Supporting Health Visitors and Fostering Resilience Literature Review
Authors: Ann Pettit and Rachel Stephen March 2015
Developed by the Institute of Health Visiting on behalf of Health Education England and the For more information see www.ihv.org.uk Department of Health © Institute of Health Visiting 2014 Supporting Health Visitors and Fostering Resilience Literature Review
Reader information box
Audience Health visitors Health visitor service providers Strategic leads health visiting practice Local authority commissioners Local authority councillors NHS and Public Health England area teams Health Education England commissioners (Local Education and Training Boards) Providers of health visitor education including higher education institutions, private providers, charities and other voluntary sector organisations
Document purpose This document provides health visitors and organisations with evidence-based information about supporting the health visiting workforce and building resilience.
Title Supporting Health Visitors and Fostering Resilience –Literature Review (2015)
Publication Date March 2015
Cross reference documents Developing Resilience with Compassion: A Health Visiting Framework, Managers’ document (2015) Developing Resilience with Compassion: A Health Visiting Framework, Practitioners’ document (2015)
Review Date: March 2016
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The Institute of Health Visiting is a Centre of Excellence: supporting the development of universally high quality health visiting practice; so that health visitors can effectively respond to the health needs of all children, families and communities; enabling them to achieve their optimum level of health, thereby reducing health inequalities.
Acknowledgements We would like to thank all the children and families who have enriched our health visiting practice and inspired this literature review.
Thanks to all the health visitors who have shared their views and personal stories. We are creating knowledge together about how to build resilience with compassion in health visitors. Through engaging in this narrative we hope to transform culture and facilitate the development of compassionate relationships where health visitors can express their vulnerability and be responded to compassionately.
Special thanks to all the members of our task and finish group particularly Sue Burridge who coordinated the recruitment and retention subgroup, and to all our expert advisors. The contributions of Prof Dame Sarah Cowley, Prof Ros Bryar, Robert Nettleton and our colleagues at the Institute of Health Visiting have been invaluable.
Task and Finish Group Martin Munro (HR Director, NELFT/iHV), Caroline Ward (Assistant Director of Children’s Services, NELFT), Chris Manning (Doctor, Action for NHS Wellbeing Chair), Paula Carr (Family Partnership Model Supervisor), Paulette Kerr (iHV Regional Lead South), Helen Lake (Restorative Supervisor), Anne Sinclair (Health Visitor (HV), Central London CH Trust), Rachel Fulford (HV, Ealing Hospital NHS Trust), Sue Burridge (Practice Teacher, NELFT), Ruth Hudson (Practice Teacher, Virgin Care), John Lawrence (HV, Royal Marsden), Karen Whittaker (Senior Lecturer, University of Central Lancashire), Sue Mills (Health Visiting Locality Lead, Bedfordshire and Hertfordshire).
Expert Advisors Professor Paul Gilbert ( Derby University; Director of Compassionate Mind Foundation), Professor Aidan Halligan (Director of Education UCL, Director of Well North), Professor Angie Hart (University of Brighton), Caroline Hudson, Josh Cameron and Penny Lindley (Senior Lecturers, University of Brighton), Juliet Hopkins (Consultant Child Psychotherapist), Naomi Misonoo (Clinical Psychologist), Paquita De Zulueta (Honorary Senior Clinical Lecturer Imperial College London), Professor David Peters (University of Westminster; Centre of Resilience), Dr. Stephen Pettit (Reader, Cardiff University), Ruth Rothman (Education Manager, Family Nurse Partnership), Mark Williamson (Director, Action for Happiness). Finally we would like to thank our families and friends whose love and care have enabled us to remain compassionate and resilient.
Ann and Rachel
This literature review was commissioned and supported by Health Education England and the Department of Health. © Institute of Health Visiting, Feb 2015
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Contents
Executive summary 7 Background 7 Methodology 7 Key findings 7 Conclusion 10 Recommendations 12 Introduction 13 Literature search strategy 14 Positive practice environments 15 Models of support 17 Supervision 17 Safeguarding supervision 18 Key points safeguarding supervision: 19 Clinical supervision 20 Restorative supervision 21 Key points: supervision 22 Mentorship 23 The ideal mentor 23 Mentoring and health visiting 24 Key points: mentoring 25 Coaching 26 What is coaching? 26 How coaching differs from mentoring 26 Evidence for the effectiveness of coaching in the NHS 26 Key points: coaching 28 Courageous conversations 29 Why it is important to consider courageous conversations 29 Open-to-learning conversations 30 Key points: courageous conversations: 31
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Relationship-based models of intervention 32 Rationale for the inclusion of relationship-based models within the framework 32 Solihull Approach 33 How does the Solihull Approach work? 34 Family partnership model 35 Mellow parenting 36 Strengths based approach 37 Lessons from the Family Nurse Partnership model (FNP) 38 Support framework for Family Nurses 38 Key points: relationship models of intervention 42 Action learning 43 Balanced approaches 43 Unbalanced approaches 44 Action learning sets 44 Key points: action learning 45 Performance feedback 46 The principles of effective feedback 46 Multisource (360-degree) feedback 46 After action review 48 Key points: performance feedback 49 Interagency / disciplinary groups 50 Work discussion groups 50 Schwartz Centre Rounds® 51 Compassion circles™ 51 Key points: inter agency groups: 51 Peer support 52 Peer support in practice 53 Adverse outcomes 54 Key points: peer support 54 Potential outcomes of implementing the models of support 55
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Resilience 55 Definition of resilience 56 Professional resilience 56 Education and training to build resilience 57 Characteristics of resilient individuals 58 Key points: resilience 59 Compassion 60 Key points: compassion 61 Self-compassion 62 Key points: self-compassion 62 Compassionate resilience 63 Compassionate resilience 63 Enhancing self-awareness 63 Being in the now 64 Developing acceptance 65 Expressing vulnerability 65 Building supportive relationships 65 Fostering hope 66 Key points: compassionate resilience 66 Towards a resilience framework 67 Conclusion 69 Recommendations 72 Future research 73 References 74
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Executive Summary
Background To support the Health Visitor Implementation Plan, the Department of Health has funded a number of interventions aimed at realising the benefits of the expanded health visitor workforce.
The work is commissioned via Health Education England (HEE), and one of the interventions is the development of a support framework for health visitors. A number of key publications provide the contextual background in exploring how to effectively support health visitors to foster their resilience. Bryar et al (2012) describe a range of components of a positive practice environment, and the factors to consider in the recruitment and retention of health visitors have been outlined by Whittaker et al (2013). The importance of organisational culture is also emphasised by the Francis Report (2010) in order for the NHS to deliver services and professional practice in line with the core value of compassionate care. Hence, resilience is not a value in its own right, but a key requisite for practitioners and organisations to deliver compassionate and effective care. The working assumptions of this review are that this places demands on the resilience of the NHS and its workforce. In order to retain an expanded and renewed health visiting workforce, this review highlights some key questions about approaches to the support of health visitors that will foster their resilience and help retain them within the workforce to deliver compassionate care in health visiting practice.
The questions considered as part of the review were: What models of support or mechanisms are available to, and used by, health visitors? What support do health visitors consider helpful? What types of support would health visitors like to have more of? What support do health visitors value from training, and what would they value in any future training? Methodology
A systematic consultative review process was utilised (Hart and Heaver, 2013). The review includes a variety of sources which are not exhaustive due to the short research time factored into the project delivery. A broad general search using academic databases was undertaken initially using a range of terms. From this and the initial consultation process, six key themes were identified including professional identity, leadership and organisational culture, recruitment and retention, models of support, and resilience education and training. The literature review concludes with discussion of a support framework drawn from the literature, a survey of health visitors and discussions with the task and finish group and other advisors. Key Findings
A range of models of support and concepts have been identified that could support compassionate behaviour in the workplace and enable health visitors to be more resilient when faced with challenges. These include: supervision, mentoring, coaching, courageous conversations, relationship-based models, action learning, performance feedback, interagency/disciplinary groups, peer support and compassionate resilience.
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Supervision: Currently within health visiting in England the picture is varied and supervision is carried out at various levels and in several different guises. If the emotional consequences of this work are not mitigated they will affect a professional’s wellbeing as well as their ability to work effectively. Professionals receiving supervision with a restorative function report an improvement in both professional and personal outcomes, including their resilience to stress whilst maintaining compassion, improved working relationships and team dynamics, managing a work/life balance more effectively and an increase in enjoyment and satisfaction related to their work. Safeguarding supervision is an important element in helping to mitigate the effects of vicarious trauma and compassion fatigue. It is recommended that organisations provide an externally run, structured and intensive debriefing session for staff following serious incidents.
Mentoring: The impact of high workload, staff shortages and time conflict presents mentors with consistent dilemmas in relation to managing commitments. Competing demands can lead to exhaustion and feeling of being overwhelmed. Mentoring ‘fosters talent’ in the organisation, increases productivity, improves communication, and mentoring improves retention. When managers fail to recognise the increased workload associated with the mentor role, it can result in increased mentor anxiety. It is important to distinguish between the widespread use of mentorship as part of the delivery of pre-registration nursing education, and mentoring in support of the development of practitioners in their established professional role. The latter is more relevant to the retention of the health visiting workforce.
Coaching: Coaching focuses on improving performance and the development of skill. It is an integral part of the NHS frameworks for leadership and professional development. Benefits to coachees include an increased sense of motivation and enthusiasm, and also an ability to deal with frustrations encountered. There is an opportunity to improve the deployment of coaching, particularly through the development of internal coaches, so that even greater benefits can be achieved.
Courageous conversations:Developing skills in managing ‘courageous’ conversations is one of the components of the NHS Leadership Academy training programme. Part of any professional relationship for the health visitor, be it with clients, colleagues, other professionals or managers, will involve having challenging conversations that need to occur whilst maintaining the relationship. These are a key factor in developing ‘conflict-resilient workplaces’.
Relationship models of intervention:“Making a difference” has been identified as a key motivating factor for health visitors. The development of the relationship with the client is held to be what makes the ‘real difference’ in improving outcomes for service users. However, there is evidence to suggest that it is increasingly difficult for health visitors to build relationships with their client. This may affect morale, job satisfaction and professional self-esteem and there is a risk of losing people from the profession if they feel unable to “make the difference”. In addition to improved outcomes for children and families, training in relationship-based models of intervention improves health visitor job satisfaction, competence, consistency, self-awareness, and relationships with clients and colleagues. This reflects the practice orientation of health visiting that needs to be aligned with service organisation (Cowley et al, 2013).
Action learning:Facilitation skills are crucial to ensuring that individuals feel safe to engage with the action learning process, and there are organisational challenges in supporting people to develop these skills quickly. To work well, action learning requires mutual commitment to participate.
Performance feedback: Feedback is important to improve understanding and review progress. Multisource (360 -degree) feedback is a tool to help employees improve and focus on their development. It can identify a starting point for the development of new skills, measure progress as skills are worked on over time, and identify blind spots in behaviour. After Action Review (AAR) is a process which can provide insight into performance, team work, leadership and culture. In the AAR process staff take responsibility and this facilitates self-efficacy which is important for job satisfaction, engagement and retention of staff.
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Interagency/disciplinary groups: Interagency/disciplinary groups can support the development of meaning, clarify roles and responsibilities, and contain the emotional impact of the work. Models such as work discussion groups and Compassion CirclesTM are designed to offer a safe place for facilitated reflective dialogue for interagency groups. Their effectiveness has not yet been researched. Schwartz Centre Rounds® are multidisciplinary forums where health professionals meet monthly to reflect and acknowledge work-related psychological, emotional and social challenges. The evidence base for these is developing and a 2-year research study commenced in May 2014.
Peer support: Peer support relies on a trusting relationship with another individual, allows for the setting of performance goals, and involves observation and reflection. It is often seen as a key element in the delivery of quality patient care but its application is complex and variable, although highly beneficial. There can be negative results including conflict, criticism, failed social attempts, emotional over-involvement, and reinforcement of poor behaviour and diminished feelings of self-efficacy.
Potential outcomes of implementing the support models
Resilience: Resilience is not just about survival it is about learning, finding healthy ways to cope and even thriving in the face of adversity. The government strategy for mental health highlights the importance of individuals and employers recognising and building resilience. Adopting an ecological preventative approach in developing resilience-promoting environments is recommended.
Compassion and self-compassion: Compassion enhances staff satisfaction and engagement, and contributes to the performance of organisations. It can increase the ability to receive social support, which may result in more adaptive profiles of stress reactivity. The creation of resilient cultures starts with leaders who foster compassion at the individual and organisational level. Enhancing self-compassion develops our ability to be compassionate.
Development of a new concept
Synthesising the literature on support, resilience and compassion led to the development of the compassionate resilience concept.
Compassionate resilience: The concept of compassionate resilience has been progressed to incorporate three components and the skills to develop it. The components are: self-compassion, learning how to maintain resilience in order to sustain compassion, and compassionate cultures including compassionate leaders. Six skills that will support practitioners in developing their ability to remain resilient and sustain compassion even in challenging circumstances have been identified: enhancing self-awareness, being in the now, developing acceptance, expressing vulnerability, building supportive relationships, and fostering hope.
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Conclusion
There are a wide range of models or mechanisms available to provide health visitors with support. Each approach is evaluated and their key aspects outlined. Overall the following are issues for development: 1. Professional identity With the transfer of commissioning of health visiting services to local authorities this year, there needs to be clarification of roles and responsibilities, particularly in relation to inter-professional working. Values-based recruitment and taking into account the psychological contract between employers and practitioners are important considerations. There is a need to share stories of good practice in health visiting and the use of narrative to change culture and promote the complexity of work with vulnerable families and communities. Overall, it is clear that health visitors need to feel valued and feel that they have made a difference. There needs to be a clear career progression path (Whittaker et al, 2013) which has also been identified as a key motivator for staff, reducing stress and promoting wellbeing (NHS Employers 2014; POSHH, 2012).
2. Providing access to supportive relationships There is a need to provide access to supportive relationships, a key component of positive practice environments (Bryar et al, 2012). Health visitors value the support of their peers, which is an important consideration as mobile working is leading to reductions in access to informal support. Models such as the Samaritans peer support model could be considered. Sawbridge and Hewison (2011) are exploring this in nursing. Preceptorship programmes are needed. However, preceptors also need support and education for this role (Hudson et al, 2014). There is the need for a range of support mechanisms such as mentors, coaches and restorative models of support.
Compassionate relationships are a key factor. Being open to suffering and motivated to take action to relieve this is important. Developing health visitors’ courage to acknowledge and communicate vulnerabilities is necessary. There are links with the 6Cs (DH 2012) and the four principles of health visiting i.e. search for health needs, stimulation of awareness of health needs, facilitating health and enhancing activities, and influencing policy.
3. Emotional aspects The emotional aspects of health visiting have not been well documented. Lindley (2013) highlighted how student health visitors found it difficult to cope with what they saw in practice, but this also acted as an incentive to do something about it. Openness to participate in reflective practice is a key aspect, and openness of leaders to hear and respond builds a safe place where trust can develop. Some literature exists in the nursing field e.g. Menzies Lyth (1960) who highlighted the risk of defensive behaviour if anxieties are not contained, and Sawbridge and Hewison (2011) who have highlighted the emotional labour of nursing. The limitations of comparing findings from nursing studies to health visiting are recognised. Having a safe place where people can express vulnerability and acknowledge the emotional impact of their work can prevent burnout and enhance patient care e.g. through restorative models of support on a one-to-one basis or in supervision groups, or through multidisciplinary groups such as Schwartz Centre Rounds® (The Point of Care Foundation, 2014). Further research is needed to explore the emotional labour of health visiting.
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4. Organisational culture and resilience Resilience is a complex and evolving concept. Varied definitions exist but all include the concept of adversity. Cultural considerations are important (Ungar, 2008). An ecological definition is recommended placing the health visitor in the context of the system where everyone has a responsibility. Compassionate business models need to be developed (Karnally, 2013) where the organisation’s culture and leadership, and individual’s needs are all considered. A position needs to be reached whereby individuals are not just positively coping with adversity, but transforming adversity (Hart and Gagnon, 2015) and not just surviving, but thriving (Wendt et al, 2011).
Key factors in professional resilience are professional identity and professional competence, values, support, reflection, positivity, emotional insight, work/life balance, spirituality, humour and a healthy work environment (McCann et al 2013, McAllister& McKinnon 2009; Jackson et al, 2007; Hunter and Warren, 2014). These can be planned for and developed with experience and education and training. Resilience builds over time and with experience. The feeling that someone has made a difference is important in developing resilience.
5. Education and learning Education and learning to be resilient is not a linear process. Exposure to brief stressful experiences, which are managed effectively, leads to self-efficacy and builds resilience (Rutter, 2012). It is important therefore that health visitors face the adversity with support and do not adopt defensive behaviours such as avoidance or detachment. Continuous professional development is important; communities of practice are a good way to share knowledge and experiences, using narrative and the sharing of good practice.
Education is important. This includes education and support for influencing policies that perpetuate inequalities and promoting policies to enhance resilience, including those that address staff wellbeing (POSHH, 2012), reduce stress (NHS employers, 2014a) and build resilience (DH, 2009).
6. The Framework for Resilience A resilience framework has been developed which provides a menu of support where there are ten models/concepts to choose from. Compassion is a key consideration. Compassionate resilience has three components: 1. self-compassion, 2. learning how to remain compassionate and resilient, and 3. compassionate cultures including compassionate leaders. The concept includes self-compassion and six resilience skills which can be learned to build resilience and compassion.
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Recommendations
All staff, including senior managers, need access to supportive relationships and training in resilience skills including self-compassion.
Further research needs to explore the emotional labour of health visiting. It is clear that peer support models need to be developed, especially in the light of an increasingly mobile working nature of health visiting. A range of support mechanisms need to be provided to health visitors: Every health visitor should be encouraged to access a form of supervision that includes the restorative function. As a way to developing ‘conflict resilient workplaces’, health visitors should be encouraged to undertake training in ‘courageous conversations’. Health visitors should have access to relationship-based training programmes which develop strengths-based approaches and should be trained in the skills necessary to facilitate self-compassion.
Health visiting leaders and employers need to ensure health visitors are provided with resources to experience, make sense of, and respond to suffering.
They should promote workplace compassion through role modelling and encouraging work-life balance, facilitating the nurturing of supportive relationships. The development of compassionate business models in health visiting warrants consideration and research. Practices to support compassion such as selection and socialisation processes, which facilitate noticing, feeling, sense-making and acting in a compassionate way should be implemented. Overall, managers need to provide support, enabling and encouragement for practitioners to develop relationships with their clients. There is a need to create narrative centres through the communities of practice and the Institute of Health Visiting, and for further research to enhance understanding about what contributes to health visitors’ compassionate resilience. There is a need for national benchmarks or a quality standard to support the implementation of these recommendations.
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Introduction
The Department of Health has funded a number of interventions aimed at realising the benefits of the expanded health visitor workforce.
The work is commissioned via Health Education England (HEE) and the development of a support framework for health visitors forms one of those interventions.
The overall objectives of the project are to:
Undertake a literature review and to scope effective models of support currently available in practice settings. Develop a support framework, which may make use of action learning sets, led regionally and supported by an iHV lead at regional level. To identify individual development needs locally, co-ordinate coaching and mentoring support and ensure that restorative support is made available more widely through the iHV and other channels. Ensure that appropriate support is in place for newly-qualified health visitors providing advice, peer-to-peer support, shadowing, mentoring and coaching in the first year of practice. Support cross-fertilisation between proficient and expert professionals, including practice teachers and newly-qualified health visitors.
