Casebook: The Life and Times of a Health Visitor

By A. M. Houston

Everyone experiences struggles and challenges at some point in life. In the UK, if you have children under five years of age, you have the opportunity of support from a highly trained health professional called a health visitor. This often-misunderstood postgraduate role involves helping families to improve their health while navigating the hurdles of life.

The emotional mountain of daily struggles can seem overwhelming for young families. The health visiting service offers a metaphorical hand to hold alongside practical help and advice enabling parents to climb life’s occasionally difficult and often emotional mountains.

To regard health as something that can be created, maintained, and improved is the mission of the health visiting service. Prevention of ill-health has always been seen as imperative. The health visitor encourages families towards this goal by offering support for their family health needs. Through case study this book offers insight into how the health visitor manages to create health and prevent ill-health with some surprising results.

Managing the steppingstones to good health and avoiding the pitfalls of poor mental health can often seem impossible for new or even experienced parents. Accepting the helping hand of the health visiting service has the power to deliver a positive and quite profound effect. This book lifts the veil on the largely hidden work of this unsung, health professional. In this book you will find that the role of the health visitor is so much more complex than their famed job of ‘just weighing babies.’

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Sep 15, 2023
• ISBN: 9781788231077

A. M. Houston

A. M. Houston trained as a nurse and midwife and then focused on public health by training as a health visitor. She worked in the National Health Service in the UK for many years. A.M. Houston became interested in health research and left frontline practice to concentrate on community and family health and completed her PhD at King’s College London.   Dr. A.M. Houston returned to frontline community service and developed a special interest in child development, early learning, developing practice and most of all helping families with their pre-school children.  Throughout her early years’ work, A. M. Houston passionately believed in the importance of reading to pre-school children as a valuable initial part of a child’s progress into education.

Book preview

Background

‘I’m gonna get your legs broke for Christmas,’ she said spitting out every word in my direction.

‘I know people who can do that,’ she said jabbing a bony finger in my face.

I had been visiting as planned; all about promoting health and supporting this petite single mum of 35 with her two preschool children and her new 19-year-old live-in boyfriend.

Alana had housing problems, she said when I visited and she was worried about the speech development of her youngest child. I could smell the lingering aroma of cannabis. I was originally pleased to visit to help and advise Alana as I was the family health visitor. However, when I knocked on the door, I hadn’t bargained on the domestic incident that erupted while I was there. As the mismatched couple battled it out physically in the small kitchen, I shepherded the children into a corner of the living room, singing the ‘Wheels on the Bus’ in a vain attempt to drown out the scary noises emanating from the kitchen. The battle raged on intensively for ten minutes. On we sang, ‘the dogs on the bus go Woof! Woof! Woof!’ Two little trusting grubby faces looked into mine as I smiled while worrying about my safety. I had entered by the back door, through the kitchen, so I knew I couldn’t leave by the front door as it had a wardrobe up against it. A common occurrence at that time in homes where drugs were used. If the police called round, they had a problem entering the front of the house.

While I was singing, cuddling and musing on my predicament, quiet had descended on the house. Alana re-appeared and like a whirlwind, raced past me and upstairs in a vicious quest to fling all of Donald’s, the resident, child-like, 19-year-old’s belongings out of the bedroom window.

When Paul McCartney wrote about letting things be, he certainly couldn’t have had health visitors in mind.

The health visitor professional Code of Conduct doesn’t allow the assumption that everything will be alright in the end without intervention. As an important advocate for the child, the health visitor is unable to ignore the needs of the child. In this case, these children had a right not to be frightened in their own home, not to hear the screams of their mother and not to become emotionally immune to the sound of adults fighting.

I was duty-bound to refer the family to Children’s Social Care for support and help. I told Alana of my plan to involve other services and that had ultimately led to the threat of a forthcoming and unpleasant Christmas present. I did eventually, beat a hasty retreat through the backdoor, past the shirts and underpants now blowing around the garden. I remember I was breathless and trembling by the time I reached the car.

‘Why? Oh! Why is Alana wasting her time with this goofy childish 19-year-old? He is just another child for her to look after,’ I had moaned to the social worker.

The social worker looked me straight in the face and said, ‘I have it on very good authority that he is hung like a donkey.’ I had no riposte for that explanation.

