Introduction and background

The particular expertise of health visitors in supporting children and young families was recognised in a government report outlining the future of health visiting, Facing the Future (Department of Health (DH), 2007} and they were seen as central in delivering the Child Health Promotion Programme (DH, 2008), now called the Healthy Child Programme (HCP) (DH, 2009a). In it there is 'an agreed and defined lead role for the health visitor ... to ensure that the various practitioners contributing to the [HCP] communicate with one another and provide a holistic, co-ordinated service tailored to local needs' (DH, 2007: 67).

Pilot schemes have been put in place to test the role and explore the training and support needs of health visitors to lead the HCP. Subsequently, a report was published on the first phase of Action on Health Visiting Programme called Getting it right for children and families (DH, 2009). This defined five key areas of work for health visitors covering both leadership of multi-skilled teams to deliver the universal HCP and targeted support for vulnerable families.

The importance of health visiting in government policy has been further reinforced and a momentum developed by a recent commitment in the 2010 spending review to invest in 4,200 new health visitor positions by 2015. The Health Visitor Implementation Plan 2011-15 (DH, 2011) outlines the key role health visitors will play in providing support to children and families. The approach is progressive, ranging from signposting to community services and 'universal' delivery of the HCP, to 'universal plus' for more acute needs through to 'universal partnership plus' for complex and ongoing needs requiring multi-agency input. The role of health visitors, in conjunction with other professional groups, in relation to safeguarding and child protection is flagged and, in addition, there is greater emphasis placed on building community capacity and taking on community leadership roles.

Purpose and aims of the study

The study was carried out in partnership with a primary health community trust and supported with a Higher Education Funding Council in England grant allocated to the Open University Centre for Excellence in Teaching and Learning. The broad aim was to generate qualitative data related to the situated practice of health visitors and interpret this with reference to policy drivers and conceptual frameworks in order to provide insights to underpin recommendations to the trust. The data generated by the focus group interviews were interpreted through frameworks related to a 'communities of practice' approach (Wenger, 1998; Wenger et al, 2002) and by drawing on other relevant literature related to workplace learning (Eraut 2007 and Gherardi, 2006), inter-professional collaboration (Edwards et al, 2009} and leadership (Chreim et al, 2010; Harris and Spulane, 2008). The study aimed to explore the following areas:

* Participant perceptions of their role and skills with a particular emphasis on leadership dimensions and the extent of their influence

* How participants coped with new challenges, difficulties or problems

* How they shared expertise (to benefit from or act as a resource for others)

* How they worked with other agencies on shared agendas.

Method and data collection

Approval for the study was granted by the internal Research and Development Team via Learning and Development and Clinical Effectiveness committees. It was established through a local Research Ethics Committee that the study did not need to go through formal ethics review.

Four focus groups were organised (total sample=32) with health visitors drawn from two primary health community trusts (two focus groups per trust). There were challenges in getting this level of engagement due to workload pressure issues and the sample was self-selected rather than purposive. This provided limitations in terms of representativeness and generalisability and the study provided a snapshot in time rather than being longitudinal. However, it is recognised that the purpose of focus groups is varied (Barbour, 2010) and in this instance the aim was aligned to action research. It was hoped that by engaging health visitors in a process of discussion and reflection that this would in itself contribute to changes in perspectives and practice. Health visitors were reassured about confidentiality and agreed to verbatim quotes being used anonymously in the report to the trust and in any subsequent published work.

A broad framework of questions was used for the first focus group based on the defined areas outlined in the previous section and the discussion was recorded, transcribed and analysed through categorisation of key themes. As data were restricted to transcripts from four focus groups this categorisation was done manually rather than through a software package.

Authors undertook the task independently and discussed and refined categories until consensus was reached. The key themes were used to shape the framework of questions for subsequent focus groups and a similar process undertaken to identify dimensions of the themes, with ongoing dialogue between the three authors to challenge and refine those emergent dimensions and cross-check the validity of the initial categorisation.

The authors met at intervals as a research steering group to interrogate the data as described and also to make iterative links to theory. Two of the authors were involved in moderating the focus groups and were able to add additional insights into group dynamics, mood of the group and non-verbal behaviour.

Results and discussion

The main themes emerging from the data and their dimensions are found in Table 1.