The key deliverables of the project are:
Provision of evaluated, effective models of support in a national support framework, with the delivery supported by iHV leads and a team of stakeholders at a regional level. To work with regions to identify individual development needs locally and co-ordinated coaching and mentoring support and where necessary for restorative support to made more widely available. To ensure appropriate support is in place across the country for newly-qualified health visitors to access advice, peer-to-peer support, shadowing, mentoring and coaching in the first year of practice (aligned with induction and preceptorship frameworks – project 2) Identification and development of cross-fertilisation mechanisms between proficient and expert professionals, including practice teachers and newly-qualified health visitors, including through the e-Community of Practice.
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A key deliverable of the project is to undertake a literature review and to scope effective models of support currently available in practice settings.
This report assesses the literature underpinning the development of a framework to provide support and build resilience in health visitors.
This will underpin the other deliverables within the project and contribute to ensuring that a framework of appropriate support is in place for newly-qualified, as well as already qualified, health visitors including, for example, advice, peer-to-peer support, mentoring and coaching to build and support resilience.
The Department of Health (2013) has acknowledged the stress of health visiting practice. The 2013 NHS staff survey found that 41% of health visitors had felt unwell in the last 12 months as a result of work-related stress. Research has shown that there is a link between staff wellbeing and patient quality of care (The National Nursing Research Unit, 2013) indicating the importance of addressing the structural and contextual sources of stress as well as the methods that organisations and individuals may use to ameliorate or eliminate stressors.
A literature review was undertaken to identify literature concerning support available and used by health visitors as well as mechanisms used to develop resilience. The methods used to undertake the literature review are outlined below followed by discussion of the findings. The literature review concludes with discussion of a support framework drawn from the literature, a survey of health visitors, and discussions with the task and finish group and other advisors.
Literature search strategy
The search process aimed to identify pertinent literature to answer the questions:
What models or mechanisms of support are available to and used by health visitors (HVs)? What support did health visitors consider helpful? What types of support would they like to have more of? What support did they value from training and would value in any future training?
A systematic consultative review process was utilised (Hart and Heaver, 2013). This is an iterative process in which discussions with a range of professionals in practice and educational settings established areas of interest before the literature search, with findings fed back to them following the search. The review includes a variety of sources that are not exhaustive to the short time available for the research, which was factored into the project delivery.
A broad general search was undertaken, initially using terms such as resilience, support, coping, hardiness (USA), compassion and health visitor, health visit*, nurs*, health profession* public health nurs*. From this and the initial consultation process, six key themes were identified including professional identity, leadership and organisation culture, recruitment and retention, models of support, and resilience education and training. The searches then focused on these key areas, and the three members of the literature review team each looked at separate themes. Pertinent literature was identified through searching databases including Cumulative Index to Nursing & Allied Health Literature (CINAHL), British Nursing, Medline, Google Scholar, Google and Applied Social Sciences Index and Abstracts (ASSIA). The literature included articles, research studies, books, and policy guidelines.
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Positive Practice Environments
The impact of the context of practice, the organisations and environments within which health practitioners work has been acknowledged in the Positive Practice Environments (PPE) initiative supported by the International Council of Nurses and other international health bodies (WHPA, 2008). Positive Practice Environments are defined as: ‘…settings that support excellence and decent work. In particular, they strive to ensure the health, safety and personal wellbeing of staff, support quality patient care and improve the motivation, productivity and performance of individuals and organisations’ (WHPA, 2008, p.1). Elements of PPE which are particularly relevant to the provision of support and development of resilience include (ICN, 2007 cited in WHPA, 2008p.2):
Fair and manageable workloads and job demands/stress;
An organisational climate reflective of effective management and leadership practices, good peer support, worker participation in decision-making, shared values;
Work schedules and workloads that permit healthy work/life balance;
Opportunities for professional development and career advancement;
Professional identity, autonomy and control over practice;
Support, supervision and mentorship;
Open communication and transparency.
The PPE initiative recognises the importance of the context of practice and the multiple factors that impact on the delivery of care by health practitioners. In work aimed at supporting the delivery of the most effective primary health care nursing, Bryar et al. (2012) developed a model of the components needed based within the PPE requirements, illustrated in Figure 1.
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Figure 1: The Primary Health Care Workforce Development Roadmap (Bryar et al, 2012 p.14)
PHC Nursing Workforce Development Roadmap Positive Practice Environment
Incentives
Competencies centerednessPeople Education Quality
Improvement
Human Resurces Inter-Professional
and Partnering
for Primary Care working
Perspective
Public Health Public
Regulation Health and Safety
Technology
Comunication on on Comunication
and Information
Leadership Skill-mix Managerial Support
As illustrated in this model, if health visitors are to provide the most effective care, which is people-centred, they need to take a public health perspective and make use of partnership and inter-professional working. Organisations need to support this through, amongst other things, the provision of appropriate leadership and managerial support that enables health visitors to work in an environment which contains the above features of PPE providing support and helping develop resilience. In the UK the Family Nurse Partnership model, discussed under ‘Relationship-based Intervention’, possesses the components of a PPE and could be considered as a working example.
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Models of support The following sections provide an overview of existing models of support that have been found to be helpful by health visitors and also models that have potential application to the profession.
Supervision
A number of stressors are associated with the health her client behaviours or verbalisations is seen to be and helping professions, including time pressures, central to the therapeutic relationship. Supervision workload, having multiple roles, and emotional issues provoked self-awareness, thoughtfulness, curiosity, and (Lambert et al 2004, Lim et al, 2011). Frequent within that, an opportunity to think about what was environmental stress associated with human pain and being transferred to the practitioner from the client distress in the workplace can impact on the physical and as a way of better understanding and therefore mental wellbeing of health professionals and result in working with the client to bring about positive change burnout and, in some cases, traumatic stress-like and self-awareness. The idea of emotional toil or labour symptoms (Stamm, 2010). These negative stress was also recognised: “The concept of emotion work outcomes can impact not only on the wellbeing of involves the management of emotions by an individual in health professionals, but also on their ability to care order to conform to the demands of the particular social effectively for others (Barnett et al, 2007.). situation” (Bendelow, 2009 p.156). Emotional labour is central to health visiting. Donetto et al (2013, p37) This section looks at the various types of supervision explored the views of health visiting service users. Their and the evidence for their effectiveness in promoting study highlighted the difficulty for some clients when resilience and mitigating environmental stress. they felt judged by health visitors or where there was Supervision is considered good practice now across a no opportunity for them to explore their feelings and range of professional disciplines and has a number of emotions in a way that they felt comfortable with. forms. In general it consists of practitioners meeting This demonstrates the importance of the health regularly with another professional, not necessarily visitors’ ability to show empathy with the client but more senior, but normally with training in the skills also the importance of them being able to mask of supervision, to discuss casework and other disapproval or negative feelings even if that is what professional issues in a structured way. This is often they are experiencing. known as clinical or restorative supervision or consultation. The purpose is to assist the practitioner Wilfred Bion’s (1962) insights into the analytic process to learn from his or her experience and progress in have had a profound influence on how psychoanalysts expertise, to provide emotional containment to the and psychotherapists understand emotional change and practitioner, as well as to ensure good service to the pathological mental states. This is reflected in the Solihull client or patient. Approach to working with children and families (Douglas, 2010) and has been incorporated into what the Wave The concept of managing one’s own responses to Trust (2013: Appendix 3) recommends as ‘Professional client’s emotions had its origins in the psychotherapies. Reflective Supervision’ amongst the ‘core knowledge Indeed supervision has been found to have benefits in and skills’ necessary for the early years workforce to psychotherapy research, improving the working alliance, improve outcomes for young children through their symptom reduction and treatment retention (Bambling work with families. One of Bion’s most influential ideas et al, 2006). Recognition and personal understanding of concerns the notion that we need the minds of others the practitioner’s feelings and thoughts regarding his/ to develop our own emotional and cognitive capacities.
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Bion used the metaphorical concept of the container Their results suggest that positive coping might not and the contained – his reasoning being that the baby be enough to reduce the negative effects of stress, fills the mother (the container) with its anxiety and whereas maladaptive coping (suppression and denial) emotion and the mother is in turn contained by another might significantly increase the negative effects of stress. such as the father. The question arises: what happens McCann et al (2013) suggest that in terms of resilience, when there is no container for the mother? Bion there are a number of individual and contextual factors suggests that the mother becomes full, saturated that contribute to levels of resilience in nurses, work that or overwhelmed and is no longer able to provide appears relevant to health visitors as well. These include adequate containment for her baby. We know that a work/life balance, hope, control, support, professional parent who can help their child manage and process identity and clinical supervision. However, they their emotions contributes to the architecture of their concluded that what remains unknown is whether child’s brain (Schore, 2001). resilience can be strengthened in nurses. There are various types of supervision that health visitors are Using Bion’s model, if the health visitor is in the role of currently receiving and these are discussed below. container for multiple mothers what happens if she/ he is uncontained? A recent research briefing paper by Safeguarding supervision the NSPCC (2013) stated that there is a personal cost to working with traumatised children and families. There All health visitors will receive some form of are several different terms that describe the damage safeguarding supervision, ensuring that health visitors that can be done by being a helping professional, of families where existing risks and vulnerabilities have these include: vicarious trauma, secondary trauma, been identified are given guidance and a forum to think compassion fatigue and burnout. If the emotional about the safety of the child. Turbitt (2012) states that consequences of this work are not mitigated they will the quality of supervision has a direct bearing on the affect a professional’s wellbeing as well as their ability quality of service delivery, and outcomes for children, to work effectively. Vicarious trauma can accumulate families and communities. The National Health Visiting over a long period of time or it can be brought about Service Specification (NHVSS) 2014/2015 stipulates that by one-off traumatic events. The NSPCC research has health visitors must receive a minimum of three monthly found that one way to manage levels of vicarious trauma safeguarding supervisions of their work with their most among professionals is with rigorous supervision and vulnerable babies and children. It also stipulates that peer support. When particularly serious cases occur, it this supervision should be provided by colleagues with can be helpful to have an externally-run, structured and expert knowledge of child protection. Importantly, it intensive debriefing process to ensure that the team can states that supervision must “maintain focus on the child move on and continue to work effectively. and consider the impact of sadness and anger on the quality of work with the family” (NHS England 2014 In the course of their literature review, McCann et al p14). Barker (2007) believes that safeguarding (2013) found that nurses use a number of positive coping supervision should incorporate Proctor’s (1986) strategies including problem-focused coping, taking time model (see Figure 2) to promote an effective response out, and giving and receiving support from co-workers. to safeguarding children.
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Figure 2: Proctor’s model of supervision (Proctor, 1986)
Clinical Supervision
Restorative function: Gives attention Formative function: Focuses on Normative function: Helps ensure to the emotional needs of the health developing skills, understanding that the professional standards and visitor, how they have been affected and ability, by reflecting on and professional/organisational roles by the work with clients, and how to exploring the work of the person are met; is the gate-keeping or deal with them constructively. being supervised. quality-control function
The possibility of significant harm coming to a baby or a child within their caseload as a result of child abuse is an ever-present fear for health visitors. Health visitors will experience, witness or read in the media about incidents that have happened which heightens their awareness. While for some this responsibility acts to motivate and drive them to excellence in practice, for others it may become paralysing, or impact negatively on their emotional health. Turbitt (2012) suggests that scrutiny rather than support, and stressful working environments being accepted as normal, can impact negatively on the quality of supervision offered. From the existing literature it is difficult to assess the quality and frequency of safeguarding supervision for health visitors, or to consider whether it develops the resilience of health visitors. In her review of the literature regarding safeguarding supervision in health visiting, Botham (2013) found that there is little or no standardised guidance provided to undertake safeguarding supervision and, as a result, the content and process is open to individual and organisational interpretation.
Botham found evidence of efficacy, quality and value for health visitors and school nurses, and cites two reports (Hall, 2007; White, 2008- cited in Botham 2013) and other recent authorities in support of its benefits including Laming (2003; 2009); DCSF (2009); Ofsted (2010) and Munro (2010).
Key points: safeguarding supervision:
Organisations should provide an externally run, structured and intensive debriefing session for staff following serious incidents. Use of a model and framework for safeguarding supervision would improve quality and provide effective evaluation of the supervision process. Safeguarding supervision is an important element in helping to mitigate the effects of vicarious trauma and compassion fatigue.
19 Supporting Health Visitors and Fostering Resilience Literature Review
Clinical supervision
Clinical supervision is viewed as having a separate function to safeguarding supervision and does not have to be carried out by a professional with expert skills in safeguarding. Clinical supervision has been part of health visiting for many years and its value in combating stress and improving practice is acknowledged by many in the field (Palsson et al 1996; Walsh et al, 2003). Currently within health visiting in England the picture is varied and supervision is carried out at various levels and in several different guises.
Brunero and Stein-Parbury (2008) carried out a literature review to look at evidence of effectiveness of clinical supervision. They concluded that clinical supervision provides peer support and stress relief for nurses (restorative function) as well a means of promoting professional accountability (normative function) and skill and knowledge development (formative function). This is essentially the model that was first developed by Proctor (1986) and that has been adopted widely in the UK and abroad.
Sloan and Watson (2002) cited by Botham (2013) found that Proctor’s (1986) model is the most commonly used model. However they also contest that one model does not fit all aspects of nursing, and a ‘one fit for all’ philosophy should not be sought; individual organisations and supervisors should choose a model that suits them and their service. They state that there is an absence of supporting evidence to suggest that any model is wholly suitable, choice within service areas should be considered. Bidmead (2013) identified that the health visitors in the inner city area that she studied were not receiving supervision other than safeguarding supervision. On the other hand, clinical supervision has been an integral part of successful interventions in health visiting (Davis and Spurr 1998; Barlow et al, 2003; Brocklehurst et al, 2004; Davis and Tsiantis, 2005; Barnes et al, 2011). When asked to describe models of support that foster health visiting resilience, restorative supervision was frequently mentioned as being helpful (Institute of Health Visiting ‘Health Visiting Survey’ 2014).
Restorative Supervision
Supervision with a restorative function has seen a growing interest in health visiting in recent years. This type of supervision contains elements of psychological support including listening, supporting and challenging the supervisee to improve their capacity to cope, especially in managing difficult and stressful situations (Proctor, 1986). Hunter and Warren (2013) who carried out a study of resilience in midwifery suggest that, whereas traditional clinical supervision has focused on clinical competency, recommendations from the literature also encompass the need for interventions aimed at enhancing personal confidence and self-efficacy, and addressing stress management techniques (Gillespie et al, 2007; Arvidsson et al, 2008 – cited by Hunter and Warren, 2013).
Table 1 sets out a list of reported outcomes of restorative supervision from Australian research (Brunero and Stein-Parbury, 2008). Many of these reported outcomes are related to resilience, and factors commonly associated with the measurement of employee resilience.
20 Supporting Health Visitors and Fostering Resilience Literature Review
Table 1: Restorative supervision (reported outcomes of restorative supervision categorised by Brunero and Stein-Parbury 2008 based on Proctor’s model)
Listening and being supportive Empathy Improved coping at work Sense of community Accessing support Catharsis Better relationships amongst staff Self-understanding Engagement in the workplace Improved relationships with colleagues Safe group environment Trust Sense of security Reduced conflict Satisfaction Reduced tedium Lower received anxiety Reduced burnout Understanding colleagues Personal accomplishment Increased interest relief Personal development Relief of thoughts and feelings Coping
Hunter and Warren (2013) suggest that, to date, there has been limited research that has tested the hypothesis that interventions such as restorative supervision enhanced resiliency in midwives or nurses, and no report of the use of resilience theory in midwifery or nursing education. They suggest that there is thus ample scope for developing a research programme in this area.
Within the UK, South Warwickshire Foundation Trust (SWFT) has developed a programme of restorative supervision, which they state is ideal for professionals working within complex and challenging professions. Their literature emphasises that this model of restorative supervision differs from other models of supervision often used within services, as the focus of the supervision session is the supervisee as opposed to their work. The model therefore underpins managerial and safeguarding supervision by focusing on the capacity of the professional to engage in their work rather than on the work itself.
The University of Warwick is currently carrying out an independent evaluation of the SWFT model, and, although this has yet to be published, the team’s literature states that there have been numerous positive qualitative outcomes from the programme to date. Professionals report an improvement in their resilience to stress whilst maintaining compassion, improved working relationships and team dynamics, managing a work/life balance more effectively and an increase in enjoyment and satisfaction related to their work alongside many more beneficial outcomes both professional and personal.
Quantitative findings recorded as pre and post-supervision measures have shown a positive trend in the reduction of symptoms of burnout and secondary traumatic stress whilst improving the individual’s sense of compassion satisfaction, the pleasure they derive from doing their job.
21 Supporting Health Visitors and Fostering Resilience Literature Review
Key points: supervision
If the emotional consequences of this work are not mitigated, they will affect a professional’s wellbeing as well as their ability to work effectively.
“Stressful working environments being accepted as normal” can impact negatively on the quality of supervision offered.
Currently within health visiting in England the picture is varied and supervision is carried out at various levels and in several different guises.
Restorative supervision underpins managerial and safeguarding supervision by focusing on the capacity of the professional to engage in their work rather than on the work itself.
Professionals receiving restorative supervision report an improvement in their resilience to stress whilst maintaining compassion, improved working relationships and team dynamics, managing a work/life balance more effectively and an increase in enjoyment and satisfaction related to their work, alongside many more beneficial outcomes both professional and personal.
22 Supporting Health Visitors and Fostering Resilience Literature Review
Mentorship
The concept of mentoring has been used for many years within nursing and health visiting.
Within this review of the literature we aimed to explore the definition of mentoring, evidence of its effectiveness and problems with the approach. We started by exploring the broad research, and then focused on the literature around mentoring and health visiting.
In the UK, the role of formal mentoring became more mentorship as instrumental in preparation of students established in the context of professional education or trainees for professional registration in nursing or and training in health and social care during the 1970s health visiting. Within the nursing professional and 1980s (Downie and Basford, 2003). Continuous literature, this latter function is dominant in ways that assessment was also introduced during this period and are not representative of the more general literature passing or assessing students in practice became the concerning mentoring and mentorship for career responsibility of the mentor in 2001 (Duffy, 2003). development and progression. While educational Prior to this, the Department of Health (DH) defined mentorship can be included in this wider concept, its the mentor as a registrant who facilitated learning, and dominance within the nursing literature and in practice the assessor was another registrant (Gopee, 2008), (owing to the system-wide allocation of human resources highlighting a role and function narrowing circumscribed to its provision for trainees) somewhat eclipses the wider by the context of professional education and training. developmental mentorship that could, in principle, be offered to health visitors established in their role to In all areas of industry and business it has been support their resilience. Bearing this in mind, the established (Clutterbuck, 2004) that mentoring extensive literature on mentorship in nursing education ‘fosters talent’ in the organisation, increases is found to be, at best, tangential to the purpose of this productivity, improves communication, and improves review’s focus on fostering resilience and retention of retention. This wider and more general concept of health visitors. mentorship overlaps with, but can be distinguished from,
Definitions of mentoring “Mentors are guides, they lead us along a journey of our lives. We trust them because they have been there before. They embody our hopes, cast light on the way ahead, interpret arcane signs, warn us of lurking dangers, and point out unexpected delights along the way” (Daloz, 1986, p.17). Levinson’s definition of the term (below) links it strongly with teaching and advising; he also talks about the mentor’s role in assisting the mentee to realise his or her dream or perhaps ‘goal’. “The term mentor…generally means teacher, advisor or sponsor….The mentor has another function, and this is developmentally the most crucial one: to support and facilitate the realisation of the Dream” (Levinson, 1978, pp.97-98).
23 Supporting Health Visitors and Fostering Resilience Literature Review
Mentoring and health visiting
Until recently, in health visiting it was possible to distinguish the role of educational mentor for trainees from a wider concept of developmental mentorship.
This is because the former role was characteristic of pre-registration nursing education, while health visitor students were supported and supervised by practice teachers (PTs) with a dedicated teaching role.
