The Journal of the Community Practitioners’ and Health Visitors’ Association April 2015 Volume 88 / No. 4 Community PRACTITIONER

Voting for health Get your voice heard

Interview CPD Professional Rachael Maskell Dog bites in children Antenatal anxiety p20 p27 p42

www.communitypractitioner.com | www.unitetheunion.org/cphva

Community PRACTITIONER Contents Volume 88 Number 4

Unite/CPHVA Editorial Existing Unite/CPHVA members with queries relating to their membership 3 A vote for change should contact: 0845 850 4242 or see: Amy Brewerton www.unitetheunion.org/contact_ us.aspx for further details. News round-up To join Unite/CPHVA, please see: 4 A look over the biggest stories from www.unitetheunion.org www.communitypractitioner.com Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN Member focus Tel: 020 3371 2006 10 News and opinions from members and their colleagues Community Practitioner journal Association Unite/CPHVA members receive the journal p14 free each month and have free access to all 13 Latest updates from Unite/CPHVA content from 2004 onwards via the online archive.

Non-members of Unite/CPHVA and Special report 14 Healthy competition ELECTION institutions may subscribe to the journal Special Report: From healthcare to politics to receive it every month and access the Amy Brewerton online journal archive. Our six-page special report looks at how those 17 Political union Non-member subscription rates: working in health can use their voice, views and Individual (UK) £125 Amy Brewerton experience to influence and engage with the Individual (rest of world) £145 20 Interview: Rachael Maskell political process in the run-up to May’s election Institution (UK) £145 Institution (rest of world) £195 Amy Brewerton Subscription enquiries may be made to: Community Practitioner Antenna subscriptions, Ten Alps 22 Research evidence and resources p24 Community Practitioner Subscriptions The Barn 6 Abbey Mews Clinical features Robertsbridge TN32 5AD 24 Supporting families with a fussy eater www.cphvabookshop.com Dr Emma Haycraft, Dr Gemma Witcomb The journal is published on behalf of Unite/ and Dr Clare Farrow CPHVA by: Ten Alps Publishing 1 New Oxford Street London WC1A 1NU CPD Tel: 020 7878 2300 28 Reducing dog bites in children Dr Caroline Furnell and Dr Fiona Finlay For editorial contacts, please see the panel over the page. Professional and research Advertising queries: Claire Barber Tel: 020 7878 2319 32 The lived experience of homeless women: [email protected] insights gained as a specialist practitioner Production: Dr Maria Fordham Ten Alps Creative – Design and production 38 Students’ and tutors’ perceptions of the p47 Magazing Printing Company use of reflection in post-registration nurse © 2015 Community Practitioners’ and education Health Visitors’ Association Linda Stirling ISSN 1462-2815 42 Early intervention for increased The views expressed do not antenatal anxiety associated with foetal necessarily represent those of the editor nor of Unite/CPHVA. Paid advertisements in the journal development risk do not imply endorsement of the products or Rebecca Balakrishna and Melanie Teixeira services advertised. Last word 47 Educating practice teachers and specialist mentors for their new role Lisa Bayliss-Pratt

April 2015 Community Practitioner 1

Editorial

Community PRACTITIONER A vote for change Editorial Advisory Board Obi Amadi – Unite/CPHVA Lead Professional Officer Maggie Breen – Macmillan Clinical Nurse As CPHVA members, you really do have a Specialist – Children and Young People, The Royal Marsden Hospital NHS Foundation Trust Toity Deave – Associate Professor for voice – don’t be afraid to use it Family and Child Health, Centre for Child and Adolescent Health, University of the West of England, Bristol Barbara Evans – Community Nursery It’s already been a couple of Nurse, Leicestershire Partnership NHS Trust months since I started working on Community Practitioner. The journal’s Gavin Fergie – Unite/CPHVA Professional usual editor, Polly Moffat, began her maternity leave at the start of January Officer for Scotland and Northern Ireland and I have been filling in while she takes some time away from the office Brenda Poulton – Emerita Professor of to get to know her new arrival – a baby boy, if you were wondering! Public Health Nursing, University of Ulster Janet Taylor – Specialist Health Visitor You might notice a few changes to your journal this month as we try to Public Health, South Eastern Health and Social Care Trust, Belfast make you – the members of CPHVA – the central focus. You’ll see that our Surrinder Bains – Health Visitor and news pages now include comments from social media and our website, Visiting Lecturer, Bath Spa University which are fantastic ways to engage and interact in real time. You will also Louise Rowlinson – School Nurse, notice new member pages where we showcase some of the interesting, impressive and Cambridgeshire Community Services innovative work you have been involved in. NHS Trust Elaine Haycock-Stuart – Senior I’ve really enjoyed meeting and talking to members at the recent CPHVA Awards and Unite/ Lecturer, School of Health in Social Science, University of Edinburgh CPHVA Question Time events, and I hope to be able to speak to even more of you as the year Lucretia Baptiste – Senior School goes on. It’s also been great to play more of a role in the weekly #CPHVAtt Twitter Tuesday Nurse, Barts Health, Tower Hamlets chats, which help to feed fantastic new ideas into the journal.

Editorial Team Getting to know you better, both as professionals and individuals, will really be one of my Louise Naughton – Managing Editor main priorities as deputy editor. I really want you to get your voice heard, and help you [email protected] connect with colleagues, CPHVA and policymakers about the things that really affect you and Amy Brewerton – Acting Editor your service users, day in, day out. [email protected] Jane Appleton – Professional Editor [email protected] With the general election coming up next month, it’s even more important for healthcare Tel: 020 7878 2404 professionals to use their voice - and their vote - to help make a difference. Naveed Khokhar – Designer [email protected] The CPHVA colours are inspired by the suffragettes, who fought hard to give women the right to vote. Make sure you exercise this hard-won right by registering and using your vote on Unite/CPHVA Honorary Officers May 7. It’s vital that your first-hand, front-line experience is represented at the polls. Polly Toynbee – President Elizabeth Anionwu – Vice-President The election is a bit of a theme for this issue, and we take a look at Unite’s role in politics, and Chris Cloke – Vice-President why it’s so important for everyone to get involved. Unite Health Sector Officers Tel: 020 3371 2006 Unite head of health, Rachael Maskell, has been selected as the Labour candidate for York Obi Amadi – Lead Professional Officer Central and will be standing in the upcoming general election. She took some time out of her Rachael Maskell – Head of Health busy schedule to talk to Community Practitioner about her journey into politics. Kevin McAdam – Acting Head of Health Gavin Fergie – Professional Officer for As ever, we’d love to hear your thoughts and feedback via Facebook, Twitter, the website or Scotland and Northern Ireland face-to-face. If you’d like to be featured on our member pages, then get in touch and tell us a Rosalind Godson – Professional Officer little about what you’re up to, and don’t forget to join #CPHVAtt every Tuesday from 7pm. for School Health and Public Health Dave Munday – Professional Officer See you there! Jane Beach – Professional Officer Ethel Rodrigues – Professional Officer Shaun Noble – Communications Amy Brewerton Officer [email protected] Deputy Editor Barrie Brown – National Officer Community Practitioner James Lazou – Research Officer

April 2015 Community Practitioner 3 COMMUNITY PRACTITIONER NEWS ROUND-UP A look over the biggest stories from www.communitypractitioner.com

School nurse numbers must increase to meet SRE needs

cRoss-paRty WRITE ON government A selection of the report has latest blogs from recommended that www.commprac.com sex and relationship Aeducation (SRE) should be given Pioneering pilots statutory status in schools. Ros Godson talks The Commons Education about her hopes and Select Committee, who put fears as she prepares together the report, also to go through NMC recommend that schools should revalidation for the first address the shortage of school time nurses, as numbers of nurses have not risen along with the feel more comfortable receiving National Curriculum. We are the champions number of pupils. SRE from a health professional Pornography, ‘sexting’ and Dave Munday explains According to the report, the rather than a teacher, and that cyberbullying were all identifi ed how upskilled health number of pupils in state schools schools may choose professionals as ways in which the SRE needs visitors can help in England has risen from 6.93 other than teachers to deliver the of pupils have changed in recent spread the message to million in 2009 to 7.14 million in information, such as nurses or years, with younger teens and colleagues and peers 2014, and is expected increase to outside organisations. children having access to sexual 8.02 million by 2023. Conversely, The report also highlights the material and pressure from an New beginnings the number of school nurses has need for children to begin to earlier age. Amy Brewerton remained static at around 1,200. receive appropriate SRE before The committee also proposed introduces herself to ‘We recommend that the reaching puberty, and that the that SRE should be renamed Community Practitioner Government ensure that there correct names for genitalia should ‘relationship and sex education’ readers as the new are suffi cient school nurses be used as part of the education, to emphasise the central role of deputy editor of the training places, and that the ratio as an inability to correctly identify relationships. journal of school nurses to children is body parts may represent a maintained,’ the report states. weakness in safeguarding. It is The full sTory Findings from the report also recommended that this should www.commprac.com/news/school- Statutory supervision: nurse-numbers-must-increase-to- suggest that in many cases pupils be a requirement as part of the the end? meet-sre-needs Jane Beach reflects as the NMC Council reach a decision on the future of We asked you midwifery regulation Should school nurses deliver sex and relationship education? Yes 70% No 5% Get involved - read, share It should be a combined approach 25% and comment on the latest blogs on our website. To vote on issues affecting your profession, head over to www.commprac.com

4 Community Practitioner April 2015 News

Parents spend £35,000 Children to have more in first five years say in family courts Young people ReseaRch has shown that The survey also highlighted involved in family parents spend an average of significant regional variations, law cases are to £35,000 on their children by their with parents in London have a greater say fifth birthday. spending more than twice the in issues that affect A study of 2,000 parents, amount of those in Wales, with their future. conducted by insurance firm annual costs of £9,711 compared Justice Minister Aviva, revealed that childcare is to £4,220. Simon Hughes the biggest expense for most The average overall spend for has announced parents. parents in Scotland is just under that a new system Families are also spending an £6,000 per child, with parents will make it easier officer. average of £47.70 on nappies in Northern Ireland spending for children to voice their A gaming app to help every month for each child under slightly less at £5,450. views in cases such as living explain the court system to five, with children’s food and arrangements after family young people is also being formula costing an average of £41 separation or when children developed. a month per child. Is this an accurate are potentially being moved In 2014, there were 90,000 Nearly £700 is spent on clothes estimate of the true into care. children involved in cases in every year. This does not include cost of having a child? Children will be given the the family courts. uniforms and school equipment, Tweet us your thoughts chance to contribute via The new proposals will which add an extra £670 to the @CommPrac meetings, letters or pictures, apply to all young people annual household budget. or having their viewpoints aged 10 and above Other costs include leisure and communicated by a social family trips, which cost an average The full sTory worker or Children and The full sTory www.commprac.com/news/ of £650 a year per child, and toys, www.commprac.com/news/parents- Families Court Advisory and children-to-have-more-say-in- which come in at £640 a year. spend-35k-in-first-five-years Support Service (Cafcass) family-courts Commissioning transfer guidance launched he Department of Health (DH) has Commenting on the guidance and issued updated guidance on allocations for 2015/16, members the transfer of of the Unite/CPHVA Facebook page commissioningT for 0-5 services. The planning and paying for had plenty to say public health services for 0 to Sherri G 5 year olds, including health We have been assured we remain employed by the NHS! But visiting, transfers from the NHS who knows? to local authorities in October 2015. Yvonne D The new factsheet sets CNNs being halved and management under sever threat out the timelines and will leave a massive shortage of skill mix and wealth of responsibilities of the various knowledge and experience in the HV teams! service providers, including arrangements, health visitors local authorities, clinical will continue to be employed Debra B commissioning groups and by their current employers and From a safeguarding of children perspective are we not part health and wellbeing boards. not local authorities, and will still of a multi-agency team? It also defines which services lead delivery of the Healthy Child will be provided by which Programme. Julie E professionals, and sets out the In 5 years time there will be few, if any, HV services left in scope of the health visiting The full sTory www.commprac.com/news/ the NHS. service. commissioning-transfer-guidance- Under the new commissioning launched

April 2015 Community Practitioner 5 News

Tweets from the International Day of Zero Tolerance on FGM Health professionals urged @ObiCPHVA Wales need 2 step up mandatory reporting of FGM still lots 2 do in to discuss FGM awareness raising #endFGM the goveRnment has announced a seRies ‘What we want is for FGM to be mainstream – @Amy_Brewerton of measures to prevent and punish the practice of where everyone knows what to do, everyone knows Bringing together groups and female genital mutilation (FGM). the referral pathways. There’s still a lot to do but we’re joining things up at a local level is a focus for PH #endFGM At a summit to mark the International Day of Zero working really hard on it. In a year’s time I hope we’ll Tolerance on FGM, ministers and leaders gathered be further down the road to erasing FGM in the UK.’ @Eripio8 to set out how the new rules will help protect those If current trends continue,15million more girls will who are victims, or at risk, of this form of abuse. be cut by 2020. #protectthegirls Public Health Minister Jane Ellison announced #endFGM that a new system of recording FGM will come @mwbloem Every girl deserves into force, with clinicians being able to report on a to grow up free of violence & child’s record that they are at potential risk of being discrimination. #EndFGM subjected to the illegal and abusive procedure. @maternityww An extended programme of training will also be Women who have undergone offered to health professionals by Health Education FGM twice as likely to die in England aimed at improving communication and childbirth #EndFGM sensitivity to help recognise and identify this form @SarittaGonzalez of abuse. This will include e-learning, pathways and Supporting health workers in educational materials. effort to #endFGM is critical. Speaking to Community Practitioner about Let’s stand together to stop this how public health nurses can help to tackle FGM, human rights violation. Ellison said: ‘I would encourage all healthcare @dorsetpolice professionals to make sure they raise the issue, have Alerting the girl’s or woman’s the conversations. I think one of the problems in that family to the fact that she is disclosing information about past is that we just didn’t talk about FGM, but now The full sTory FGM may place her at risk of we are talking about it and I’m seeing some fantastic www.commprac.com/news/sure-start-centres-to-get- harm #endfgm leadership in local areas. labour-boost

Sure Start centres Community focus for public to get Labour boost the LabouR paRty has pRomised that suRe staRt health recommended centres will receive additional The guidance also describes funding and places if the party how people can be mobilised wins the next general election. to provide volunteer and peer Shadow Education Secretary roles to enhance individual Tristan Hunt pledged that the engagement with public health centres will not only operate with and wellbeing issues. double the amount of spaces - The transfer of public bringing them up to 118,000 - but health commissioning to they will provide childcare access local authorities provides the and the premises will be available ideal platform for individuals to charity organisations. to play a greater part in the The plans aim to re-establish community-centRed patients and communities, the health of themselves and their Sure Start centres as community working is the key to reducing publication sets out ways in which communities, according to the hubs and to engage with families health inequalities, according to a services can react and respond to report. from harder-to-reach areas. new report issued by Public Health local needs. The full sTory England (PHE). The document suggests that www.commprac.com/news/sure- Responding to the challenge ‘place-based approaches’ will THE FULL STORY start-centres-to-get-labour-boost set out by NHS England’s Five offer providers the opportunity to how important are sure start www.commprac.com/news/ centres? tweet us your thoughts Year Forward View to evolve the empower communities to thrive by community-focus-for-public- @commprac way health services engage with using an evidence-based approach. health-recommended

6 Community Practitioner April 2015

News

@Unite_CPHVA #CPHVAtt Quitting smoking Twitter Tuesday marks Teenage pregnancy at DH week of action linked to improved Every Tuesday, @Unite_ mental health CPHVA hosts a live Twitter all-time low chat from 7-8pm, giving peopLe who smoke aRe members and non-members more likely to suffer with an opportunity to discuss anxiety and depression, new a topical issue, using the hashtag #CPHVAtt. research suggests. A study looked at the In February, the Department of Health prevalence of these mental (DH) undertook a week of action for health visiting, with the aim of sharing health conditions among stories about how health visiting has smokers and compared them been transformed to increase access to to non-smokers and ex- services and improve the experience of parents and children. smokers. As part of the week, @Unite_CPHVA Levels of anxiety and hosted a chat in conjunction with depression reported by the DH on improving transition to parenthood and maternal mental long-term ex-smokers were health. indistinguishable from people The 89 participants of the chat who have never smoked and included health visitors, patients and members of the public. Below is a much lower than current selection of the best tweets from the FiguRes ReLeased by the seen in some local authority areas. smokers, suggesting that discussion. Office of National Statistics Between 2012 and 2013, the quitting smoking could help @TheSMILEGroup #hvs are critical (ONS) show that conceptions conception rate among under- people combat anxiety and when it comes to identifying, among under-18s in England are 18s dropped by 12.3% to 24.3 per depression and improve supporting &signposting #pnd so continuing to fall. 1,000, the lowest since records mental health. it’s essential they’re trained, vigilant Pregnancies occurring in this began. More than 18% of smokers & empathetic #cphvatt group have reduced by almost 50% reported suffering from anxiety The full sTory across the whole of England since or depression, compared to @Pandas_uk we feel the www.commprac.com/news/ most important time is during 1998, with a reduction of up to 60% teenage-pregnancy-at-alltime-low 10% of non-smokers and 11% pregnancy to help recognise all of ex-smokers. mental health illnesses #CPHVAtt Reassurance over pregnancy vaccines @PopTartsandPND #CPHVAtt my local HV team man the phone Public Health England (PHE) has issued clarification of the risks of 9-10 and 4-5 outside those hrs vaccines during pregnancy with the publication of new guidance. it’s answerphone. No good for Expectant mothers can be assured that while current advice working mums or for timely follow recommends that these vaccines should not be intentionally up administered during pregnancy, these measures are precautionary @steagu80 remember that dad and there are no known risks associated with inadvertently may need some help and support receiving the vaccines in the early stages of pregnancy or before. too. #CPHVAtt Despite the apparent safety of these vaccines, infection of these diseases themselves can have serious consequences for the @PNDandMe I’d like to see unborn child. Perinatal Mental Health training compulsory for *ALL* HVs. You are The full sTory a mums 1st contact after MW.it is The full sTory essential. #CPHVAtt www.commprac.com/news/reassurance-over-pregnancy- www.commprac.com/news/ vaccines quitting-smoking-linked-to-beating- @angelabinkee2 Support for depression PTSD following traumatic births really needed #CPHVAtt Building Great Britons report released @AndreaJohns20 transformed services include more training to the aLL paRty First 1001 Days manifesto which It makes nine recognise and support mums with paRLiamentaRy Group was launched by the APPG in recommendations for the PND & maternal mental health (APPG) for Conception to Age October 2013, and it presents the government, commissioners and pathways #CPHVAtt 2 has published the Building results of evidence presented by service providers. Great Britons report setting out a panel of experts into the factors @PNDNerves time is a factor how best to support early years that affect emotional and social The full sTory Many HVs don’t have the time anymore #CPHVAtt service delivery. development of children, from www.commprac.com/news/building- The report is in response to the conception to the age of two. great-britons-report-released

8 Community Practitioner April 2015

Member Focus

Caring for the community in Cameroon

Student health visitor Cerys Russel spent six weeks in Cameroon helping to transform local services. She shares the first stage of her journey with Community Practitioner

The firsT projecT i worked wiTh in Cameroon was with a vastly disadvantaged group: orphaned children, for whom access to education - a crucial social determinant to health - is difficult. The school serves orphans, child prostitutes and street children, attempting to change the course of their current trajectory. Although it is difficult to attain accurate quantitative data regarding the incidence of child trafficking, due to inaccurate birth records, the reality of its occurrence is abundantly clear. The school provided two vital services - safety and education. However, the provision of these services was limited to school hours during term time only, leaving homeless children vulnerable overnight. Through negotiation and donation of numerous blankets I established a child protection initiative, which manifested as artificially low; precipitating a downward a sample of saliva or blood. This method was a safe haven named ‘Gabriels Gateway’ where a spiral wherein undiagnosed HIV+ individuals chosen for many factors; primarily because classroom was utilised as a safe overnight area. have staggering misconceptions regarding results were available within a few minutes, Over the duration of my voluntary work this transmission and unknowingly spread the virus. rather than a few days. This enabled counselling, initiative broadened. Community support and I set about initiating a ‘Stop the Stigma’ HIV/AIDS which focused on de-stigmatisation, health engagement increased, enabling them to offer screening drop-in day, which would provide promotion and referrals to the treatment childcare to mothers/caregivers who prostituted culturally sensitive health promotion to those centre (if appropriate) on the same day. Further, themselves, providing safety to children while who sought it at a private (and free) drop-in everyone who attended was provided with a their caregiver worked. centre. leaflet detailing modes of transmission, which I was also able to spend considerable We conducted a door-to-door promotional had been translated to their native ‘Lamnso’, time working as a team member within the survey to advertise the drop in day and establish and condoms. To my astonishment, many of International University Bamenda Outreach an estimated attendance. The focus on what the women who attended, some of whom Service in Kumbo Town. This service was HIV/AIDS is, primary prevention, secondary were prostitutes, confessed to have been given partially government funded, but primarily screening and tertiary healthy behaviour/ condoms by volunteers in the past, yet reported supported by means of charitable funds. A lifestyle changes were explained. To my absolute having never been shown how to use them. large proportion of orphaned children had HIV surprise, the majority of households were Some had been attempting to use them as and had been orphaned by AIDS. However, I interested. I was even asked to promote the femidoms, clearly without success. I found found that the extreme stigma still associated initiative within the local church, mosque and this discussion very powerful, it reinforced the with AIDS within this community causes the school. A total of 187 people were screened paramount importance of sustainability in both epidemiological prevalence rates to remain using HIV point-of-care test kits which analysed voluntary work and health promotion.