I had cried bitter tears about my proposed, broken leg Christmas present when I got back to the GP (General Practitioner) surgery where I was based. I was going to have broken legs AND I had alienated a client who would never work with me again AND what was going to become of the children? I railed on through tears. My GP colleague sat me down and said, ‘First of all, she doesn’t know where you live, second of all, she is full of hot air and third of all, she could not organise a piss-up in a brewery. Don’t waste your energy worrying about this.’

He was quite right of course. It was all hot air and over a period of 18 months, I did manage to work with the family in a supportive team with an assigned social worker. Do you want someone else to take on this case? That was the question posed to me by my safeguarding supervisor. The logical thing is, of course, to say, ‘yes, give this case to someone else.’ I suppose and maybe this is a weakness, I just don’t have it in me to say, I can’t do that. If you always see everything as a challenge that you definitely want to take on, then health visiting just might be the best place to be.

It took ages to win Alana over; some meetings just took grim persistence from all the professionals involved. I might say that not joining in with other people’s anger is a learned skill for the health visitor. Nevertheless, the family issues were eventually resolved with continuity, familiarity, persistence and from my point of view, a depth of care for the plight of these children. At the final Child Protection meeting, Alana was asked about her view of the help and support she had received at a difficult time in her life.

‘Well,’ said Alana, ‘I am thankful for the help I have received from housing and speech therapy and the substance misuse team. I am looking forward to moving nearer to my mum and the one thing that I do want to request is to keep on with my health visitor.’

It was with a wry smile that I looked down at my legs and announced that the new house was out of my geographical area and I was sure that she would enjoy meeting her new health visitor.

Promoting health and supporting families is very hard work. It is often stressful, commonly thankless and greatly misunderstood. In a long health visiting career, I smiled when people suggested how lovely it must be to have a job that involved just going round weighing babies. Purposefully, in this casebook, there are few highlights of the straightforward elements of the job. I loved the role of the health visitor when everything was just right. Building the relationship with the new mother, or the new parents who have just moved and you can say, ‘that went well.’ I could make the appropriate directions to local services. I thought of these visits as the ‘Hello’ ‘Goodbye’ visits and ‘I’m here if you need me.’ They were extremely important visits in their own right because I really did want that parent to call on me in the future. However, this book will be concerned mainly with the complexity of the role of the health visitor. The visits when you say ‘Hello’ on the doorstep and it is the very beginning of a long journey that you and the client embark on with the sole intention of creating health. In this book, I would really like to try to explain how that is done.

It is my hope that these pages can go some way towards demonstrating the real world of the health visitor. The challenges faced by the profession in a time of rapid policy change are many. Cutbacks and targeted interventions often miss the mark both for those who commission the service at the behest of the government and for the dedicated health visitors working in preventive services. The test continues for both policy makers and health visitors in managing to support families. The health visitor will always be an advocate for the voiceless; it remains to be seen who can be an advocate for the continuance of the health visiting service itself.

The Author

I come from a large family of Irish heritage and I wanted to be a nurse from a very early age. My greatest pleasure was my nurse outfit and my time spent in bandaging dolls and teddies and obliging siblings. I could never have known that the stereotypical toy nurse’s outfit that I played in, every day, would have nothing on the heavily starched and weighty nurses’ uniform that I would eventually wear in a large city hospital. So precise was the uniform code that we spent a whole afternoon learning how to wear it. Cufflinks here, stiff collar studs there, rolled-up sleeves just so. Bib front apron like this and not like that, fob watch just here and never there. Starched cap like this and not like that. Never answer the ward door in rolled-up sleeves, always in your white cuffs. I found that there were lots of rules and a lot to remember. This health business was going to be a bit more complicated than I first imagined.

In the probationary days of the brand-new student nurse, we liked to time ourselves to see how long it took to get ready in the morning. At first, it was 30 minutes just getting into the outfit. After six months, my fastest speed was 15 minutes. Not a hair out of place and every button fastened. Starched white cuffs in place, hair off the collar, no jewellery, collar sparkling white and fresh bib apron tightly secured with a stiff starched white belt fastened at the side. I was ready for my work with patients; I knew I had an awful lot to learn but I was very keen to begin.