With the recent growth in the number of health visitors emerging theme surrounded support from managers, there has been the need to engage more PTs in training colleagues and higher education institutions (HEI). new students. Traditionally, the PT has trained one Omansky (2010) noted managers failed to recognise specialist community public health nurse (SCPHN) the increased workload associated with the dual role, annually (Nursing and Midwifery Council (NMC), 2008). leading to mentor anxiety. Fischer and Webb (2008) However, in view of the recent additional training found mentors felt undervalued by managers, evidenced requirements, this route is unsustainable in terms of by their failure to support them. The final emerging capacity. The NMC revised this policy advising that PTs theme related to education, learning and assessment. may now manage up to three learners (NMC, 2011). Poor continuing professional development impacted They are supported in this task by health visiting negatively on student learning (Myall et al, 2007) and ‘mentors’ who undertake the majority of the preparation of mentors was crucial to positive student practice teaching with the PT supervising the process outcomes. Kenyon and Peckover (2008) identified that and undertaking responsibility for signing-off the a forum for sharing of experiences and learning would assessment learners’ proficiency. Anecdotal evidence promote consistency in assessment but, due to the both regionally and locally indicates a considerable pressure of clinical commitments, priority is not always degree of resentment and disquiet among health given to attending annual mentor updates (McVeigh, visiting mentors. The commitment for the training 2009). Haydock et al (2011) identified the value of good of SCPHNs runs alongside mentors’ ongoing partnership arrangements with the HEI, while the need responsibility for a caseload of children under five for more user-friendly and succinct documentation was and their families, and the requirement to continue highlighted as a prerequisite by Pulsford et al (2002). to maintain professional skills and knowledge. Morton (2013) carried out a study to find out what The impact of high workload, staff shortages and time support health visitor mentors required. Powerlessness conflict presents mentors with constant dilemmas was identified as the overarching theme within Morton’s in relation to managing commitments. For many data. Participants argued the role had been imposed mentors, work overload was counteracted by working upon them. Some participants felt coerced into the overtime, and some reported feeling overwhelmed role and reported feeling taken for granted while and exhausted due to competing demands (Omansky, receiving little meaningful recognition of the effort 2010). Controversially, some managers and co-workers and consequence of maintaining the dual role. With perceived the mentor as having additional help as reference to the managers, one participant commented: opposed to additional responsibility. Haydock et al ‘They don’t seem to empathise with what we do, and (2011) identified professional ‘burnout’ among some how hard we really do try’ Morton (2013, p33). PTs. Fischer and Webb (2008) and Kenyon and Inadequate staffing levels exacerbated this burden. Peckover (2008) undertook community-based studies Morton found that mentors felt unprepared for their role where mentors experienced different challenges, and and some of them were less qualified than the mentees. concluded the nature of the community environment Indeed during iHV training sessions it was identified intensifies difficulties associated with planning to that health visitors with only one year postgraduate accommodate patients and students. The second experience were being asked to be mentors. Mentors
24 Supporting Health Visitors and Fostering Resilience Literature Review
in Morton’s study felt that they were not valued or and/or mentors and appreciated how pivotal this was supported to undertake the work emotionally and nor to their development as a health visitor. Several factors were they given time to undertake the role in the way were identified by Devlin and Mitcheson (2013) as being they would have wished. important for a positive mentoring experience these included: proximity, continuity and reciprocal positive Sayer (2013) has completed a longitudinal study of regard, together with clinical expertise. Another factor health visiting students from one London university mentioned was that mentees valued their mentor’s to explore managers’ views regarding issues faced by acknowledgment of their previous learning. student and newly-qualified health visitors. Themes emerging from the data for trainees and newly-qualified Outside the confines of nursing education, mentoring health visitors were: the importance of personal is an integral part of the of the NHS frameworks for attributes; the value of experience; the need for support; leadership and professional development and is managing self and others. The analysis suggests that offered through the NHS Leadership Academy (2012). previous experience, either nursing/midwifery work At present, the potential for mentoring as a supportive or life experience, is a key enabler regarding intervention is likely to be limited by a) the conflation assimilation into the SCPHN role and performing the of developmental or career mentorship with role on qualification. Support from practice teachers educational mentorship for professional training; b) is crucial to the socialisation process during training the recent conflation of practice teacher and mentor but preceptorship support is lacking for most newly functions in health visiting; and c) the recent, possibly -qualified health visitors. short-term, pressures on capacity for mentorship within the health visiting workforce due to increased demands Although this paints a bleak picture of health visitor to deliver increased throughput of trainees. These mentoring in the UK, there is some evidence to combine to give the unfortunate perception of suggest that, at least in some areas of the country, mentorship as part of the problem rather than a where it is well managed, the picture is improving. solution to the demands on professional resilience in Devlin and Mitcheson (2013) carried out an evaluation health visiting. However, points b) and c) are arguably of three models of health visitor practice teaching in the short-term effects of the health visiting implementation east of England with their evaluation including feedback plan that can be mitigated by a clarification of the wider from students on their experience of mentoring. They potential of mentoring and mentorship as adopted more found that most of the students had predominantly widely in the NHS and other organisational contexts. positive relationships with their practice teachers
Key points: mentoring
In all areas of industry and business it has been established (Clutterbuck, 2004) that mentoring ‘fosters talent’ in the organisation, increases productivity, improves communication, and improves retention. The impact of high workload, staff shortages and time conflict presents mentors with constant dilemmas in relation to managing commitments. Competing demands can lead to exhaustion and feelings of being overwhelmed. When managers fail to recognise the increased workload associated with the educational mentor role, it can result in increased mentor anxiety. Adequate preparation of mentors is crucial to positive mentee outcomes. Mentors require adequate experience and to have developed a sense of mastery for the role themselves if they are to be successful Proximity, continuity and reciprocal-positive regard, together with clinical expertise, are important elements for the success of mentor/ mentee relationships. Within health visiting, the role of the mentor has become associated with a form of practice teaching, to cope with the greatly increased number of students since 2011. Positive developments beyond the health visiting implementation plan include building on induction and preceptorship of newly-qualified health visitors to offer mentorship in line with wider developments in mentoring emerging leaders within the NHS. Institute of Health Visiting projects on developing a career framework and developing a cadre of Fellows offer the potential to hold on to this more promising vision of mentoring in support of resilience.
25 Supporting Health Visitors and Fostering Resilience Literature Review
Coaching
Coaching, as opposed to mentoring, has been used less frequently within health visiting; however, there is some evidence from the training and consultation groups facilitated through the iHV that some Trusts are offering coaching to staff. Traditionally, coaching within the NHS may only have been seen as an appropriate support for personnel in senior strategic positions within organisations.
What is coaching?
Coaching is centred on unlocking a person’s potential Sinclair et al (2008) completed a study into the to maximise his or her own performance. A focus on effectiveness of coaching in the NHS. They found that improving performance and the development of skills personal benefits to coachees included an increased is the key to an effective coaching relationship (Fieldon, sense of motivation and enthusiasm, and also an ability 2005). Brandt (2013, p 56) states that “Coaching to deal with frustrations encountered. Most benefits is effective because it is personal, behaviour-oriented identified were at the level of behaviour, or how people and targeted to the individual”. Coaching is not, were going about their work. These included having a however, telling someone what to do and how to do it. more objective and strategic approach, better work Occasionally, it involves overseeing what is being done prioritisation, increased confidence, improved ability and advising how to do it better. Over recent years, there to influence key people, better team management and has been an increasing trend of individuals taking greater enhanced self‐presentation in job applications. They responsibility for their own development (Parsloe and also suggested that what coachees seemed to value Rolph, 2004 cited in Fieldon 2005). If individuals most about coaching included having space to reflect on are to do this they need support and advice and the their work, having a safe environment in which to work coaching relationship appears to provide employees through options, being encouraged to find the answers with the appropriate support they need in order to for themselves, having a new perspective on their situ- achieve their developmental aims (Whitmore, 2002). ation and being able to draw on the expertise of their coach. Within their study, Sinclair et al (2008) also looked How coaching differs from mentoring at the differences between external coaches brought in from outside the organisation and internal coaches. They Table 2 below outlines the differences between coaching found only minimal differences between them, however, and mentoring: importantly coaching does not have to they suggested that coachees would also benefit from be performed by someone from the same professional improved information about coaching, including how background as the coachee/ person being coached. It coaching works and what it can be used for, as well as does not contain the same role-modelling expert/novice help in choosing a coach. They concluded that, although component. In addition, coaching tends to be more time it is clear that when coaching takes place it is delivering limited where mentoring can continue for many years. benefits for the NHS, there is also an opportunity to improve the deployment of coaching, particularly Evidence for the effectiveness of coaching in the NHS through the internal coaches, so that even greater benefits can be achieved. “Coaching and mentoring are an integral part of the of the NHS frameworks for leadership and professional development. They are also important skills for public service managers and usually form part of management development programmes”. (NHS Leadership Academy, 2012)
26 Supporting Health Visitors and Fostering Resilience Literature Review
Table 2: Differences between coaching and mentoring relationships. (Source: Jarvis, 2004)
Coaching Mentoring
Relationship generally has a set duration. Ongoing relationship that can last for a long time.
Generally more structured in nature and meetings are scheduled on Can be more informal and meetings can take place as and when a regular basis. the mentee needs some advice, guidance or support.
Short-term (sometimes time-bounded) and focused on specific More long-term and takes a broader view of the person. developmental areas /issues.
Coaching is generally not performed on the basis that the coach Mentor is usually more experienced and qualified than the mentee. needs to have direct experience of their client’s formal occupational Often a senior person in the organisation who can pass on knowledge, role, unless the coaching is specific and skills focused. experience and open doors to otherwise out-of-reach opportunities.
Focus generally on development/ issues at work. Focus is on career and personal development.
The agenda is focused on achieving specific and immediate goals. Agenda is set by the mentee, with the mentors providing support and guidance to prepare them for future roles.
Coaching focuses on specific development areas/ issues. Mentoring focuses on developing the mentee professionally.
Within the nursing literature, the study of the in general. In Kelton’s study she evaluated the effectiveness of coaching appears to have been limited effectiveness of a clinical coach (CC) role created by to time points in the recipients’ career where they were one school of nursing and midwifery in response expected to make significant change. This includes the to ongoing concerns about students’ level of evaluation of its effectiveness in supporting nurses and competency. She found the model of clinical coaching, midwives to develop clinical leadership competencies that was adopted for supporting marginal performer (McNamara et al, 2014). They concluded that coaching or ‘at risk’ students, was effective at developing and action learning were positively experienced by their practice. participants and contributed to the development of clinical leadership competencies, as attested to by the There is relatively little mention of coaching within programme participants and intervention facilitators. the health visiting literature. However HEE (2011) in They recommended that, with coaching and action an accompanying document to the Health Visiting learning interventions, the focus should be on each Plan acknowledged that, by 2015, approximately participant’s current role and everyday practice, and 60% of the workforce would be newly qualified and on helping the participant to develop and demonstrate inexperienced. They stated that “Commitment has been clinical leadership skills in these contexts. given within the health visitor programme to supporting the newly-qualified practitioners during the first two Kelton (2014) evaluated the effectiveness of using years of practice to aid transition from theory to practice coaching to work with students whose performance was and from novice to expert” (p11). The document also reported to be marginal. Within health, working with acknowledged that practice teachers and mentors any staff whose performance or behaviour is in question need to be skilled in supporting development of team can be extremely challenging and at present this is done members alongside delivery of development activities, through the process of performance management, which using strengths-based approaches and motivational is poorly defined. Managers will often cite working interviewing skills. The HEE suggests one way of this with difficult or poorly performing staff as particularly being realised was for health visitors to develop challenging to them, and it can affect team performance coaching skills in order to support inexperienced staff.
27 Supporting Health Visitors and Fostering Resilience Literature Review
The direct relevance of coaching to resilience is not obvious without being contextualised. At a general level, coaching concerns improved performance under challenging if not adverse conditions. The analogy is drawn with coaching for physical fitness, as being the capacity to recover quickly from exertion, to perform at a high level, or to endure, for example by tolerating pain. This raises the question of which elements of performance are to be improved and which are not. Coaching is a generic skill that needs to be applied appropriately to the performance requirements of context. Coaching could improve resilience that is either emotionally ruthless or compassionate. Thus, it is important to consider carefully the alignment of individual and organisational performance requirements when determining the focus of coaching.
Key points: coaching
In coaching there is a focus on improving performance and the development of skills. Coaching and mentoring are an integral part of the NHS frameworks for leadership and professional development. Traditionally, coaching within the NHS may only have been seen as an appropriate support for personnel in senior strategic positions. Benefits to coachees include an increased sense of motivation and enthusiasm, and also an ability to deal with frustrations encountered. ‘Clinical coaching’ can be used to work effectively with “marginal” staff with performance issues. Consideration needs to be given to the alignment of the performance requirements of individual practitioners and organisations so that resilience is promoted to reflect the therapeutic basis of professional-client relationships as sensitive, attuned and reciprocal (Douglas, 2010). There is an opportunity to improve the deployment of coaching, particularly through the development of internal coaches, so that even greater benefits can be achieved. Health Education England suggests developing the coaching skills of practice teachers and mentors as one way of developing them for their roles.
28 Supporting Health Visitors and Fostering Resilience Literature Review
Courageous conversations
Within the literature related to developing resilience within health visiting, there are many reminders that good relationships are an important component of resilience.
There are, however, examples (Whittaker et al, 2013) where maintaining good relationships with colleagues whilst maintaining your integrity and need to be heard is, at times, challenging for health visitors.
In addition, Whittaker found that health visiting areas of school life. Whittaker (2013) discussed some managers’ abilities to respond sensitively to staff was of the ongoing difficulties health visitors have with sometimes compromised. This may in part be due to managers and seniors that result in difficult and mutually pressures felt from those senior to the managers. unsatisfying conversations. Part of any professional It is difficult for professionals to develop professional relationship for the health visitor, be it with clients, resilience in a ‘bubble’ and the impact of the colleagues, other professionals or managers, will organisational culture is strong. Leadership training involve having courageous conversations that need to be within the NHS is currently being spearheaded by the had whilst maintaining the relationship. Patterson et al NHS leadership academy, and part of that training (2002) argue that the root cause of many – if not most incorporates preparing leaders for the ‘challenging’ – human problems lies in how people behave when conversations that they will inevitably encounter. This others disagree with them about high stakes issues. training is being offered at band 6 and 7 level, and it is A report by the State Government in Victoria, Australia hoped that all health visitors will eventually have the (2011) deals with the importance of developing opportunity to engage with the programme. This section ‘conflict resilient workplaces’. They suggest that costs highlights some of the key messages from the literature. of unresolved conflict are many, ranging from individual distress, to broken relationships and strained There are many different terms used to describe organisational resources, mental and physical these conversations, such as ‘courageous’, ‘challenging’, wellbeing, absenteeism, counter-culture activities ‘difficult’ or ‘crucial’. Patterson et al (2002) describe it and ongoing dissatisfaction, lost productivity, lost as learning to communicate best when it matters most. opportunities, declining trust and morale, increased A review of the literature reveals very little in terms of disputation, time spent on case management, and models with a clear evidence base. However, there are difficulties with recruitment and retention. They state a wide number of best-selling titles that deal with the that a conflict resilient workplace is underpinned by subject (Patterson et al, 2002; Grimsley et al, 2012). strong communications and relationships, supported and demonstrated from the board level down. A conflict Why it is important to consider courageous resilient workplace does not rely solely on formal dispute conversations processes, but emphasises positive relationships and strong communication, so that conflict is managed When New Zealand school leaders were asked to identify early, at the lowest possible level, and with the most the issues that created challenging problems for them, appropriate response. It is one that integrates strong they nearly always indicated people problems (Cardno, diagnosis (‘what is the cause of the problem?’) with 2007). Furthermore, the leaders indicated that many of appropriate decision-making about the best response the problems were longstanding, difficult to resolve, and (‘is this best managed through adjudication by a third had negative consequences that spilled over into other party, or can we resolve this better through non
29 Supporting Health Visitors and Fostering Resilience Literature Review
-confrontational approaches such as mediation, a Open-to-learning conversations courageous conversation or facilitation?’). Facilitated approaches to resolving conflict include models such as The evidence-based model Open–to–learning conflict coaching and appreciative enquiry, both cited conversations was developed by Robinson et al (2009) at as being effective within the State Government of Auckland University. This draws on the theory from Chris Victoria (2011). Argyris, a social and organisational psychologist who has done extensive empirical and intervention research They also suggest that conflict presents opportunities on the interpersonal effectiveness of leaders in real, on for people to strengthen their relationships with the job situations (Robinson and Lai, 2006; Cardno and themselves and others. Resolving the issues is only Piggot-Irvine, 1997). Table 3 outlines the key values and one of the desired outcomes when people are in strategies the model employs. dispute. Behaviour change is achieved in part, by increased self-awareness and insight. With increased self-awareness, we are more likely to discover our choices and shift our behaviour.
Table 3: The guiding values and key strategies of “Open-to-learning” conversations
Guiding Values Key Strategies
Increase the validity of information. Disclose the reasoning that leads to your views. Information includes thoughts, opinions, reasoning, Provide examples and illustrations of your views. 1 inferences and feelings. Treat own views as hypotheses rather than taken-for-granted truths. Seek feedback and disconfirmation.
Increase respect. Listen deeply, especially when views differ from your own. Treat others as well intentioned, as interested in learning Expect high standards and constantly check how you are 2 and as capable of contributing to your own. helping others to reach them. Share control of the conversation including the management of emotions.
Increase commitment. Share the problems and the problem-solving process. Foster ownership of decisions through transparent and Require accountability for collective decisions. 3 shared processes. Foster public monitoring and review of decisions.
30 Supporting Health Visitors and Fostering Resilience Literature Review
At the heart of the model is the value of openness to 2001). Skills in identifying, acknowledging and learning – learning about the quality of the thinking and managing feelings are thus seen as important information that we use when making judgments about prerequisites for effective challenging communication. what is happening, why and what to do about it? An Rosenberg (2013) also highlights as key to success the Open-to-learning conversation, therefore, is one in which skills of observing without evaluating, and skills in this value is evident in how people think and talk. Do communicating based on needs. He suggests these they assume the validity of their views and try to impose skills are related because evaluations are often masked them, however nicely, on others, or are they searching expressions of our needs. Rosenberg cites Gibb’s for ways to check and improve the quality of their (1961) suggestion that evaluation is often harmful in thinking and decision-making? Robinson (2013) cites interpersonal communication because it generates Argyris and Schon (1974) who suggest that conversations defensiveness. He explains that when people hear an about the quality of performance are difficult because ‘evaluative or judgement statement’ they often perceive they have the potential to threaten relationships by criticism. Blame, insults, put-downs (critical remark), triggering discomfort and defensiveness. In the face labels, criticism, comparisons, and diagnoses are all of such threats, leaders often experience a dilemma forms of judgment, which may lead to feelings of between pursuit of their change agenda and protection defensiveness, self-absorption, threat and weakness. of their relationships. Cardno (2007) found that leaders may often want to raise issues of poor performance but Rosenberg suggests that learning to communicate are concerned about the resulting stress and conflict this only what we have observed, without linking it to an will bring to them and their team. evaluative or judgemental statement, is a far more effective way to communicate, as it is less likely to Several models, including Rosenberg’s iconic work activate the defensive arousal of the other. Observation (2013) ‘Non Violent Communication’, discuss the is linked to communicating based on needs, as an importance of acknowledging feelings - both our own observation exposed without the evaluative mask is and others’. There are inevitably many difficult emotions easier to connect with one’s needs (Rosenberg, 2013). that arise when an individual attends to a situation and Rosenberg strives to encourage people to make a clear understands it as being relevant to his or her current differentiation between communicating our observations goals (Lazarus, 1991). Negative emotions alert us to objectively and accurately to someone without attaching the possibility that our needs or interests are being a judgement to them. He acknowledges that this is threatened or harmed; positive emotions signal difficult to do in practice as it means circumventing expansion and harmony and contribute to broaden and our instincts, however he believes it is a skill that can build our resources for future interactions (Fredrickson, be taught.