Members start advice line cphVA member Vicki stennett has been involved in developing ‘we wanted more flexibility for working families who an out-of-hours health visitor advice line to extend the reach can’t attend normal clinics, reduction in Gp attendances and of the health visiting service in kirklees, west Yorkshire. she inappropriate A&e attendances, and for health visitors to explains a little bit about the initiative. engage with fathers. ‘we came up with a telephone advice line because there ‘Mobile working allows the health visitors manning the line was less disruption for staff, it covered the whole of the area, to work from home if they wish. figures show that without the is accessible for everyone and people wouldn’t have to bring line, people would have gone to the Gp, called nhs 111 or have their baby out to an evening clinic. plus we already had the waited to see a health visitor or midwife. Two would have even technology to do it, including instant access to online medical gone to A&e. feedback has been really positive and there’s records, which made it different to nhs 111. been nothing negative’.

10 Community Practitioner April 2015 Member Focus

CPHVA Question Time: Salford

The first of this year’s Question Time events addressed revalidation, local commissioning concerns, the use of social media and integrated working

What members thought

Rachel Scrafton, student health visitor ‘I’ve been qualified as a nurse for 5 years but I only found out about the new Code a week ago. Revalidation I didn’t know about beforehand but it seems doable, it’s not stressing me out! As a student health visitor you have to do all that anyway, so it’s just continuing it.’

Margaret Koller, health visitor ‘It’s been very useful coming here, especially as I’ve been cphVA QuesTion TiMe cAMe To sAlford on of commissioning to local authorities, with some chosen in one 23 February, giving attendees the opportunity to confused about whether this would change who of the pilots. It’s given me information that I can use if put their burning questions to a panel of experts. they were employed by and if this would affect people are asking why I am Josephine Johnson, Project Officer for Public their indemnity cover. Panelists were on hand to doing this or that. It’s definitely Health at NHS England; Eustace de Sousa, National reassure the audience that it wouldn’t affect the been very useful.’ Lead for Children, Young People and Families at employment of NHS staff, although Josephine Public Health England; Dave Munday, professional pointed out that local commissioning may affect Jackie Smith, officer and lead on health visiting at Unite/CPHVA; the structure of workforces. health visitor and Jane Beach, professional officer for regulation On the topic of social media, the majority ‘Doing more at Unite/CPHVA were all on hand to field questions of attendees admitted to not being active in a additional CPD in addition to from the audience on a range of burning topics. professional capacity, with some worried about mandatory The evening kicked off with a presentation on breaking policies and guidelines. All of the panelists training should be revalidation from Jane, looking at the ins and outs explained that they are heavy Twitter users, finding useful and interesting, better of the process that all registered nurses, including it a useful professional tool, provided guidance – than just doing fire safety or information governance. I’m SCPHNs, will be required to undertake every three such as that issued by the NMC, CPHVA or local feeling much happier about it.’ years from 2016. Linking this to the amended NMC trusts – was adhered to. Some audience members Code, which was released earlier this year and found that social media, such as closed Facebook comes into force this month, Jane explained how groups, can be a useful way of contacting hard-to- Helen Gundy, portfolios, CPD, appraisals and personal reflection reach groups. student health will need to be collected as early as possible to The role of multidisciplinary teams was discussed visitor ensure the revalidation process runs smoothly. by the panel, with members unpicking what they felt ‘I wasn’t aware of Attendees – a combination of CPHVA members did or did not fall within the health visitor or school the revalidation process at all. I’ve and non-members – were particularly concerned nurse remit, with a feeling that with additional time heard about it but about how they would be able to show evidence and support, SCPHNs would be able to take a more didn’t realise to what extent it of reflection and whether this would increase holistic approach to health and social needs. would have an impact on what workloads, and there were concerns that the NMC Just as the session adjourned for a warm supper of I do. It was interesting to hear about commissioning and how hadn’t been forthcoming with information about vegetable chilli, the feeling of evening was summed people view that is going to the revised Code or the revalidation requirements. up by Eustace, who concluded that ‘in the words of impact the service.’ Participants posed questions about the transfer Keith Lemon – I’d say that’s bang tidy.’

April 2015 Community Practitioner 11 Member Focus

Education hub launched Tweet and greet uniTe/cphVA hAs lAunched an online training resource Student and Twitter user @SophieSW14 explains why social media can be a useful professional tool designed to assist members achieve continuing professional development (CPD) credits. Twitter has a wealth of opportunity for health Modules span product visitors. People use Twitter for different reasons; updates, clinical condition some people use it for personal use, to follow learning and case study celebrities and catch up with friends. I used reflection, to name a few, with Twitter for these reasons until I saw how I could children and families firmly use it professionally and academically. at the heart of all discussions. Twitter can develop skills necessary for Across all educational material, being a health visitor, such as communication, professionals will be invited to negotiation and open-mindedness. It helps you register, reflect and complete to write concisely, formulate your arguments and online CPD tests – very similar to encourages you to look at the bigger picture. A Community Practitioner’s very health visitor has a number of important roles own CPD papers and modules. from leading and delivery child and family health, CPHVA’s educational hub is providing additional services through health brought to you in association centres or Sure Start centres, and perhaps the with hand picked reliable and most important; to enable vulnerable children credible experts. and their families to develop and be safeguarded, The hub’s partners are pleased with the help of other health and social care to provide CPD training support professionals. Having 140 characters to express through self-educational your thoughts and feelings teaches you to think material across their individual before you speak, which allows you to consider professional websites – enabling how you feel and how to convey that in the best CPHVA members the access to a possible way. wealth of resources to help you Twitter chats are another valuable resource. Perhaps you are struggling with work, or are improve your knowledge and These are live chats on a particular subject. The confused in relation to an aspect of your practice. ultimately provide better patient topic can be general or specific, for example There will be people on Twitter who have care. looking at a particular policy or guidance. They experienced the same as you. People support To access the hub, visit: can help you learn about a particular area and one another on Twitter as we are a community www.communitypractitioner.com allow you to communicate professionally with - you can discuss your problems (maintaining people who may or may not have the same confidentiality, of course). opinion as you. These ‘debates’ motivate you Social media has many benefits professionally. to think about your own opinion and certainly The health and social care sector is utilising social Have you got a challenge your thoughts and feelings. media a lot more because of it’s many benefits, story to share? Twitter also offers a chance to connect with so why not take the plunge. There are people If you or a colleague have people locally, nationally and even internationally, that can help you find your feet and it’s easy to done something recently expanding your network. You can learn about sign up - so go for it and you’ll never look back! that deserves a mention in practice in your local area and within other Community Practitioner, get in settings. It opens up opportunities for jobs, touch. Whether it’s an award projects and research. I’ve been offered a lot you’ve received, an innovative Having 140 characters to through Twitter. Perhaps there is a gap in your project you’re working on, an interesting experience knowledge, you want to identify good practice or express your thoughts and you’ve had or an insightful want to find a new job - all of these opportunities feelings teaches you to think event you’ve attended, we can arise through Twitter. want to know. Simply email Research is prevalent on Twitter, so you could before you speak, which [email protected] be a part of that research. Many people share allows you to consider how or tweet @CommPrac with a resources and research with their followers so sentence or two about your you feel and how to convey this permits you to be able to maintain research- experience and we will get back to you. focused, so your practice is up to date. that in the best possible way. Lastly, Twitter is a great support network.

12 Community Practitioner April 2015 Association

Unite’s head of Unite in Health health becomes Catch-up with… Regional Events Labour candidate unite in health are rAchAel MAskell, heAd of Kevin McAdam continuing their regional health at Unite, has become the training sessions following new Labour candidate for York the success of last year’s Central. events She was named following the The programme of training events final selection from an all-female for this year focuses on continuing professional development (CPD) and shortlist of election hopefuls. raising concerns. The events will talk you Rachael will be looking to through what CPD is, why is it important, retain Labour’s parliamentary seat how to demonstrate evidence and information on the e-portfolio. in May’s general election, against Attendees will also taken through York Central candidates standing a step-by-step process of how to for the Conservatives, Liberal raise professional concerns, including whistleblowing. Democrats, UKIP, Green Party and The events are free for members (£75 the Trade Unionist and Socialist for non-members) including lunch, and Coalition. will be held from 10am to 4pm in the following locations: Posting on Twitter after learning the news of her Somerset 8 April 2015 selection, she said: ‘Thank you to Bristol 9 April 2015 York Labour Party for putting your London (Moreland Street) 16 April 2015 trust in me to ensure we secure a Leeds 22 April 2015 Labour victory in May.’ keVin McAdAM is sTeppinG inTo rAchAel MAskell’s shoes Crawley 21 April 2015 The general election will take as head of health at Unite while she takes a step back to focus her Newcastle 23 April 2015 Slough 23 April 2015 place on 7 May. To read more pre-election activities. Community Practitioner caught up with him to find out more. Derby 8 May 2015 about Rachael’s hopes and plans Londonderry 11 May 2015 for the election and beyond, turn Belfast 12 May 2015 Tell us a little bit more about your background with unite to our interview on page 20. Salford 13 May 2015 For last 16 years I’ve been a full-time officer covering a range of Cardiff 2 June 2015 industries. The last 12 years I’ve worked mainly on the health side, London (Holborn) 4 June 2015 representing 4,000 members in Northern Ireland, including health Birmingham 9 June 2015 @Unite_CPHVA #CPHVAtt visitors, school nurses and district nurses. I’m also the chairperson of Follow and tweet your the Trade Union Forum in Northern Ireland, which is the group for To read more about the agenda and to register your interest for a particular professional officer health trade unions, and that brings me in direct contact with the event, visit: www.unitetheunion. team on Twitter! health minister and the Department of Health at a range of levels. org/how-we-help/list-of-sectors/ Obi Amadi healthsector/healthsectorrepstraining @ObiCPHVA how long are you serving in rachael’s absence? I’m really glad Rachael has had the opportunity to stand for a Labour Rachael Maskell eRedbook party seat in York Central, and I really wish her well. My role will be to @RachaelMaskell fill in for her as national officer for – at this stage – probably around receives CPHVA Kevin McAdam four months. What happens after that is for the organisation to decide, endorsement @KevinMcAdam but I’ll be giving my full support during that period. Gavin Fergie Unite CPHVA are delighted to support @GavinFergie what do you hope to achieve while acting as national officer? and endorse the digital development I think one of the main priorities for everyone in Unite is to look of the Personal Child Health Record Rosalind Godson towards the general election, to provide support wherever possible. in the form of the eRedbook. Our members support parents and families @RosGodson One of the things we’re looking at in health is what would happen on a daily basis in addressing the Dave Munday in the event of a Labour government and how we can best interface health needs of their children, and @DavidAMunday with that government to benefit the health service and it’s workers. the addition of an accessible digital record will only enhance this working Jane Beach what would you say is your proudest professional acheivement? relationship. @Beach_Jane I’m not sure that one is any more important than the other. Our goal Unite CPHVA look forward to year-on-year is to keep the health service public, and for every year we participating in this development and Ethel Rodrigues will ensure that progress reflects the do that to some extent, that’s an achievement. It’s a long-term goal, so @Ethel_Rodrigues needs of community practitioners, the longer we work at it we’ll achieve it in different ways. health visitors and families.

April 2015 Community Practitioner 13 Special report Healthy

competition With one in seven politicians reported to have never had a ‘proper’ job, Amy Brewerton examines the minority of MPs who have come from a healthcare background

It’s not A cAreer pAth for everyone, But A all MPs ought to have, and that healthcare professionals small number of MPs started off their professional lives clearly possess. as frontline health workers before moving into politics. Most MPs also run weekly ‘surgeries’ where members Although under-represented in Westminster – only 1.4 of the public from their constituency can come along to per cent of MPs who were successful in the last general air and share their complaints – a setup not exactly alien election had a healthcare background, compared to to most nurses, doctors and other healthcare staff. 25.1 per cent from business and 13.8 per cent from the As many MPs will attest to, it also helps to have a legal professions – there are several politicians who have thick skin and to not be offended or shaken by criticism made this transition. – another thing that the majority of nurses and health It’s easy to see why some practitioners have followed visitors will also have experience in. this path; after all, healthcare professionals are the best Politicians are frequently criticised for being out of placed of all when it comes to imparting knowledge touch with the needs of ordinary people, and the fact about the inner workings of the health and social care that one in seven MPs have reportedly never had a job sector, as well as their own experiences and ideas about outside of politics hardly helps their cause. what the NHS needs to do to improve. Yet there are a handful of MPs who have worked on They also have a number of transferable skills that the front line of health and have first-hand experience of could be as useful in political situations as they are in working in caring settings. healthcare scenarios. We examine some of the current members of The ability to talk and listen to people from all sections parliament who have made the move into politics from of society and work towards shared goals is a skill that the broader spectrum of health. healthcare to politics to healthcare

14 community practitioner April 2015 Lord Robert Winston Lord Ara Darzi David Anderson MP Doctor and fertility expert Lord Leading surgeon and Labour Former care worker, miner and Robert Winston is a Labour peer peer Lord Ara Darzi joined Labour MP Dave Anderson in the House of Lords. Prior the House of Lords in 2007, represents the Blaydon to joining the House of Lords following his appointment as constituency in Tyne and Wear. in 1995, Lord Winston gained Parliamentary Under-Secretary Prior to becoming a eminence in fertility medicine, of State. member of parliament in having led improvements His background is in 2005, Anderson held a number in IVF technology including minimally-invasive and of roles, including working pre-implantation genetic robotic surgery, and has as a carer for the elderly in screening. He has worked in a developed new techniques and Newcastle-upon-Tyne. number of NHS hospital settings technologies in these areas. He made the move into since qualifying in medicine in As a peer, he led a national politics after the local council 1964, and led the House of Lords review to plan the direction changed the provision for Select Committee on Science of the NHS over a ten-year the elderly care service, and Technology. He speaks period, recommending the and he became trade union frequently in the House of Lords development of academic officer within the council on education, science, medicine health science centres and that eventually led him to and the arts. polyclinics. parliament.

Liz McInnes MP Grahame Morris MP Jenny Chapman MP Labour MP Liz McInnes won her Labour MP for Easington Labour MP for Darlington Jenny seat in the 2014 by-election for Grahame Morris spent his early Chapman was elected to her the Heywood and Middleton career working in a research seat at the last general election constituency, following the death capacity for the NHS. in 2010. of the incumbent MP. She has His role as a medical Prior to her move into worked for the NHS since 1981 laboratory scientific officer in politics she studied psychology and was employed as a senior Sunderland led him to become which led to her caring for biochemist at Pennine Acute an active member of his trade prisoners through her role as a Hospitals NHS Trust before prior union and serve on a national prison psychologist to being elected. McInnes was advisory committee for the Using the experience she previously a branch secretary NHS. gained, Chapman is currently for the Pennine Acute Branch of Morris’ move into politics Shadow Prisons and Probation Unite. came in 2010. Minister.

April 2015 Community Practitioner 15

Special Political report Union As a CPHVA member, you play an prIncIples of heAlth vIsItIng The four principles of health visiting were first defined important part in informing national by the CPHVA in 1977, and to this day are used to strategies, policies and priorities guide training of health visitors and the development of the profession. They appear most recently in the 2015/16 National Heath Visiting Core Service cphvA hAs A long And IllustrIous hIstory Specification used by NHS England. of influencing and campaigning on a national level. From its beginnings in 1896, right through the current The principles are: general election, the organisation and its members Search for health needs have been instrumental in affecting policy, guidelines Stimulation of an awareness of health needs and initiatives that have had a positive effect on Influence on policies affecting health generations of families and health visitors. Facilitation of health enhancing activities In the earliest days of the profession, women politics involved in health visiting were closely aligned with The third point in particular might be one that not all the women’s rights movement, since charitable and health visitors feel falls under their remit, but it remains caring professions were among the very few areas central to the role of the health visitor if they are to be were women were given a level of social responsibility truly effective in their mission to deliver the other three in any way comparable to that of men. principles. While the struggle for equal rights and votes for women rumbled on, social reform facilitated the heAlth vIsItor ImplementAtIon plAn development of services that began to resemble the The development of the Department of Health (DH) health visiting service we have today. The CPHVA logo Health Visitor Implementation Plan was led largely colours are based on the original green and purple by Unite/CPHVA and their work on the Action on colours of the suffragette movement, signifying this Health Visiting programme. At the time of the last close tie and the battles fought and won by early general election in 2010, the priority for the incoming pioneers of the profession. government in terms of the health visiting service Times may have moved on, but the ethos of was to maximise the numbers of health visitors and campaigning, influencing and improving remains. For the optimise their effectiveness and reach. CPHVA of today, politics isn’t just about politicians. Any CPHVA were heavily involved with this process, issue, big or small, can be political - and members have representing health visitors and the profession to the ability to inform themselves, campaign for, or change policymakers through campaigning, meeting with civil things which they feel, on some level, can be improved. servants and discussion at the national conference. You might not feel particularly ‘political’, but just by Members were included in these discussions and reading through your copy of Community Practitioner informed of their progress through events run by the or attending conferences, and engaging with and organisation and articles in Community Practitioner. sharing any of the topics raised, you are becoming part The end result of this work and campaigning was the N i N te/cphva of the process. But your involvement, and that of the 2011-15 Health Visitor Implementation Plan, which led CPHVA, doesn’t end there. to a sizeable increase in the health visiting workforce Behind the scenes, CPHVA officers and executives represent the profession of their members in a number of ways that have affected your professional, and the cpHVa logo colours are probably even family, lives. They do this by representing based on the original green you and voicing the things you tell them to those with UN i the power and influence to action change. Some of the and purple colours of the most significant ways in which Unite/CPHVA have been suffragette movement influential are described ahead.

