk of social victimization, and a recent rise in number of acts of filicide of developmentally disabled children has included several cases of autism. In this article, possible risk factors for filicidal behavior in families with autistic children and prevention strategies are reviewed.

Health needs assessment in the health visiting service and the impact on the ethnic community

The purpose of this article is to share the experience of using a health needs assessment tool in health visiting practice in Great Britain, with clients who do not speak English. This is an important issue in developing equity of practice across the growing multi-cultural and diverse populations of the United Kingdom. The paper outlines the findings relevant to these issues drawn from a wider study that used qualitative methods to observe and interview both health visitors and clients regarding the use of the tool. It focuses on one vignette to demonstrate the practical and difficult issues when a formal system is used to assess needs in clients who do not speak English as a first language.

Nurse referrals of children to social services

This literature review examines current referral systems and processes used by community nurses when making referrals of children in need and children in need of protection to social services departments. The problems surrounding definitions of need, children in need and children in need of protection are considered. The ambiguity of the language used and the difficulties encountered by community nursing staff in trying to identify criteria and thresholds for referral are highlighted. The review focuses on research exploring the assessment and referral processes used by community nurse, in particular by health visitors, and draws attention to the lack of research concerning these areas. Government recognition of the problems encountered by agencies working in this field is acknowledged in recent Department of Health publications.

Stressed parents with infants: reassessing physical abuse risk factors

OBJECTIVE

This study aimed to examine the relationship between a range of potentially adverse psychosocial and demographic characteristics identified in the immediate postpartum period and child physical abuse potential at 7 months.

METHOD

Data collected as part of a randomized controlled trial of a nurse home visiting programme for vulnerable families with newborns was used. Women (181) were recruited in the immediate postpartum period. At 7 months, 151 participants were available for evaluation. Potential for child physical abuse was assessed using the Child Abuse Potential (CAP) Inventory.

RESULTS

Significant risk indicators identified by univariate analysis were financial stress, elevated Edinburgh Postnatal Depression Scale (EPDS) scores, education level less than 10 years, concern regarding the provision of housing, and domestic violence characterized by verbal and social abuse. There was no association between child abuse potential and sole parenthood, poverty, young maternal age, history of childhood abuse, or psychiatric history. Two variables were found to be of independent significance using a logistic regression model; elevated EPDS and perceived difficulty "making ends meet."

CONCLUSIONS

The findings indicate that perceived stress relating to finances, accommodation and relationships in the immediate postpartum period are associated with heightened child physical abuse potential at 7 months. Elevated EPDS in the early postpartum period is also a risk indicator. The outcome of this study suggests that perinatal assessment of child abuse risk is possible and simple and is related to perceived stressors at the time surrounding delivery. This is independent of a range of demographic variables traditionally thought to predict high risk.

Online practice guidelines: issues, obstacles, and future prospects

The "guidelines movement" was formed to reduce variability in practice, control costs, and improve patient care outcomes. Yet the overall impact on practice and outcomes has been disappointing. Evidence demonstrates that the most effective method of stimulating awareness of and compliance with best practices is computer-generated reminders provided at the point of care. This paper reviews five steps along the path from the development of a guideline to its integration into practice and the subsequent evaluation of its impact on practice and outcomes. Issues arising at each step and obstacles to moving from one step to the next are described. Last, developments that could help overcome the obstacles are highlighted. These include 1) more rapid knowledge acquisition using data mining, 2) better accommodation to imprecise knowledge in clinical algorithms using fuzzy logic, 3) development of a shareable model for guideline representation and execution, and 4) more widespread availability of clinically robust information systems that support decision-making at the point of care.