Key points: courageous conversations
Part of any professional relationship for the health visitor, be it with clients, colleagues, other professionals or managers, will involve having challenging conversations that need to be had whilst maintaining the relationship. Patterson (2002) describes courageous conversations as “learning to communicate best when it matters most”. Developing the skills to have effective ‘courageous conversations’ is a key factor in developing ‘conflict resilient workplaces’. Conflict presents opportunities for people to strengthen their relationships with themselves and others. Developing skills in managing ‘courageous’ conversations is one of the components of the NHS Leadership Academy training programme.
31 Supporting Health Visitors and Fostering Resilience Literature Review
Relationship-based models of intervention
Rationale for the inclusion of relationship-based models within the framework
There is substantial evidence in the literature that what makes health visiting most professionally satisfying for health visitors is the opportunity and capacity to form effective and sensitive relationships with families in the community.
At the same time, this aspect of practice is also However, there is increasing evidence to suggest that it demanding and therefore pivotal to support needs and is difficult for health visitors in many areas of the country resilience. Crowther and Cowan (2011) studied effective to develop relationships with their clients. There is relationships which help vulnerable parents and improve also evidence to suggest that this affects morale, job outcomes for children. They state that previous studies satisfaction and professional self-esteem. Ausbrooks and evaluations demonstrate that the development of (2011) found that a sense of job satisfaction was a the relationship with the client is what makes the ‘real protective factor that allowed practitioners to withstand, difference’ in improving outcomes for service users. endure and bounce back from the myriad of stressors Crowther and Cowan (2011) cite Bell and Smerdon they face in their working lives. She also found that what (2011) in their literature review and suggest that human kept practitioners working with vulnerable families in relationships are essential to effective service provision. their jobs was their ability to realise their “mission;” Whitaker et al (2013) identified that the idea of “making for health visitors the evidence would suggest that a difference” was the key motivating factor to entering “making a difference” comes under this mantle. health visiting (students) and remaining in it (qualified However, as a prelude to this work on resilience in health health visitors). Whitaker et al also identified that health visiting, the iHV (2014) surveyed a group of 600 health visitors recognised that, in order to make a difference by visitors across the country. Health visitors were asked improving life chances, enhancing children and families’ what was important to them about their job; the health, protecting children and vulnerable adults, questions asked were aligned to factors that the several things needed to happen. Firstly, health visitors literature has identified as being linked with professional needed to gain access to people in their home, form a resilience. 100% of health visitors surveyed identified relationship with them and gain information about their that “making a difference” was a key factor for them, private lives, which then enables health visitors to offer however only 21% strongly agreed that they felt they appropriate help and support. This is complex and were currently achieving that. skillful work especially when considering that many of the clients that health visitors will be working with Cowley et al (2013) reported on a part of the doctoral the most, are those that trust the least. Puckering et al work of Bidmead (2013) who found that in inner city (1996, p.540) state “that it is the very factors which put areas of deprivation, the size of the health visitor the children at risk that make it harder for parents to caseload is a very important factor in influencing the engage in support for themselves or their children”. ability of the health visitors to establish relationships Therefore, having the ability to engender trust in parents with parents. Bidmead found that caseload sizes in who are scared, angry and hypersensitive to criticism Britain are extremely variable and that it is not is arguably one of the most skillful within the health unusual for caseloads in Britain to be above the visitor’s role. It is what puts the ability to form and model level recommended, and not to be linked to deprivation good relationships at the core of health visiting practice. levels. Health visitors included in the study by Bidmead It is how health visitors define themselves and are found their caseload sizes unmanageable (typically in able to derive a sense of mastery and pleasure from excess of 400 under-fives to one fulltime health visitor). their work. If we consider that this is 15 times the size of caseloads held by Family Nurses, the enormity of the pressure
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that the health visitors are under becomes evident. understanding of the importance of attachment in their Bidmead (2013) also found that health visitors valued children’s development. It also means that early signs of the relationship that they developed with clients; mental health problems – whether in the infant or the however, due to the pressure they were under and the parent – may be missed, increasing the risk of serious organisational culture, this was extremely difficult in mental disorders, which are costly both in financial and some areas. She states that the “organisational issues human terms. identified by parents and health visitors highlighted the need for parents and health visitors to have time to Perhaps it is not surprising, therefore, that health visitors develop relationships in an unhurried atmosphere” listed the Solihull Approach as one of the most valuable (p13). Bidmead identified several organisational issues trainings they had engaged in within the iHV survey that prevented or hindered the client/ health visitor (2014). The Solihull model puts the relationship with the relationship; amongst them were pressures of record client as central to intervention and places great value keeping. Working with other agencies in particular on factors such as containment and reciprocity. There this applied to children’s centre staff, who were are indeed other relationship-based programmes which increasingly seen to be taking over the work of health have been developed in the UK such as Mellow Parenting visitors in the home. This is of particular concern and the Family Partnership model. Within this section we considering the complexity of this work and the have also referred to the Family Nurse Partnership (FNP) extensive work of Olds et al (2002) who clearly identified Model as this model also focuses on the relationship the complex nature of this work and the high level of between the client and the nurse as a factor that is skill required to achieve positive outcomes for families. central to its success. Although it is acknowledged that In addition, the obviously demoralising effect this has this is not a model that can be adopted in its totality in on health visitors may impact on their resilience. Skill health visiting, many of its features are similar to the mix was felt to have contributed to health visitors being other models. However, the attention to fidelity within left with safeguarding work, which was seen as less the FNP programme, small case-load sizes, supervision, rewarding than more preventative intervention. Lack training and support structures and the recognition of management support for relationship-based work that the emotional wellbeing of the nurse is central to was also seen as a major issue. The Children and Young the success of the programme, has contributed to its People Mental Health Coalition (CYPMHC) also suggest continued growth. In essence, the acceptance, support caseloads can pose a problem. Building trust takes and encouragement from their seniors that family time and effort that health visitors cannot spare if their nurses receive to build relationships with their clients caseload is too large or too complex (they cite Barlow empowers them to make use of a good model of et al, 2007; Department of Health et al, 2009; Adams intervention. It is arguably an extremely good example 1998). There can be a ‘postcode lottery’ in health visitor of a Positive Practice Environment in the UK and as provision with many service cuts, or health visitors such it will be valuable to consider factors that have having to delegate interventions. Additionally, the contributed to its success within the context of focus for delivering many interventions can be on the developing resilience in health visiting. children’s centre workforce, rather than health visitors (Adams, 1998). Bidmead’s (2013) work reported above Solihull Approach sets out the rationale for the later development of a suite of instruments, suitable for evaluating the parent-health The Solihull Approach was first developed in 1996 visitor relationship and the extent to which organisations by joint working between health visitors and support them, which are now validated and available. psychotherapists in Solihull, to work with families on feeding, sleeping and behavioural difficulties. It has The CYPMHC states that if we fail to address the now been adopted by a wide number of health visitors problems outlined above, some families will continue to in the UK. be reluctant to engage with professional staff, and treat them with distrust. This means that they may miss out on valuable interventions and support, including a better
33 Supporting Health Visitors and Fostering Resilience Literature Review
How does the Solihull Approach work?
Containment
Behaviour Reciprocity Management
The Solihull Approach model combines three theoretical concepts, containment (psychoanalytic theory), reciprocity (child development) and behaviour management (behaviourism). It provides a framework for thinking for professionals working with families. Containment and reciprocity underpin relationships and brain development as well as the quality of an attachment.
According to Douglas and Brennan (2004), knowledge Moore et al (2013) found that there was a substantial of the process of reciprocity can help the practitioner amount of research that has provided evidence for to understand the relationship between a parent and the effectiveness of the Solihull Approach with health a child and to work with the parent or family on the visitors. Douglas and McGinty (2001) found that relationship. This can be done on an individual basis following training in the Solihull Approach, health or within a parenting group. Parents appreciate this visitors reported greater confidence and job satisfaction. knowledge too, and are often able to change their In addition, it changed practice in 88% of health visitors behaviour and improve their relationship with their trained in the approach. Douglas and Whitehead (2005) children when the pattern of interacting is brought carried out a qualitative evaluation of health visitors and to their awareness. The Solihull Approach uses the found that using the Solihull Approach during their work concepts of containment and reciprocity to explain enabled them to focus more on emotions. In addition, how the infant brain develops within relationships. it improved consistency in practice, and, again, health However, an understanding of the importance of visitors reported better job satisfaction. Health visitors reciprocity and containment within relationships is also reported improved relationships with other transferable to other relationships and thus contribute professionals, which would suggest that the relationship to a sense of connectedness, known to be a key building skills that they utilise with clients have a component of resilience (Mental Health Strategic wider impact. Partnership, 2013). In addition, the increased skill levels and feeling of ‘I am making a difference’ are also likely to improve professional pride and resilience.
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Family Partnership Model
The Family Partnership Model (FPM) is an evidence-based method, developed by the Centre for Child and Parent Support. Its effectiveness has been demonstrated through a number of research trials which indicate positive benefits to the developmental progress of children (e.g. Davis & Rushton, 1991; Marlow et al, 1998), parent-child interaction (Barlow et al, 2007; Puura et al, 2005) and the psychological functioning of parents, families and children (e.g. Davis & Rushton, 1991; Davis & Spurr, 1998).
Its intention is to enable all practitioners to understand Bashford and Seal (2012) suggest that it is clear that the processes and skills of helping so they can use their mothers in their study placed significant importance own technical expertise more effectively. This is achieved on the development of the relationship and the by taking into account internal processes and addressing characteristics required (trust and a feeling of the psychological and social issues which may present ‘connectedness’ between the client and practitioner), when individuals and families have problems (Davis and which were all crucial in obtaining favourable positive Day 2009). outcomes. They state that the implementation of the FPM in Somerset has been a significant opportunity Bashford and Seal (2012) describe the impact of using for staff to reflect, to develop and learn new skills and the FPM within a health visiting team using a case study. increase self-awareness. Relationships are enhanced as They suggest that critical to the success of the delivery staff are able to empathise, listen and summarise while of the Healthy Child Programme is the ability of staff to moving parents through the structured ‘helping process’. engage with families and to establish effective working Feedback from parents demonstrated that they feel relationships that result in measurable outcomes. The listened to, supported and able to change their model, although originating from parents’ concerns behaviour. Observations of staff within home visits about professionals not listening to them and not demonstrated an increased confidence in working with recognising them as people with skills of their own, families with a more structured and focused approach. has since developed to support all parents, both for Relationships appeared to be stronger and mutual preventive/promotive purposes and for those who respect evident, even when working with families may be experiencing difficulties with their children, where traditionally engagement has been minimal. through the use of a structured ‘helping process’. The Staff reported that the use of the framework is effective ‘helping process’ constitutes the following phases: when supporting problem solving, and confidence has increased considerably in setting SMART (Specific, Relationship building Measurable, Achievable, Realistic and Timely) targets. Exploration The model also uses the same helping process for staff Shared understanding supervision in case work where staff are also listened to and empathised with, a partnership where shared Goal setting understanding will support staff goals to meet the Strategy planning outcomes with clients. The FPM also clearly identifies Implementation the importance of providing skilled supervision and the Review development of an infrastructure within an organisation. Ending
35 Supporting Health Visitors and Fostering Resilience Literature Review
Mellow Parenting
Mellow Parenting is a parenting programme for families where the children (0-5 years) are either on a child protection plan or the extent and nature of associated risk factors for child development give significant concern that child protection might become an issue (www.mellowparenting.org).
It was developed for families where there were severe Mellow Parenting is traditionally a group intervention relationship problems and around 25% of participating but also offers practitioners training in a detailed parent/ families had a child on the Child Protection Register infant observation system. Key components that aim to (Puckering et al., 1994; 1996). Seventy four per cent of facilitate engagement, and empower parents to reflect mothers entering the Mellow Parenting programme and learn from their own experience, include the use reported at least one hostile or indifferent parent figure of video feedback as a means of encouraging parents in their childhood and sixty per cent reported no current to reflect on their own behaviour and the response of confiding friend or family member was available for them their children. While time-consuming and demanding, (Puckering et al., 1999). This programme offers health structured observations of mother-child interaction have visitors and other family practitioners a framework by been shown to distinguish problem dyads (Puckering which to work with families who find relationships most et al, 1994). The programme is thought to successfully difficult. There is currently an independent meta-analysis engage parents ‘at the extreme end of the spectrum’ of the evidence for the effectiveness of Mellow Parenting (Puckering, 2004). Mellow Parenting aims to reach which will be published by Edinburgh University this year. these parents by providing a more nurturing context In addition Randomised Controlled Trials (RCTs) are being in which to develop their own relationships and their conducted in Belfast, and the Mellow Bumps (antenatal own skills alongside applying those to the relationships programme) is part of the THRIVE trials in Scotland, with their child (Figure 3). one of the largest independent evaluations of parenting programmes that has been conducted in the UK.
Figure 3: Mellow Parenting Model (babies and toddlers).
Transport and crèche Focus on strengths Facilitation team
Feedback on Providing a Joint lunch Exploration of life parent-child own Improvements nurturing and activity events that impact videos using in parent-child experience for with parents on parenting strengths-based relationship parents and children approach
Home visit Invitation to attend to visit Invitation Home Have a go at home tasks Build up parents’ relationship with each other
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Strengths-based approach
Central to the Mellow Parenting philosophy is the concept of working with families’ strengths as opposed to lowering self-esteem and encouraging defensive behaviours by focusing on deficits.
Practitioners are supported to develop the ability to 1996). In a pilot study of people with serious mental identify sometimes embryonic or brief episodes of health issues, people were asked to identify the factors positive interaction between parents/ infants. This is that they saw as critical to recovery. The most important not to say that weaknesses and concerns are ignored elements identified included the ability to have hope, but rather they are reflected upon in a way that is as well as developing trust in one’s own thoughts empathetic to the perspective of the parent. In this way and judgments (Ralph et al, 1996). Strengths-based a strengths-based approach becomes a way of building approaches are shown to be effective in developing and relationships, developing self-esteem, motivation and maintaining hope in individuals, and consequently many hope. It does not in any way however detract from the studies cite evidence for enhanced wellbeing (Smock need for ongoing assessment of risk. et al, 2008). Much strengths-based practice has an internal component, which is therapeutic in nature, Indeed there is much evidence for the effectiveness and which involves locating, articulating and building of strengths-based approaches and HEE propose upon an individual’s assets or capabilities. It also aims to that health visitors can also utilise these skills when assist with finding solutions for current problems based mentoring colleagues. In mental health there is a on currently available resources. Similarly, MacLeod strong focus on recovery and positive psychology – an and Nelson (2000), in a review of 56 programmes, found inherently strengths-based perspective. Petersen and evidence to support the view that an empowerment Seligman (2004) state that “The relationship is hope approach is critical in interventions for vulnerable -inducing”. A strengths-based approach aims to increase families. A strengths-based perspective shows how the hopefulness of the client. Having a sense of hope the practitioner can work positively towards partnership, is also believed to be a factor which builds resilience. by building on what parents already possess. As Further, hope can be realised through strengthened Graybeal (2001) explains, ‘the identification of strengths relationships with people, communities and culture. is not the antithesis of the identification of problems. Researchers have found that by encouraging pride in Instead, it is a large part of the solution’ (p.234). achievements and a realisation of what people have to contribute, communities generate increased Programmes such as Mellow Parenting, which have a confidence in their ability to be producers not recipients philosophy of strengths-based working with clients, of development (Foot and Hopkins, 2010). Strengths present an opportunity for health visitors not only to -based models have also been shown to help change build resilience in their clients, but the resulting shift in entrenched and destructive behaviours, family justice focus from deficits to strengths may also impact on their research using this model has been shown to reduce own resilience and the resilience of the colleagues that drug use, lower rates of arrest and conviction and they mentor. improve higher levels of social functioning (Shapiro,
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Lessons from the Family Nurse Partnership Model (FNP)
The FNP was developed in the USA (Olds et al, 2003) and is one of the most popular and well-researched home visitation parenting programmes (Browne and Jackson, 2013).
It is also cited as a prevention strategy to reduce child In a study of the Family Nurse Partnership workforce abuse and neglect as well as promoting maternal and by Robinson et al (2013) they reported that 80% of child health (Olds, 2002). Positive findings from nurses and supervisors rated their job as ‘better’ or the evaluative research carried out in the USA, in the ‘much better’ than their previous job. This is perhaps absence of a universal health service, have led to not surprising when one considers their training, the cross-party government decision to use the NFP resources and low client caseload. However, are there (known as the FNP in the UK) as a targeted, secondary lessons that can be learnt from the FNP model, which prevention service offered to ‘every vulnerable, first-time could support resilience within health visiting? Robinson young mother who meets the criteria and wants to join’. et al (2013) found that family nurses rated the quality of The current criteria are that the mother is recruited at their supervision highly. In turn, supervisors were very under 28 weeks gestational stage of pregnancy and is positive about the support they had received from the 19 or under at the date of their last menstrual period. FNP National Unit. The supervisors said that they feel As a result, the FNP in England is designed to act as a ‘part of the FNP family’ indicating a strong sense of support system to work alongside the universal Healthy belonging, and compassionate and available leadership. Child Programme. One of the largest randomised In addition, nurses spoke about the “high quality” of -controlled trials as to the effectiveness of this their training and were extremely clear about their role. programme is currently underway in England, with the findings expected later this year. What is of particular interest to the current project is whether there is evidence of greater resilience within family nurses, many of whom have come from the field of health visiting.
Support framework for Family Nurses
The Family Nurse Partnership is a highly targeted model which has a number of fidelity measures that are rigorously applied in order to maintain optimum outcomes. The fidelity process begins during the set up and recruitment of the teams and the measures put in place which facilitates support and resilience are shown in Table 4.
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Table 4: Support and resilience features of the Family Nurse Partnership Programme
FNP fidelity measures Interviews for team supervisors are attended by a member of the FNP National Unit (interviewing includes considering emotional intelligence and personal characteristics such as personal warmth). Nurses and supervisors attend residential study days where they are given the theoretical framework and clinical tools to prepare them for the work. FNP nurses carry a caseload of no more than 25 cases and supervisors carry a caseload of no less than 2/3 families. The supervisor provides clinical supervision for each nurse on a weekly basis. The supervisor receives supervision from a psychological consultant allocated to the programme once a month. The team receive psychology supervision once month. There are at least 4 team meetings per month facilitated by the supervisor: two to discuss programme implementation and two case-based meetings to identify client challenges and solutions. This will include skills practice and role play to give nurses an opportunity to practice approaches before the client visit. The supervisor makes a minimum of one home visit every 4 months with each nurse for field supervision purposes. The supervisor uses programme reports to assess and guide programme implementation, inform supervision, enhance programme quality and plan team-based learning. Family Nurses receive one day training based on the Compassionate Mind Approach.