April 2015 community practitioner 17 Special report

and improved understanding of the importance of the unIte In heAlth profession. As the implementation plan approaches its On a broader level, Unite’s health branch has been end, and commissioning for services transfers to local instrumental in campaigning for fairer pay for NHS authorities a few months later, it is still as important as workers, through lobbying the government and ever that the achievements and progress made over balloting members for strike action when solutions the past four years continue to be felt, to ensure an can’t be reached. NHS workers have received ‘real enduring and efficient programme of specialist public terms’ pay cuts for the past eight years, and pay has health nursing. been cut by 12-25 per cent since 2010. Since the government ignored recommendations 1001 crItIcAl dAys from the independent pay review body that NHS politics The period between conception and age two was workers should receive a cost of living rise, Unite have flagged as a crucial stage for influencing the health been in discussions with politicians including the and social outcomes that affect individuals for the secretary of state of health, Jeremy Hunt, to secure a rest of their lives. A cross-party manifesto setting out fair living wage for members. suggested interventions was established, agreed on by Pay offers suggested by the government have been politicians from across the political spectrum. voted on and acted upon by Unite, which culminated CPHVA were heavily involved in campaigning for in October 2014 in the first strike of NHS workers for and enforcing the representation of best practice over 30 years. Negotiations over pay are ongoing, with in this manifesto, getting involved with the all party your views and ballots being used to inform priorities parliamentary group and meetings with key figures, and discussions. pushing for the best – rather than the cheapest – solutions, and ensuring that the importance of early usIng your voIce intervention and the crucial role of health visitors were With the election approaching, this really is your flagged throughout. chance to have your say on the future. Party politics is The follow-up to the original manifesto, Building ever further removed from the daily lives of ordinary Great Britons, sets out how these aims and objectives workers, and many voters feel understandably can be achieved, and along with a number of other disengaged from the process. It might be hard to feel stakeholder organisations, the CPHVA have been involved in this process, but it’s impossible not to be vital in ensuring that the experiences and interests of involved if you want things to change. members are heard. It’s unlikely that the thoughts, priorities and values of any individual will align completely with nmc code that of a political party; even MPs rarely agree with CPHVA have played an important role in The Nursing everything put forward by their own party. Unite N i N te/cphva and Midwifery Council (NMC)’s updated Code and the professional officer Dave Munday advises that development of the upcoming revalidation process. members shouldn’t feel too torn when choosing Consultation on the draft version of the document who to vote for. He suggests that the electorate resulted in significant changes to the final version, and should base their decision on a main issue that is Unite/CPHVA worked closely with the NMC to ensure important to them, and campaigning for change in that both the Code and the revalidation process were the issues that don’t reflect their own views.

UN i applicable to specialist community public health One of the reasons CPHVA exists to represent you nurses (SCPHNs). CPHVA professional officers are taking and to make sure you are heard. The more you can part in the NMC revalidation pilot which will help to feed into this process, the more you are likely to flag and iron out any difficulties in the process. get out.

18 community practitioner April 2015

Special report Rachael Maskell Labour candidate for York Central and head of health at Unite speaks to Amy Brewerton about her election plans

unIte’s heAd of heAlth rAchAel mAskell has had a busy few months, and things don’t look like they’re going to calm down for her any time soon. As well as leading 100,000 Unite in Health members through one of the most turbulent times for their sector, Maskell has also been working hard behind the scenes to secure her place as a parliamentary candidate for the Labour party. The day we spoke, she was still caught in the whirlwind of activity that had followed her selection as Labour’s candidate for York Central earlier the same week week. In the weeks and months to come, she will be tirelessly following the campaign trail to defend the constituency’s seat in May’s general election – and, if successful, for the duration of her tenure in parliament. Physiotherapist Maskell still practices one weekend a month in between her Unite and pre-election duties, and feels that this patient contact is vital to get a picture of the issues on the ground in the health service. Having represented so many Unite in Health members, including the CPHVA, she also values the insight she has gained into the opinions and thoughts of those working on the front line in all areas of health. She took some time out of her busy schedule to talk to Community Practitioner about her path into politics, how CPHVA members can mobilise themselves to We’ve seen this government condem NHS staff, we’ve change the NHS, and why it is so important to have a seen them reorganise the NHS when of course they health presence in parliament. said they wouldn’t, introducing cuts and privatisation. If this government were to get back in, the NHS would how did you first come to be involved with unite? be unrecognisable from where it is now – and we will I started, like so many people, as a member of a health lose our NHS, it’s a very simple fact. We will see such union. I was a physiotherapist working in the NHS and privatisation that we will not have a health service. became the rep at the hospital I was working at, and We’ve also seen a dumbing down of the terview became the convener for the hospital. I then went to preventative agenda. We know that investment in work for the union. I’ve held various roles - I headed prevention is an investment in people’s lives. I’ve up the equality portfolio to start with, then the not-for- been working with Andy Burnham for about the last profit sector for seven years. When this government three years in putting together Labour’s health policy. came in I led for the NHS. I was a regional official before I’ve been very much about setting out the future of leading for health, so I’ve always had a strong footprint what health and care should look at, and again really in health. focusing on ensuring that prevention is central to that.

iN What inspired you to make the move over into how do you think your experiences working in politics? healthcare have helped you? I believe that health workers are best placed to set I continue to practice. I work a weekend a month in the out the future of the health service and therefore it’s NHS, and I think it’s kept me very grounded with what’s important to have people with health experience happening in the NHS. Not just with patients - working actually working in parliament and changing policies. with my members across the health sector has really We have seen a real dismissal of the value of the NHS. kept me grounded with what’s happening in the NHS. It

20 community practitioner April 2015 helps workers to determine what’s happening and what to make sure they’re listening and engaging with people should happen in the health service, and I continue to – and I believe that Labour are best placed to do that, want those voices to be heard in parliament. hence our historic links with the trade union movement. do you think people are put off by the word ‘politics’? do you think the nature of political campaigning is I think politics itself has become quite a passive changing? exercise for so many people - so many people are I think there are so many ways of campaigning and I think disenfranchised - but I think we’ve really brought what campaigning does is to make politicians go further, forward the experience of members, and we really do faster. Of course we have the ability now to campaign engage them as a union. That’s what Unite’s political online, but there is nothing more effective than when a strategy is all about – it’s really ensuring that working health worker is standing before a member of parliament people are heard, are listened to, and influence policy. telling their story. We have an amazing story in the NHS, If we don’t listen to people who are working on the but we also have a story where things have got really front line then we are never going to get policy right. difficult in the past few years. We think about the cuts to NHS pay, we think about cuts to terms and conditions, we can there be more engagement among healthcare think about cuts to services - I think people need to hear professionals? the real story about what is happening in the NHS. There I think that this election is going to be so crucial, and is a real alternative out there, and Labour, I think, their would encourage all health workers to play a very active health policy is probably the most exciting policy that role. I think that health workers deliver the best message they’ve put forward, therefore it’s something to really get to the electorate about the state of the health service, out of the armchair for, to campaign for and to fight for. so I would be encouraging all Unite’s NHS workers to go out and campaign in their constituencies and to talk how important is it to have health workers in about what they experience and see all around them parliament? in the NHS. Obviously I believe that Labour has got a We don’t have many clinicians - there’s never been a strong plan moving forward and will support patients physiotherapist in parliament - but we do need people and clients in a far better way than anything we’ve got who have been there from all different parts of the at the moment – particularly the integration between service. I always think that the health service is like a physical health, mental health, and social care. Bringing human body and you need all the parts there for it to that holistic approach back into the heart of the NHS be able to work. On the parliamentary benches I think will be crucial. Making sure that the patient drives the we need to have people with a range of experiences finances and the structures around them, rather than in the NHS to work together to make sure we can the structures determining what happens to patients. build a health service that is fit for the future. We’ve got nobody with a clinical experience in that sense. So Who inspires you most in terms of politics, past or I think this is real opportunity to make sure we’ve got present? somebody there, but also representing people with I’m totally inspired by the 1945 government. At a time such a spread of professions of economic austerity, where we had so many people We’ve got over 100,000 Unite members working in coming back from serving our country and needing jobs, the NHS – I am already well versed in the arguments and our government renationalised so many services, built the know the challenges facing so many of our members. welfare state, including the NHS. As a result they created Thinking of our CPHVA members in particular we need the jobs, economic growth, and a welfare state to support to make sure we’ve got a safe skill mix, staffing levels us. I think if it can be done in 1945, it can be done now. so we’ve got safe caseloads, if we look at school nurses, We should take the spirit of 1945 into this election - 70 the average child just gets 12 minutes a year of school years on - to ignite hope again across our country. nursing, we need to make sure we’ve got enough top health professionals. I think that background I’ve got as What advice would you give to those who are front line clinician but also a representative of 100,000 disillusioned with politics, or who would just like health workers will be so useful for the Labour party but to become more involved? also for building the NHS of tomorrow. I would encourage all Unite members to look at what’s happened in Greece recently. The power is in their hands. If they want to make a difference and they’re i still believe that health workers are best placed to frustrated with the situation and how things are, it’s set out the future of the health service and therefore when workers join together and organise that they can bring about change and make a difference. I believe it’s important to have people with health experience that the future of politics is about people taking a actually working in parliament and changing policies collective stake in the political system. Politicians need

April 2015 community practitioner 21 Antenna

ReseaRch evidence Energy drinks increase Alcohol messages Naps affect sleep quality hyperactivity in children should focus on social in children over two A study has found a strong link between consequences A systematic review of original published sweetened beverage consumption (including Results from a study of university-aged research has found evidence that napping energy drinks) and hyperactivity or inattention students examining the effects of alcohol may be associated with later and shorter in school-aged children. warnings has found that those who are aware duration of sleep in children aged over two The study, undertaken by researchers from of the potential social consequences are likely years. Yale University, was conducted on a sample of to drink less. Researchers examined existing published 1,649 children with a mean age of 12.4 years. Undertaken on a sample of 211 students evidence regarding the effect of napping in Participants were asked to record the with a mean age of 18.9 years, researchers children aged 0-5 against measures of child drinks consumed in the preceding 24 hours, supplied participants with materials that development and health. and completed a five-item hyperactivity and described an episode of drinking, framed as The 26 papers identified in the study looked inattention subscale questionnaire to measure having been written by a recent graduate. at development outcomes such as night symptoms. The materials either described positive sleeping, cortisol, behaviour, obesity and Results showed sweetened beverage outcomes or negative consequences as a accidents. consumption was higher among boys result of their personal drinking experience. A consistent theme among the studies was compared to girls. Children in the study After reading the accounts, participants that napping was associated with later onset consumed up to seven sweetened drinks per were then asked to record their future day, with an average of two drinks per child. intentions with regards to their own alcohol of night-time sleep, which was also shorter in Researchers found the chance of a child consumption. duration and of poorer quality, particularly in being hyperactive or inattentive increased Students who had read about positive children more than two years old. by 14% with each additional sugary drink social consequences as a result of not drinking Authors however noted that there were consumed, once other variables were taken were more likely to record lower alcohol limitations of the studies, including the into account. intentions. fact that in most cases, behaviour and Those who had consumed energy drinks Those who had read about negative health development was reported by parents or were 66% more likely to report hyperactivity consequences were also more likely to state carers rather than health professionals. than those who had not. an intention to consume less alcohol. Although more research is required into the The authors recommend that children should The authors conclude that public health link between napping and behaviour, health not consume sweetened energy drinks and that messages highlighting the social and health and cognition, the study found evidence to more research is needed into the link between outcomes of drinking alcohol are likely to be indicate that napping negatively affects night- more effective in this population. such beverages and hyperactivity disorders. time sleep.

Schwartz DL, Gilstad-Hayden K, Carroll-Scott A, Kingsbury JH, Gibbons FX, Gerrard M. (2015).The Grilo SA, McCaslin C, Schwartz M, Ickovics JR. effects of social and health consequence framing Thorpe K, Staton S, Sawyer E, Pattinson C, Haden C, (2015). Energy Drinks and Youth Self-Reported on heavy drinking intentions among college Smith S. (2015) Napping, development and health Hyperactivity/Inattention Symptoms. Acad Pediatr. students. Br J Health Psychol. 2015 Feb;20(1):212- from 0 to 5 years: a systematic review. Arch Dis 6. doi: 10.1016/j.acap.2014.11.006 20. doi: 10.1111/bjhp.12100. Child doi:10.1136/archdischild-2014-307241

Child Feeding Guide NICE updates guidance on gestational diabetes app launched The National Institute for Health and Care Excellence (NICE) has updated guidance for the diagnosis and postnatal care of women with gestational diabetes. Nearly 90 per cent of A SMARTPHoNE APP FoR IPHoNE AND women who have diabetes during pregnancy have gestational diabetes, which may or Android devices has been launched to help may not resolve after pregnancy. parents manage mealtimes with a fussy child. The new recommendations suggest that pregnant women should be diagnosed with Developed by a group of psychologists from gestational diabetes if they have a fasting plasma glucose level of 5.6 mmol/litre or above, Loughborough University Centre for Research into or a two-hour plasma glucose level of 7.8 mmol/litre or above. Eating Disorders (LUCRED), who are also parents This new threshold is intended to standardise the current variation in glucose levels currently of pre-school children, the app offers strategies used to diagnose the condition, and is likely to lead to an increase of diagnosed cases. and tools that can be used to help tackle fussiness The guidance also states that women with gestational diabetes whose blood glucose in a positive way. The accompanying website, levels have returned to normal after birth should also be offered lifestyle advice that www..childfeedingguide.co.uk, aims to help to includes weight control, diet and exercise, and a fasting plasma glucose test 6–13 weeks assess and monitor feeding behaviour, learn about after the birth to exclude diabetes. common feeding problems, and access tips and The full guidance is available at: www.nice.org.uk/guidance/NG3 tools that can be used to implement changes.

22 community Practitioner April 2015

Clinical Feature

Supporting families with a fussy eater

dr eMMa haYcraFT Senior Lecturer in Psychology, Loughborough University, UK dr GeMMa WiTcoMB Research and Teaching Fellow, Loughborough University, UK dr claire FarroW Senior Lecturer in Psychology, Aston University, UK

We all knoW children Who are fussy eaters. Half of all parents report having a child who is fussy or eats a limited diet (Reau, Senturia, Lebailly & Christoffel, 1996). These fussy or difficult eating behaviours are often significant, persisting for months or years (Farrow & Blissett, 2012), and a poor diet in childhood frequently continues into adulthood and is linked to obesity and various A common child eating behaviour which songs about foods, or encouraging children to preventable diseases, such as cancer and lots of parents find worrying is food refusal. pick out and touch different foods when out diabetes (Nicklas & Hayes, 2008). How this Many children go through a phase known shopping or at a market. fussiness is managed early on affects whether as ‘food neophobia’, or fear of new foods, However, while the evidence suggests that children outgrow it or if it will continue as typically around 18-24 months, where they repeatedly offering new foods a number of they get older and this is why parents and become wary of new foods or of foods that times is necessary for a food to become liked, caregivers have such a vital role in helping they previously liked (Birch & Fisher, 1998). we know that parents tend not to offer young children to develop healthy eating habits. During this phase, children often appear children a disliked and refused food more While information about milk feeding fussy and many parents are unsure how to than around five times (e.g., Carruth, Ziegler, and weaning is abundant, practical advice respond to this. There is good evidence that Gordon & Barr, 2004) and part of this may be about child feeding once weaning has a food may need to be offered up to 15 times related to the difficulty in keeping track of occurred is lacking (Schwartz, Scholtens, before children trust it and are willing to taste exposures. Lalanne, Weenen & Nicklaus, 2011). Our own it (Wardle, Carnell & Cooke, 2005). Once the In the UK, daily consumption of research confirms that parents find available child deems a food to be ‘safe’, it can take a five portions of fruit and vegetables is resources about feeding young children and further 15 offerings, or ‘exposures’, before the recommended. However, only around one in promoting healthy eating to be “too basic” child develops a liking for it (Wardle et al., five children achieve this (Health and Social and that parents often resort to searching for 2003). This means that it is vital that parents Care Information Centre, 2014). The Child information independently (Mitchell, Farrow, continue to offer foods that their child dislikes, Feeding Guide has a whole section devoted Haycraft & Meyer, 2013). as only by increasing children’s familiarity to ways that parents can increase children’s The five most common pitfalls encountered with a food will it become likely to be eaten fruit and vegetable intake. For example, by parents are: (Aldridge, Dovey & Halford, 2009). using real fruits and vegetables in messy Food refusal These food exposures can be part of a play, ‘growing your own’, or getting children Children’s unhealthy food preferences meal or snack, or they can occur outside of involved in food preparation and cooking. By Pressuring children to eat meals when children may be more relaxed, for making a food more familiar, it is much more Using food as a reward example, playing with food (e.g., messy play likely to be subsequently eaten (Aldridge et Parental use of restriction with cooked pasta or dried beans), singing al., 2009).