Theme 1; Role, knowledge and skills

The data reflected a focus on early intervention and health promotion in relation to children from 0 to 4 years old and their families. Participants acknowledged the value of initial training in preparation for the role, but stressed the importance of gaining experience while having an effective management structure:

'Although university gave me the paper qualification it didn't necessarily give me what I needed to actually be a ground-based worker.' (Focus group 2)

They emphasised the contextual nature of their 'insider knowledge' comprised of useful information about family networks in a particular community:

'When you drive a taxi in London you have to learn what's called The Knowledge to know where the streets are, so I call it the Health Visitors' Knowledge ... you are aware of what issues might be impacting, so you can direct your questioning ... to be more focused.' (Focus group 1)

This reflects Eraut's observations that professional knowledge and understanding is often tacit and takes the form of shared meanings and understandings which have not been codified (Eraut 2007) and are actively created rather than acquired from established sources (Gherardi 2006). Participants did make reference to codified knowledge such as research-based evidence but less frequently, with no applied examples and keeping up to date with government policies and directives and current practice debates was generally seen as an individual responsibility. The distinction between codified and non-codified knowledge is similar to the distinction made by Appleton and Cowley (2008) between prepositional and non-propositional types of knowledge. In their study of health visitors' assessment of family health needs they undertook a detailed categorisation of different types of knowledge utilised and were able to identify more frequent applied examples of prepositional knowledge, possibly because they were involved in direct observation of practice (Appleton and Cowley 2008).

The need to know 'who's who and what's what' (focus group 2) highlighted the local nature of knowledge and the skills of health visitors in establishing relationships with different groups to access their knowledge and expertise. This type of 'know who' is discussed in Edwards et al 2009 as an important, but not sufficient, skills component important in the development of relational agency. This is a 'capacity for working with others to strengthen purposeful responses to complex problems' (Edwards et al, 2009: 133) and is particularly relevant to inter-professional work where challenging issues can be examined from a range of different perspectives to give enhanced insights and stimulate new forms of action. Health visitors were able to give some specific instances of inter-professional dialogue that had developed their understanding and practice and stressed that being challenged by colleagues and challenging them are important learning opportunities.

Participants valued their universal, proactive and preventative role and the privileged non-stigmatising access they had to families. They identified communication skills as essential in undertaking an holistic assessment of family needs and the critical importance of relationship building in being able to work effectively with families, 'when you know you've developed that relationship that's huge ... you think I've actually got there, I've cracked it' (focus group 3). Participants also gave examples of signposting, referral and co-ordination skills entailed in forming effective formal and informal networks and partnerships with colleagues and a range of agencies. Their role in referral and co-ordination is also flagged in the DH (2011) document, but this falls short of collaborative work and what Edwards refers to as the building of common knowledge, that is a key factor in the development of relational agency across boundaries of practice ( Edwards, 2005; 2011).

The unpredictability of practice was highlighted and this required skills in time management and complex decision making around priorities:

'You'll get a phone call and that's it ... you know they [planned visits] have to go by the wayside and you could have a domestic violence case where you're therefor a few hours, and it's juggling.' (Focus group 2)

Making decisions and professional judgements were flagged in relation to child protection issues in particular, and this was a recurrent area of concern for health visitors. Judgements were often couched in terms of knowing when to refer and supporting families at risk was identified as the main focus of their role.

Theme 2: The development of expertise

Participants identified various factors they saw as helping them to undertake their work effectively and develop expertise against other negative factors that mitigated against this (see Table 2). Participants in all four focus groups stressed the importance of informal peer support and guidance and valued opportunities for shared learning. They also said that supervision had a key role in their development and identified a range of functions of supervision including maintaining and demonstrating accountability, facilitating professional learning and development and providing personal support. There was a view that the potential richness and supportive dimension of supervision is compromised if it is reduced to 'ticking boxes', and there were negative comments about what participants saw as a 'managerial structure' of clinical supervision which over-stretched the supervisors in terms of the number of people they had to supervise and excluded practitioners employed at Band 6 level. In any change process, capacity for effective supervision that encourages reflection on an ongoing dynamic situation is essential and there are risks in adopting an approach that 'may discourage learning, reflection and knowledge sharing -for instance by putting value exclusively on individual tasks and performance' (Wenger, 2002: 156).