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Robinson et al (2013) also report that the family nurses Key aspects of the FNP Support Model described the work as intense and the phrase “emotional labour” was used on several occasions. One nurse Job satisfaction is inextricably linked with the ability commented: “We thought it would be easier, with a and time to form therapeutic relationship with clients. lower caseload, but it wasn’t. I never got up to full The tight framework of supervision and support capacity.... but it felt as though I did – it was very hard allows the nurses to cope even with high levels of work. We’d be writing things up at 8pm, asking each “emotional labour”. other, ‘How are we going to cope?” (p.7). Family nurses are confident and able to use their Family nurses work intensely with clients and the skills as they have the time, resources and practice development of the therapeutic relationship is central opportunities to enable them to. to the work. However the finding that fewer than 25 The fidelity measures interwoven into the programme vulnerable clients was a considerable pressure to including joint visits with supervisors, regular skills contain and manage perhaps puts into perspective the practice training, case analysis sessions allows for rich enormous strain and expectations put on health visitors personal development and client engagement. who hold on average in excess of 400 clients in their caseloads (Bidemead, 2013), many of whom will be The National Unit brings a sense of belonging and extremely vulnerable with complex needs and multiple security to the teams making it feel like a “family”. children in their families. It is perhaps not surprising Family nurses struggle to cope with caseloads of fewer that 41% of health visitors in the NHS survey (2013) than 25 clients who will vary in vulnerability. Health stated that they could not deliver the care to which visitors are routinely managing caseloads in excess of they aspired. 400; this, in conjunction with other issues identified by Bidmead (2013), makes forming therapeutic Robinson et al (2013) have been able to use the NHS relationships with clients (central to the work of the survey 2011 and their own survey of family nurses to health visitor) impossible. make direct comparisons between family nurses, other nursing groups and health visitors. Figure 4 below FNP supervisors carry out regular joint visits with their outlines the results with regards to areas relating to nurses allowing them to identify strengths and areas professional resilience. It is striking that the family for growth. This will also allow supervisors to identify nurses and supervisors report feeling better in relation when staff are ready to undertake mentoring roles to all of the issues, which include feeling valued and for others. supported. In addition, health visitors are shown to feel they have least opportunity to use their skills in comparison to the other nurses.
40 Supporting Health Visitors and Fostering Resilience Literature Review
Figure 4: Components of job satisfaction: comparison with national results
Sources: FN Survey 2012, and National NHS Staff Survey 2011 (Robertson et al 2013)
There is now overwhelming evidence to suggest that the first 1001 days of life (conception to the 2nd year of life) are critical to improving outcomes for children (Wave Trust, 2014). Indeed there is now a cross-parliamentary agreement to focus support and resources on this period of life. The Family Nurse Partnership focuses on providing intensive support to parents in this period of their baby’s life. Their role is clearly delineated with a clear cut-off point at two years, which allows a focusing of resources and agreement around priorities. This may indicate that a smaller more boundaried role delivered within a PPE would bring the greater job satisfaction to health visitors and improved practitioner resilience. It could also be argued that this would in time bring improved outcomes for children and families in addition to added value for the organisation.
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Key points: relationship models of intervention
The development of the relationship with the client is what makes the ‘real difference’ in improving outcomes for service users. “Making a difference” has been identified as a key motivating factor for students’ decisions to enter health visiting and health visitors’ rationale for remaining in the profession. Having the ability to form and model good relationships is at the core of health visiting practice. It is difficult for health visitors in many areas of the country to develop relationships with their clients. There is also evidence to suggest that this affects morale, job satisfaction and professional self-esteem. There is a risk of losing people from the profession if they feel unable to “make the difference” and thus lose a key motivator to remain engaged with the demanding but most critically important therapeutic basis for practice. Overwhelmingly large health visitor caseload size is a very important factor inhibiting the ability of the health visitors to establish relationships with parents. Pressures of record keeping, less qualified staff being deployed to take on work with families, lack of support from managers to take on relationship work are also inhibiting factors. Where health visitors are unable to establish relationships with clients, valuable interventions and support, including a better understanding of the importance of attachment in their children’s development, will be reduced. It also means that early signs of mental health problems – whether in the infant or the parent – may be missed, increasing the risk of serious mental disorders, which are costly both in financial and human terms. Training in relationship-based models of intervention improves health visitor job satisfaction, competence, consistency, self-awareness, and relationships with clients and colleagues, in addition to improved outcomes for children and families. The fidelity measures, values and structures of the Family Nurse Partnership model have contributed to its success and place it as an example of a ‘positive practice environment’.
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Action learning
Action learning is a commonly used approach for leadership development and has been discussed in a wide range of academic literature (see for example O’Neil & Marsick, 2007; Marquardt et al, 2009; Raelin, 2008; Cho and Egan, 2009). It is a popular method of developing an organisation’s human resources and has been driven by perceived outcomes and relevance to organisational issues (Marquardt, 2004; Bolt, 2005; Raelin, 2007).
Action learning has been defined as ‘a process of fundamental learning unit in an organisation. reflecting on one’s work and beliefs in the supportive/ Participants in action learning environments learn as non-confrontational environment of one’s peers for they work by reflecting with their peers. This reflection the purpose of gaining new insights and resolving real helps individuals gain insights into their, and their business and community problems in real time’ colleagues’, workplace problems (Raelin, 2008). (Dilworth and Willis, 2003, p.11). Action learning has been widely discussed in academic literature and The ‘action’ in action learning provides the pathway to Cho and Egan (2009) detail a wide range of academic learning with the consequence that any given task will literature dedicated to action learning. be a vehicle for learning (Raelin, 2008). The ‘learning’ can occur at individual, team, or organisational levels The use of action learning can contribute to improved (Marquardt, 2004). However, addressing an issue is performance and helping staff to learn by reflecting useful only if there is learning from the experience on their practice and decision-making (Jackson and (Rooke et al., 2007; Raelin, 2008). Thurgate, 2011). Both individuals and organisations can benefit from action learning, as when used Balanced approaches correctly at an organisational level, it can help improve communication, work environments, cooperation, Revans (1971, 1982, 1998) emphasised the importance shared vision and development. It has also been of taking a balanced approach, where action learning is suggested as being a useful approach for developing regarded as an optimal method for connecting learning human resources through individual learning and and work (de Haan & de Ridder, 2006). Thus learning is development (Willmott, 1994; Vince, 2003, 2004; focused on learning for more effective action (Marsick Reynolds & Vince, 2004; Pedler, et al 2005; De Loo, & O’Neil, 1999). Through a balanced process of action 2006; Marquardt et al., 2009;). However, there is a need and learning, people can develop skills to learn from for participants in an action learning process to strike their experiences and personal development may occur a balance between action and learning (Revans 1971, from reflection on action (Pedler et al., 2005; O’Neil & 1998, Pedler, 2002; Kuhn and Marsick, 2005; Raelin & Marsick, 2007). Action learning balances working on Raelin, 2006; Tushman et al., 2007). a problem and learning through that process (O’Neil & Marsick, 2007). Balanced action learning programmes The basis of action learning is the premise that have been shown to enhance both individual and people learn more effectively when working on real-time organisational outcomes (Tushman et al, 2007). Cho and problems occurring in their own work setting (Day, 2000; Egan (2009) show that key success factors in a number of Reynolds & Vince, 2004) and that they learn best when balanced action learning studies include the effective use reflecting together on real problems occurring in their of project or learning teams for organisational learning, own organisation (Raelin & Raelin, 2006; Vince, 2004). deliberate reflective practices and management support, Senge (1990) suggested that teams (otherwise known and participants being provided with adequate time as learning teams or action learning sets) are the for reflection.
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Unbalanced approaches
Action learning programmes can, however, develop involves reflection and action. The learning sets are ‘action’ at the expense of ’learning’ (Raelin, 2008). supported by experienced facilitators (Dewar & Sharp Action is not the goal but the means by which learning is 2006; McCormack et al. 2009). achieved; however, ‘learning-oriented action’ instead of balancing ‘learning with action’ is often what takes place Evidence for the effectiveness of action learning sets (Rooke et al., 2007). Imbalances between action and highlights outcomes such as enhanced critical thinking, learning can only be overcome by reflective practices finding creative solutions to problems in the workplace, which are required to convert experience into knowledge increased self-confidence in individuals and improved and which is fundamental to learning to provide a basis communication skills (Johnson, 1998; Booth et al. 2003; for future action (Raelin, 2008). Thus action learning Dewar & Sharp, 2006). In a study undertaken by Napier is ‘the process of stepping back from experience’ University (Leadership in Compassionate Care Programme (Coghlan and Brannick, 2005) to process what the Team, 2012) action learning helped participants to experience means, with a view to planning further explore challenges to developing compassionate caring action. An unbalanced approach is unproductive, as practice. Key actions were developed by participants to ‘action without learning’ is unlikely to return results and help them respond to such challenges in the workplace. ‘learning without action’ does not engender change The skills and confidence of participants as facilitators (O’Neil & Marsick, 2007). Thus action learning must were also enhanced, with potential benefits for all balance action and learning (Pedler, 2002; Kuhn & aspects of their practice, including more effective Marsick, 2005; Raelin & Raelin, 2006; Tushman et al., communication strategies and the skills to continue to 2007). Where learning oriented action learning practices be researchers of their own practice. occur and are deemed to be successful they tend to be aimed toward personal learning but not organisational Action learning has often been used in the health sector, learning, as there is a less clear process for transferring particularly in relation to nursing and midwifery (see for personal action learning into organisational contexts example: Learmonth, 2005; Bell et al, 2007; Board and (Willmott, 1994; De Loo, 2001, 2002, 2006; Donnenberg Symons, 2007; Wilson et al, 2008; Edmonstone, & De Loo, 2004; Vince, 2004; Pedler et al., 2005). Pedler 2008; Richardson et al, 2008; Walia, 2014;). A multi et al (2005) suggests that individualised approaches can -faceted educational pilot programme for new nurses result in employees focusing on their own job-related and midwives was implemented in Scotland in 2010 issues but be isolated from the wider organisational to accelerate their clinical practice and leadership context (Cho and Egan, 2009). development (Machin et al, 2014). The use of facilitated action learning sets by nurse consultants at two NHS Action learning sets trusts in Brighton to support their development of strategic leadership skills is discussed by Young et al Action learning sets (ALS) are used widely for (2010). Here, the settings, process and outcomes, organisational and workforce development. Action including benefits to patients, of the organisations were learning sets (usually comprising six to eight people) assessed. One further example used online action bring participants together to support each other and learning sets as part of a national pilot development to explore challenging experiences from the workplace. pathway for Advanced Nursing Practice in Scotland Participants work to develop their own understanding (Currie et al, 2012). In this study a range of benefits of a situation through careful questioning and an and limitations of online ALS was identified. While expectation of being challenged. This allows the flexible access and sharing experiences with others development of a new understanding about a situation, was emphasised, issues of multiple commitments which in turn allows them to take new actions. There is and lack of group cohesiveness interfered with the also a commitment to take responsibility in the process process. The need for face-to-face sessions to provide and to work with the personal values, feelings and getting-to-know-you opportunities and to enhance attitudes that may arise. The process is cyclical and commitment to the group process was identified.
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There are many definitions and variants of action and learning or learning sets and resilience. The primary examples include business-driven action learning, focus of action learning is learning in, through and inter-organisational action learning, critical action for action. However, it is reasonable to infer that the learning, auto action learning, self-managed action benefits of action learning are likely to contribute learning, project action learning, developmental action to resilience through fostering such outcomes as learning, work-based learning, and internet-based action improved self-efficacy and control, a positive set of learning (Cho and Egan, 2009). Action learning is more group relationships and a sense of empowerment to often used for personal development than organisational align individual actions with organisational goals. At growth and is more predominant in this context in the the time of writing the University of Birmingham, education and public sectors (De Loo, 2001, 2002, 2006; Institute of Health Service Management is researching Donnenberg & De Loo, 2004; Pedler et al., 2005; Vince, action learning sets to support hospital clinical leaders 2004; Willmott, 1994). in delivering compassionate care. Outcomes of such work may be of interest to health visiting services Within the literature reviewed there can be no firm as an example of action learning focusing on conclusions of a direct relationship between action ‘support’ and ‘compassionate care’.
Key points: action learning
A number of aspects have been identified as crucial to successful action learning (Leadership in Compassionate Care Programme Team, 2012):
Facilitation skills are crucial to ensuring that individuals feel safe to engage with the action learning process; There are organisational challenges in supporting people to develop these skills quickly; To work well, action learning requires mutual commitment to participate; Participants can find it problematic to attend action learning sets as part of their working day; Action learning and action learning sets may contribute to some of the determinants of resilience although their primary concern is with learning.
45 Supporting Health Visitors and Fostering Resilience Literature Review
Performance feedback
The importance of feedback for employee morale and job satisfaction (Whittaker et al 2013), health and wellbeing (Partnership for Occupational Safety and Health in Healthcare 2012) and reducing workplace stress (NHS Employers 2014a) as well as improving patient outcomes (The Point of Care Foundation 2014) has been documented.
In the iHV survey (2014) health visitors described Developing practitioners’ skills in self and peer feedback as something they valued and would like assessment and providing feedback can facilitate more of in order to develop their knowledge and skills. effective learning (Svinicki and McKeachie 2011). Open communication and transparency are recognised Encouraging self-assessment as part of the process as important components of positive practice facilitates responsibility and develops skills. Building environments (ICN, 2007, cited WHPA, 2008 p.2). on the person’s self- assessment and having a dialogue is important (Wilson 2008). Feedback is important to improve understanding and review progress. Feedback also helps the manager to Models for providing feedback assess their effectiveness and can develop their practice. It can motivate as well as develop knowledge and skills Two specific models have been reviewed in considering (McKimm 2009). King (1999) suggests that barriers to support for health visitors to foster their resilience. These feedback may include a fear of upsetting the person, are multisource (360-degree) feedback and after action compromising their self-esteem and their relationships. review (CollIison 2014). The person may become defensive, and strategies to address this include naming and exploring the resistance Multisource (360-degree) feedback and enabling the person to take responsibility (King 1999). Thus, the process by which feedback is delivered There are several domains to professional competence, and the skills of the person proving the feedback are and multisource (or 360-degree) feedback is designed important considerations. to assess in particular the relational and humanistic competencies (Sargeant, Mann, Ferrier 2005). It is a The principles of effective feedback tool to help employees improve and focus on their development. It uses the combined perspective of a Constructive feedback is timely and starts with the manager and several peers – from four to ten people positive, is specific, refers to a behaviour that can looking at the teamwork, communication, leadership change, offers alternatives and choice (King, 1999; and management skills of an employee. It can identify a Svinicki and McKeachie, 2011). Sadler (1989) suggested starting point for the development of new skills, measure that to benefit from feedback the person needs to progress as skills are worked on over time, and identify understand the standard or goal to be achieved, be blind spots in behaviour and its impact (Vanek 2013). It able to compare their level with this, and take action also provides a means to recognise strengths and build to address the difference. Accuracy and specificity is on them. important (Wilson 2008). This is supported by King (1999) who suggests that recognising the person’s 360-degree reviews alone will not change a person. efforts, enabling them to express their views and However, there is some evidence that facilitated supporting their development, will enhance motivation. feedback enhances successful behaviour change (Nowack 2005).
46 Supporting Health Visitors and Fostering Resilience Literature Review
A meta-analysis of 26 longitudinal studies indicates How the feedback is delivered is important, as significant but small effects sizes (Smither et al, 2005). individuals may perceive them negatively, and they When using these findings it may be unrealistic to expect should not be used as a substitute for good leadership large performance improvement after 360-degree and management (Nowack 2005, Vanek 2013). feedback. A lower number of raters undermines Starting 360-degree reviews from the top down in an reliability of the responses. Eight to ten raters maximises organisation can be helpful. Performance issues should the reliability (Nowack 2005), with the NHS Leadership be addressed directly and immediately and not left for Academy (ND) recommending 12 raters as optimum. the 360-degree review (Vanek 2013). If the individual has not received regular feedback from their manager The employee will need support to carry out the changes this is unlikely to be a positive experience. Acceptance identified, which will take time. There is some evidence of the feedback is influenced by perceptions of that coaching coupled with 360-degree feedback can objectivity, credibility of the process, relevance facilitate behaviour change (Smither at al 2003). Smither of competencies being assessed and the way the and Walker (2004) found that 70% of written feedback feedback is delivered (Sargeant et al, 2005). Nowack was generally positive and favourable comments are (2005) advises caution in the way feedback can be given associated with improved performance. Managers who and the profound impact upon the individual’s wellbeing received a small number of unfavourable comments of being compared to others. He cities neuroscientific showed greater improvement. However managers who evidence from Dickerson and Kemeny (2004) which received a large number of unfavourable behavioural showed that when stress is interpersonal, i.e. due to comments declined in performance. It is important being compared with or judged by others, the effect to note that a meta-analysis on over 3,000 studies on cortisol is three times greater than when stress is found that one third of all studies showed declines impersonal, and takes 50% longer to reach baseline. in performance (Klugar and DeNisi 1996). This is The compassionate model (Gilbert 2010) is helpful important when considering effective support to in understanding this response and considering how build health visitors’ resilience. to facilitate a compassionate process in providing feedback and building a person’s resilience. 360-degree reviews are for the benefit of the individual not the team or the organisation, therefore it is crucial Often the questions in 360-degree reviews are pre-set, the individual accepts the concept and process. however they can be customised to meet the specific Preparation for the 360-degree review should involve needs of the organisation or the group of employees ensuring that employees are happy to engage in the being reviewed. Technical or performance skills process, and consider what to do with those who are should not be evaluated or rated with this tool. It is not able to participate in the review for whatever reason recommended that individuals are in post for more (Vanek 2013). The process of completing the 360-degree than one year before using the 360-degree review. feedback can take six weeks (NHS Leadership Academy Administering 360-degree reviews is a skill, and is best ND) – a lengthy period that may be time intensive for learnt by observing and working with someone else with organisations. Scale feedbacks are quicker for the experience before doing it alone (Vanek 2013). Thus, person completing the review but open texts have the use of mentoring to support feedback, reflection more meaning. User fatigue should be considered and learning can enhance the acceptability of feedback (Vanek 2013), particularly if individuals are expected thereby facilitating change (Sargeant et al, 2005). to complete these for a number of colleagues.
47 Supporting Health Visitors and Fostering Resilience Literature Review
After action review
The after action review approach process considers the use of four simple questions which people can easily remember, so that they become embedded in their practice and in the organisational culture. These have been described by Collison (2014) and illustrated in Figure 5 below
Figure 5: After action review model
Agreed Facts i) What was supposed ii) What actually happened? to happen?
iii) Why was there a difference? iV) What can we learn from this?
Shared Opinions
At University College Hospital a significant number of AAR has been used predominantly in analysing specific staff from across disciplines have trained in the after events to increase awareness, generate understanding, action review (AAR) process (Halligan 2012). The process facilitate behaviour change, learn and develop an action is embedded in the organisational culture and used to plan. Learning from adversity and sharing experience is facilitate effective teamwork and enhance performance a key factor in building resilience (McAllister and Kinnon, (Walker et al 2012). It has been used to analyse 2009). Rutter (2012) suggests that a reflective style, significant events as well as being on the agenda for commitment to relationships, and personal agency are routine team meetings. It is designed to use a blame-free characteristics of resilient individuals. Applying this to approach and facilitate long-term learning. This approach the AAR process would suggest that this could seems very relevant to building health visitor resilience contribute to building resilience. However, it could as McCann et al (2013) found that opportunities for also be applied in the context of a shared experience feedback and debriefing contributed to nurses’ resilience. in providing feedback. It can be used to examine a situation where performance could be improved or AAR can provide insight into performance, team work, to celebrate and publicise a situation with excellent leadership and culture. All of these are important outcomes. This is in keeping with the strengths-based components of a positive practice environment (Bryar approach used by health visitors in working with clients. et al, 2012). Although it appears a simple process, Once good practice has been identified it is important conducting an AAR involves exploring values, beliefs to share expertise and learning, as this is influential in and principles, and requires skills including leadership, building resilience and enabling practitioners to thrive courage and effective communication in having in practice (Wendtet al, 2011). challenging conversations. This links with the findings of Whittaker et al (2013) on the importance of the Walker et al (2012) describe the implementation of AAR psychological contract, exploring expectations and through multi-professional training using experiential engaging staff. methods, with the aim to develop leadership skills. The
48 Supporting Health Visitors and Fostering Resilience Literature Review
process requires protected time, a safe environment 2012). In the AAR process staff take responsibility and a skilled trained facilitator. It is important that and this facilitates self-efficacy which is important for participants are clear about the purpose and the four job satisfaction, engagement and retention of staff key questions are used. All participants explore and (Whittaker et al, 2013) and for developing resilience verbalise their expectations so it is important that they (Rutter, 2012). The AAR process is also said to benefit feel psychologically safe. A solution is generated by the patient care and the Trust by enhancing listening skills team, which creates ownership of the change. Involving and communication and building resilience during staff in decision-making and sharing values are important stressful times (Walker et al, 2012). in creating a positive practice environment (Bryar et al,
Key points: performance feedback
Feedback is important to improve understanding and review progress. Barriers to feedback may include a fear of upsetting the person, compromising their self-esteem and their relationships. Multisource (360-degree) feedback. • 360-degree feedback is a tool to help employees improve and focus on their development.
