It is important to note that pseudonyms have been used throughout the case study in order to protect confidentiality, in adherence with the NMC (2008) Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives.
Health visiting practice involves the planning of activities aimed at improving the physical, mental, emotional and social health and wellbeing of the population, preventing disease and reducing inequalities in health (DoH, 2006). Children who come from families with multiple risk factors and are even more likely to be disadvantaged in terms of poor health and social outcomes such as developmental delay, behaviour problems, safeguarding concerns, mental illness, substance misuse, teenage parenting, low educational attainment and offending behaviour (WAG, 2012). The role of the Health Visitor is to identify children and families that are at high risk and or have low protective factors and to ensure that they have a personalised service to meet their needs. The services required may range from one off interventions to long term intensive support. The Health Visitor will ensure that adequate supportive resources are allocated to the family and will engage and work with key partners/agencies to meet the wider health needs of the children and families (WAG, 2012).
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This case study will explore the needs of a family within the student health visitors practice case load. Lisa, a 24 year old mother of three, was living in a third floor flat without a working lift. Her partner Chris was working fulltime so she was left to alone look after a baby and three year old twins. This meant Lisa was effectively trapped in the flat as she felt unable to safely move all the children downstairs to get out. This came to the attention of the health visitor who was concerned that Lisa was 7 weeks postnatal and had not been attending well baby clinic with the baby as planned. Consequently a follow up home visit was arranged to compete the baby’s 8-week check and it was an opportunity for Lisa to complete the Edinburgh Postnatal Scale (EPDS) as per local trust policy. During the follow up visit Lisa disclosed to the student and Practice Teacher that she had been feeling low and was finding it difficult to get motivated. Lisa was aware that not leaving the flat during the week when Chris was at work was having a negative effect on her own wellbeing and her children’s development. She stated that her relationship with Chris had become increasingly strained; he was working long hours at a local factory in order to provide for his family, which resulted in the couple spending very little time together. Lisa also disclosed that they had not planned to have any more children after having the twins due to financial difficulties, but Lisa had become pregnant while taking the contraceptive pill. Lisa mentioned that on occasions, when Chris comes home in the evening, the twins would still be in their pyjamas and he was becoming increasingly frustrated with the situation; however, he was aware that Lisa was enduring a significant lack of sleep during the night due to the baby waking for feeds and understood she was exhausted in the day needing to meet the needs of two active three year old girls. Lisa stated she felt isolated and trapped by the situation but felt helpless and unable to improve how she was feeling due to the factors which were out of her control. The lack of social housing and the high cost of private rental properties meant that the family were unable to move. Lisa and Chris both had difficult relationships with their families and had limited social support. Lisa’s EPDS result was 18 which was of concern, however, research suggests that this screening process may not be leading to effective identification of PND, with studies finding that more than half the cases of PND are unrecognised by health visitors and GPs (Kulsar, 2011; Seeley et al, 1996).
This family was chosen for discussion because a significant body of evidence has emerged including the recent reviews by Tickell (2011), Field (2010) and Marmot (2010) indicate that the initial first years of a child’s life have a major impact on their overall health potential, and future happiness and wellbeing. The Millennium Cohort findings also suggest that during the early years of a child’s life, maternal depression can have a significant effect on healthy attachment and bonding which can have profound effects later in life.
Experiencing mental health problems is extremely difficult at any time, however, there are considerably greater implications when experienced during pregnancy and the postnatal period, possibly leading to serious consequences for the mother, her infant and family members (NICE, 2007). PND is defined by Robertson (2010) as a non-psychotic depressive condition that can often affect women in the first six months following childbirth. Conversely, Gibson et al. (2009) define PND as a mental and emotional disorder, which can often occur in women up to one year after child birth. Robertson (2010) identifies that the symptoms of PND do not differ from symptoms of mild to moderate depression experienced at other times except for the likelihood that the baby will often be the focus of the women’s worries, thoughts and feelings, which develop into a deep longer term depression. The Confidential Enquiries into Maternal Death (2008) reported PND as the leading cause of maternal death in the UK. The enquiry reported 29 maternal deaths were as a result of suicide during pregnancy or within the first six months postnatal. WHO (2010) predicts that depression will be a leading primary cause of disability due to ill health by the year 2020. Mental health is a central public health issue that should be a priority and PND is a significant contributor to this public health issue, with a number of studies showing women are of increased risk of developing depression following childbirth than at any other time in their lives (Almond, 2009).
There is a plethora of literature relating the prevalence of PND. The Department of Health (2011) and Royal College of Psychiatrists (2011) report that 1 in 10 mothers in the United Kingdom experience PND, which is the statistic frequently quoted. However, Almond (2009) argues that the true incidence is much higher, estimating that as many as 1 in 5 women suffer PND. Most episodes of PND resolve spontaneously within three to six months but evidence indicates 1 in 4 affected mothers continue to suffer for more than a year after childbirth (BMJ, 2010).