24 Community Practitioner April 2015

Clinical Feature

We developed a free app for tablets REFERENCEs and smartphones called Child Feeding Aldridge, V.K., Dovey, T.M., & Halford, J.C.G. (2009). The role of familiarity in dietary development. Guide, which provides evidence-based Developmental Review 29(1): 32-44. information and practical support for anyone Birch, L.L., & Fisher, J.O. (1998). Development of eating behaviours among children and adolescents. who is concerned about children’s eating Pediatrics 101: 539-549. behaviours. Carruth, B.R., Ziegler P.J., Gordon A., & Barr S.I. (2004). Prevalence of picky eaters among infants and toddlers In addition to supporting parents and and their caregivers’ decisions about offering a new food. Journal of the American Dietetic Association 104: caregivers (henceforth referred to as 57-64. ‘parents’), it is also a useful resource for health Farrow, C. & Blissett, J. (2012). Stability and continuity of parentally reported child eating behaviours and feeding practices from 2 to 5 years of age. Appetite 58(1): 151-156. professionals to use and share with families Health and Social Care Information Centre (2014). Statistics on Obesity, Physical Activity and Diet: England that they work with who are encountering 2014. www.hscic.gov.uk/catalogue/PUB13648/Obes-phys-acti-diet-eng-2014-rep.pdf these common feeding difficulties. Mitchell, G., Farrow, C., Haycraft, E. & Meyer, C. (2013). Parental influences on children’s eating behaviour The app helps explain the science and characteristics of successful parent-focussed interventions. Appetite 60: 85-94. behind children’s eating behaviour, allows Nicklas, T.A. & Hayes, D. (2008). Position of the American Dietetic Association: Nutrition guidance for healthy parents to assess and monitor their own children ages 2 to 11 years. Journal of the American Dietetic Association 108(6): 1038-1044. and their child’s responses around food Reau, N.R., Senturia, Y.D., Lebailly, S.A., & Christoffel, K.K. (1996). Infant and toddler feeding patterns and and mealtimes, and provides strategies to problems: normative data and a new direction. Pediatric Research Group. Journal of Developmental and address fussiness in a positive way. Behavioural Pediatrics 17: 149-153. One unique feature of the app is that it Schwartz, C., Scholtens, P.A.M.J., Lalanne, A., Weenen, H., & Nicklaus, S. (2011). Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite 57: 796-807. describes the five most common feeding pitfalls that families encounter. It explains Wardle, J., Carnell, S., & Cooke, L. (2005). Parental control over feeding and children’s fruit and vegetable intake: How are they related? Journal of the American Dietetic Association 105: 227-232. what they are, why they occur, and advises Wardle, J., Cooke, L.J., Gibson, E.L., Sapochnik, M., Sheiham, A., & Lawson, M. (2003). Increasing children’s parents about what to do when they are acceptance of vegetables: A randomised trial of parent-led exposure. Appetite 40: 155-162. encountered.

Mary Seacole Awards 2015-16 For nurses, midwives and health visitors

From 27 February applications will be invited to participate in the prestigious Mary Seacole Awards programme for 2015-16.

These awards, funded by Health Education England, provide the opportunity to undertake a specific health care project or other educational/developmental activity that benefits and improves the health outcomes of people from black and minority communities.

Want to find out more? Visit one of our workshops taking place on 19 March in London and 26 March in Birmingham.

Book a workshop: Email [email protected]

Publication code 004 808

April 2015 Community Practitioner 27 Practice: CPD

Reducing dog bites in children

correct interpretation in >90% human previously owned a dog. The parent/child Dr Caroline Furnell BM MrCPCH Specialist Registrar in Community Child Health and expressions. This lack of interpretation may pairs completed surveys and knowledge- Neurodisability. contribute to the high incidence of bites in based scenario tests, 43 per cent of children Sirona Care and Health younger children. failing the test. Bath Bites may have serious consequences Older children had higher odds of passing for children and adolescents and a review the test than younger children, as did children Dr Fiona Finlay MB BS DCH FrCPCH of the literature revealed that a range of with white parents versus non-white parents. Consultant Community Paediatrician Sirona Care and Health interventions have been considered to try More than seven out of ten of children had and reduce dog bite injuries. Studies have never received dog bite prevention education IntroductIon looked both at dog bite awareness and - although 88 per cent of parents desired it, Dog bites cause a significant burden of injury the effectiveness of specific educational the majority not knowing where to go receive to society with a particular impact on children. prevention interventions. this education. Data published by the Health and Social Care Dixon (2013) went on to evaluate a video- Information Centre revealed that there were results of lIterature revIew based prevention intervention in a paediatric 6,740 hospital admissions specifically for dog Presutti (2001) emphasises the important role emergency department. In a cross-sectional, bites and strikes in England and Wales, a 6 per that a dog can play in family life, but stresses quasi-experimental study 120 five to nine- cent increase from the previous year. the need for education programme providing year-olds and their parents completed a The data also showed a worrying increased clear boundaries for a dog within the family. 14-point simulated scenario test, with ‘yes’ or risk related to deprivation with an admission Families should avoid ‘humanising’ their dog ‘no’ answers, about safe dog interactions pre/ rate three times higher for the 10 per cent (e.g. allowing it to sleep on furniture or beg post a video intervention. The video lasted most deprived areas compared to the 10 per at the dinner table), as this type of behaviour approximately 20 minutes and was called cent least deprived areas (24.1 admissions per can confuse the animal making it difficult ‘Dogs, Cats and Kids’. The test pass rate was 100,000 compared to 8.1 per 100,000). Rates to distinguish between animal and master, 58 per cent pre-intervention and 90 per cent of admission were highest in the north of increasing the risk of biting. post-intervention, younger age being the England and lowest in the South West. Dog Presutti also stresses that children need only predictor of failing the post test. bite admissions were highest in the Summer to learn to avoid running and screaming in Knowledge scores increased in 83 per cent months and in the 0-9 year old age group. the presence of a dog, and dogs should not of children. The greatest increases were in Children suffered more injuries to their head be greeted by presenting an outstretched questions involving stray dogs or dogs that compared to other age groups where the hand. Hugging or kissing a dog expresses were eating or fenced. The authors concluded main injuries were to the wrists, hands and submission and is confusing to the animal, that video intervention would be helpful forearm (HSCIC, 2014). which may lead to more aggressive behaviour. in addressing the dog bite problem, but Studies by Bernardo and colleagues (2002) Dixon and colleagues (2012) conducted a recommend further studies on effectiveness and Reisner and colleagues (2011) have cross-sectional study sampling three hundred by measuring dog bite incidence or injury shown that >50 per cent of children bitten 5-15 year olds and their parents presenting to severity. are under the age of seven, and many are a US paediatric department with non-urgent Chapman and colleagues (2000) also bitten by either the family dog or a dog that complaints or dog bites. designed an educational programme for they know. Meints (2010) has shown that Eleven per cent of children participating primary school children called ‘Prevent-a-Bite’. young children may misinterpret dog’s facial had a current dog bite, 23 per cent had The intervention consisted of a 30-minute expressions. Four, five and six-year-olds, and prior dog bites and 72 per cent currently or lesson conducted by an accredited dog adults were tested on neutral, aggressive and happy human and dog facial expressions. While <1 per cent adults made mistakes, Children need to learn to avoid running and screaming in 69 per cent of four-years-olds interpreted aggressive dog faces as smiling and happy. the presence of a dog, and dogs should not be greeted by 35% of five year olds and 25% six year olds presenting an outstretched hand. misinterpreted dog expressions but gave

28 Community Practitioner April 2015 Practice: CPD

handler who demonstrated various ‘do’s and don’t’s’ of behaviour around dogs. Children practised patting the dogs in the correct manner and were shown protective body postures to adopt when approached or knocked over by dogs. A resource kit for teachers was also distributed. Seven to ten days after the intervention the children were let out to play unsupervised in the playground with a dog tethered nearby, with a videotape recording their actions. Those children in the intervention group displayed much better precautionary behaviour when compared to controls. Wilson (2002) also found that a dog safety programme resulted in a significant increase in the ability of children to identify high risk situations involving dogs, with the benefits being even greater in those children whose parents were also given dog safety information. Prevention interventions targeted solely towards parents have shown mixed results. Sheilds and colleagues (2012) enrolled 901 parents attending a paediatric emergency department with young children in an urban area in USA, where there was a high exposure UK legislation targeting ‘dangerous dogs’ has not been to stray and dangerous dogs. The parents completed a kiosk assessment shown to reduce the number of dog bites. and received a report which contained information aimed at increasing knowledge about either dog bite prevention (n=453) Since its inception in 2005 various studies interactive child-dog scenes and asked to or other safety behaviours (n=448). have assessed its effect. In 2009, Meints and de choose a safe or unsafe outcome for the story. Participants were phoned two to four weeks Keuster looked at its impact in children under Children were then tested at eight weeks, six later for a follow-up interview to measure seven. In this age group the intervention was months and one year. knowledge differences. Those who had successful and showed that children were Some were allowed to take the DVD and received information about dog bites scored better equipped to make safe choices after booklet home while a second group received significantly higher on two of the three dog viewing it. only the booklet. Those children with the bite knowledge questions, although only 13 This was taken further in 2012 by Schwebel DVD did show more correct responses and per cent of respondents answered each of the and Morrongiello. They offered children they were able to retain this information. questions correctly. aged three and a half to six years the same Younger children benefit from using the The authors concluded that tailored written training programme and then assessed their DVD especially. Parental questionnaires at material, designed for low literacy audiences, knowledge in three different ways. eight weeks showed 38 per cent of children may effectively communicate with families, They looked at pictures of risky behaviour, interacted more safely with their own dog although it is unclear how the knowledge simulated behaviour with a dolls house and and 50 per cent behaved better with dogs in gained is translated into preventative then introduced children to a live dog. The study general. behaviours. found that although children were successfully Morrongiello and colleagues (2013) Researchers have looked at the impact of taught knowledge about safe engagement conducted a pre/post intervention/control the ‘Blue Dog Programme’, an educational with dogs, the intervention did not influence study to assess whether exposure to the resource which started as an interactive CD- recall or implementation of safe behaviours. Blue Dog positively impacted upon parent rom with a printed parent guide. It contains Meints and colleagues went on to do a behaviours. The authors found no difference information with stories and scenarios to longitudinal study to assess the impact of the in behaviour pre and post intervention educate children about safe dog interactions. Blue Dog story modules on DVD, particularly with parents showing risky reactions and It was developed by a team of professionals looking at whether acquired knowledge encouraging children to interact with the dog from multiple disciplines and is administered changed behaviour with their own dog. despite knowing little about its disposition. by a charitable trust. Children were shown a set of 15 different They highlight the need for effective

April 2015 Community Practitioner 29 Practice: CPD

interventions targeting both parents and children. conclusIon Orritt (2014), writing in the BMJ, points out that politically driven UK legislation targeting ‘dangerous dogs’, has not been shown to reduce the number of dog bites, and a review of the lite rature has shown that there are few studies looking at the effectiveness of educational invention programmes. In an effort to reduce the number of dog bites in children and adolescents medical and veterinary professionals need to work together to develop effective, evidence http://www.hscic.gov.uk/article/4722/Dog-bites- known health benefits:we need evidence based policy. hospital-admissions-in-most-deprived-areas-three- BMJ 2014;349:g4081 based management strategies promoting times-as-high-as-least-deprived Presutti RJ. Prevention and treatment of dog bites. Am safe interactions with dogs. Meints K, Racca A, Hickey N. How to prevent dog bite Fam Physician. 2001;63(8):1567-72 injuries? Children misinterpret dogs facial expressions. Inj Prev 2010;16:A68 Reisner IR1, Nance ML, Zeller JS, Houseknecht EM, references Kassam-Adams N, Wiebe DJ. Behavioural characteristics Bernardo LM1, Gardner MJ, Rosenfield RL, Cohen B, Meints K, de Keuster T. Brief Report: Don’t kiss a associated with dog bites to children presenting to an Pitetti R. A comparison of dog bite injuries in younger sleeping dog: The first assessment of the “blue dog” urban trauma centre. Inj Prev. 2011;17(5):348-53 and older children treated in a pediatric emergency bite prevention programme. J Pediatr Psychol 2009 department. Pediatr Emerg Care. 2002 Jun;18(3):247-9 nov-dec;34(10) 1084-90 Schwebel DC, Morrongiello BA, Davis AL, Stewart J, Bell M. The Blue Dog:evaluation of an interactive software Chapman S, Cornwall J, Righetti J, Sung L.Preventing Meints K, Lakestani N, De Keuster T. A longitudinal programme to teach young children how to interact dog bites in children: randomised controlled trial of an assesment of the Blue Dog Bite Prevention Programme. educational intervention. BMJ. 2000;320(7248):1512-3 www.thebluedog.org/en/research/blue-dog- safely with dogs. J Pediatr Psychol 2012;37(3):272-81 programme/research-topics Dixon CA, Pomerantz WJ, Hart KW, Lindsell CJ, Shields WC, McDonald EM, Stepnitz R, McKenzie Mahabee-Gittens EM. An evaluation of a dog bite Morrongiello BA1, Schwebel DC, Stewart J, Bell M, LT, Gielen AC.Dog bites: an opportunity for parent prevention intervention in the pediatric emergency Davis AL, Corbett MR. Examining parents’ behaviors education in the pediatric emergency department. department. J Trauma Acute Care Surg. 2013;75(4 and supervision of their children in the presence Pediatr Emerg Care. 2012;28(10):966-70 Suppl 3):S308-12 of an unfamiliar dog: does The Blue Dog intervention Wilson F, Dwyer F, Bennett PC. Prevention of dog improve parent practices? Accid Anal Prev. 2013; Dixon CA1, Mahabee-Gittens EM, Hart KW, Lindsell bites:Evaluation of a brief educational intervention 54:108-13 CJ. Dog bite prevention: an assessment of child program for preschool children. Journal of Community knowledge. J Pediatr. 2012;160(2):337-341 Orritt R. Dog ownership has unknown health risks but Psychology 2003;31:75-86

cPd questions (please visit www.communitypractitioner.com/cPd to submit your answers) 1. rates of admission for dog bites are highest in Sleep on the furniture London Be greeted with an outstretched hand The North None of the above South West 7. Dog safety programmes 2. Where do children suffer most injuries? Are more effective if parents are also given safety information Head Have little effect in teaching precautionary behaviour Leg Are not suitable for the under-fours Forearm

3. What age of child is most likely to be bitten? 8. The Blue Dog programme 0-7 Improves implementation of safe behaviour in over 90% of children 7-10 Was shown to be effective in children over 7 10-14 Is only effective when children can take the booklet home

4. admission rates for dog bites 9. Dog bites Are highest in the winter months Have a low risk of infection Are highest in deprived areas Are usually from male dogs Have shown a steady decline in the last 5 years Are routinely treated with trimethoprim 5. young children 10. The following are true Are less likely to be bitten by a dog they know Are good at interpreting the dogs face UK legislation targeting dangerous dogs has not significantly May think an aggressive dog is smiling reduced the number of dog bites Over 70 per cent of 10-year-olds have received dog bite prevention 6. it is good for your dog to education in school Be humanised The Blue Dog Programme is delivered by health visitors

30 Community Practitioner April 2015

Professional and research

The lived experience of homeless women: insights gained as a specialist practitioner

IntroductIon population in single homelessness (Bines,1994; dr MarIa FordhaM, PhD, RN, RM(L), RHV, NP Senior Lecturer (SCPHN), University of Bedfordshire The home reserves a very special space Citron et al, 1995; Connelly et al, 1997) and family Correspondence to [email protected] experience which has something to do with the homelessness (Cook et al, 2004; Vostanis,1999). fundamental sense of our being. Home is where Since then the Queen’s Nursing Institute (QNI) abstract we can be what we are. We feel a special sorrow Homeless Health Initiative (HHI) (QNI, 2007, 2008, In this article, insights into the lived experience of for the homeless because we sense there is a 2009) and the Department of Health (DH, 2010) homeless women arising from a PhD study on the specialist role of the SCPHN in homelessness are deeper tragedy involved than merely not having have produced resources and guidance. Currently, presented. A key narrative text of a rough sleeping a roof over one’s head (van Manen, 1990:102). DH homeless commissioning frameworks are pregnant woman is included. The reflexive narrative Van Manen (1990) articulates how home is being developed. study, used an eclectic, philosophical framework intrinsically linked to a sense of ‘being in the To inform my specialist SCPHN practice which included reflective practice/guidance, narrative inquiry, and storytelling methodologies. Story texts world’ (Heidegger,1962). But what happens to the and provide evidence for a local Health Needs uniquely illuminated complex knowledge about ‘being’ of a homeless person? How do they live in Assessment report, I led focus groups interviews homelessness and homeless health care. Homeless the world and who are they? In this paper, I draw with homeless people in refuges, hostels women were found to be a heterogeneous group insights into the lived experience of homeless and day centres (Fordham, 2007). I found which included former health professionals. The women’s stories were often shocking; they were women, drawn from a PhD reflexive narrative engagement with homeless women and men frequently contextualised against a background of study on health and homelessness (Fordham, highly successful, contrary to the literature cited service exclusion, including GP services, learning 2012). When I ventured into specialist community above. Respondents articulated how focus group disability services, mental health services, housing public health nurse (SCPHN) homelessness dialogue contrasted with the often dehumanising services and social services. The role of the specialist nurse (SCPHN) in engagement with homeless people practice in 2006 there was little national or local experience of repeated attempts to access health is illuminated. A therapeutic model of ‘Effective guidance on homelessness that I could draw on services. In them, they expressed their experiences Engagement with Homeless People and Homeless for public health nursing practice. There were of healthcare and were able to constructively Families’ is presented to guide health professionals in few UK qualitative studies on the way homeless contribute to local service improvement. Similarly, holistic care. The author invites the reader to dialogue within their teams on how homeless people are people experienced ill health, or how they felt therapeutic engagement in homeless outreach included or excluded from SCPHN services. In this poor health had contributed to becoming clinics reflected the stories of disengagement way, the term ‘audiencing’ rather than transferability homeless. There was substantial literature on why by mainstream health services. Having always of findings is used in a continuing dialogue with homeless people may not participate in research, visited women in their homes as a SCPHN, hearing the reader to improve the health and wellbeing of homeless women. highlighted by Daiski (2007), including distrust stories of being homeless told by homeless of authority (Breaky, et al 2001, Smith et al, 1991), women particularly intrigued and challenged me. Key words chaotic lifestyles (Power et al, 1999), inadequate The insights I gained were developed through Homeless women, reflective practice, narrative collection methods related to participants’ literacy reflective practice and guidance beyond my skills (Power et al, 1999) and prioritisation of former understanding of homelessness in generic addiction needs over research engagement (Hills, practice. These insights are the focus of this paper. 2003). There was, however, a plethora of research In it, I present a story text from the narrative study indicating poor health compared to the rest of the and a synopsis of seven core texts which illuminate

Key points

• Homeless women are a heterogeneous group of people of varying ages and included professional women • Housing ‘priority need’ pregnant rough sleepers who are deemed as ‘intentionally homeless’ are not eligible for social housing • Mainstream health services are often ‘hard to reach’ for homeless groups. This prevents complex health issues being effectively addressed • Childhood trauma is a significant feature in homelessness • Dialogue around ongoing generic SCPHN support for mothers who have children taken into care should be considered in ongoing service development to prevent some women becoming homeless