• 360-degree feedback can identify a starting point for the development of new skills, measure progress as skills are worked on over time, and identify blind spots in behaviour. • 360-degree reviews will not change a person. However there is some evidence that facilitated feedback enhances successful behaviour change. • 360-degree reviews are for the benefit of the individual not the team or the organisation. • Acceptance of the feedback is influenced by perceptions of objectivity, credibility of the process, relevance of competencies being assessed and the way the feedback is delivered. After Action Review. • AAR can provide insight into performance, team work, leadership and culture. • AAR has been used predominantly in analysing specific events to increase awareness, generate understanding, facilitate behaviour change, learn and develop an action plan. • In the AAR process staff take responsibility and this facilitates self-efficacy that is important for job satisfaction, engagement and retention of staff.
49 Supporting Health Visitors and Fostering Resilience Literature Review
Interagency / disciplinary groups
Opportunities for professional development, peer support and sharing values are important elements of positive practice environments (Bryar et al, 2012).
Resilient strategies can be developed through Through exploring the experience and reflecting on the building positive professional relationships (Jackson implication of what has been seen and experienced in et al, 2007) and positive learning experiences (McAllister the group, participants develop their understanding of and McKinnon, 2009). Coming together regularly in institutional and interpersonal dynamics and the possible an interagency/disciplinary group can support the emotional meaning of communications (Tavistock and development of meaning, clarify roles and Portman, 2015). An understanding is developed of responsibilities, and contain the emotional impact unconscious emotional reactions or psychological of the work. Clarifying roles, responsibilities and defences, which may be preventing them from noticing accountabilities is important in a complex system such painful feelings in themselves or others. The process as children’s services (DH, 2013a). Inter-professional of ‘containment’ is a key component (Bion, 1962). learning can facilitate integration and collaboration Menzies Lyth (1960) described how nurses used (CAIPE, 2012). Sharing experiences of vulnerability detachment in managing anxiety and that a certain and resilience facilitates learning, emulating strengths amount of this is healthy. However, the sustained use and preventing pitfalls (McAllister & McKinnon, 2009). of defensive strategies can exacerbate stress and Acknowledging strengths promotes pride in professional increase the risk of burnout (Gray and Smith 2009). practice. Through story-telling fresh insights are Work discussion groups provide a safe place where developed, creativity is enhanced and groups can emotions and the use of defensive behaviours can be respond more effectively to change (Allen et al, explored. The emotional labour of health visiting is not 2001). Developing integration improves the quality widely discussed in the literature, although the demands of services and enhances the experiences of staff of supporting families experiencing distress, tragedy (NHS Confederation, 2014). and suffering is a significant component of health visiting practice. Having the opportunity to enhance Three models of interagency/multidisciplinary support understanding of the use of defensive strategies could were examined. These are work discussion groups, prevent sustained use of these behaviours which may Schwartz Centre Rounds® and compassion circles. contribute to burnout.
Work discussion groups Jackson (2008) describes the use of work discussion groups in educational settings which enabled teachers to Work discussion groups have been developed as a manage the challenges of their work, their role and their component of professional training at the Tavistock relationship with the students. This resulted in a learning and Portman NHS Foundation Trust. Professionals from environment in which personal, professional and whole varied backgrounds discuss their work with children school development was enabled. Work discussion and families using a psychoanalytical framework of groups can be applied in different settings, but there understanding (Canham, 2000). An experienced are some considerations to bear in mind. For example, -based learning approach is utilised. The group has participants need to acknowledge and be sensitive to approximately five members, is held in a stable setting unconscious processes, and understand that the work and facilitated by a trained, experienced facilitator. discussion is about exploring their personal experiences Participants bring a written record detailing an and relationships. A clear differentiation between interaction observed between themselves and others the work discussion group and supervision or involved in a work situation. The group enables members psychotherapy needs to be made. Jackson (2008) to share their experience and their concerns through describes the importance of the facilitator clarifying their discussion. Although it is based on psychoanalytic theory, role and task when working in different settings. The the discussion is theory-free and emphasises a non facilitator does not provide solutions to problems, and -judgmental approach to everyone involved, including this can lead to frustration if participants are expecting oneself (Rustin, 2008). to find an immediate answer. In addition, participants
50 Supporting Health Visitors and Fostering Resilience Literature Review
may be anxious about sharing their problems in front of evaluation commenced in May 2014 and is led by colleagues or managers who might judge them. Jackson Professor Jill Maben. This national UK study aims to (2008) suggests that effective working relations can be evaluate the effect of Schwartz Centre Rounds® on staff established between participants when management wellbeing at work, the relationships between staff and hierarchies are not represented. The work discussion patients and the provision of compassionate care. group is designed to enable a participant-observer to cope more effectively with their working setting and Compassion circles facilitate reflective practice (Rustin, 2008). The development of compassion circles has been Schwartz Centre Rounds® informed by the compassionate mind model (Gilbert 2010), the work of Professor Jon Kabat Zinn, and Nancy The Francis Report (2010) identified the potential of Kline (2005). Compassion circles are offered to people Schwartz Centre Rounds® to support staff to deliver connected through health and social care. They are compassionate care. These have now been designed to offer a safe place for facilitated reflective implemented in a number of organisations in England, dialogue for groups of up to 12 people. Anyone with an who receive training and support from The Point of interest in being compassionate to themselves and in Care Foundation. building sustainable compassionate cultures in health and social care can attend. A host and facilitator work Schwartz Centre Rounds® are multidisciplinary forums together to create a space for reflection (Frameworks where health professionals meet monthly to reflect and for Change 2014). The host invites people to join the acknowledge work-related psychological, emotional circle and the facilitator runs the group. The benefits are and social challenges (Goodrich, 2011). A range of reported as providing time to reconnect with core values, professions and specialities share their experiences to consider self-compassion and make plans for and gain support from colleagues. Each round lasts maintaining boundaries and personal wellbeing, and for an hour and starts with a case presentation by the time to reflect on culture in the workplace. Compassion team who cared for a particular patient. They describe circles have been well-received by those who have the impact that the case had on them and a trained participated in their implementation (Frameworks for facilitator guides discussion, allowing space for the Change 2014). Frameworks 4 Change is now actively audience to reflect with the panel on similar experiences seeking partners to research the benefits of compassion they may have had (Kings College London, 2014). circles to staff wellbeing, team working and patient There is a growing evidence base (Goodrich, 2012) experience. They have just started a project called that suggests that offering this kind of support benefits Sustaining Compassion in High Pressure Environments clients, team working and potentially facilitates cultural with a Central London Community Trust which is drawing change (The Point of Care Foundation, 2014). A two-year on the work of the Westminster Centre for Resilience.
Key points: interagency groups
Interagency/disciplinary groups can support the development of meaning, clarify roles and responsibilities, and contain the emotional impact of the work. By using work discussion groups, exploring experience and reflecting on the implication of what has been seen and experienced in the group, participants develop their understanding of institutional and interpersonal dynamics and the possible emotional meaning of communications. Schwartz Centre Rounds® are multidisciplinary forums where health professionals meet monthly to reflect and acknowledge work-related psychological, emotional and social challenges. Compassion circles are offered to people connected through health and social care and are designed to offer a safe place for facilitated reflective dialogue for groups of up to 12 people.
51 Supporting Health Visitors and Fostering Resilience Literature Review
Peer support
Peer support has been identified as a component of a positive practice environment (Bryar et al 2012) and as a contributing factor in fostering resilience (Jackson et al 2007; McAllister & McKinnon 2009, McCann et al 2013; Hunter and Warren, 2014).
It has been described as ‘a voluntary, non-evaluative Peer support can be delivered in many ways, for example and mutually beneficial partnership between two individual one-to-one sessions; self-help/support groups; practitioners of similar experience who have participated online computer-mediated groups; and educational in training and who wish to incorporate new knowledge environments. Such support can take place in a wide and skills into practice’ (Waddell and Dunn 2005, p. 84). range of environments (e.g. home, hospitals and clinics), Alternatively, Dennis (2003, p. 323) defines peer support and can be provided in many ways (e.g. professional as ‘the giving of assistance and encouragement by an programmes, volunteer organisations). Peer support individual considered equal’ while recognisng that this can be provided by educators, advocates, leaders may be over-simplistic. Peer support relies on a trusting and counsellors and can be delivered as a primary relationship with another individual, allows for the intervention or part of a comprehensive programme. setting of performance goals, and involves observation Dennis (2003) identified three attributes which appear and reflection (Brooks and Moriarty, 2009). During regularly in peer interventions and which support peer times of need, individuals turn to social relationships relationships: emotional, informational, and appraisal. for support in response to barriers or deficiencies encountered in the healthcare system. In this context, Emotional support is needed when individuals encounter the enhancement of supportive relationships and situations that damage self-esteem and create doubts strengthening social relationships for health promotion about ability and performance (Wills, 1985). Having is important (Stewart and Tilden, 1995; World Health someone available to discuss personal difficulties helps Organization (1998). In the patient environment, peer to counteract the effects of such threats. Such emotional support has been recognised as having a positive impact support (Wills and Shinar, 2000) can include caring, on the health outcomes (Lakey and Cohen, 2000). Peer encouragement, listening, reflection and reassurance, support has also become significant in the delivery of while avoiding criticism or advice-giving (Helgenson and quality healthcare (Cox, 1993; Eng and Young, 1992). Gottlieb, 2000). This interaction helps to foster, for As such, it is important that the health visiting profession example, the experience of feeling accepted or being has a clear understanding of this concept. However, cared for despite having personal difficulties (Cobb, delivering peer support is complex and its application 1976; House, 1981). Informational support might be can be vague and variable, although its benefits continue sought to resolve problems and can include advice, to be sought (Dennis, 2003). suggestions, facts and feedback (Wills, 1985; Burleson et al., 1994). Informational support provides knowledge to Peer support is often seen as a key element in the the individual to solve problems and includes: relevant delivery of quality patient care but its application is resources; independent assessments regarding the complex and variable, although highly beneficial (Dennis problem; alternative courses of action; and guidance 2003, Lloyd Jones 2005). The concept of peer support about effectiveness (Wills and Shinar, 2000). Appraisal has been used extensively in teacher and medical or affirmational support affirms the appropriateness of education, as well as with health educators (Gingiss the individual’s emotion and behaviour (House, 1981). 1993; Lam et al 2002; Sekerka and Chao 2003). However, Specific approaches include encouragement, in healthcare the application of peer support has been reassurance, assistance and communication of optimism limited, and only a few studies discuss the benefits and (Wills, 1985). Together, these help generate positive difficulties (Cheate, 2001; Aston and Molassiotis, 2003). future expectations. The concept was initially introduced into teacher education and developed to aid the transfer of new Founded on shared experience, and sense of belonging, skills from the classroom into the workplace (Joyce there is evidence to suggest that peer support positively and Shower, 1982). affects psychological and physical health outcomes in
52 Supporting Health Visitors and Fostering Resilience Literature Review
several ways known as direct, buffering, and mediating consideration with the increase in mobile working in effects (Cohen et al., 2000; Helgesson and Gottlieb, health visiting and the potential reduction in accessing 2000). The direct effect suggests that peer support peer support. directly influences health outcomes through mechanisms such as social integration. Incorporation The recognition that teams in healthcare organisations into peer relationships can enhance social integration, are crucial to their success (West 2013) has informed which may reduce feelings of isolation, a condition a programme of work focused on harnessing the associated with increased negative affect and sense of potential of the nursing team to provide staff support. alienation and diminished feelings of control and self An analysis of the factors contributing to the well -esteem (Cohen et al., 2000). The buffering effect -publicised ‘failures’ in care including those itemised model of peer support either protects individuals from in the Health Service Ombudsman’s report (Abraham potentially harmful influences of stressful events or 2011), events at Maidstone and Tunbridge Wells determines individual responses to potentially stressful (Healthcare Commission 2007), and Mid-Staffordshire events (Cohen et al., 2000; Cohen and Syme, 1985). The NHS Foundation Trust (Francis, 2010 [and later 2013]) mediating effect of peer support intervenes indirectly found that attention to the needs of staff, if they were to influence health through emotions, cognitions, and to provide compassionate care, had been largely behaviours (Stewart and Tilden, 1995). overlooked (Sawbridge and Hewison, 2011). There was no acknowledgement of the emotional component of Peer support in practice nursing work and the impact this could have on the provision of compassionate care (Hewison and Peer support is a model that has been adopted within Sawbridge 2014, Sawbridge and Hewison, 2013). In a range of health related professions. For example it is view of this, an action research study was undertaken included as a component in the national induction and to explore the feasibility of using a model developed preceptorship frameworks for health visiting (iHV, 2015). by the Samaritans organisation with ward teams in The Health Visitor Implementation Plan outlines a career three NHS acute Trusts in England (Sawbridge et al path for newly-qualified health visitors that begins with a 2014). Although it was not possible to implement the period of preceptorship and consolidation and results model, a number of key lessons were learned which in specialisation after two years. Newly qualified have informed subsequent work. Identification of the practitioners are able to access preceptorship issue (Hewison and Sawbridge 2012; Sawbridge and programmes which include peer support opportunities Hewison, 2012) has led to interest in, and support for to discuss caseload concerns with health visitors who further work in this area. Currently a ‘co-production’ are in a similar situation (Morris-Day, 2014). Hudson, approach (Hewison et al, 2012) is being taken in a project Hart & Dodds (2014) highlight the role of the with an acute and a community trust to enable ward preceptor in building professional resilience and teams to develop ‘self-managed’ approaches to staff the need for preparation and support for preceptors. support, and to evaluate the impact of leadership development on the delivery of compassionate care. The Royal United Hospital, Bath, developed a A further study to examine these issues in mental health preceptorship pathway to support a high number of care settings is in the process of being commissioned. newly-registered nurses as soon as they took up their roles. This workplace preceptorship programme Hamrin et al (2006) evaluated peer-led support groups included peer support, and evaluation indicated that the in the nursing education environment. Anxiety in this pathway provides a high standard of support (Chapman, environment is well documented with stress greater 2013). Rotherham Doncaster and South Humber NHS during the initial period of clinical practice (Admi, 1997; Foundation Trust’s children and young people’s mental Beck & Srivastava, 1991; Kleehammer et al, 1990; health service employ peer support workers, who have Pagana, 1998; Jones, and Johnston, 1997; Martyn, 1997). been recognised as bringing benefits to the organisation Kless (1989) suggested that enduring stress in nursing (Oldknow et al, 2014). Sawbridge and Hewison (2011) education can impede students’ success, resulting in describe how peer support in an ambulance service attrition. Methods used to reduce nursing students’ provided an informal opportunity to debrief. When the perceived stress during their education include service was reorganised this informal support was lost supervision and team meetings, advice seeking, and and there was a subsequent increase in staff feeling discussion of problems with supportive colleagues (Leary stressed and an increase in their sickness levels. They et al, 1995). Becker and Neuwirth (2002) evaluated peer highlight the fact that such models of support are not social support by asking senior nursing students to act as as visible or well understood. This is an important teaching assistants to augment clinical experiences for
53 Supporting Health Visitors and Fostering Resilience Literature Review
junior students. Reported benefits of this support is not routinely available, while a key advantage intervention included a decrease in junior students’ of informal support is its accessibility in the workplace, anxiety, an appreciation of the availability of additional which suggests the impact upon staff experience of work role models, and an increase in collegiality among environments and routines needs to take into account students. Such peer support groups were used to any unintended, adverse impact upon peer support. mitigate occupational stress in healthcare workers in Rather, the ‘team around the health visitor’ should be Sweden. Staff assessed as being at risk met in weekly positively valued and recognised. group sessions to reflect on work stress and provide peer support. (Peterson et al, 2008) Gillard et al (2014) Adverse outcomes considered peer worker roles in mental health services. They found that there were specific mechanisms that While peer support has numerous favourable would benefit peer workers, these were: (i) building consequences, less attention has been paid to potential trusting relationships based on shared lived experience; adverse outcomes. Negative results include conflict, (ii) role-modelling individual recovery and living well with criticism, failed social attempts, emotional over mental health problems; and (iii) engaging service users -involvement, reinforcement of poor behaviour and with mental health services and the community. diminished feelings of self-efficacy (Heller et al., 1991; Illich, 1981; Marshal et al., 1990; Rook, 1984; Informal support Stewart and Tilden, 1995). Further, while peer support is a potentially cost-effective intervention, the possibility In a recent iHV online survey, health visitors were asked of overburdening exists through the inappropriate use ‘How do you get support with pressure and stress at of peers as a replacement for professional services work?’ The frequently reported source was ‘informal (Giblin, 1989). support from colleagues sharing an office’ (n=1002, 85%). This underlines that regardless of any formal support measures, peer support is well established within the professional culture of health visiting. Indeed, ‘formal/ scheduled peer support’ was the least -frequently cited source of support at 14%. This may reflect little more than that formal / scheduled peer
Key points: peer support
Peer support relies on a trusting relationship with another individual, allows for the setting of performance goals, and involves observation and reflection. It is often seen as a key element in the delivery of quality patient care but its application is complex and variable, although highly beneficial. There is evidence to suggest that peer support positively affects psychological and physical health outcomes in several ways known as direct, buffering, and mediating effects. Specific mechanisms can benefit peer workers: (i) building trusting relationships based on shared lived experience; (ii) role-modelling individual recovery and living well with mental health problems; and (iii) engaging service users with mental health services and the community. There can be negative results including conflict, criticism, failed social attempts, emotional over-involvement, reinforcement of poor behaviour and diminished feelings of self-efficacy. Preparation and support for preceptors is an important consideration. ‘Informal support from colleagues sharing an office’ is widely valued in health visitor professional culture and should be recognised and positively cultivated.
54 Supporting Health Visitors and Fostering Resilience Literature Review
Potential outcomes of implementing models of support
Providing support to health visitors, using a range of the models described, has the potential to foster their resilience and compassion. The concepts of resilience, compassion and compassionate resilience are examined below.
Resilience
The concept of resilience is complex and interlinks with the concept of emotional wellbeing (Mguni et al, 2011).
Resilience is viewed as a dynamic process that considers consideration as they influence how vulnerability is both the past and the future, enabling a person to build expressed, which responses are regarded as effective, resilience before they reach a crisis. However, if we focus and which values and beliefs underpin these responses on wellbeing without considering resilience we may (Dutton et al 2014). When faced with similar adversities, overlook practitioners who have high wellbeing but are there is a wide variation across cultures in how people vulnerable to future shock. Resilience is not just about cope (Ungar, 2008). For example, Music (2011) describes survival, it is about learning and finding healthy ways how egocentric western cultures promote autonomy to cope (Hunter and Warren 2014). Resilience can be and individuality. There has been some research planned for, developed and practised. Context and exploring resilience in nursing and other professions process are important considerations (Cowley 2008). (e.g. Mc Cann et al 2013, Hunter and Warren 2014, The context of health visiting practice can contribute Adamson et al,2012; Wendt et al, 2011 ) but research to an increased risk of adversity and therefore it is relating to health visitors is limited (Lindley, 2013, important to understand what contributes to health Hudson et al 2014). visitors’ resilience. Cultural norms are an important
The iHV practitioner survey (2014) found that 89% of health visitor respondents thought that learning how to personally develop resilience was important. However only 12% agreed strongly that they were currently able to achieve this, whilst 50% reported not having enough time to reflect and develop self-awareness. Thus individual motivation was constrained by practical time constraints highlighting the importance of considering how the system is contributing to this.