Evidence from a recent study by Kulcsar (2011) reveals that 70,000 mothers in the UK suffer from PND each year and half of these mothers and their families suffer in silence each year. The sooner a mother with PND gets help, the less damaging it will be for her and her family, but early treatment depends on being able to recognise the condition.
In the majority of cases the health visitor will be the first and only contact with individual or family experiencing difficulties in their mental health (CPHVA, 2009; Millar and Walsh, 2000).
Therefore the health visitor’s role is pivotal in the detection of PNDthrough the screening procedures and during the subsequent referral process.
It is essential therefore that the health visitor has the skills necessary for the detection of mental health problems and is able to deliver interventions that promote a client’s mental health; early identification and support for families is a key intervention highlighted by WAG (2012). The health visitor’s role is to assess for depression using national recommendations (NICE, 2007).
Identifying needs and recognising the appropriate level of need can be achieved through several approaches. Maslow (1954) introduced the concept of a hierarchy of needs. This hierarchy is often presented as a pyramid. The bottom level of the pyramid forms the most basic needs, while the more complex needs are located at the top of the pyramid. Needs at the bottom of the pyramid are basic physical requirements including the need for food, water, sleep, and warmth. Once the lower-level of need have been met, people can move on to the next level of needs, which are for safety and security. As people progress up the pyramid, needs become increasingly psychological and social. Soon, the need for love, friendship, and intimacy become important. Further up the pyramid, the need for personal esteem and feelings of accomplishment take priority. Like Carl Rogers, Maslow emphasized the importance of self-actualization, which is a process of growing and developing as a person in order to achieve individual potential.
This assignment will now explore the framework utilised for the assessment of the family’s needs. In cases where there is a perceived need The Welsh Assembly Government (2006) advocates the use of a holistic needs assessment to be carried out by the health visitor. The framework adapted and implemented by the local trust (Local Trust, 2008) is based on the Common Assessment Framework (CAF) (Department of Health, 2000) which offers an effective tool for early identification of additional needs. The CAF provides the health visitor with a consistent approach to the systematic collection and recoding of information that focuses on the child’s needs and strengths, taking account the role of parents, carers and the impact of wider environmental factors on parental capabilities, in order to gain a holistic view of a family’s situation. However, this would not be possible without effectively engaging the family within the process, this requires being open and honest with parents and appreciating that they may be fearful that they are being viewed as failing (Aldgate and Bradley, 1999).
The structure of the assessment framework provides a basis for implementing support and appropriate intervention and a mechanism for the health visitor to make judgements on how best to support the family such as making appropriate referrals and sharing information within agencies in order to raise awareness within the multi-disciplinary team of the factors which are impacting on the family’s health and well-being.
The health visitor has a lead role in co-ordinating agencies in order to ensure that the family is not overwhelmed with contacts unnecessarily. The health visitor’s role also involves anticipating and reacting to needs as they present plus maintaining up-to-date, accurate documentation that includes a record of the involvement of other services.. In this way, provision of appropriate services are determined and made available as the need arises (DoH, 2004).
Appleton and Cowely (2008) states the assessment of a family’s health need is a vital element of health visiting practice and requires the health visitor to utilise many skill, knowledge and judgements to make a pivotal assessment in assessing need, safeguarding children and in determining levels of health intervention to be offered to children and their families.
For the purpose of the case study the domains of the framework will be discussed individually concentrating on the child’s developmental needs, parenting capacity and family and environmental factors.
The Assessment Framework (DoH, 2000) assisted the student health visitor to contemplate the wider determinates of health such as the social, economic and environmental conditions which have an impact on health (Dahlgren and Wightehead, 1991). In relation to this case study the rationale for a follow up home visit was that Lisa had not been attending well-baby clinic with Amy as planned. The student health visitor had not previously met Lisa thus the home visit provided a valuable opportunity for her to form a relationship with Lisa in the security of her own home and facilitated the initial assessment (Streeting, 2010).
Environmental and family factors
The home visit was a valuable opportunity for the student health visitor to begin to make an assessment of the home environment in order to ascertain if it is a safe, appropriate environment for a child to live in. Lisa and Chris’s flat appeared to be a relatively hygienic environment with necessities such as water/heating/sanitation facilities and cooking amenities; sleeping arrangements were suitable. The family were experiencing financial difficulties. Although Chris was employed the household income was low. Lisa was unemployed having previously worked in retail prior to having children, but due to lack of childcare the couple had made the decision that she would stay at home to look after the children. The effects of hardship can increase the likelihood of behavioural problems that can affect a child’s ability to learn, which in turn affects educational and economic outcomes and these adverse behaviours can have long-term detrimental effects on the dynamics of low-income families (Duncan, Claussens, and Engel, 2004).