32 Community Practitioner April 2015 Professional and research

the experience of homelessness and women’s consent from patients whom, without exception, History of psychosis feelings about their health and wellbeing. wholeheartedly agreed that I should write their Possible pregnancy personal stories into the narrative. Indeed, it aIM seemed to form part of their empowerment story. Everything is disclosed so easily. I ponder on this The aim of this paper is to illuminate the lived As such, it became a joint study with those whose couple’s relationship. A few minutes later Cain experience (van Manen, 1990) of homeless lives had been affected by homelessness and raises his sleeve to show me bruises and a slash women who attended outreach clinics or warmly encouraged me on. mark on his arm. Domestic violence added to lived in hostels where insights were developed my concerns. Whilst domestic violence is through a process of reflective practice and analysIs oF reFlectIve data recognised as a leading cause of homelessness self-inquiry (Johns, 2013). The ‘Being Available Template’ (BAT) (Johns, 2009) (Buck, 2002; Quilgars & Pleace, 2010) a strategy was used in the study as an organising framework for coping with domestic violence in rough- Methodology towards a deeper understanding of holistic care. sleeping couples is undeveloped. The narrative study was constructed using Figure 1 shows its development in relation to Just when my professional anxieties are at reflective practice guidance (Johns, 2009; homelessness. Within it, the core therapeutic their highest Mary discloses that she had a Schon, 1983). of holistic practice with homeless people is young baby taken into care last year and she irreducible; unfolding insights contributed to the thinks she is pregnant again. narratIve constructIon whole of my homelessness SCPHN practice. “No-one would take my child away”, Cain The research method drew on Johns’ (2009) mumbles. I note the protective warmth in his Six Dialogical Movements, which evolves narratIve text naïve reply. from reflective journaling towards narrative Mary’s Story – a homeless pregnant woman: “How would you feel about being pregnant performance using reflective guidance and Despair and Delight again?” I ask. extant theory. Coherence is woven through Winter Rough Sleeper Clinic “Oh great” she replies “really great.” each movement. This is important as narrative We watch the pregnancy test indicator. Slowly, research positioned in the constructivist It’s freezing again. Val, the homeless centre silently the + sign appears. The room becomes paradigm seeks to understand meaning manager, is impatient for me to meet a vulnerable, filled with their delight. For awhile they remain rather than provide a scientific explanation. young rough-sleeping couple, two of the six totally unaware of the effects of the issues Coherence made the narrative study plausible rough sleepers on my clinic list. Mary and Cain revealed to me on future child-rearing. I muse and believable. Richardson & St Pierre’s (2005) shyly enter the room. Both look underweight and on the very few pleasures that greet homeless Creative Analytical Practices (CAP) was used to cold. I ease their discomfort, moving chairs into people and engage within-the-moment in determine criteria for aesthetic merit regarding place to welcome them, seeking engagement. their delight. It has a huge pleasurable impact reader/audience engagement: i.e. narrative The couple have slept rough whilst applying for on their present life circumstances. should make a substantive contribution social housing in this area. Mary speaks slowly Mary begins to reminisce about Ruby, her to an understanding of social life; invite through stray strands of dark hair. Her borderline daughter, who was taken into care at six-months interpretative responses through the way it is learning disability becomes visible as we dialogue of age. From her navy track-suit pocket she pulls a written, be artistically shaped and complex. together. Her list of medical and social problems creased photograph of a bonny-faced baby. The Seven texts in my narrative study centred grows, edging my concern towards despair: trauma of sudden removal, Mary’s most significant on women. The stories of these women bereavement, is acutely evident. She yearns for were shocking and thought-provoking. The Raised by a mother with a heroin addiction Ruby who is in long term foster-care, pending specialist role of the SCPHN in homelessness Mother imprisoned for stabbing her father adoption. Talking animatedly, she expresses her enabled therapeutic intervention at crucial Childhood sexual abuse grief for the first time to a health professional, points and ensured effective multi-agency Learning disability causing me to reflect on the aftermath of parents collaboration. The outcome of this often A heroin user - unknown hepatitis status when children are suddenly removed and the resulted in the prevention of rough sleeping Asthma - no inhalers lack of health support offered to mothers. I muse; and evictions when ill health was present. Epilepsy - no medications Does SCPHN education extend adequately into ethIcs parental health needs post-removal of children? Ethical approval Does it consider learning disabled mothers With the proviso that identifying details were and homelessness as core elements in removed and pseudonyms (Morse, 2002) used vulnerable communities? in the study, the chairperson of the local ethics Holding and intending committee and the clinical effectiveness lead the realisation of a Or are these areas excluded - marginalisation of the Trust confirmed that the submission of a vision of practice towards carried into education, feeding exclusion of effective inclusion of homeless research proposal to the PCT research governance vulnerable groups? people in health services committee and the local ethics committee was Allowing Mary to therapeutically express unnecessary. Developing self in professional Figure 1: Model of effective therapeutic her bereavement as well as her delight in this practice does not require ethical approval (Carson, engagement with homeless people and pregnancy secures effective engagement. 1994; Johns, 2002; 2009). However, I did obtain oral homeless families There is an enormous amount of partnership

April 2015 Community Practitioner 33 Professional and research

actions I have to initiate networking towards their ongoing care (Figure 2). Housing Supporting this young couple to engage with homeless services underpins my advocacy role. Prompted services Drug treatment Midwife in reflective guidance I consider ‘advocate’. services Gadow (1980) identifies existential advocacy as unique to nursing. Rather than consumerism advocacy, “a trouble-shooter willing to intervene when systems violate an individual’s rights” (p.84), she argues that existential advocacy is. Health Visitor GP The concept of professional involvement as a Specialist unifying and directing of one’s entire self in relation SCPHN to another’s need ... in order that patient and nurse can participate as unified selves in the patient’s process of self-determination (Gadow, 1980:90-99) Contact Health Learning Disability Visitor in previous Yet, I do feel like a troubleshooter in Mary’s Team area struggle for self-determination. I ponder on Hebblethwaite et al’s (2007) note that Contact Social learning disability makes survival in homeless Social Services Services in environments difficult. Reduced capability previous area results in fear, anxiety and despair, at a time when, despite increased physical and mental health needs, access to health services is Figure 2: Partnership actions for ongoing care difficult. Michael (2008) also describes how, People with learning disabilities can find it more does not confer social housing rights and Mary Society, 2010), unaware of the exclusion difficult to identify and describe symptoms of was later assessed as ‘intentionally’ homeless. they are causing to ‘invisible’, voiceless illness, and much harder to navigate the health The learning disability team will not accept communities who are unable to fit into system to obtain treatment. These problems Mary because she is not registered with a GP. I mainstream care. also make it more difficult for NHS professionals have to wait for the consultant to contact me My knowledge on the way rules impede to deliver treatment effectively (p.16) later. (Later, Mary’s IQ test score was 71. The services access and my practice vision of I negotiate the balance between acting as criteria for Learning Disability service inclusion inclusion is growing. I must move politically a trouble-shooter on their behalf and working is 70. Mary was not offered services. Arguably and practically at a strategic level to change in partnership towards self-determination, complex disabilities and homelessness makes perceptions and policy. a way of enablement. Drawn from Mary’s people more vulnerable and borderline Public authorities should never be allowed past experience, their values towards self- criteria should be assessed holistically with to treat their duties towards adults with determination are clear; they want to engage criteria lowered in complex need). learning disabilities under the Human Rights services to be able to parent effectively. It takes four attempts to find a GP who will see Act 1998 and the Disability Discrimination But, I spend two hours trying to engage Mary today, despite not having any medications Act as optional (including their positive services – a three hour time commitment for asthma or epilepsy and her pregnancy. duties under the Disability Equality Duty. with this couple today, confirming under- Even then she will only be offered temporary (A Life Like Any Other, Committee on resourcing and illuminating limits in homeless registration, denied preventative interventions Human Rights [HL/HC 2008:95]). services. Service access issues shock me: such as the asthma clinic which she requires. Ongoing story Social Services refuse to see Mary until The very care which I regard as my role to I lead two professional strategy meetings. 28 weeks of pregnancy. I challenge them coordinate is limited. Mary is seen through a The third strategy meeting is attended for about addressing parenting issues early particular lens which conspires against equity the first time by social services when Mary is in the ante-natal period, perhaps through of health care provision. Yet, life expectancy 28 weeks pregnant residential schemes, but funding for an is greatly reduced in people with learning I arrange an introductory visit between Mary assessment is unavailable. difficulties (Hollins, et al 1998) and the average and her health visitor – the health visitor Housing teams stress that despite the age of death is 40-44 years for those who are does not attend pregnancy and subsequent priority need rough sleepers (Crisis, 2003; DH, 2010). Mary’s baby was removed at birth. She had a category she will only be offered time-limited So what happens to Mary when multiple severe psychotic episode and was admitted temporary accommodation. If assessed as factors combine to impede access to to an acute mental health unit. Having lost intentionally homeless, she will not be eligible effective treatment? How will that make their accommodation when hospitalised, for social housing. My previous health visitor her feel when I feel despair about services? Mary and Cain returned to rough sleeping belief, held within our local health visiting Systems for vulnerable communities following her hospital discharge several teams, is incorrect - pregnancy and parenting organise themselves in silos (The Fabian weeks later.

34 Community Practitioner April 2015 AWARDS 2015 A CELEbrATioN of ProfESSioNALiSM AWARDS We are delighted2015 to announce the 2015 CPHVA Awards shortlisted finalists:

Community Practitioner of the Year Community Nursery Nurse of the Year Alison Lewis Amelia Wilton Carol Sibbald Becky Sears Catherine Nixon Sarah Rowland Sue Patterson Community Practitioner Team of the Year Early Years Mental Health Specialist Team – Team Leader/Manager of the Year South Tyneside Alison Waite NINES, Northern Ireland New Entrance Service Ruth Chittenden South Warrington 0-19 years Team Sharin Baldwin Health Visitor of the Year Educator of the Year Niamh Hanlon Jennifer Kirman Shakila Shah Martha Gibbons Sheila Lally Ruth Heffernan

School Nurse of the Year Student of the Year Angela Lovatt Emma Cummings Yvette Bynoe Karen Heggs

Thank you to everyone who submitted nominations for these awards

Thank you to our prestigious group of sponsors this year

Community PRACTITIONER

for more details about the finalists and winners, visit www.communitypractitioner.com or see the May issue of Community Practitioner Professional and research

The women Presenting health Homelessness Housing SCPHN role needs trigger outcomes towards a [Homeless positive health status] outcome

Mary Asthma, epilepsy, Evicted from social housing Cold-weather temporary Advocacy where 23 yrs borderline learning accommodation - categorised accommodation (TA), possible disability, infant in care, as intentionally homeless followed by Registered pregnancy, substance Social Landlord (RSL) misuse, domestic violence. [Rough sleeping] accommodation. RSL tenancy H/o childhood trauma and was lost during hospital stay psychosis following psychotic episode after her infant was taken into care at birth. Returned to rough sleeping. Pamela Traumatised by being Illness, loss of employment Night-shelter; Enablement 45 yrs sectioned under the Mental leading to loss of house Sofa-surfing; Health Act. Subsequently diagnosed with a brain (Rough sleeping) Post narrative: tumour Hospice until her death

Heidi Sprained ankle, alcoholism, Released from prison following Rough Sleeping; referred to Enablement 54 yrs estranged from adult first offence a hostel where she stayed children, H/o childhood for 2 years trauma; adult torture; [Rough sleeping] personality disorder

Dora Sprained ankle, alcoholism, Unknown Rough Sleeping Advocacy 30 yrs fear of hospital. H/o children taken into care as [Rough sleeping] a young mother

Lucy Severe self-harm, H/o Escaping parental and sibling Hostel; then lived with Enablement 16 yrs childhood trauma including violence in family home partner’s family presence of maternal mental health illness and [Hostel] a sibling with learning disability Ros Huntington’s Chorea; Unknown Night shelter Advocacy alcoholism. H/o childhood (prevention of imprisonment 22 yrs trauma [Night shelter] following breach of ASBO)

Ariella Feeling alienated and Loss of relatives family home. Hostel and then onward Enablement 21 yrs frightened by hostel Limited family support following into Social housing culture. H/o childhood mother’s premature death. bereavement [Hostel] Figure 3: Synopsis of women involved in the narrative study dIscussIon and their journeys’ into/out of homelessness are complex health and social needs. The majority Mary’s story shows the complex nature of illuminated as well as the SCPHN role either as an had experienced complex trauma occurring in homelessness and the plight of some homeless advocate and/or enabler in partnership working childhood, mostly from child sexual abuse but pregnant women who may be rough sleeping. towards ongoing health and well being. also childhood bereavement. Maguire et al (2008) It also raises issues about the support offered to Fig 3 presents a diverse range of women notes how further research is required in complex mother’s who have children taken into care and experiencing homelessness. Various age ranges trauma and homelessness to identify effective the nature of disengagement by health and other were represented from sixteen to fifty-four. psychological interventions for homeless people. services in homelessness. Other stories giving Two of the women had been full-time health insight into the lived experience of homeless professionals. Most were mothers including beIng avaIlable to eFFectIvely women were equally as poignant as Mary’s. In those who were rough sleeping. All the women engage wIth hoMeless woMen Figure 3, I offer a synopsis of those women who had experienced difficulty around health service Fig 3 does not illuminate the intensity of the featured in the narrative study. Their health needs engagement since becoming homeless. All had women’s experiences as much as stories do. In

36 Community Practitioner April 2015 Professional and research

stories, their daily struggles, suffering, courage, is to engage effectively. The homeless women in Fordham M. (2012) Being and Becoming as a Specialist Public Health Nurse - Weaving the Net in Homeless Health knowledge and their search for peace and well- this study were not ‘hard to reach’; health services Care. Unpublished PhD thesis. University of Bedfordshire being was illuminated. Having concern for the were. The ‘Effective Engagement with Homeless Fordham M. (2007) in Fordham M. (2012) Being and person meant knowing the person as I worked People and Homeless Families’ therapeutic Becoming as a Specialist Public Health Nurse - Weaving with them therapeutically, often in dramatic model is presented in this paper to guide SCPHN the Net in Homeless Health Care. Unpublished PhD thesis. University of Bedfordshire circumstances. A key insight was seeing each teams towards effective engagement with Gadow S. (1980) Existential advocacy: philosophical person as a unique human being, without homeless people including homeless families. foundations of nursing. In Nursing Images and ideals: prejudice. Like Sycamore (2006), I found that Beyond health services, the study findings have An Opening Dialogue with the Humanities, (ed. Stuart F. most women wanted a home. However, some implications for social services, housing, police, Spicker and Sally Gadow). New York: Springer did not. Ironically, Pamela found her home with probation and the voluntary sector. Gaydos HL. (2005) Understanding Personal Narratives: an approach to practice. Journal of Advanced Nursing the homeless, being an advocate and living 49 3 254-259 simply in a deep spirituality which, may or may conclusIon Hebblethwaite A, Colman M, Hames, Forsyth A, Donkin not, have been an associated symptom of her In this paper, I have presented insights into the M. (2007) Investigating the Experiences of People who undiagnosed brain tumour. Heidi also had a Have Been Homeless and are in Contact with Learning lived reality of being a homeless women as seen Disability Services Learning Disability Review 12 3 25-34 precarious relationship with accommodation; through my specialist SCPHN role through a Heidegger M. (1962) Being and Time (Trans Macquarrie feeling at times it was safer to “sleep under the process of self-inquiry (Johns, 2009). I have noted J, Robinson E. 2008) Oxford: Blackwell Publishing stars”, a reference to the extreme violence she how advocating and enabling homeless women Hills E. (2003) Self Esteem in the lived experience of experienced living at home. in their health care requires effective engagement. Homelessness (Unpublished dissertation) University of Nottingham in Crocombe S. (2008) The Health of In therapeutic spaces of being available The ‘Effective Engagement with Homeless People Homeless People in Nottingham: an Exploratory to homeless women, I found the ‘genius of and Homeless Families’ therapeutic model is Study, Dissertation for Master of Nursing Science: University women’, noted by Pope John Paul II (1995), presented to guide SCPHN teams towards of Nottingham: School of Nursing, Faculty of Medicine despite their enduring hardship. compassionate engagement with homeless Hollins S, Attard MT, von Fraunhofer N, Sedgwick P. (1998) Mortality in people with learning disability: risks, causes, In every time and place... women’s dignity has people including homeless families. Issues and death certification findings in London. Developmental often been unacknowledged; they have often surrounding engagement and compassion are Medicine & Child Neurology. 1998; 40: 50-6. been relegated to the margins of society. This has highly transferrable into all areas of public health Johns C. (2013) Becoming a Reflective Practitioner 4th prevented women from truly being themselves .... work. Further support for parents who have had ed. Oxford: Wiley-Blackwell reflect carefully on what it means to speak of the children removed and taken into care was raised Johns C. (2002) Guided Reflection Advancing Practice. Oxford: Blackwell Science “genius of women” in order to let this genius be as a key issue for ongoing SCPHN dialogue. Maguire N, Johnson R, Vostanis P, Keats H, Remington R. more fully expressed in the life of society (p.10) (2009) Homelessness and Complex Trauma A Review of Krumer-Nevo and Benjamin (2010) in their reFerences the Literature. Southampton: University of Southampton paper on poverty knowledge, show how social Belenky MF, Clinchy B, Goldberger N, Tarule J. (1986) Michael J. (2008) HEALTH FOR ALL Report of the Women’s Ways of Knowing the Development of Self, Independent INQUIRY into access to healthcare for distancing occurs through ‘Othering’, Mind and Voice. New York: Basic Books people with learning disabilities DH, London ‘...Othering cushions middle-class people Benner P. (1984) From Novice to Expert. Menlo Park: Addison Morse J. (2002) Writing my own experience. Qualitative leaving their values unviolated and protected Bines W. (1994) The health of single homeless people. Health Research. 2002 12:1159-1160 Discussion Paper 9, University of York: Centre of Housing from any potentially impinging cultural O’Donohue J. (1997) anam cara Spiritual Wisdom from Policy relativism...’ (p.698) the Celtic World. London: Bantam Books Breaky W, Susser E, Timm P. (2001) Mental Health Services for I challenged myself, do I or other health Okri, B. (1997) A Way of Being Free. London: Phoenix Homeless People in Thronicroft, G. (Ed) Measuring Mental professionals, protect ourselves through Health Needs 2nd Edition. London: Gaskell Publishers Pope John Paul II (1995) Letter of Pope John Paul II to Women. Rome: Vatican Press Othering? Fitzpatrick et al (2011) notes a rise Carson R. (1994) Teaching ethics in the context of the in “middle-class” homelessness. I chose two medical humanities. Journal of Medical Ethics 20(1):235-238 QNI (2009) Briefing: Assessing homeless families’ health needs. London: Queen’s Nursing Institute professional women (Fig 3) to illuminate how Citron K, Southern A, Dixon M. (1995) Out of the Shadow: homelessness can affect professionals. My Detecting and Treating Tuberculosis Amongst Single QNI (2007) Facing the Future A Review of the Role of Homeless People. London: Crisis Health Visitors. London: Queen’s Nursing Institute hope was to prevent Othering which I believed Clandinin D, Connelly FM. (1990) Stories of Experience QNI/HHI (2008) Homelessness Briefing Spring 2008 . contributed to exclusion of homeless women and Narrative Inquiry Educational Research American London: Queens Nursing Institute Educational Research Association and men from health service engagement and Richardson L, St Pierre EA. (2005) Writing: A method of promote instead compassionate engagement. Connelly J, Crown J. (1997) Homelessness and ill health: Inquiry. In Denzin, N. & Lincoln, Y.S. (eds) (2005) The Sage Being available to therapeutically engage with Report of a working party of the Royal College of Book of Qualitative Research. 3rd ed. London: Sage Physicians. London: Royal College of Physicians homeless women was a time of growth and Spry T. (2001) Performance Ethnography An embodied Cook J, Vickers M, Walters S, Gorton S. (2004) The Vital methodological praxis. Qualitative Inquiry 2 6 706-732 humility in my professional practice, listening Link: Preventing Family Homelessness. London CPHVA Schon D.A. (1983) The reflective practitioner. How to their stories through a shared womanhood Crisis (2003) Statistics about Homelessness. Fact Sheet professionals think in action. Aldershot: Ashgate and shared humanity. 7. London: Crisis Publishing Ltd Daiski I. (2007) Perspectives of homeless people on their Sycamore R. (2006) Homelessness and Women in 2006. IMplIcatIons For practIce health and health needs priorities JAN Original Research. London: Homeless Link Oxford: Blackwell Publishing Ltd Through stories of practice, I hope to enable other The Fabian Society Policy Report (2010) Hardest to Fay B. (1987) Critical Social Science Cambridge: Policy Press Reach? The politics of multiple needs and exclusions. health professionals to grasp the experience of Fabian Society Report 63. London: Shelter Fordham M. (2014) Reflective Practice: Health and homelessness in which complex health needs Homelessness - Weaving a Net of Care as a Specialist van Manen M. (1990) Researching Lived Experience. are often evident. The challenge for professionals Practitioner Community Practitioner 87 6 29-33 New York: State University Press