Peer relationships between health visitors, relationships between health visitors and supervisors and between health visitors and other colleagues within their immediate domain eg, community nursery nurses, might be said to constitute their 'community of practice' (Wenger, 1998). However, an exclusive focus on their community of practice as the site for knowledge sharing, learning and development would minimize the importance of learning across professional boundaries (Akkerman and Bakker, 2011). This is of particular relevance to health visitors as they are positioned at the boundaries between nursing, public health and high input safeguarding, between general practice and children's centres and between the NHS, Local Authorities and the voluntary sector.

Theme 3: Role tensions

The main tensions identified from the data have been categorised along four dimensions related to: autonomy and integration; universality and targeting; flexibility and standardisation and quantity and quality. In the transcribed data it could be seen that these tensions were played out against an organisational, regulatory and policy context and were potentially influenced by the extent to which health visitors were located within their own community of practice or engaged in multi-professional and inter-agency practices (see Figure 1).

Participants valued their standing as 'autonomous practitioners' and there was some evidence that any change brought with it fear of losing that autonomy and professional identity:

'It's almost they are afraid to let go of that model and then if they did come into the bigger team and share more ... oh dear, what may happen ... I think there is a lot ofthat.' (Focus group 1)

This relates to the work of Edwards et al (2009) where findings from their study highlighted practitioner concerns about loss or dilution of their professional identity and losing their specialist and core expertise in more integrated ways of working:

'The negotiation of changing identities is perhaps particularly challenging for practitioners who are relatively low status and who work in systems of high accountability' (Edwards et al, 2009: 26).

This can become a barrier to change with practitioners holding on to established ways of working that maintain existing identities.

Participants spoke of 'excellent relationships' with other Healthcare professionals and social workers and 'good Units' with Sure Start. Some participants found it helpful, particularly in terms of professional support and networking, to be attached to a GP practice. Problems in having a truly integrated workforce were identified, such as the bureaucracy related to shared decision-making:

'You share those concerns early on and unfortunately they wait till there's a crisis mode before they actually say there is a need. ' (Focus group 1)

There were criticisms of some of the tools of integrated working such as the Common Assessment Framework. Selbie (2009) also found that health visitors in her study were not convinced that the tools they had at their disposal supported them in their role of management of risk to children.

The increased focus on targeted child safeguarding, in the context of national pilots of the Nurse-Family Partnership Programme (DH, 2009c), has impacted on the amount of time spent on universal 'public health' and there was some unease about this.

There were concerns about being 'too much of a generalist' and indications that individuals rose to the challenge of child protection - 'I just think I get a buzz from it' - and could, therefore, play a significant role in more intensive work with vulnerable families.

However, there was also a view that over-specialisation in child protection could lead to 'burn out1 and being 'de-skilled' in certain areas (focus group 2). An associated dilemma was that targeting services can bring with it stigmatisation and act against building trust and relationships; a highly valued aspect of the health visitor role.

There was much debate in all the focus groups about whether the effectiveness of health visitor practice could be measured accurately and concerns about whether quantitative evidence really reflected the nature and the quality of the work undertaken:

'A eureka moment for a family that's been very difficult to engage is when they pick up the phone and ask you something - that is a massive shift for that family. A commissioner wouldn't be interested ~ I cannot see them being interested in that ... because it's of no consequence, it doesn't bring any money in.' (Focus group 3)

There was a firm view that the recording and standardising of the number of visits alone in response to regulation did not reflect the quality of the work or the flexibility and autonomy required to be an effective practitioner.

Theme 4: factors affecting leadership development

Leadership is a key dimension of the health visitor role, identified in policy documents and outlined in the NHS Leadership Framework; but this was the area that participants found most difficult to articulate directly. The dimensions identified that impacted on leadership development included role clarity, combining hands-on delivery of services with a leadership role, professional barriers to effective partnership work and organisational culture.

In terms of influence, health visitors talked about their influence on children and families (although they acknowledged this was difficult to quantify) but there were more limited examples of influencing other professional groups: 1GPs very much ask our opiniont and will use us as a resource' (Focus group 4). Although some shared activities and positive relationships with colleagues from other professions were highlighted: 1We have got a good relationship with the social services, they do address our concerns and they think very highly of us ...', these appeared to be mainly in the form of information giving or sharing and referral rather than more in depth collaborative work that would give more opportunities for influence and leadership.