55 Supporting Health Visitors and Fostering Resilience Literature Review
Definition of resilience
Resilience is a dynamic, developmental process that involves an interaction between individual and environmental factors (McCann et al 2013, Cicchetti, 2010, Rutter 2012).
It is a complex and evolving concept with varied Professional resilience interpretations, some of which are at odds with deeper understanding of the concept, derived through research. An important factor in fostering professional resilience Resilience is described as an ability to overcome is exploring the personal and professional values of difficulties and bounce back from adversity, or a process practitioners (Wendt et al 2011). Recruiting staff with of adaptation to adversity (McAllister and McKinnon, values that are aligned with those of the role and the 2009). Rutter (2012) describes resilience as a process, organisation warrants consideration. Such values-based which is supported by Hunter and Warren (2014). He recruitment processes are now used by many employers. suggests that it is built through the development of Skills for Care (2014) has developed guidance to self-efficacy following successful coping with repeated support values-based recruitment, and values related brief stress experiences. Resilience is not just a reactive to the NHS Constitution are being embedded in NHS process, and a preventative approach can be utilised. recruitment processes (NHS Employers, 2014b). Potentially stressful events can be identified, planned Values-based recruitment is reported to contribute to for and practised (McCann et al, 2013). creating positive work environments and to staff feeling more valued (NHS Employers 2014b). Hart and Gagnon (2015) describe the lack of consensus in defining resilience and highlight that the only common There is a limited but growing body of research on factor in all definitions is the idea of adversity. They professional resilience. In a review of the literature define resilience as overcoming adversity whilst across five professional groups (nurses, social workers, potentially changing or significantly transforming aspects counsellors, doctors and psychologists) professional of that adversity. This is supported by Wendt et al (2011) resilience is defined as “ the ability to maintain personal who describe how social workers and teachers have and professional wellbeing in the face of ongoing work thrived in demanding work contexts. Hart and Gagnon stress and adversity” (McCann et al 2013, p61). Work/life (2015) argue that there is a highly individualised notion balance was identified as a consistent influencing factor of resilience prominent in policy, and the wider political across all professional groups. Other factors included and economic context in which the concept of beliefs and self-reflection, insight gained through peer resilience, and resilience research and practice, sits support and supervision and professional identity. should be considered. Thus a strategic, ecological Contextual factors were predominantly relational approach, which takes into account interactions between including work colleagues, mentors and role models the person and their environment, is recommended, a and client connectedness. The limitations in comparing premise supported by Adamson et al (2012) and Hudson studies using different professional groups, definitions et al (2014). This includes uniting resilience and practice and measurements of resilience are recognised. development with a social justice approach to address health inequalities (Hart and Gagnon, 2015). Such an Adamson et al (2012) propose an ecological approach approach is congruent with the goals and principles of to professional resilience, which considers the interplay health visiting including reducing health inequalities between self, the practice domain and the space in and influencing policy. The DH (2009) suggests that, by between (i.e. mediating factors such as supervision and investing in the emotional resilience of staff, employers peer support). Hudson et al (2014) support this model play a role in tackling health inequalities. An ecological and highlight the importance of examining the “space in definition of resilience therefore incorporates individual, between“ and the need to grow professional resilience societal and environmental interaction and the through addressing common adversities. These include capacities of individuals to change structures through workplace incivility and bullying, role strain, workload emancipatory actions. and lack of time. Newly-qualified and inexperienced
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practitioners have been identified as particularly hold about each other (the psychological contract) can vulnerable. Thus it is important to prepare and support be influential. Feeling valued was particularly important. preceptees and consider supportive models that may When this informal and unwritten contract is perceived alleviate organisational constraints. to be breached, it can influence motivation and engagement (Maben, 2008). Thus employers need to Education and training to build resilience be proactive in understanding these expectations. Clear roles and responsibilities are important particularly in the The government strategy for mental health (DH, 2011) light of inter-professional working and the future transfer highlights the importance of individuals and employers of commissioning of health visiting services to the local recognising and building resilience. The public health authorities. Transparent processes, which engage responsibility deal (DH 2011) pledges to provide all staff employees in decision-making and are responsive, with the environment, knowledge and tools to maintain adopting supportive management styles and creating and develop wellbeing and resilience. NHS Employers learning opportunities, are important considerations has developed a strategy to address this pledge (NHS (Whittaker et al, 2013). These factors have also been Employers 2014). Boorman (2009) concluded improving identified as important features of a positive practice staff health is an enabler to high quality care, patient environment (Bryar et al, 2012). satisfaction and improved efficiency. This has been supported by Maben et al (2012) who found that where As a result of the interaction between individual, staff are supported there are higher levels of job environmental and contextual factors, resilience is not satisfaction and patients’ rating of their care. Hart and fixed. Adopting a preventative approach in developing Gagnon (2015) suggest that developing resilience can resilience promoting environments is recommended involve building individual and environmental assets or (McCann et al 2013). Rutter (2012) suggests that changing the restrictions to both. They question how protective factors may be built through successful coping much social adversity should be tolerated before social with adverse experiences. Exposure to stresses may arguments should be made rather than targeting increase vulnerability through a sensitisation effect or individuals for interventions. They suggest knowledge decrease vulnerability through a steeling effect. What of oppression and addressing inequalities should be seems to be influential in building resilience is success included in understanding adversity and resilience. leading to self-efficacy, rather than overcoming minor Considering how practice spreads in organisations stresses. Hunter and Warren (2014) support the and co-producing knowledge with researchers and importance of self-efficacy and active coping techniques practitioners and clients to enhance understanding in developing resilience. There is a correlation between of resilience is recommended. Creating communities parental overprotection, which leads to a lack of of practice could potentially offer the medium to successful accomplishments and emotional regulation, facilitate this process. and lower psychosocial resilience (Tusaie and Dyer 2004). Exposure to brief periods of stress increases resistance Resilience is influenced by the interaction between to later stress (Rutter 2012), such that there is a steeling individual and environmental factors (McCann et al, effect of successfully coping with challenges. Lindley 2013). Individual factors include personality, gender, (2013) supports this highlighting the importance of an attachment style, stress, coping skills, emotional open supportive relationship in facilitating this process. regulation, professional experience and knowledge, as The availability of supportive relationships is recognised well as personal histories and life story. Individuals who as increasing resilience (DH 2009, NHS Employers 2014). are able to develop secure attachment styles are more able to access support in times of need and to show In addition to addressing the environmental and support for others (Dutton et al, 2014). Vulnerable contextual issues, intervention can also be offered groups include newly-qualified and inexperienced at an individual level. Jackson et al (2007) propose practitioners, those in poor health or those whose roles five strategies for developing professional resilience cross different work environments (Hudson et al, 2014). including:
Environmental factors include culture, area, team 1. Maintaining life balance and spirituality working, supervision and resources. The perceived 2. Understanding personal strengths and vulnerabilities level of “bad events” and perceived social support or a sense of connectedness is most influential (Tusaie and 3. Using reflection to assist in meaning making Dyer, 2004). Whittaker et al (2013) highlight how the 4. Building positive professional relationships perceptions and beliefs that employees and employers 5. Maintaining positivity
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These components are common to many resilience difference between their expectations and the reality -building programmes, as well as noticing and changing of their experience. In order to be resilient the negative automatic thoughts, mindfulness, and individual needs the capacity to contain and tolerate developing an understanding of values and beliefs and negative emotion. This enables them to think about it resilient thinking (McDonald et al 2012, Chade -Meng (mentalise) and if it is too much to manage alone then to Tang 2012, Riley and Gibbs, 2013, NHS Elect, 2014; share with compassionate others (who provide a secure Action for Happiness, 2014, Wickremasinghe 2014). base). When an individual feels an excessive demand to carry negative emotion alone, she may become Resilience thinking is closely related to Cognitive detached from her feelings and work perfunctorily or Behavioural Therapy (CBT), namely the fact that it is become depressed, anxious or ill (Menzies-Lyth, 1960). not an adversity itself that triggers our emotional Practitioners may retreat into the safety of routines and response and subsequent actions; it is our beliefs and tasks to escape the emotional distress of clinical practice. interpretations about the adversity. For example we say Experiencing the anxiety can provide an opportunity for things like “she made me so angry” but in fact it was our growth if the anxiety is contained. beliefs about / interpretation of her behaviour which led us to become angry. One approach to learning to be Resilience is not just about survival, it is about learning resilient is the A-B-C model (Ellis and Dryden, 2007) of and finding healthy ways to cope and even thrive resilient thinking (where “A” is the adversity”, “B” is our (Wendt et al 2011). Resilience fluctuates across time, beliefs and “C” is the consequences - e.g. how we feel developmental stage and context (Tusaie and Dyer, and act). A doesn’t simply lead to C, there is always a B 2004). It is a continuous process incorporating a in between and our Bs are often based on unhelpful or recognition and acceptance of challenges, identifying inaccurate thoughts. It is important to learn how to look our reactions to challenging situations and having out for unhelpful “thinking traps” (e.g. mind-reading, strategies to stay in control and enjoy life. Dobbin (2014) blaming others, blaming self, believing it is permanent suggests that by learning about resilience and developing etc.) - these are vital life skills that can be taught. the skills to relieve their own stress, practitioners can integrate these skills into their clinical practice, thereby Through sharing experiences of resilience and facilitating the development of these skills in clients. vulnerability, health professionals can learn from one another and facilitate prevention of future adversity Characteristics of resilient individuals (Jackson et al, 2007). This is supported by McAllister and McKinnon (2009) who recommend that education Most research on resilience has focused on examining and training programmes should include three children in adverse circumstances. Protective factors components. These are: which facilitate resilience have included social connection with family and other adults including peers, 1. Including discussion of resilience within positive role modelling, discreet monitoring of wellbeing undergraduate education – covering issues such as and coaching to facilitate goal setting and elevate identity building, coping and strengths development, expectations (McAllister and McKinnon, 2009). The learning leadership for change. limitations in applying findings from research with children to adult populations are acknowledged. The 2. Including discussion of resilience within practice characteristics of resilient adults include an internal locus contexts - opportunities to reflect, practise and learn of control, prosocial behaviour, empathy, positive self from one another, positive role models, sharing -image and optimism. These enable them to build coping strategies. supportive relationships and adapt to change (Friborg et al, 2003). Factors that have influenced the ability 3. Professional culture generativity. This can be to cope with stress have been identified. These are facilitated through dialogue where resilient meaningfulness (the stressor makes sense and thus practitioners share stories and lessons from their coping is desirable), manageability (identifying and experience through seminars and publications, searching out the resources needed to meet the and using creative media such as art and film. demands of the situation) and comprehensibility – the view that the world is understandable and meaningful In describing a resilience undergraduate education (McAllister and McKinnon 2009). programme, Lindley (2013) outlines how surprised health visiting students are by what they see in practice Research on resilience has focused on learning not just and how difficult they find this emotionally. There is a from people who survived following extreme adversity
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but those that thrived i.e. post traumatic growth (Linley that more research is needed to understand these and Joseph, 2004). An example is the holocaust survivor personal domains and how they interact with Victor Frankl (Frankl, 2006). Wendt et al (2011) have professional factors including professional identity, explored how social workers and teachers have thrived context and work culture. in demanding work contexts. They identified the importance of self-awareness in balancing personal Managing stress and building health visitors’ resilience and professional lives. Personal values, beliefs and life is a complex issue which requires an in-depth experiences including the desire to make a difference understanding of the cultures within which it operates, and seeing the day-to-day work as being connected to combined with preventative, strengths-based a bigger cause, having and being a role model and approaches to working with organisations, groups, enjoying the challenge were also influential. They teams and individuals. Developing compassionate recommend that insights into these personal domains cultures is an important factor to consider in should be included in education strategies. They suggest this process.
Key points: resilience
Resilience is not just about survival it is about learning and finding healthy ways to cope. There is a need to grow professional resilience through addressing common adversities. The government strategy for mental health highlights the importance of individuals and employers recognising and building resilience. Values-based recruitment contributes to creating positive work environments and to staff feeling valued. Transparent processes which engage employees in decision-making and are responsive, adopting supportive management styles and creating learning opportunities are important considerations. Adopting a preventative approach in developing resilience-promoting environments is recommended.
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Compassion
The Francis Report (2013) highlighted a lack of transparency and a culture of intimidation within the NHS and led to the governmental drive to create a culture of compassion.
However, competition between services and targets are or alleviate suffering (Gilbert 2010). Compassion is continuing to create challenges in enabling this process. described as “intelligent kindness” and is central to The Department of Health (DH, 2012) emphasised the how people perceive their care (DH 2012), and involves importance of addressing the burden of bureaucracy; searching for things we can do and not waiting to be however the largest ever study of NHS culture has found asked (DH 2013). This requires that we notice the person that quality of care is often compromised by too much is suffering and have the time to care. Lack of time to regulation, excessive box ticking and highly variable staff build relationships has been identified in the iHV survey support (Dixon–Woods et al, 2013). They recommend (2014) as a concern for health visitors which may signify developing person-centred rather than task-centred that they are prevented from being able to show cultures, which is in line with the components of a compassion. Gilbert (2010) outlines six core attributes of positive practice environment suggested by Bryar et al compassion: attentional sensitivity, motivation, empathy, (2012). They argue that there are strong links between sympathy, distress tolerance and non-judgemental staff experience and patient mortality rates. This is also positive regard. Chambers and Ryder (2009) describe echoed by Maben et al (2012) and emphasised in the the importance of dignity and respect in providing NHS Constitution (DH, 2013). compassionate care. These are supported by the Department of Health (DH, 2012) and are described Compassion enhances staff satisfaction and engagement as core values in the NHS Constitution (DH 2013). and contributes to the performance of organisations (Karamally, 2013). Frost et al (2005) argue that although Compassion involves a dynamic interpersonal process, compassion contributes to the financial success and which unfolds at three levels: personal, relational and performance of organisations, adopting compassionate organisational (Dutton et al, 2014). The ability to practices for strategic means can weaken the integrity contain emotional distress is a key attribute of of such practices. DeZulueta (2014) argues that compassion (Gilbert, 2010) and develops in the context external rewards may reduce intrinsic motivation and of a trusting relationship. Lindley (2013) identified make people less altruistic. The DH (2012) outlines openness as a factor that built a safe place for reflection the importance of creating a compassionate and promoted resilience. This included individual organisational culture where the emotional impact of openness to participate in reflective practice, team caregiving is recognised and staff feel valued and cared openness and team leaders’ openness to see what for. The implementation plan for this vision includes was happening and respond sensitively. This, in turn, supporting positive staff experiences and developing enables people to express their vulnerability. Brown a cultural barometer to enable staff to reflect on their (2012) describes how it is the capacity to face, name and organisational culture. share these negative emotions, which makes it possible to work with them. It is natural to want to keep things Compassion can increase the ability to receive social positive, but this is best achieved after negatives have support, which may result in more adaptive profiles of been accepted as inevitable, faced and named. Obholzer stress reactivity (Cosley et al, 2010). It can also prevent and Roberts (1994) describe helpful examples of working empathic distress, strengthen resilience and with individual and institutional suffering in The prevent burnout (Klimecki et al 2013). Both self Unconscious at Work. Compassion involves an -compassion and compassion are associated with acceptance that life brings suffering and, by turning improved emotional resilience (Neff, 2011). Compassion towards this suffering, it is hoped that developing is an essential health professional attribute identified positive coping strategies will build resilience. in the NHS Constitution (DH. 2013) and is one of six key nursing values, the ‘6Cs’ (DH 2012), which also apply in White (2013) recommends that organisations invest in health visiting (NHS England 2014). It is defined as “a meeting employees’ core needs so they are motivated sensitivity to the suffering of self and others, with a deep to bring more of themselves to work, which in turn commitment to relieve it” (Dalai Lama 1995). It involves contributes to sustainability. This is supported by an engagement with suffering, and action to prevent Maslow’s (1971) hierarchy of needs and attachment
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theory (Bowlby, 1988). Once a secure base is established compassionate care. They found integrating by responding compassionately to the individual’s needs compassionate activities with other organisational then they are more able to explore, learn and develop. processes and quality initiatives was important. Dutton et al (2014) support the importance of meeting core needs, saying a sense of being valued is created Organisations can develop shared values through sharing through the interactions that people experience at work. stories about compassionate events or through formal Feeling valued was identified by Whittaker et al (2013) as polices such as the Chief Executive (CE) being informed influencing engagement and retention of health visitors. in the event of a significant employee event. Frost et al Compassion from others is important in preventing or (2005) also suggested that narratives capture the lived reducing compassion fatigue (Dutton et al, 2014). experience, and how people feel about the organisation Compassion fatigue may arise when people are unable creates a collective experience and organisational to do what they consider is the right thing. Forty-five identity. They describe how the caring response of the CE percent of health visitors in the iHV survey (2014) of Reuters after the 9/11/2001 crisis was told and retold, expressed concern that they could not deliver the care creating a shared recognition of the value placed by the they aspired to, and 45% said stress was affecting their organisation on its employees. Greenhalgh (2013) health. These figures suggest that there are a large supports the use of narratives in creating a number of health visitors at risk of compassion fatigue. compassionate culture, saying that a compassionate organisation facilitates narrative practices, contextualises White (2013) suggests that the creation of resilient challenges and develops future-orientated stories. In this cultures starts with leaders who foster resilience at way a compassionate ethic becomes institutionalised the individual and organisational level. However, and resilience enhanced. She argues that, rather Karamally (2013) argues that everyone has a than tightening procedures, the solutions to a lack of responsibility for creating culture. Compassionate organisational compassion centres on interpersonal leadership is a skill and a way of being which can be relationships and developing collective narratives. developed. Undertaking compassionate mind training can enhance the ability to respond compassionately Atkins and Parker (2012) argue that organisational (Gilbert, 2010). This develops the capacity for self efforts are ineffective if individuals do not have the -compassion and for understanding how to support capacity or motivation to engage in compassion. people through difficult situations by understanding For example, developing managers’ emotional the pressures people experience and how this activates regulation abilities enhances coping self-efficacy their threat system, how people respond when they feel rather than emotional distress in the face of threatened and how to support people to develop more suffering, facilitating a compassionate response. productive ways to solve problems (Gilbert, 2010). Modelling compassion by managers and leaders can create the contexts where people can express their Edinburgh Napier University and NHS Lothian’s (2012) values and learn to be more compassionate. They Leadership in Compassionate Care project involved recommend providing individual training programmes embedding the principles of compassionate care in incorporating these two components in order to the educational curriculum, supporting newly-qualified increase organisational compassion. nurses, facilitating the development of leadership skills and identifying beacon wards as centres of excellence in
Key points: compassion
Compassion enhances staff satisfaction and engagement and contributes to the performance of organisations. Compassion can increase the ability to receive social support, which may result in more adaptive profiles of stress reactivity. Compassion involves a dynamic interpersonal process which unfolds at three levels: personal, relational and organisational. Organisations need to invest in meeting employees’ core needs so they are motivated to bring more of themselves to work. The creation of resilient cultures starts with leaders who foster resilience at the individual and organisational level.
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Self-compassion
The public health White Paper (HMG, 2010) defines mental health as “resilience, confidence and self-esteem”.