Lisa and Chris live in an area with adequate amenities such as a local General Practitioners Surgery and pharmacy, with good transport system to the nearby towns. However, Lisa and the children had become isolated in their home due to Lisa’s current mental health issues and lack of support.
Housing was a factor that was adding to the difficulties Lisa was experiencing, specifically the issue relating to leaving the flat and having no operational lift. Shelter (2012) recommend that housing and children’s services work together to collect information that identifies the impact of bad housing on outcomes. Completing a CAF will assists the health visitor to identify causes for concern and liaise with local the housing department where appropriate. In full consultation with Lisa, a letter was provide to the local housing authority highlighting concerns the family had. Joint Working Shelter believes that a stable home and immediate environment are fundamental to the wellbeing of children. Research by Shelter (2006) shows that outcomes are seriously undermined if there is failure to recognise problems and put a child’s need for a stable and decent home at the heart of any practice. Lisa and Chris were awaiting a move to a house and at the point of writing this case study they were still situated in the flat, however, the lift had been repaired but continued to be out of use on several occasions.
As Lisa’s mental health was a cause for concern an assessment was undertaken by using the 10 question Edinburgh Postnatal Depression Scale (EPDS), (See Appendix 2). It is acknowledged as a valuable and effective way of identifying mothers experiencing depression (Cox et al, 1987). The EPDS is a tool that is simple but effective screening tool. Mothers who score above 13 are likely to be suffering from depressive symptoms. The EPDS score should not override clinical judgment. Lisa scored 18 out of 30 and it was agreed that she would make an appointment with her GP for further assessment, to confirm the diagnosis and discuss treatment options.
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Listening visits were then offered; this is a form of treatment provided by the health visiting service. A study by Turner et al (2010) indicated all 22 women who were interviewed after receiving this service reported the visits as beneficial, although many of them had also required additional intervention to manage their symptoms. For women with mild to moderate mental health problems, active listening provides opportunities for women to describe their experiences and tell their stories, and represent a useful way of establishing good rapport (Kulsar, 2011).
A fundamental strategy in the promotion of maternal mental health is the use of effective skills to form a therapeutic relationship. Health visiting is recognised as being a relationship-based activity (Cowley, 1995 and Kendall, 1993). It is essential therefore that the health visitor has the skills necessary for the detection of mental health problems and is able to deliver interventions that promote a client’s mental health through fostering good, open communication. Research by Saunders (2001) into assessing a family’s needs and vulnerability has demonstrated that a client-centred, open approach promotes a trusting relationship that is empowering.
The Assessment Framework DoH (2000) recognises that consideration should also be given to any social or environment disadvantages that can have an impact on the child’s development. Amy was now seven weeks old and from holistic observation and assessment of her growth measurements she was at the normal stage of health and development for her age. Lisa was due to attend her 8 week postnatal visit with her GP the following week. The World Health Organisation (2008) reports that “maternal mental health is inextricably linked with both physical and psychological development of children”. Tackling the maternal mental health needs is likely to benefit these important outcomes. Field (2010) supports this, stating that maternal physical and mental health is a key driver of life chances throughout childhood which can have a major impact on inequalities in health and wellbeing as an adult. When PND is untreated it is associated with many adverse effects on the infant and can impact on child development with potentially severe consequences in behavioural and physical development (Smith, 2011; Meredith and Noller, 2003).
Bowlby (1988) identified the importance of attachment between mother and infant, highlighting the infant’s need for a responsive parental figure that is both physically and emotionally available. More recent evidence indicates that a depressed mother may not be able to provide the attention and stimulus an infant requires in the early stages required for emotional and cognitive development. The consequences initially can be behavioural problems, issues with eating and sleeping, plus delay in speech development which can lead to problems socialising (Smith, 2011). Lack of maternal bonding and responsiveness in situations where mothers experience long-term depression can significantly affect a child’s self-esteem and increase their own chances of developing depression later in life, reducing their quality of health and wellbeing (Murray et al., 2011). The Acheson report (1998) reinforces this by saying the best way to reduce inequalities in a child’s mental and physical health is to focus on the interventions offered to parents. The evidence also indicates PND may lead to relationship breakdown which can have a destructive effect on the family and society as a whole (Field, 2010).
Providing for the child’s physical and emotional needs involves ensuring appropriate provision of food, drink, warmth, shelter, clean and appropriate clothing and adequate personal hygiene in a secure safe, stimulating environment; parents should also be able to communicate positively verbally and non-verbal (body language), which is fundamental to a child’s health and development (Cowie, 2012; DoH, 2000).