The data reflected the view that their practice role lacked boundaries: 'Health visiting is so poorly defined in terms of the job description it's like if you've got a job and nobody else fits into the category give it to the health visitor' (Focus group 3) and this is potentially exacerbated by new policy drivers to take on enhanced community leadership and capacity building roles (DH, 2011). Participants emphasised the amount of stress created by expectations of other professional groups in relation to the 'monitoring' role of health visitors. This put them in a position of having accountability without decision-making power and influence:

'Monitoring is the grey area ... but the responsibility of carrying families like that without having any decision made but to sit on it for a time until something happened, that's a massive responsibility and is very, very stressful. (Focus group 4)

The critical importance of the health visitor role in relation to work with vulnerable families was highlighted more than 15 years ago (Appleton, 1996) and it still appears that health visitors are under pressure because of their lack of influence in decision-making processes. It was also difficult for them to wield influence when there was a lack of understanding about the health visitor role: "There was a room full of people, a crosssection of education [and] local authority and somebody said, "So what do health visitors do then?" and I said "Right, OK, would you like meto tell you?" And I got up with my flip board and they were just absolutely amazed.' (Focus group 2)

When it was mentioned explicitly, leadership and the development of leadership skills were partly related to individual traits: ? think some of it is personality1 (focus group 4), but working relationships, role models and organisational culture were also identified as factors that influenced the development of leadership.

In theoretical debates about leadership there is a general move away from a heroic construction towards a more distributed form of leadership (Harris and Spillane, 2008). Definitions vary but, in general, a more distributed form of leadership is seen as more conducive to organisational change, particularly in the context of emerging ways of working that are based on collaboration, networking and multi-agency working rather than single organisation work. This model is particularly applicable in a primary health care context (Chreim et al, 2010).

The transcripts give many examples of what might be referred to as 'leadership in action' but there are also instances where health visitors report a lack of understanding of their roles by colleagues in other agencies; a sense that different types of documentation, tools and working practices are being imposed rather than that they are involved in influencing and shaping them; and that they are generally in the dark about the direction of change and feel powerless and disengaged from decision making processes. There are tensions around paying lip service to the notion of distributed leadership without creating the organisational conditions in which health visitors are able to draw upon and develop their skills in building relationships of trust and influence to drive forward change.

The logical corollary of more distributed leadership is a flatter, less hierarchical structure with more opportunities for engagement and participation of key groups to influence and effect innovation and change.

Recommendations

Areas for consideration to initiate change in the direction of policy drivers are based on the perspectives of health visitors and aligned to the perspective of distributed leadership and change and Edwards' framework for interprofessional working discussed previously:

* Clear vision articulated and communicated within and across all organisations responsible for universal/targeted service provision for children and families

* Consultation and specification of newrole(s) within this broader vision. Clarification over combination of leadership role and universal delivery of services plus more intensive targeted input to vulnerable families

* Increased organisational capacity for delivering supportive and developmental reflective supervision (to cover both generic and child protection practices)

* Specific areas for multi-professional work and service improvement identified to enable health visitors to take on distributed leadership roles

* Training needs analysis with a focus on leadership development needs

* Time frame that enables systemic learning - ie, interaction between practitioners learning about new ways of working and shaping of broader strategies.

Conclusion

The study has highlighted a number of challenges in the current heath visitor role including workload pressures, role overload and lack of inter-professional influence. There was some evidence of disaffection and negativity within the focus groups but also a wealth of evidence related to skills and expertise in networking, co-ordination, use of initiative, professional judgement, priorities setting and relationship building with a range of stakeholders within and across different areas of practice.

The increased number of health visitors is a very positive move to address the challenges but establishing new ways of working to improve service provision is a significant undertaking and policy alone will not necessarily make it happen effectively. There are tensions in their current role which will remain or even intensify with the new emphasis on building community capacity in the 'big society" rhetoric of the coalition government. Moving forward into a key leadership role will entail 'letting go' and delegating some of the more routine work they do to 'lead health visiting and wider skills mix teams across early years settings, working with Sure Start Centres and others' (DH, 201 1: 12) and delivering, within these multi-skilled teams, valued ways of working with children and families that puts them in the centre of responsive and integrated service provision.

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Author affiliation:

Lindsay Brigham BA(Hoos) MA

Staff Tutor, Faculty of Health and Social Care, The Open University

Claire Maxwell BSc(Hons) RN DiP DN RHV

Learning and Development Coordinator, Newcastle Upon Tyne Hospitals

Ann Smith PhD MSc BA

Researcher

Correspondence to: Lindsay.Brigham@open.ac.uk