April 2015 Community Practitioner 37 Professional and research

Students’ and tutors’ perceptions of the use of reflection in post-registration nurse education

IntroductIon the BenefIts and effectIveness LInda stIrLIng GN, RHV, RT, FiHV, BSc Hons, PGdip Ed. MSc This is a small-scale, qualitative study looking at of refLectIon Team Leader, Health Visiting Staffordshire and Stoke-on- students’ and tutors’ perceptions of the use of reflection Reflection was found to improve students’ self- Trent Partnership Trust in post-registration nurse education. The study awareness and self-confidence (Smith & Jack, aBstract involved a purposive sample of six post-registration 2005; Glaze, 2002). Reflective journaling is a written The aim of this study was to explore post-registration nurse students and three tutors. The benefits of record that students create as they think about nurse students’ and tutors perceptions of the use of reflection have been highlighted in a number of various concepts learned, about critical incidents reflection in education. The benefits of reflection have been highlighted in a number of studies; however, there studies (Langley and Brown, 2010; Glaze, 2002; Smith involving their learning, or about interactions is a paucity of literature on students’ perceptions of the & Jack, 2005; Asselin, 2011; Bulman, 2008) however, between students and teachers, over a period of use of reflection in post-registration nurse education. A there is a paucity of literature on students’ perceptions time for the purpose of gaining insights into their qualitative approach was used to explore the six post- registration nurse students’ and three tutors perceptions of the use of reflection in post-registration nurse own learning (Thorpe, 2004). Reflective journaling of the use of reflection in education. Semi-structured education. This paper refers to the type of reflection enabled students to examine their own attitudes, interviews were used to access perceptions and the data that Schön (1983) describes as ‘reflection on action’. such as fear of exposure and self-doubt (Langley was analysed. The findings of this study are discussed under the themes; benefits of reflection, barriers to Practitioners reflect on actions, judging their success and Brown, 2010; Kerka, 2002); and to see problems reflection and suggestions for improvement of the use and whether any changes to actions could have from the perspectives of others (Langley and Brown, of reflection. Conclusions include recommendations for resulted in different outcomes. Reflection increases 2010). However, studies have shown that nurses future research and practice. Recommendations include tutors providing sufficient time and regular support for students’ confidence in justifying actions and supports can be selective when remembering experiences reflective practice without the constraints of using set decision making in professional practice (Glaze, 2002). and this plus vulnerability or fear of reprisal can reflective models. These findings have implications for As post-registration nurses have to engage in complex make reflection seem like a negative experience those involved in curriculum development for post- registration nurses’ education and those seeking to decision-making processes (QAA, 2010) as an integral (Newell, 1992). Reflection benefits professional develop reflective abilities in students. part of their everyday practice it is important to practice. Glaze (2002) found that reflection improves investigate their perceptions of reflection as this could nurses’ confidence in justifying their actions and Key words Post registration nurse education, reflective activity, influence the education of post-registration nurses. supporting their decision making (Glaze, 2002), reflection on action Reflection also enhances professional practice and although empirical evidence has questioned improves patient care (Gustafsson and Fagerberg, the use of reflection to explore the nuances 2004), which is the major premise of nurse education of professional practice and decision making (NMC, 2004). Therefore, it is important to explore (MacLaren et al, 2002). Langley and Brown (2010) students’ perceptions surrounding its use in education found that empowerment was a positive outcome so that its full potential to improve professional of reflective journaling as individuals took control of practice and patient care can be realised. The main their circumstances, achieving personal desires and aims of this study were to determine post-registration goals. Empowerment is necessary for innovation nurses’ and tutors perceptions of the usefulness or and imaginative problem solving. Following benefits of reflection on the learning process reflection, students were found to become more and the opportunities available to undertake assertive and their thinking was more strategic and reflection, examining both support and politically astute (Glaze, 2002). Being politically astute barriers experienced by students. is a requisite for post-registration nurses (QAA, 2010). Reflection was found to have benefits for LIterature revIew the students’ learning. Glaze (2002) found that There is a paucity of literature on students’ critical reflection enhanced students’ learning perceptions of the processes involved in through the process of perspective transformation becoming a reflective practitioner (Smith & Jack, (Mezirow, 1991); a process through which adult 2005; Glaze, 2002) and the benefits of reflective learners develop different frames of understanding journaling (Langley and Brown, 2010). Reflective and action, which results from a transformative writing is considered a key component of portfolio learning experience. Reflective journaling was also assessment because it provides evidence of seen by students as a vehicle to narrow the theory- skills and development, and increasing clinical practice gap (Langley and Brown, 2010); a more competence (Smith & Jack, 2005). Three themes favourable perception expressed by the students were drawn from the literature; the benefits of the than the tutors from the same faculty. Reflective use of reflection; barriers to the use of reflection; journaling was found to improve the students’ and the negative aspects of the use of reflection. writing skills (Langley and Brown, 2010). However

38 Community Practitioner April 2015 Professional and research

some studies report that reflective journaling does Table 1: A sample of data analysis to identify codes not necessarily result in higher levels of reflection MEANING CODE CONDENSED MEANING CODE CODE (Chirema, 2007; Van Horn & Freed, 2008). Although guided reflective journaling was found valuable I think I had more insight in how More insight on how far I had Insight into progress made in assisting students to achieve higher levels of far I had come come reflection and learning (Lasater & Nielsen, 2009). I learned more about myself Learned more about myself Self-awareness and the journey rather than the Learned more about the Learned about process BarrIers to the use of refLectIon learning journey than the learning rather than product The literature highlights internal and external barriers to reflection. External barriers were seen Reflection has helped me Organise my thought better Organise thoughts organise my thoughts by students to be the greatest barriers, including a lack of time (Langley and Brown 2010; Smith & Jack, Reflection has helped me to Helped my decision Improved decision making make decisions making 2005, Glaze, 2002) and grading by the University (Langley and Brown, 2010; Glaze, 2002). Smith & Jack Reflection has helped me Helped improve practice Improved practice improve my practice (2005) suggested the introduction of protected time for reflection. Students need time to develop Definitely enables student to Assists students to think Reflect on practice think about practice about practice reflective skills and overcome barriers (Platzer et al 2000, Glaze, 2002) and a safe environment to foster Helps student link theory to Student links theory to Links theory to practice practice practice reflection (Glaze, 2002). A safe environment is one where students can trust their peers and tutors Has a positive influence on Positive influence on future Enhances future practice (Glaze, 2002; Langley and Smith, 2010); because a future practice practice lack of trust and freedom of expression were seen Yes it helps you unpick some Helps unpick some issues Improves problem solving as barriers to reflection. Fears were also raised about issues the legal implications of documenting thoughts; I don’t think I learn academically Don’t learn academically No academic learning this illustrates influences in nursing practice that relate to a blame culture (Smith & Jack, 2005). I learn more about myself Learn about self Increases self-awareness Frequent interruptions from staff and clients in the clinical area provided the students with a barrier to reflecting with their mentor (Langley and Brown, due to size and convenience sampling. Some had previously not occurred to the researcher. 2010), a view shared by Smith & Jack (2005). As students believed there was not necessarily a The target population for this study was adult learners with competing family and work correlation between reflection and good nursing post-registration nurses (from various nurse commitments, frequent interruptions at home practice (Smith & Jack, 2005). Research could backgrounds including critical care; A&E; palliative were also cited as a barrier to reflective journaling further explore this viewpoint, which appears care and midwifery) undertaking current education by students (Langley and Brown, 2010). to be synonymous with the view of flawed self- at a specific university and tutors / lecturers The literature highlighted a number of internal perception. working with the university. A purposive sample barriers to the use of reflection. Some students was selected, which maximises the richness of showed a lack of insight presenting a barrier to research desIgn information obtained. Six out of 10 proposed reflective development (Glaze, 2002) and some The study employed an interpretive approach to students and three out of the proposed five tutors students found difficulty in discarding early nursing explore in depth the complexities of the perceptions were interviewed. Sample triangulation between socialisation. Other internal barriers included a lack of a small number of participants (Basit, 2010). A students and tutors perceptions was used to check of interest in reflective journaling (Langley and qualitative approach was employed to provide the credibility of data (Basit, 2010). The interviewer Brown, 2010) and a lack of understanding of the depth rather than breadth of information. The attempted not to influence the interview process. purpose, goals and benefits of reflective journaling researcher aimed to explore the reality of a small Confidentiality of information was maintained that was seen to lessen the students’ motivation to number of participants to ascertain their perceptions throughout the study (BERA, 2004). Before engage (Langley and Brown, 2010). Students found on the use of reflection in post-registration nurse proceeding with the study ethical approval was reflection difficult and required personal discipline education. Semi-structured interviews were used to gained from the local ethics committee. (Smith & Jack, 2005). Finally, students also found it collect data for this study; the most favoured type of All interviews were recorded and then difficult to associate themselves with writing down interview in health research (Polit and Beck, 2006). A transcribed by the researcher. Transcripts were negative experiences (Smith & Jack, 2005). series of semi-structured questions were formulated analysed using guidance from Graneheim and in advance of the interviews and the same questions Lundman (2004). Transcripts were read several the negatIve aspects of refLectIon were asked of tutors and students. Freedom of times to ensure immersion in the data and to Reflection can lead to a flawed perception expression about their perceptions enhanced the obtain a sense of the whole.. The text was divided of one’s own self and can be a selective and richness of data collected; the in depth discussion into meaning units; which are key phrases or misleading process (Newall, 1992; Smith & Jack, provided high validity. The aim of the semi- sentences which contain one idea. The meaning 2005). Some students are cynical about the structured interview was to promote self-disclosure units were abstracted and labelled with a code (see value of reflection (Langley and Brown, 2010; of participants’ thoughts and feelings (Morse and table 1). The various codes were compared based Smith & Jack, 2005). Although the sample was Field, 2002). The interviewer probed participants to on differences and similarities and sorted into not representative of the larger population explore their answers discovering information that categories and themes (see table 2).

April 2015 Community Practitioner 39 Professional and research

Table 2: A sample of data analysis to identify themes reflection to improve academic learning; Theme Benefits of Reflection in Post Registration Education Megan: ‘I don’t think I learned academically’ A view that is not supported by the literature Category Personal Benefits Benefits to Practice Benefits to Learning (Glaze, 2002). However, all tutors did highlight Code More insight into progress Improved practice Importance of process the benefits that reflection had in assessing made over product students’ understanding and decision making; Self-awareness Reflection on practice No academic learning a view shared by Smith & Jack (2005).

Improved organisation of Links theory to practice Enhances learning BarrIers to refLectIon thought All student and tutors thought previous negative Improved decision making Enhances future practice Honest reflection on experiences of reflection impacted upon students’ difficulties enabled further Improved empathy Improves problem solving progression through perception of reflection. Four students reported too course much reflection in post-registration nurse education; Identification of weakness Identify hidden areas requiring change which was burdensome. One student questioned Identification of the value of reflection due to flawed self-perception; strengths a view reflected in literature (Smith & Jack, 2005; Langley and Brown, 2010). One tutor believed that research fIndIngs and dIscussIon of identifying and addressing individual learning the students’ personality and experience affected their The results are presented alongside the discussion needs to enhance learning is well documented ability to cope with the negative aspects of reflection. to enhance the narrative and provide context. The (Petty, 2009). One student and tutor believed that All students felt they had a good knowledge freedom of expression during interviews offered a reflection assisted in the identification of hidden of the use of reflection and that it was a process rich source of data; providing recommendations for areas of a students’ practice that required change. A they used to improve their practice. However, all improvements in practice and further research. This view not reported in the literature reviewed. Further students acknowledged that the only time they qualitative approach created a depth of information research could unlock this potential for reflection to undertook academic reflection was as a part providing a greater understanding of the social improve students practice in areas unknown to them. of the summative assessment process on post- world as it is lived by post-registration students and Students only know what they have experienced or registration courses. In their experience they felt tutors. The research findings are presented under been taught. They do not know what they do not that the faculty had not adequately prepared them three themes identified from analysis of the data. know, and reflection can be used to unlock these for this reflection; a view shared by all three tutors. Using direct quotes from participants shows some hidden areas of practice for students. This would One of the greatest hurdles expressed by of the data from which the results emerge; helping create safer and more effective practitioners. students to the use of reflection was the lack of to illustrate the meaning and feeling of participants. All students and tutors believed that reflection time; a view expressed in the literature (Glaze, Pseudonyms are used in place of participants’ names improved nursing practice and one tutor 2002; Smith & Jack, 2005; Langley and Brown, to maintain confidentiality. The three themes are: included benefits to future practice; although 2010). Although the literature highlighted 1. Benefits to reflection literature questions the correlation of the use of the benefits of reflective journaling (Langley 2. Barriers to reflection reflection and being a good nurse (Smith & Jack, and Brown, 2010) one participant questioned 3. Improvements on the use of reflection in 2005). Participants alleged an improved ability whether students really kept a reflective diary. post registration education. to problem-solve and make decisions. ‘Not many people keep a reflective diary, do they?’ Students preconceptions of reflection based on Chloe: ‘it has helped me organise my thoughts Other external barriers to reflection were previous experience, shaped their perception of the better and helped me make decisions’ believed to be imposed by the faculty, including benefits of the use of reflection in their current course. However, questions can be raised about the restricting students’ freedom to select a reflective However, all six students felt that through the process validity of self-report as a method of data collection model and making the reflective exercise too of reflection they learned more about themselves, as it leaves room for response bias (Moskowitz, prescriptive. Students had been prevented from Karen: ‘I learn more about myself and my own 1986). Further quantitative research could be using Gibbs model of reflection and some students attitude and perhaps the attitudes of others’. used to investigate the validity of reflection and reported difficulty in choosing a reflective model A view supported by the literature (Glaze, improved decision making. However, Glaze that was acceptable to tutors. An internal barrier to 2002; Smith & Jack, 2005) and by all three tutors. (2010) reported reflection improves the nurses’ reflection expressed by one student was their own A strong argument for the benefit of reflection confidence to justify actions and support decision state of mind. If the participants had a positive self- was the ability to empathise with others; making in professional practice. perception, reflection would be an effective and Rachel: ‘more about the attitudes of others… One student and one tutor reported that balanced process; however, if the participant had stepping into others shoes being empathetic… reflection helps students’ link theory to practice, a a negative self-perception then reflection became looking at other people’s perceptions of things’ view shared by literature (Langley and Brown, 2010; an ineffective process that was unbalanced. A A view shared by all students and tutors. Evidence Schutz, 2007). Participants believed that reflection number of students found it difficult to write shows that empathy is reported as an integral helped them to focus on the process of learning down negative experiences, a view synonymous component of the patient-nurse relationship (Innes rather than the product of learning; a view supported with the findings of (Smith & Jack, 2005). et al, 2006). Reflection was also thought to identify by anti-behaviourist theorists, who believe that the students’ strengths and weaknesses, which is a setting learning outcomes can limit learning (Petty, suggestIon for Improvements useful skill when identifying learning needs. The value 2009). However, one student questioned the use of All students believed that reflection would be more