I looked forward to starting on ‘the wards’ following the first six-week teaching block of lectures in Nursing School. Anatomy, physiology, bed-making, bed-bathing and stabbing oranges with needles. The practising was over, now it was real life! When I arrived on my first ward, I just loved everything about it. The smell of the freshly starched linen sheets. The omnipresent aroma of antiseptic; that hospital smell, just lingering in the air and mixing with the aromatic camphor oil¹. In those days, every ward loved and used camphor oil. There was the bathing of patients and caring for wounds. Learning about health treatments all the time and watching very poorly people get better with my help. It was deeply rewarding from day one and I found it amazing.

Fortunately, for me, I was a tiny bit wise to some of the tricks played on raw student nurses. One student nurse colleague was sent on an errand to another ward some distance away at the other end of the hospital to ask if she could have a long weight. ‘Of course,’ said the nurse who answered the distant ward door, wearing her cuffs of course. My colleague was starting to worry about how long she had been absent from her ward, as she stood in the corridor, facing the closed door and wondering if she should ring the bell again. After 15 minutes, the nurse came back and smiled and said you can go now you have had your ‘long wait.’ As the penny dropped, my sheepish colleague returned to report on her long weight/wait. She returned to her ward to face the merriment of the only slightly less junior nurse who had the temerity to send her on the wild goose chase.

Another colleague was sent to fetch a Montgomery’s Tubercle again from a distant ward. New terminology and learning about new equipment was complex if you were a brand-new student nurse. This poor colleague walked all the way repeating the words Montgomery’s Tubercle, lest she should forget her important errand for this mysterious piece of equipment. She too had rung the bell of another distant ward and passed on her serious request. The junior nurse who had answered the ward door was tetchy and informed her that she was unable to provide this item and that the student (hapless and now crestfallen having failed in her quest) might like to look up her anatomy and physiology book to discover that she already had quite a few Montgomery’s Tubercles² of her own and in any case, the supercilious door opener said, ‘You cannot borrow other peoples.’ Being brand new was turning out to be a treacherous occupation.

I liked all of it though as I went from placement to placement. Every ward had ways of doing things and learning the ways was first on the agenda in a new placement. If ward A, did it like this, then sure as ‘eggs is eggs’ ward B did the same treatment differently. At that time, training was very hierarchical and terribly junior staff never spoke to terribly senior staff. I remember in one ward, Sister, in Royal Blue and a very frilly starched cap, only ever came out of her office for the doctor’s round and to serve the patient meals. Even then she only ever served the meat, the staff nurse served the vegetables and junior staff ran up and down the long Nightingale ward³ giving out the meals to each patient. It was one of the amazing mysteries to me that even although the Ward Sister seemed to live in the office; she knew exactly what was going on in the ward.

My life as a nurse became filled with deep and sometimes difficult embedded memories. I remember one night on night duty, we had a very ill gentleman die in bed number one. Hardly had we come to terms with the death of this man in the first bed when the man in the next bed also passed away. They had both been very seriously ill. However, the man in bed number 3, wide-awake and aware of our proceedings, clutched my hand and pleaded with me to move his bed. ‘Death is moving down the ward, nurse,’ he said, his voice breaking with emotion. ‘I don’t want to be next.’ I think back to how young I was at 17 to be dealing with such serious emotion associated with that night of caring for the living and the dying. We moved the worried gentleman, in his bed, into the middle of the Nightingale ward and left an empty space where bed number three should have been. Death couldn’t visit bed number three; well not that night anyway! ‘Thank you, thank you, thank you, nurse,’ said the man. He awoke, in the early morning with the first shafts of daylight streaming in through the huge windows. We had worked quietly through the night of deaths, a little team of three, and all was normal again in the morning.

My favourite ward was gynaecology. That was what led me to train and qualify as a midwife, immediately after my general nurse training. I had the intention of returning to this particular women’s speciality that I had loved so much. One of the reasons I think that I had liked it was the ethos on that particular ward. The hierarchy was flattened, you could speak to anyone, including Sister. On this ward, the Royal Blue boss made everyone’s role feel important. It really felt like a team approach in this environment and the staff were always happy. I hadn’t met this idea in my training – that everybody was important. I liked that very much.