Cowie (2012) states that how and to what extent a parent interacts and the extent of infant attachment can be influenced by any difficulties the parent is experiencing. In this particular case the assessment of Lisa’s low mood could affect her ability to parent to full capacity in offering the components necessary for positive parent/infant bonding and attachment to occur, which is vital to the development of a child (Department of Health, 2004). Lisa’s emotional health was a cause for concern. The Department of Health (2000) reinforce this suggesting that a parent’s emotional health has an impact on parenting and the nature and quality of early attachments, which in turn can affect the characteristics of the child’s temperament, adaptation to change, response to stress and degree of appropriate self-control.
Therefore, by utilising the Assessment Framework, the needs and problems presented by the family were identified (DOH, 2000). Early recognition of parental issues is important to establish supportive, child-focused interventions; the needs of the child must always be paramount (Local trust, 2008).
The assessment the National Service Framework, WAG (2006) recognises that appropriate interventions and referrals should be made to other agencies if needs or problems are identified. The DOH (2010) puts forward the notion that working with such a complex situation requires an appropriate level of knowledge, understanding, skills and abilities. The CPHVA (2009) would agree as they suggest that assessing the risks for children relies on the skills, knowledge and abilities of the health visitor, therefore it is essential that all relevant information is shared between professionals.
Consequently, Lisa was informed that, due to me being a student, my practice teacher (her health visitor) would need to be informed of all information disclosed. It was explained to Lisa that this was to ensure that the family gained the correct level of support.
An important role of the health visitor is sign posting and involving other agencies, including those within the voluntary sector that can for some families provide the most valuable intervention. Supporting parents is central to the current government’s approach to improving children’s lives, which was highlighted in the strategy paper Every Child Matters (DoH, 2003).
It has been acknowledged for some time that family support services should be offered where needs have been assessed, and where there is a probability of increasing positive outcomes for children and families (McAuley et al, 2004). A timely referral was made, with Lisa’s full informed consent, to Home-Start which is a voluntary organisation situated locally but also operating on a national level and is one of the leading family support charities within the UK. The service is based on carefully selected and appropriately trained volunteers offering regular confidential and non-judgemental support and friendship. Practical help is given to young families under stress in their own homes thus preventing family crisis or breakdown. Home visiting volunteers are available to call weekly, and support can continue for as long as the family needs it or until the youngest child turns five.
The objectives of Home-Start are to safeguard, protect and preserve good health, both mental and physical, of children and parents. Not having a good support network and having a partner that works long hours increased Lisa’s feelings of isolation and loneliness which contributed to the development of PND. Following referral, Lisa and her matched volunteer got on well together and the volunteer helped her get motivated to leave her flat and get out for short walks initially. Lisa was able to use some of her volunteers home-visiting time getting little jobs done, such as hanging the washing out. Lisa’s Home-Start volunteer offered her vital links into the community, helping her access a mother and baby group, which provided a further opportunity for Lisa to build a support network that would help her to increase her confidence and parenting skills.
McAuley et al (2004) state that mothers receiving the support of a Home-Start volunteer when they were experiencing high levels of stress reported that they valued the service and considered that it had a positive effect on their lives and relationships with their children and partners. Conversely, research carried out by Health Visitors in Formby made suggestions that more intensive short-term support service (maybe twice week for parents who may have PND or multiple births) would enhance the outcomes. However, in Lisa’s situation, the weekly listening visits provided by the health visitor provided an increased level of intervention, which proved successful.
In accordance with the Nursing and Midwifery Council (2008), accurate documentation and record keeping is vital and therefore clear, concise and factual documentation was provided in the Child Health records, recording all home visits made to the family home and telephone conversations. Hoban (2005) clearly illustrates the importance of accurate and effective record-keeping as he suggests that it is fundamental to high quality care. Lynch (2009) comments that accurate record-keeping also enables effective communication with other professionals involved in patients care. Additionally, the CPHVA (2009) clearly illustrate that the health visitor has a responsibility to consult with colleagues, other agencies if they have concerns for safeguarding and protecting children’s welfare and to make a referral to Children’s Services when the threshold regarding the risk of harm is reached.
The effectiveness of utilising the Assessment framework and intervention strategies can be evaluated by reflecting on practice. For example the Gibbs (1988) model of reflection will be used, as this model is clear and precise allowing for description, analysis and evaluation of the experience helping the reflective practitioner to make sense of experiences and examine their practice and provide an action plan for future care (Paget, 2001). As within this case study partnership working was the key to draw upon the essential knowledge, skills and experience of healthcare professionals to improve the health inequalities that were affecting the family’s health.
In conclusion there is a powerful body of evidence to show that what a child experiences during the early years lays down a foundation for the whole of their life. A child’s physical, social, and cognitive development (The Marmot Review, 2010)
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