40 Community Practitioner April 2015 Professional and research

beneficial if students were given time to reflect on help improve nursing care through empathy, Innes A, Macpherson S, McCabe L. (2006) Promoting person- something they identified as important, a view improved decision making and critical thinking; centred care at the front line, Joseph Rowntree Foundation. Available from: www.jrf.org.uk/publications/promoting- shared by Smith & Jack (2005). Reflection should therefore time should be set aside to undertake pebon-centred-care-front-line [Accessed October 2013]. take place in a venue that provided privacy and reflection. This may involve tutors reducing Langley ME, Brown ST. (2010) Perceptions of the use of space; a view supported by Glaze (2002). All students other learning or assessment activities in favour reflective journals in online graduate nursing education. and tutors expressed the need to explore different of reflection. Tutors should also allow students Nursing Education Perspective 31(1): 12–7. models of reflection to maximise effectiveness. Both freedom to select a reflective model of their choice Lasater, K. & Nielsen, A. (2009). Reflective journaling for believed the faculty could facilitate this by delivering following exploration of different models, this would clinical judgment development and evaluation. Journal a lesson or module on reflection. All tutors felt that enhance student’s engagement in the reflective of Nursing Education, 48, 40-44. the student should be able to identify which model process. Tutors should take notice of other barriers Maclaren JA, Woods M, Smith J, Gilbert J, Diomo C, Villar- they found most effective. to reflection found in this and previous studies Hauser L. (2002) Reflecting on your expert practice. Nursing Times 98(9): 38–9. All students wanted tutors to be available each when using reflection in education. Faculties could week for open tutorial support or include a 15 improve students’ preparation for reflection and Mezirow J. (1991) Transformative Dimensions of Adult Learning. San Francisco: Jossey-Bass. minute reflective session at the end of a weekly offer regular support through# guided reflection lesson. Students believed they would benefit from enabling students to reach a higher level of thinking. Morse JM, Field PA. (2002) Nursing Research: the application of qualitative approaches. Spain: Nelson-Thomas. guided reflection by tutors; guided reflection has These recommendations could improve been reported as superior to personal or unaided the use of reflection in post-registration nurse Moskowitz, D. S. (1986). Comparison of self-reports, reports by knowledgeable informants, and behavioural reflection (Duffy, 2008). Most students and all tutors education and subsequently professional observation data. Journal of Personality, 54, 294-317 felt their suggestions for change would be easy and practice and patient care (Gustafsson and Newell R. (1992) Anxiety, accuracy and reflection: the cost effective to implement. However, one student Fagerberg, 2004), the major premise of nurse limits of professional development. Journal of Advanced felt sceptical about these changes; believing that education (NMC, 2004). Nursing 17(11): 1326–33. education was about outcomes and not quality, Nursing and Midwifery Council (2004) Standards of Rachel: ‘It’s a product world not one that is references proficiency for specialist public health nurses. London: NMC. interested in developing the individual. Organisations Asselin, M.E. (2011). Using reflection strategies to link course knowledge to clinical practice: The RN-to-BSN student Petty G. (2009) Evidence-Based Teaching: A Practical would not allow the time for reflection’. experience. Journal of Nursing Education, 50, 125-133. Approach. Oxford: Nelson Thornes. Basit TN. (2010) Conducting Research in Educational Platzer H, Blake D, Ashford D. (2000) Barriers to learning concLusIon Contexts. London: Continuum. from reflection: a study of the use of group-work with post- Overall this study set out to explore students and British Educational Research Association (BERA) (2004) Revised registration nurses. Journal of Advanced Nursing 31(5): 1001–8. tutors’ perceptions on the use of reflection in post Ethical Guidelines for Educational Research. Nottingham: BERA. Polit, D. F. and Beck, C. T. (2006) Essentials of Nursing Research: registration nurse education and as a result a number Bulman, C. (2008). Help to get you started. In C. Bulman Methods, Appraisal, and Utilization, Volume 1. London: Lippincott and S. Schutz (Eds.). Reflective practice in nursing (pp. Quality Assurance Agency (QAA). (2010) Benchmark of recommendations have been made which aim 219-242). Oxford, United Kingdom: Blackwell. statement: Health care programmes: health visiting. Available to improve the use of reflection in post registration Chirema, K.D. (2007). The use of reflective journals in the from: www.qaa.ac.uk/en/Publications/Documents/Subject- courses. Although the sample size of this study was promotion of reflection and learning in post-registration Benchmark-Statements-Common-purpose-Consultation- nursing students. Nurse Education Today, 27, 192-202 small the recommendations are an excellent starting draft-Health-and-Social-Care.pdf [Accessed August 2014]. point for tutors to consider when using reflection as Duffy, A (2008) Guided reflection: a discussion of the essential components. British Journal of Nursing, 7, (5) 334-339 Schön, D. A. (1987). Teaching artistry through reflection- a form of assessment or to enhance learning. in-action. Educating the reflective practitioner. San Glaze JE. (2002) Stages in coming to terms with reflection: Francisco, CA: Jossey-Bass Publishers. student advanced nurse practitioners’ perceptions of their LImItatIons reflective journals. Journal Advanced Nursing 37(3): 265–72. Schutz, S (2007) Reflection and reflective practice. Although tutors perceptions on the use of Graneheim UH, Lundman B. (2004) Qualitative content analysis Community Practitioner. 80(9):26-9. reflection were used to validate those of in nursing research: concepts, procedures, and measures to Smith, A. Jack K (2005) Reflective practice: A meaningful achieve trustworthiness. Nurse Education Today 24: 105–12. students further analysis could explore the task for students. Nursing Standard, 19, 33–37. Gustafsson C, Fagerberg I. (2004) Reflection, the way to relationship between their perceptions. professional development? Journal of Clinical Nursing Thorpe K. (2004) Reflective learning journals: From 13(3):271–80. concept to practice. Reflective Practice. 5(3):327–343 Key fIndIngs and recommendatIons Kerka S. (2002) Journal Writing as an Adult Learning Tool Van Horn, R., & Freed, S. (2008). Journaling and dialogue pairs to promote reflection in clinical nursing education. The key findings not found in previous literature (Report No. ED-99-CO-0013). Washington DC: Office of Educational Research and Improvement. Nursing Education Perspectives, 29, 220-225. were the use of reflection to identify the students’ strengths and weaknesses; a useful skill when identifying students learning needs. Tutors could Key points implement a reflective activity at the beginning of • The use of reflection in nursing post registration education improves practitioner’s ability to a learning experience to identify students learning empathise; make decisions; and bridge the theory practice gap needs. Also participants believed that reflection • Tutors and practice teachers should support students through guided reflection using guided reflective models to ensure higher level thinking could be used to identify hidden areas of practice • Those designing curriculums should ensure sufficient time is given to supporting reflection, requiring change. Dedicated time set aside for including reflective tutorials reflection could allow both tutor and student to • Tutors should allow students the freedom to select their own model of reflection to enhance explore areas in the students practice requiring engagement change, ensuring safe and effective practice. • Tutors should use reflection to assist students to identify their learning needs and gaps in their practice The benefits of reflective practice and journaling

April 2015 Community Practitioner 41 Professional and research

Early intervention for increased antenatal anxiety associated with foetal development risk

IntroductIon The period of 25 – 28 weeks of gestation rebecca balakrIshna (Formerly Rebecca Milford); Consultant Nurse, CAMHS, Findings published in 2002 from the Child are key in predicting incidence of autism Children’s Services, Weston Area Health Trust of the 90’s Study, revealed the detrimental (Beversdorf et al. 2005), and the first trimester effects on the developing foetus of when identifying links to schizophrenia MelanIe teIxeIra prolonged heightened states of maternal (Malaspina et al. 2008). The length and Assistant Psychologist, CAMHS, Children’s Services, Weston Area Health Trust anxiety (O’Connor et al. 2002). By identifying timing of exposure to intrauterine maternal correlations between maternal stress stress is an important factor, although any abstract: levels and several childhood cognitive and reduction may aid limitation of undesirable Evidence is growing, documenting the adverse effect emotional conditions, links between foetal consequences (Buss et al. 2012). Investigation of prolonged heightened states of maternal anxiety on the developing foetus. Recent Government neurological development and maternal into the effects of specific forms of stress is recommendations require a shift toward early perinatal mental health were established. inconclusive, but research suggests that identification and intervention for ‘at risk’ mothers. Ongoing research has continued to provide the relationship with partner can be a Following the successful development of the supporting evidence and increasingly more significant factor (Talge et al. 2013) in infant postnatal mental health and attachment care pathway in North Somerset in 2006, a new pilot specific information about the adverse outcome. Reducing maternal anxiety as was undertaken to create an antenatal pathway to consequences of intrauterine exposure to early as possible during pregnancy (or, more embrace these recommendations. Midwives were maternal stress to the infant and child. Links ideally, before) will have a positive impact on given a tool to identify women with high levels of between conditions such as Attention Deficit physical, mental and social health for ‘at risk’ anxiety, a menu of suitable options for specialist referral, and basic Mental Health training. Current Hyperactivity Disorder (ADHD) have been infants and children. services and potential additions were assessed to identified and documented (Rodriguez et The NSPCC 2013 All Babies Count Spotlight inform future planning. al. 2005) alongside autism (Beversdorf et al. report on perinatal mental health (Hogg, 2013) The tool was found effective in highlighting ‘at 2005), schizophrenia (Malaspina et al. 2008), has championed preventative interventions risk’ women, and midwives recommended changes in implementation. Midwives reported increased child depression (Van den Bergh et al. 2007), over reactive ones, highlighting how timely confidence in addressing maternal anxiety, following delayed language development (Laplante identification of antenatal mental ill health and training and receipt of a clear pathway. A higher et al. 2004) and atypical motor development provision of care is vital in reduction of harm to number of women requiring intervention were (Glover et al. 2004). both mother and child. The report identified identified than anticipated, and a geographic inequity of service identified. A pilot extension will address The identified association between 29% of midwives received no content on these issues and develop formal handover to health maternal anxiety during the gestational mental health in their pre-registration training, visitors by linking the antenatal and postnatal period, and lower levels of maternal-foetal and no training on perinatal mental health pathways. attachment, also presents serious mental services available (e.g. Improving Access to keywords and social health implications for infant Psychological Therapies (IAPT) (www.iapt. Antenatal Anxiety; Foetal Developmental Risk; and child (Alhusen, 2008). Raised levels of nhs.uk), or their role in signposting to these Antenatal Pathway; Early Intervention cortisol produced in women with exposure services. Another key finding is the current to excessive and enduring psychosocial ‘postcode lottery’ inequity of care. stress and the conditions discussed, have In his 2011 report to the government, been reliably linked. The placental barrier informing future policy in health and social care, enzyme 11-betaHSD2 (specifically its role in Graham Allen (Allen, 2011) draws particular metabolising cortisol) is key in regulating the attention to the importance of prioritising placental environment, therefore impacting perinatal mental health in women in order the neurological development of the foetus to reduce many of the previously discussed (O’Donnell et al. 2009). conditions identified in their children. The High levels of maternal anxiety during the report includes evidence of the potential 12-22 week period are identified as particularly effect of raised anxiety on the developing likely to predict outcomes of Attention foetal neurological system, and also addresses Deficit Hyperactivity disorder symptoms, the practical issues of funding intervention externalising problems and self-report anxiety within the public sector. Allen compares the in 8-9 year olds (Van den Bergh et al, 2004). cost of early intervention to lifetime costs of

42 Community Practitioner April 2015 Professional and research

the noted conditions, championing the cost Have you been experiencing stress, anxiety or panic attacks in the effective nature of early intervention. Whilst past two weeks? focusing on government fiscal cost reduction, he also recognised the considerable personal Yes No and social cost reduction that could be achieved by early intervention. Use the visual Allen identified a current bias toward analogue tool late intervention due to financial and institutional obstacles, despite the expense Score: Below 5 Score: Above 5 Previous/current and limited success. He proposed that the mental health illness NHS gives priority to early intervention or subjective Use HAD concerns of driven by local action. NICE guidelines on antenatal mental health, which already recommend the use of the ‘Whooley Below 8 8–10 Above 10 questions’ for the early identification of depression (National Institute for Health Routine health visiting and Clinical Excellence. 2007), are currently service and sure start under review and are expected to reflect this pack given refocus. Guidelines for the commissioning Inform health visitor of public health services for children Inform GP. Consider Inform for increased visits and Commissioning of Public Health Services NICE guidelines APMHS children’s centre referral for Children, (DH, 2014) reiterates the Box 1: Initial question and suggested pathway importance of identification of a broader range of mental health issues during the perinatal period and call for stronger links emphasising the importance of developing pathway involving the local midwifery team between midwifery and health visiting to regional strategies and pathways focusing as the lead. aid both identification and service provision. on this area of health, to deliver an effective The partnership between PCT and local The 2013 Report for the All Party and equitable service, with all health care authority in North Somerset at the time of Parliamentary Sure Start Group (All Party providers participating and compliant. the pilot inception clearly outlined a key Parliamentary Sure Start Group. 2013) The importance of training health care objective of ensuring the best possible identified a need for stronger links between professionals, particularly midwives, start for all babies and young children and midwifery, health visiting and children’s health visitors and GPs in perinatal their families, particularly ensuring the most centres, for effective early intervention, mental health and regional pathways is vulnerable families receive support as early ideally delivering all perinatal services ‘under highlighted, as well as recommending that as possible. They suggested strengthening one roof, with midwifery, health visiting and maternity services have access to perinatal links with the midwifery teams to ensure children’s centre services all being accessed mental health teams and to designated all families are aware of their local children from the children’s centre’. A refocus on specialist clinical psychologists. They centres before their baby is born and those the ‘age of opportunity’ (the period from also recommend improved availability of most in need of services are referred by their conception to age 2) was called for, based on timely treatment for pregnant women and midwives. Midwives therefore were key in evidence provided by The Wave Trust (The that related data should be collated with developing early assessment and referral. Wave Trust. 2013), who, commissioned by the regularity. Increasing the awareness of midwives of Department of Education, recommended the potential lifespan consequences of that midwives and health visitors should be developMent of the antenatal high levels of antenatal maternal anxiety using questionnaires to identify potential Mental health and attachMent was the initial focus and increasing their mental health and relationship issues. care pathway confidence in identification of the most Another key recommendation of the report In 2006 a pilot to develop a postnatal vulnerable women. An identification was ensuring early intervention is at the maternal mental health and attachment process was created and a menu of services heart of the 2016-2018 Comprehensive care pathway was driven by the local to refer onto, to support them in this task. Spending Review, with a commitment to CAMHS team in conjunction with the Health The group also focused on local mental a 2-3% shift in spending from late to early Visitors and a core team of other agencies. health services, raising their awareness and intervention. Following completion the pathway was encouraging them to prioritise pregnant The ten key messages in the 2012 rolled out across the county (Milford et women. Current services were assessed and Guidance for Commissioners of Perinatal al. 2009). The same CAMHS team and developed to include specifically targeted Mental Health Services made by the Joint multi agency core group then responded facilities. The intention was that this Commissioning Panel for Mental Health to the emerging research on antenatal would inform the process of developing a (Joint Commissioning Panel for Mental maternal distress and planned a further formal pathway, and improving the equity Health. 2012) include similar themes, pilot focussed on delivering an antenatal of service throughout North Somerset.

April 2015 Community Practitioner 43 Professional and research

The percentage of women identified was and consent obtained. assessment. However, through discussion predicted to be 10-12% based on figures whilst completing the visual analogue, 17% previously collated for women experiencing care pathway developMent of women scoring 5 were also identified high levels of anxiety postnataly (Milford et Several additions were made to services as requiring additional input, due to other al 2009). already in place, specifically targeting information available. pregnant women: The midwives also reported that the pIlot InvestIgatIon Provision of the Mellow Bumps (Macbeth improved care pathway, presented as a A small scale pilot was conducted to assess et al 2013) course at the Central Children’s menu for referral, increased their confidence the likely effectiveness of the proposed Centre, to be offered to all highlighted about how to access appropriate support implementations. The reviewed literature women, with the intention of rolling this and subsequently increased their suggests that the earlier high levels of out across more children’s centres as need confidence in asking the question. Gaps maternal stress are identified and reduced, dictates. in the services and problems with certain the more positive the outcome for the infant Positive Steps agreement to prioritise areas of referral were highlighted, including (Buss et al 2012). Guided by this and current pregnant women to reduce waiting times lengthy waits (despite the prioritising of timings of antenatal appointments, it was for one to one and group therapy. pregnant women) by service providers decided that mothers would be screened at Mental Health Specialist agreement to and services not always fitting specific their routine 12 week midwife appointment. provide one to one sessions teaching need. Women participating in the pilot Three community midwives from the core short term coping strategies, breathing wanted timely 1:1 conversations with a group were recruited to apply the screening techniques, resource anchors and self mental health professional, increased social process over a three month period. The soothing techniques, with the intention of networks and child care facilities. The group process needed to be simple to encourage moving toward running weekly sessions therapy sessions routinely offered by IAPT usage by midwives in their already time alongside the Blue to New mental health (www.iapt.nhs.uk) were often not what the pressured appointments. It also needed drop in. women wanted and so failed to engage to fit well with current tools used in both them. Midwives reported that there was ante natal and post natal care by midwives Four members of the core group provided some reluctance by women to use the and health visitors, to ensure usefulness the Mellow Bumps course, led by the CAMHS improved online self-referral facility. The and ease of information transfer. Current consultant nurse and the health visitor. The midwives indicated that training received ante natal questions focusing on mental HAD was used at the beginning and the during the pilot (Mental Health First Aid health tend to focus on depression (or a end of the course, and three months later, and Solution Focus Brief Therapy) had combination of anxiety and depression), for mothers who chose to attend, to assess greatly increased their confidence and so the following question, visual analogue the effectiveness of the course at aiding knowledge and had led to more profitable tool and subsequent possible pathway the reduction of Anxiety and Stress during conversations with the women they were (Box 1) was implemented alongside them. this period. Using an identical system of supporting. The HAD was considered For women answering ‘yes’ to the initial anxiety level identification in screening and useful in differentiating between anxiety question, a Visual Analogue Scale was appraisal of service minimises confounding and depression but a tool with more devised to encourage mothers’ scaling of variables and enables comparisons to be appropriate language and matching their anxiety levels. A score of over 5 was made. assessments made on other occasions used as a trigger for using the Hospital was suggested. Anxiety and Depression Tool (HAD). The analysIs of pIlot data The percentage of women presenting HAD was chosen as an already familiar and Pilot feedback from participating midwives with heightened anxiety at 15 weeks was widely used tool for Health Visitors. Mothers was predominantly positive. In particular 23%, or 61% dependant on criteria used. This identified as medium risk and high risk using the pathway encouraged and supported is considerably higher than the anticipated the HAD were offered additional support. them in their awareness and identification 10-12%. Whilst the high percentage of The midwives were provided with an of the specific issue of heightened anxiety women scoring ‘5 or over’ may suggest Ante-Natal Mental Health Referral Pathway in pregnancy. They found the information that this criteria is too broad, the midwife (Box 2) to aid them in appropriate referral. provided by the pilot regarding the impact who used only ‘over 5 as her criteria found Information about suitable resources on the unborn foetus, increased their 17% of those scoring 5 needed further and services available were given to the understanding of the important implications, referral due to further information gleaned mothers, as well as referral being made by which encouraged them to make the time in conversation. This suggests that a score the midwife to GP, health visitor and mental to assess and refer on, when appropriate. of ‘5 or over’ may be a better trigger for health specialist. The pilot was approved by They found the 15 week appointment most further assessment. One woman scored 0 the Health Trust audit, research and clinical suitable for asking the question and making but had low mood, was known to mental governance team and considered to be the assessment, as the 12 week booking in health services already, and refused to be an extension of the service development visit was often too busy. The question and assessed with the HAD. This demonstrates previously untaken. An information sheet analogue scale were found to be useful the need to use the analogue scale as an was given to every participating mother in raising the issue in clinic and for quick aid to identification of need rather than identification of women suitable for further a definitive process. Judgment using