It was very striking in that lovely gynaecology ward that the nursing actions that occurred seemed to be based on research. Of course, at that time I had no idea that I would go on in the future to achieve a Master’s degree and then a PhD. At that time, I was a lowly student, unaware of a doctorate in my future, but very aware of how little I knew as I listened intently to my next level up advisor. My knowledgeable mentor was just three months ahead of me in training. She seemed to know a lot. Pretty much everything goes in the bath in this ward she had explained. ‘That’s the professor’s way,’ she told me. This might have been my first introduction to research as she informed me that the wound infection rate on the ward was low and monitored by the professor. The said professor was very famous, very venerable, extremely forward thinking and always willing to teach. I liked that too and I was deeply impressed with the whole approach to wound management, it worked.

I qualified in midwifery and then there was a long gap before deciding that I would like to qualify as a health visitor. I never did get back to that wonderful gynaecology ward even though I studied midwifery to increase my competence in that speciality. Instead, I continued in midwifery and looked after my family as the years rolled by.

Sometimes in life, you alight on something and it feels like you have ‘come home’ and that was how it was for me with health visiting. Here was a post-graduate speciality that resonated very strongly with the things that I believed in. I could see how well-trained staff could work together to deliver a world-class service. It was meaningful and wanted by their clients, well that was my thought at the time. To me, completing this health visitor, training programme showed me that I really preferred working in services that were all about prevention. I could leave the curing, the bandages, wound dressings and delivering of babies to others. Health visiting was another way to offer a caring service that could be about creating health and preventing ill health. It seemed to me this was working with people on a deeper level. Emotional health, past life experience, environment and support structures all had a part to play for this person in front of me. No longer a hospital patient but now a client, someone that I would work alongside in partnership. I would strive to create health by building on their strengths, by encouraging them forward as I walked alongside them on their journey. I learned about promoting health, methods of prevention of ill health, partnership working, equality and advocacy. I learned about the importance of home visiting, of building a relationship based on trust. I learned how to really listen, to value silence, to not impose, to not jump in but to just wait for that important thought. Learning how to assess need, to be able to intervene early and appropriately showed me that it was possible to create health in a proactive way. Armed with this whole new range of skills, out I went into the community with the aim of making a difference and serving a population. It is my hope that this book explains how that turned out.

I have family who when they raise a glass they never say, ‘Cheers’ instead they say ‘Salut.’ They are cheering ‘Health’ as they wish good health to all. I think that is what health visitors are doing all the time, without thinking about it. They are using a Salutogenic approach: Salutogenesis means, Health Creation. This idea reminds me of the feeling I had in that gynaecology ward as a student where everything was geared toward restoring health as quickly as possible. Could I do just that in a different way as a health visitor? I thought that I could.

Although the cases presented in this book range over quite a long time period, I have changed everyone’s names to avoid identification. The cases are based on my work in both city and town. Sometimes, I have changed gender and distinguishing features but otherwise, each case study is in essence, a true reflection of practice. My aim is to draw back the veil, just a little, to uncover the invisibility of this role called health visiting. How does it do the things that it does in order to help families? How did I learn to work in this close and sensitive way with families? Health visitor training shows you a different way of being with clients. It should never be about the health visitor’s life; the focus must be reserved always for the client. Sounds simple, but learning not to talk about yourself, is a strong discipline.

Some of the cases here were long and slowly eventful. They evolved and unfolded over time. Some cases were short and dramatic. In truth that is often the way in health visiting practice. I am inviting you along on this journey, through the health visiting service, with the client on their health creating experience. Along the way, I have included little snapshots of client contact that help me to uncover more of the role of the health visitor.

In the end, this is a book about people and how the health visitor helps to create health in their life. I worked and laughed with wonderful colleagues in teams where everyone helped. There were people needing help, with woes and worries that they didn’t know what to do with. Clients with troublesome cares that they knew they needed help with. Some people had troublesome cares where they were beaten down by life’s challenges. Supporting people through health visiting meant becoming involved in the great joy of a new addition to the family, living the raw pain of loss and bereavement. Supporting families through disillusionment, disappointment or trauma can also be the lot of the health visitor. Working in the community, as a health visitor, you live alongside all of this, you take it home and put it on your bedside table and collect it up next morning to take it back to work. I found the role to be all-consuming and I loved all of it.

I especially loved the colleagues who didn’t mind putting the kettle on at 5 pm to discuss a difficult health visiting case, one more time, in the search for solutions. I had the great privilege of meeting new people every day, many who loved me, some who hated me, several who challenged my perceptions about life. Then there was my family, the people who understood the meaning of my health visiting role but didn’t complain when I needed to do just one more thing before switching off for the day. I hope that I can