44 Community Practitioner April 2015 Professional and research

other information available will also be of Moderate High great value. Concern Concern dIscussIon and Referral to Referral to recoMMendatIons G.P. Adult G.P. Adult The pilot has been very effective in PMHS PMHS meeting the objectives of increasing the and Health and Health midwives’ awareness of the important Adult PMHS Fast Track potential lifespan consequences, of high and G.P. Adult PMHS and Midwives’ Referral to Assess, levels of antenatal maternal anxiety. Short Term Coping Secondary Advise, There is a clear need for training to Strategies: Breathing Mental Deliver raise awareness and confidence for all Techniques Health Specific midwives to encourage assessment and referral for support as soon as possible. Advice, Counselling, Adult PMHS – Joint Risk factors to the unborn foetus must be Shared Care Plan Up to 6 Listening Visit, Liaise with discussed as well as increasing knowledge Developed with Mother, Visits, Signposting, Midwife, Health Partner, Secondary Mental of current government requirements and NICE guidelines, Visitor, GP, Develop Health Team, Midwife, G.P cost implications. Participating midwives EPNDS Shared Care Plan suggested training include Mental Health First Aid and Solution Focus Brief Therapy, having attended these two courses MENTAL HEALTH CORE themselves and finding them informative CARE PLAN OTHER CARE PACKAGES SECONDARY MENTAL and empowering. These courses are HEALTH Home-Start already available in North Somerset, Children and Young People’s Services – Family Support (with GP involvement) being run by members of the core team. Workers Baby Massage Course Health visitors as well as midwives are now Planning of Secondary Mental being offered Mental Health First Aid and Family Information Service Children’s Centre Activities, Health services involvement. Solution Focus Brief Therapy training as Groups and Drop-Ins well as Attachment Training to increase Housing Advising current Mental Health Management, then awareness and confidence. All midwives Parenting Classes Mellow Bumps step down. should use the question and analogue scale routinely at 15 weeks and in future, Antenatal Mellow Parenting Antenatal PEEP Remaining involved as active the midwifery leads should consider case with secondary services, Changing Patterns earlier identification of need as ideal, Parent Wise – Time out for including access to Crisis parents Service etc. including these questions in Early Bird Blue to New Drop In clinics (targeting newly pregnant women Clinic CAMHS – Attachment Work or those wishing to become pregnant) Breast Feeding Peer Support as this may provide a way of assessing Mental Health Specialist- women even earlier. ways forward, meeting with The pilot has also provided referrers encouragement and motivation for engagement from other local mental health services and agencies in providing Box 2: Example of referral pathway immediate support. Engagement has included pregnant women being prioritised by mental health services Strategic planning must take place to Two of the new initiatives (Mellow Bumps (faster appointment times), the care replicate new services that have been (Macbeth et al 2013) and Thrive) have pathway being extended (e.g. Thrive drop found to be effective at regular time and addressed these issues well, and need in combining many resources in a one geographic intervals, ensuring greater to be rolled out at regular time intervals stop shop) and improved provision of equity of service. Reasons given for women (possibly 2-3 times a year) and in varying extra facilities (e.g. Mellow Bumps group not engaging with support offered were locations. Mellow Bumps provided a (Macbeth et al 2013). Pregnant women Lack of suitability due to preferring 1:1 course specifically for pregnant women are also being encouraged to utilise conversation rather than group sessions aimed at reducing anxiety, promoting self children’s centre services. There remain Lack of child care care and maternal sensitivity. This group identified gaps in the care pathway, due Length of time waiting for support also increased their social networks and to lack of geographically similar services Need for improved social networks provided childcare. Thrive was developed and services not fitting women’s needs. Reluctance to self-refer online. at two Children’s Centres, combining

April 2015 Community Practitioner 45 Professional and research

several previously provided groups. These Key points included a 1:1 mental health drop in for support and signposting, weaning/ • High levels of maternal anxiety during the antenatal period have an adverse affect on foetal breastfeeding groups and a new rolling development • Government recommendations are to improve early identification and treatment of ‘at risk’ programme of sessions on mental health women self help techniques and giving information • Recommendations have been made for effective early identification of ‘at risk’ women and on other health and social needs (e.g. services available for referral have been evaluated and improved housing/finance/health and safety etc.). • A formal handover between midwives and health visitors is needed, linking antenatal and postnatal mental health pathways Child care was provided, increased social networks encouraged and waiting times were short, due to running the group twice current Governmental shift toward early linked with atypical handedness in the child. Early weekly. intervention. Evaluation of current service Human Development 79 107-118. Following pilot feedback, the HAD will provision (including pilot additions) Hogg S.(2013) Prevention in Mind – All Babies Count: be replaced with the GAD7 and PHQ-9 revealed a notable geographic inequity Spotlight on Perinatal Mental Health, NSPCC. as a tool for measuring anxiety and low of service and highlighted services users Joint Commissioning Panel for Mental Health. (2012) mood because IAPT services, GP services obstacles to engagement. Commissioners’ Guidance for Commissioners of Perinatal Mental Health Services, Vol. 2. Practical Mental Health and health visitors have already moved to participation will be key in resolving the Commissioning. these tools, and it will ease cross service gaps in service and providing appropriate Laplante et al. (2004) Stress during pregnancy affects evaluation and continuity of care between and useful future resources. Two of general intellectual and language functioning in midwives and health visitors. They were also the pilot additions to services (Thrive human toddlers.Pediatric research 56(3), 400-410. considered by midwives to be worded more and Mellow Bumps) were successful in Macbeth A et al. (2013) A Pilot Evaluation of Mellow usefully. addressing some of the issues raised by Bumps – An Attachment Based Antenatal Intervention, Percentages of ‘at risk’ women were service users. The expected number of University of Glasgow. higher than expected, implying a greater women reporting heightened levels of Malaspina D et al. (2008) Acute maternal stress in need for support services than previously anxiety was higher than anticipated, and pregnancy and schizophrenia in offspring: a cohort thought. However, further data needs to be evidence suggested that a score of ‘5 or prospective study. BMC Psychiatry Volume 8:71. collected to assess whether this is a typical more’ might be more useful rather than Milford R, Oates J. (2009) Universal screening and early percentage and an extended pilot will ‘over 5’ to trigger the application of mood intervention for maternal mental health and attachment include a wider geographic area and a larger scores. GAD7 and PHQ-9 mood scores were difficulties. Community Practitioner, 82(8): 30-3. sample of women. The pilot will continue to found more appropriate than the HAD. National Institute for Health and Clinical Excellence. assess the efficiency of the current service A pilot extension has been approved by (2007) Antenatal and Postnatal Mental Health, Clinical management and service guide. additions, extensions and prioritisations, service leads to assess whether findings are whilst extending them. It will also include consistent over a larger and geographically O’Connor et al. (2002) Maternal antenatal anxiety and children’s behavioural/emotional problems at 4 formally linking the antenatal and postnatal different population and will develop years. Report from the Avon Longitudinal Study of pathways (The Wave Trust. 2013), used by a formal handover procedure to health Parents and Children. British Journal of Psychiatry, the health visiting team, to move away from visitors by linking the antenatal and 180, 502-508. the current ‘goodwill’ based cooperation postnatal pathways. It will also assess the O’Donnell K et al. (2009) Prenatal stress and between professionals. This will aid health usefulness of adjustments made following neurodevelopment of the child: focus on the HPA axis visitors in identifying ante natal visits which the initial pilot. and role of the placenta. Institute of Reproductive need prioritisation. During the pilot, health and Developmental Biology, Imperial College London, London, UK. visitors will identify whether anxiety levels references Rodriguez A, Bohlin G. (2005) Are maternal smoking and are effectively reduced in the ensuing Alhusen J. (2008) A literature update on maternal- stress during pregnancy related to ADHD symptoms in postnatal period. foetal attachment. Journal of Obstetric, Gynecologic & Neonatal Nursing 37(3): 315-328. children? Journal of Child Psychology and Psychiatry and Allied Disciplines Mar; 46(3):246-54. Allen G. (2011) Early Intervention: Smart Investment, conclusIon Massive Savings, The Second Independent Report to Talge N, Neal C, Glover V. (2013) Antenatal Maternal Stress In conclusion, the pilot highlighted the Her Majesty’s Government. and Long Term Effects on Child Neurodevelopment: need for specialist training, appropriate All Party Parliamentary Sure Start Group. (2013) Best How and Why? J Child Psychol Psychiatry, 2007, Mar- tools for identification of ‘at risk’ women Practice for a Sure Start: The Way Forward For Children’s Apr; 48(3-4):245-61. Centres, 4Children. and referral menus of current local services. The Wave Trust. (2013) Conception to Age 2 – The Beversdorf D et al. (2005) Timing of Prenatal Stressors This resulted in increased confidence Age of Opportunity: Framework for Local Area Service and Autism. Journal of Autism and Developmental Commissioners. in midwives in addressing the issue of Disorders, Volume 35 No 4. Van den Bergh B et al. (2007) Neuropsychopharmacology prolonged heightened levels of maternal Buss C et al. (2012) The role of stress in brain 33(3) 536-545. anxiety. It also highlighted training needs development: The gestational environment’s long-term effects on the brain. Cerebrum April. of other key workers, health professionals Van den Bergh B, Marcoen A. (2004) High Antenatal DH. (2014) Commissioning of Public Health Services Maternal Anxiety Is Related to ADHD Symptoms, and service providers in understanding for Children. Public Health Contribution of nurses and Externalizing Problems, and Anxiety in 8- and and meeting this specific need. This midwives: guidance. 9-Year-Olds. Child Development, Volume 75, Issue 4, service development is in line with the Glover V et al. (2004) Antenatal maternal anxiety is pp 1085-1097.

46 Community Practitioner April 2015 Last Word Lisa Bayliss-Pratt Health Education England

Educating practice teachers and specialist practice mentors for their new role

ince the health Visitor via an end of project report that was well received survey was undertaken of over 700 practice Implementation Plan 2011–15: A Call and has gone on to attract much national and teachers, mentors, clinical managers and health to Action (Department of Health, international interest. visiting students. While the respondents indicated 2011), the profile of practice teachers For the first time ever, we have a good a generally positive response to the evolving and specialist mentors has been understanding of what a good and indeed a bad models of practice learning, the expectations Sraised considerably which presented a real practice placement looks like from the collective associated with these emerging roles and the opportunity to strengthen and grow the health views of student health visitors, practice teachers educational preparation and support provided for visiting workforce. This drive to increase numbers and mentors, service managers and clinical leads. them was unclear. has placed unprecedented pressure upon This engagement has enabled HEE to access Consequently, the report presents national role health visiting practice teachers to manage the qualitative information from every geographical descriptors for practice teachers and specialist educational preparation of a greater number of area of the country that has been used to practice mentors offering employers a framework students, which has resulted in the emergence enhance the quality and consistency of student to inform person specification. A competency of mixed placement models. In addition to this, placement learning and student support through framework for practice teachers and specialist the newly expanded health visiting workforce the development of common expectations and practice mentors is also described with related includes a high percentage of new and recently standards. It also gave a clear understanding recommendations for future education, training qualified practitioners who require robust of the educational roles, responsibilities and and continuing professional development. preceptorship and support. educational preparation that will enable the best Given the plethora of evidence indicating the In February 2014, Lynne Hall, Health Education use of the educational and clinical expertise of impact of the socio-cultural learning environment England (HEE) Clinical Advisor, initiated and practice teachers and mentors both now and in on the development of professional practitioners, then co-led with Pauline Watts, the Department the future. HEE have developed a number of organisationally of Health Visiting Professional Officer, a broad Practice teachers and mentors represent a focused standards for assuring quality in practice reaching Task and Finish Group. The purpose group of educationalists whose clinical and placements, also detailed in this report. They of this was to enhance quality and consistency educational expertise expands over a number of facilitate the strategic managing of practice of student placement and student support specialist community nursing practice disciplines, learning at all levels within the host provider and through the development of common standards and it is therefore important that any proposed have the potential to form part of the annual and expectations, and promotion of clearer changes or developments in how the roles are quality monitoring applied to all commissioned understanding of roles and responsibilities and defined and developed are considered in this education. Finally sharing best practice and using educational preparation. context. evidence as a basis for practice is an important The goals were to examine current models Consequently, while the primary focus of the foundation for effective practice-based learning. and experience of learning in practice, review report is centred on health visiting education, The potential to exploit technology to support the evidence base related to effective learning the findings presented have resonance across this critical engagement across the wider health in this milieu, and develop standards and all specialist community nursing practice visiting community is also considered. recommendations commensurate with excellent disciplines, nursing and other non-medical health visiting practice education. practice learning situations. In order to establish The report can be accessed from In October 2014, the Task and Finish Group current practice and experiences, a nationwide http://ow.ly/CNAYX produced a long-awaited set of resources that will help the health visiting profession to deliver placement excellence, and services that are This drive to increase numbers has placed unprecedented underpinned by access to high quality practice learning environments. pressure upon health visiting practice teachers to manage the These resources were successfully launched at education of a greater number of students. the CPHVA Annual Conference in November 2014

April 2015 Community Practitioner 47 Courses & Recruitment Community PRACTITIONER www.communitypractitioner.com | www.unitetheunion.org/cphva CONTACT: Claire Barber dl 020 7878 2319 e [email protected] Practice Lead (Early Years) Are you looking Agenda for Change Band 7 (£31072-£40964) Are you an experienced qualifi ed Health Visitor ready for an exciting to recruit heAlth leadership challenge? Highland Council has two vacancies for full time (37.5 hrs) Practice Leads visitors And (Early Years) to work alongside Practice Leads in School Years and Care & Protection services as part of an integrated Family Team. The Practice Lead (Early Years) will lead a group of Health Visitors and Community other community Early Years Practitioners with a responsibility to deliver universal and early intervention services to families with children aged 0-5 years. We prActitioners? are looking for experienced Health Visitors with excellent communication and team working skills and who are keen to develop the benefi ts of integrated services to achieve better outcomes for children and their Call us today to get your role seen families. This is an opportunity to become a leader at a time when the Scottish Government is implementing the Scottish Health Visiting Review by the people best qualified for recommendations with an increase in Health Visitor training places and additional posts across Scotland. the position. Practice Lead (Early Years) posts are currently available in the Sutherland and the East Ross districts of Highland. (Posts for Band 6 qualifi ed Health Visitors are also available in various For more information or to locations across Highland) advertise in Community Practitioner’s For further information contact Susan Russel, Principal Offi cer (Nursing) on 01463 702870 or email [email protected] recruitment section, call our advertising team: 020 7878 2319

To enquire about advertising & vacancy call 020 7878 2319 Diary Community TO ADVERTISE PRACTITIONER www.communitypractitioner.com | www.unitetheunion.org/cphva CONTACT: Claire Barber dl 020 7878 2319 e [email protected] WWW.BABYMASSAGETEACHERTRAINING.COM CPD accredited events for For Children’s Centre Staff Family Health Professionals and Parent Practioners healthcare professionals Two Day Teacher Training in Developmental Baby Massage All our seminars and webinars are free to attend for those who are registered with the Hipp Hub healthcare professional website. Places are limited so register early to with Peter Walker avoid disappointment. UK/ International – Recognised Teaching Certificate Accredited by Federation of Pre Natal Education. Feeding infants – is less more? – with Professor Atul Singhal. A Physical Therapist, International Author and Yoga Teacher Professor Singhal will review current evidence and thinking on early nutrition, with 35 Years Teaching Experience particularly in relation to protein levels in formula milk and feeding practices.

Key principles of underpinning neuroscience, psychodynamic and child Dates: development empowering parents to form a warm positive relationship with Tuesday 28th April at the Royal College of Surgeons of England, London at 6pm their baby and secure their baby’s development from birth to standing. Wednesday 13th May at the Solent hotel and spa, Fareham, Hampshire at 6pm Wednesday 3rd June at Colwick Hall, Nottingham at 6pm This course includes ; ‘Peter Walker is well known in the baby Register at www.hipp4hcps.co.uk 1) A Holding Reassurance Programme massage field. Can be taught both Prenatal and It was therefore to him that we turned Child development – with Juliette Francis Postnatal from Birth to Eight weeks when setting up training days. These An appreciation of child development can help us to meet the needs of children, as a) Secure Attachment days have been a huge success and well as understand what might happen if we don’t use this knowledge to its best b) Introduction to Baby Massage resulted in baby massage being advantage. While responding to the many and varied challenges they experience, it c) Making Tummy Time Easy offered free to parents in health can be easy to lose sight of neuro-typical development. This webinar will explore the centres and clinics throughout the UK development stages and transitions experienced by young children as well as recent 2) Developmental Baby Massage research concerning brain development. Eight Weeks to Standing Sarah Forester RGN HV Cert. Ed. Wednesday 7th October online at 6pm d) Full baby massage routine to Professional Officer (Education) Register at www.hipp4hcps.co.uk secure potential at each stage of Health Visitors Association, (Baby development including elementary Massage - Piatkus Books) motor delay and correction e) Primary preparation for sitting and ‘In House Courses’ given throughout UK standing TriYoga 3) Infant Balance and Good Posture Camden Works Using gravity for stronger foundations 57 Jamestown Road Primary preparation for sitting and London Touch-Learn International’s Baby standing NW1 7DB on the 27th and 28th June 2015 Massage Teacher Training Programme High quality resource: A copy of Peter Tel: 01752216106 Venues across the UK, plus in-house ● Practical teaching in the field Walker’s international best selling book Mobile: 07833072255 option. A five-day, comprehensive baby ● Relevant anatomy and physiology ‘Developmental Baby Massage’ plus a massage course for health professionals ● Quality supporting materials and full set of course notes and DVD given Post course support given for all teachers and parenting practitioners provided books to all students. Email; [email protected] by Touch-Learn International, the exemplary training company. This highly ● Summative assessment acclaimed programme is accredited ● Free, informative biannual newsletter by the Guild of Sensory Development ● Tutorial and on-going support (GofSD) and the University of ● Free membership of the GofSD. Wolverhampton. This quality training programme Other courses from Touch-Learn in includes simple massage techniques, Learn Baby Massage with the International 2015 coupled with an in-depth knowledge Association of Infant Massage to practise safely, ethically and ● Massage for Babies with Special professionally so practitioners feel Needs Train to become a Certified Membership of the IAIM UK confident to teach parents in a variety ● Baby Yoga Teacher Infant Massage Instructor with Chapter includes: of settings. ● Baby Signing Teacher the International Association of ● A local, national and international Included within the course: ● Baby Wearing Advisor Infant Massage (IAIM), the largest support network ● Strategies to empower parents and longest standing worldwide ● Continued professional development ● All mechanisms identified in current For further details of in-house training association solely dedicated to baby including study days with expert research to support parent-infant and UK dates please visit massage. Our curriculum is taught in speakers, trainer-led massage stroke relationships www.touchlearn.co.uk. more than 45 countries and has been refresher sessions and a biennial ● Underpinning theory based on developed and refined over 30 years international conference current research through research, reflective practice ● Access to relevant articles, information Touch-Learn International Ltd and practical experience. This has and the latest research on our website Tel: 01889 566222 [email protected] ● resulted in a widely endorsed and A regular newsletter. www.touchlearn.co.uk implemented parenting programme. Our training courses are run regularly at Our highly acclaimed comprehensive centres nationwide and are facilitated by Millpond Children’s Sleep Workshop – training comprises: experienced IAIM Trainers. ● A four-day training course including Training NHS professionals since 2007 supervised practical teaching of a Find us on Facebook - IAIM UK Chapter 100% of delegates would recommend to a colleague parent/baby massage class London: Tuesday 15th September 2015 ● Plan a range of sleep techniques ● A take home written assignment For further details please visit Our popular one-day interactive ● Evaluate intervention ● Further practical teaching and www.iaim.org.uk. In-house workshop, designed for professionals reading. trainings are available on request. working with families with babies £175 through to school age children. EARLY BIRD PRICE £160 before end By training with our highly respected IAIM (UK) Chapter July ‘15 organisation you will join a worldwide 0208 989 9597 ● Explore sleep cycles/needs network of instructors offering a [email protected] ● Understand sleep problems T: 020 8444 0040 supportive environment to teach www.iaim.org.uk ● Interpret sleep information E: [email protected] life-long parenting and relaxation skills. questionnaires and diary W: www.millpondsleepclinic.com