Indeed many would argue that all three are so closely (2014) likens the process of self-compassion to one of interlinked it would be impossible to separate them. grief with the person going through stages similar to Neff (2011) would suggest replacing the term self-esteem those described by Elizabeth Kubler Ross (1969) i.e. with self-compassion. Self-esteem involves a comparison denial, anger, bargaining, depression and acceptance. between the self and other which can be perceived to Thus people need to be aware of this painful process have a competitive thread, whereas self-compassion and the possibility of defensive behaviours. Taking time is acknowledging people’s common humanity. Self to develop a trusting relationship and proceeding at -compassion involves turning towards suffering and the person’s pace is important. There is a growing taking action to alleviate it. It is a multidimensional body of research on self-compassion which links concept that includes self-kindness (to treat oneself self-compassion and enhanced wellbeing (Neff with care rather than harsh self-judgement), common and Germer 2013), motivation (Persinger, 2012), humanity (recognition that imperfection is a shared personal accountability and coping (Neff and Lamb, aspect of human experience), and mindfulness (holding 2009) and resilience. one’s experience in a balanced perspective) (Neff 2011). Condon et al (2013) suggest that enhancing self Self-compassion fosters connectedness rather than -compassion develops our ability to be compassionate. separation or self-centeredness, and is a skill that can They found that practising compassion and mindfulness be taught (Neff and Germer, 2013). When teaching exercises resulted in people being five times more likely self-compassion it is important to consider that for some to have a helpful response to suffering. These results people self-compassion can feel very threatening and are based on a small sample size and further research is they may be fearful of it (Gilbert et al, 2011). Germer needed before they can be generalised. Epstein and (2009) suggests the self-compassion process occurs Krasner (2013) suggest developing self-awareness in stages where there is a progressive softening of and looking after ourselves improves the quality of resistance. From an initial aversion, comes curiosity care; which means that practitioners are less likely about the problem, then tolerance develops and feelings to commit errors or leave practice, all of which are are allowed to come and go until finally suffering is costly to the NHS. embraced, seeing its hidden value. Wickramasinghe
Key points: self compassion
Self-compassion involves turning towards our own suffering and taking action to alleviate it. Self-compassion fosters connectedness rather than separation or self-centeredness, and is a skill that can be taught. Enhancing self-compassion develops our ability to be compassionate towards others.
Synthesising the literature on support, resilience and compassion led to development of the compassionate resilience concept.
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The compassionate resilience concept
Health visitors’ continued exposure to distress and suffering, in conjunction with the challenges they face and the vulnerability of their client group, puts them at particular risk of burnout and stress.
On reviewing the literature, it became evident that, (Neff & Germer 2012). There is a growing body of by adding self-compassion as a route to resilience, to research on the science of compassion, its link to more mainstream approaches, we could help build a early attachment experiences and the difficulties people sustainable workforce, which will have the capacity have in experiencing it (Irons, 2013). Gilbert et al (2011) to remain not only resilient but compassionate and describe fear of compassion to self, from others and to nurturing, to both themselves and others. After others. Practitioners may find it difficult to engage in integrating and synthesising the evidence, we have activities that improve their self-compassion as they may developed the compassionate resilience concept. have difficulty responding to their own needs (Epstein De Zulueta (2014, p 2) describes compassionate and Krasner, 2013). Adamson et al (2012) highlight the resilience as incorporating two components: importance of lifelong learning to support resilience.
1. Self-compassion, as a key to resilience Self-compassion is a skill that can be taught by 2. Learning how to maintain resilience in order to sustain considering five key areas: compassion, even in challenging situations. 1. Physical - caring for your body/non-harm; Thus, compassionate resilience is the ability to respond 2. Mental - allowing your thoughts; compassionately to adversity, using effective coping 3. Emotional - accepting your feelings; strategies. Responding compassionately can be 4. Relational - connecting authentically with others; challenging, particularly if we feel threatened or 5. Spiritual - nurturing your values (Neff and dislike the source of this adversity. Developing an Germer, 2013). understanding of the neurobiology of emotions and how we relieve our distress is an important component in On reviewing the literature and a variety of resilience learning how to respond compassionately and remain education and training programmes (e.g. McDonald resilient in these circumstances. Learning how to et al (2012), Chade-Meng Tang (2012), Riley and Gibbs maintain compassionate resilience is a dynamic, (2013), NHS Elect (2014), Action for Happiness (2014), continuous process incorporating a recognition and Wickramasinghe (2014), we identified six skills that will acceptance of challenges, identifying our reactions support practitioners in developing their ability to remain to challenging situations and having compassionate resilient and sustain compassion even in challenging strategies to stay in control and enjoy life. A supportive, circumstances. These include enhancing self-awareness, nurturing environment is crucial for developing being in the now, developing acceptance, expressing compassionate resilience (De Zulueta 2014). Thus, vulnerability, building supportive relationships, and in developing this concept we suggest adding a fostering hope. third component, to DeZulueta’s proposed two components, which is compassionate cultures, Enhancing self-awareness including compassionate leaders. Understanding our emotional tendencies and We have also developed DeZuleta’s definition of recognising early warning signs can prevent us from compassionate resilience in considering the learning getting caught up in stressful responses. Recognising that component. Compassion can be cultivated with it is not an adversity itself that triggers our emotional training (Weng et al, 2013) as can self–compassion response and subsequent actions; it is our own
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beliefs and interpretations about the adversity that is Being in the now important. Looking out for unhelpful “thinking traps” (e.g. mind-reading, blaming others, blaming self, Being present in the moment is challenging as the believing it is permanent) is valuable. Considering human brain is designed to look out for threats, and whether our core psychological needs for competence so we spend a lot of time thinking about the past and (to feel effective), autonomy (to feel in control) and worrying about the future. Compared to animals we relatedness (to feel connected to others) are being met have the capacity to ruminate, plan, imagine and reflect is also important (Ryan and Deci, 2000). (Sapolsky, 1994). Recognising and naming negative automatic thoughts and feelings can reduce our stress. The compassionate mind model offers insight into how These skills can be developed through mindfulness. our complex brain functions and how our environment shapes it. It offers an easily understood explanation Mindfulness increases the likelihood of noticing our (the three circles model – Gilbert, 2010) of the brain’s negative automatic thoughts and our suffering (Atkins complicated emotional systems. Understanding the and Parker, 2012). It can help to reduce personal three key emotion systems in the brain, i.e. the threat distress as it lessens emotional reactivity and enables and self-protection system, motivation and achieving us to make sense of our experience (Dutton et al, 2014). system, and soothing and relaxing system, can develop We can shift our attention and train our brains to calm self-regulation. This requires us to pay attention, notice us down. There is a growing body of evidence for our emotional, cognitive and behavioural responses. mindfulness programmes. NICE (2009) recommends Learning how to shift attention and balance our Mindfulness Based Cognitive Therapy for preventing emotional systems can contribute to more effective relapse in those with three or more previous episodes coping with stress. It also enables us to understand of depression. Holzel et al (2011) have demonstrated how fear can activate our threat system and have how mindfulness can change the structure of the brain. dehumanising consequences. Being aware of this A mindfulness leadership course has been developed potential within all human beings enables us to by the King’s Fund (King’s Fund, 2014). The benefits of respond compassionately. McGonigal (2013) suggests mindfulness include physical and psychological stress it is not the event that is stressful but what we tell reduction; positive changes in wellbeing; reduced ourselves about the event. likelihood of becoming stuck in depression and exhaustion; and better able to control addictive Self-awareness of somatic, emotional and cognitive behaviour (Oxford Mindfulness Centre, 2014). Berry experience of stress can be developed through (2014) recommends mindfulness is taught to nurses, mindfulness and informal practices. These could include GPs and teachers. However, there are limitations to developing the habit of pausing and breathing before mindfulness which also warrant consideration. Evidence seeing the next client. Using reflective questions such suggests mindfulness can lower mood and cause as “what am I assuming about this situation that emotional distress (Rocha, 2014). Therefore, it is might not be true? In what ways are prior experiences important that the potential risks are explained to influencing me? What might a trusted peer say about the clients and that educators are appropriately trained way I managed this?” The use of work discussion groups and competent to deliver mindfulness. An interesting can build self-efficacy as individuals become aware of radio documentary has debated whether mindfulness emotional reactions, biases and countertransference can simply be used on the individual level or whether that might influence (Epstein and Krasner, 2013). it should be fused with a critique of the context when Hunter and Warren (2014) support the importance of needed (BBC, 2014). self-efficacy and active coping techniques in developing resilience. Self-awareness can also include developing an understanding of strengths. Effective feedback can be used to build people’s strengths.
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Developing acceptance
Accepting yourself for who you are and accepting It is envisaged that the development of compassionate responsibility for looking after yourself will build your resilience skills could increase health visitors’ capacity resilience; accepting that life is hard at times, suffering to tolerate distress and manage a broad range of affec- is an inevitable part of life and part of our common tive experiences. Through this process they can develop humanity (Neff, 2011). Acceptance takes courage, hopefulness, the courage to reach out and respond involves our engagement with suffering and develops compassionately, and enjoy and thrive in their practice. over time. It is a skill through which you become more adept at knowing what you can control and not wasting Building supportive relationships energy on things outside your circle of influence. Acceptance has been found to be associated with Establishing supportive relationships that provide a greater psychological adjustment following exposure to sense of acceptance and support is a key factor in trauma (Thompson et al, 2011). Accepting compassion building resilience. A reliable network of trusted from others and being self-compassionate may be more individuals can help you through difficult times. When challenging for those with an insecure attachment life is difficult, your stress response releases oxytocin style. It is important to acknowledge and accept the which motivates you to seek support (McGonigal, 2013). uniqueness of individuals and cultural diversities and The American Psychological Association (2014) suggests how they may influence acceptance. that resilient-building relationships include:
Expressing vulnerability Relationships that create feelings of trust and love; Relationships that provide role models; Life is unpredictable and one of the ways we deal Relationships that offer reassurance and with this is by numbing our vulnerability. Expressing encouragement. vulnerability can facilitate growth and success (Brown, 2012). The ability to express vulnerability is a process Relationships develop through a series of interactions that begins with an awareness of our vulnerability and over time and in different contexts. The development proceeds to acceptance and expression. Expressing of trusting relationships requires attunement and vulnerability in the context of a supportive relationship sensitive, timely and appropriate compassionate can develop the ability to tolerate emotional distress, responses. Observation, listening and containment are name feelings and, recognise bodily reactions. This can key skills in building trusting relationships. Frost et al facilitate growth and success (Brown, 2012). Individual (2005) suggest open listening enables three aspects of differences warrant respect and enabling the person to compassion, i.e. noticing, feeling and responding. Time is proceed at their pace is important. necessary to build such relationships and has been raised as a concern by health visitors. With the increasing number of health visitors it is hoped that there will be more time to build supportive relationships. Expressing vulnerability can: Chosing to connect with others under stress can Facilitate growth and success (Brown, 2012). build resilience (McGonigal, 2013). Building relationships and connections also gives purpose Develop ability to tolerate emotional distress, and meaning to our lives (Brown, 2012), which also name feelings and recognise bodily reactions. contributes to building resilience. Enhance attention and performance in workers (Gladwell, 2013).
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Fostering hope
The capacity for hope has been identified as a Hope can be enhanced through looking after our contributory factor in resilience. Fraiberg et al (1975) physical, mental, social and spiritual dimensions. This demonstrated the importance of hope in breaking the increases our capacity to handle the challenges that life intergenerational cycle of maltreatment. The psychiatrist brings. Gratitude can enhance our sense of hope and Viktor Frankl found prisoners at Auschwitz who had hope mental and physical health (Emmons and Stern, 2013). and a sense of meaning and purpose lived longer (Frankl, Developing the ability to be grateful may contribute 2006). Hope can be increased through the use of an to more effectively managing life demands (Konig and ABCDE model, which stands for adversity, belief, Gluck, 2013) and help to build supportive relationships consequences, disputation, and energisation (Ellis and (Algoe et al, 2013). We can cultivate gratitude by Dryden, 2007). Adversity is examined by asking the noticing positive events, or by keeping a gratitude question “what happened?” Beliefs are explored by journal. Writing supports the development of gratitude reflecting on how you explain things to yourself. The as it organises thoughts and facilitates integration and consequences are considered and through disputation meaning (Konig & Gluck 2013). alternative interpretations are offered. Finally through energisation you explore how things could be better in relation to that problem in the future.
Key points: compassionate resilience
Compassionate resilience incorporates three components: self- compassion, as a key to resilience; learning how to maintain resilience in order to sustain compassion, even in challenging situations; and compassionate cultures, including compassionate leadership. Six skills that will support practitioners in developing their ability to remain resilient and sustain compassion even in challenging circumstances have been identified: enhancing self-awareness, being in the now, developing acceptance, expressing vulnerability, building supportive relationships and fostering hope.
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Towards a resilience framework
In this review, models and concepts relevant to support have been discussed, drawing upon a range of literature of variable character, quality and application.
Some are more directly related to the core concerns visiting, engaging with children and families to and context of health visiting as a profession and as a promote their health and wellbeing, and at the level practice. Others are more reflective of broader contexts of practitioners and their professional effectiveness such as organisational learning. The heterogeneity of and resilience. Cutrona’s (2000) research on these models and concepts of support and the literature family support has articulated two broad forms of family reviewed require caution in proposing a valid synthesis support: ‘nurturant’ support that affirms the worth of these diverse elements. However, this review has and strengths of families regardless of what specific not been conducted in isolation from current practice. stresses may impact upon them; and ‘instrumental’ Rather, a consultative approach has been adopted in a support which is tailored to specific stresses or spirit of appreciative enquiry and being informed by live problems, for example in the form of practical help or consultation with the health visiting profession. Arising advice. Cutrona (2000) recommends optimal matching from multiple conversations, surveys, workshops and an between stress and social support. In situations that expert Task and Finish Group, a resilience framework for are controllable with readily available solutions, health visiting has been drawn together incorporating a “instrumental” support is highly valued by families. menu of ten models of support with compassion at its However, when this is not the case instrumental centre. Health visitors’ professional values and principles support may be ignored as worthless or rejected as are also key. inappropriate, adding ‘insult to injury’. However, emotional nurturing support seems acceptable in Figure 6 represents the menu of support for employers any circumstance. If this is used to help a family gain and individuals to consider in supporting health visitors more sense of self-control, then specific expertise and fostering resilience. Enabling the emotionality of may be valued and accepted subsequently. This practice to be expressed through the medium of art reflects Robinson’s (1982) seminal research that can be effective in providing opportunities for learning demonstrated that health visitors adopt relationship (Warne and McAndrew, 2008). Words cannot always -oriented and problem-oriented approaches to their capture the particular experiences of health visitors practice, with skilful practice being concerned with and a picture facilitates individual interpretation. Art combining these in ways that are appropriate. What is an effective medium in facilitating mental health is clear is that ‘nurturant’ or ‘relational’ support is a (Mental Health Foundation, 2007), and enabling necessary precondition for effective ‘instrumental’ or creativity fosters resilience. The dark night is problem-oriented support. More recent research representative of the stresses in health visiting, which provides contemporary evidence in support of the can result in health visitors worrying night and day criticality of this practice-orientation to relationships about vulnerable children and families. Health visitors and the extent to which this is aligned with service may feel alone with their responsibilities and the organisation. (Bidmead, 2013, cited in Cowley et al, picture also represents the fact that they are part of a 2013). This explains why ‘relationship’ based forms of system. The stars, the moon and the planets represent intervention are strongly represented within this review. the key support components to foster resilience. While in many healthcare contexts effective relationships Understanding the components of support available are a means to effective intervention, in heath visiting facilitates implementation of proactive, strengths they often constitute the core of effective intervention -based compassionate strategies to foster resilience. in themselves. Moreover, this is why ‘compassion’ is placed centrally within the proposed framework, being This framework is reflective of the diversity of what the heart that supplies the life blood for health visiting can be meant by ‘support’, without having established practice for clients and practitioners alike. From this a bounded definition. What is clear is that there is a secure base, there is a diversity of models of support ‘parallel process’ evident between what support and that can be drawn upon to enhance the resilience of resilience mean at the level of the practice of health health visitors within the workforce.
67 Supporting Health Visitors and Fostering Resilience Literature Review
Figure 6: The resilience framework
1 Care 2 Compassion 3 Competence Professional 4 Communication Principles/Ethos 5 Courage 6 Commitment Interagency/ Supervision Action Disciplinary Learning Sets Groups
Compassionate Peer Support Resilience
Compassion
Courageous Coaching Conversations
Relationship Performance Based Models Feedback Mentoring
68 Supporting Health Visitors and Fostering Resilience Literature Review
Conclusion
This review has reported key findings on models and concepts of support and used these to propose a framework for resilience. The findings may be considered for their potential to support resilience that is compassionate and aligned with the relational basis of much health visiting practice, working with children and families to promote their health and wellbeing.
Supervision: The effectiveness of supervision for can facilitate the mentee to begin the process of improving practice and reducing stress is now well transformation from novice to expert (Myall et al, established (Pallson et al, 1996; Walsh et al, 2003). 2007, Morton 2013). The mentoring process has been Restorative supervision now brings a greater focus on particularly challenged in health visiting in recent years, the “emotional work” of the health visitor. Restorative by being conflated with a form of ‘assistant practice supervision underpins managerial and safeguarding teacher’ role, as a means of managing large student supervision by focusing on the capacity of the workloads, rather than mentoring as a longer-term professional to engage in their work rather than on the support role in the workplace. More recent research in work itself. It is also recognises that if the emotional the east of England demonstrates a more positive picture consequences of health visiting work are not mitigated when the process is managed well. This research does, they will affect a professional’s wellbeing as well as however, highlight the importance that proximity, their ability to work effectively (Barnett, et al, 2007). continuity and reciprocal positive regard, together Professionals receiving restorative supervision report with clinical expertise, are important elements for the an improvement in their resilience to stress whilst success of mentor/ mentee relationships (Devlin maintaining compassion, improved working relationships and Mitcheson 2013). The dominance of mentorship and team dynamics, managing a work/life balance more focused on student support has the unfortunate effectively and an increase in enjoyment and satisfaction unintended consequence of adversely colouring related to their work (SWIFT, 2015). Currently, within attitudes to, and understanding of, the potential health visiting in England, the picture is varied and value of mentorship in support of the development supervision is carried out at various levels and in of practitioners established within the workforce, several different guises (Bidmead reported by Cowley, as is more widely recognised, for example, in 2013). Stressful working environments being accepted leadership programmes. as normal can impact negatively on the quality of Coaching: In coaching there is a focus on improving supervision offered (Turbitt, 2012). performance and the development of skills. The NHS Mentoring: In all areas of industry and business it Leadership Academy website states that “Coaching and has been established (Clutterbuck, 2004) that mentoring are an integral part of the NHS frameworks for mentoring ‘fosters talent’ in the organisation, increases leadership and professional development”. Benefits to productivity, improves communication, and improves coachees include an increased sense of motivation and retention. A review of the literature reveals some enthusiasm, and also an ability to deal with frustrations worrying issues surrounding mentoring in health encountered (Sinclair et al, 2008). Traditionally, coaching visiting that almost exclusively concerns mentorship in the NHS has only been offered to senior managers; of students/trainees. The impact of high workload, however, there is some anecdotal evidence that this may staff shortages and time conflict presents mentors be changing. ‘Clinical coaching’ has also been used to with constant dilemmas in relation to managing work effectively with “marginal” staff with performance commitments. Competing demands can lead to issues (Kelton, 2014). Health Education England (2011) exhaustion and feelings of being overwhelmed suggests developing coaching skills as one way of (Omansky, 2010). When managers fail to recognise preparing practice teachers and mentors for their roles. the increased workload associated with the mentor In addition, Sinclair et al (2008) suggest there is an role, it can result in increased mentor anxiety (Omansky opportunity to improve the deployment of coaching, 2010). The literature clearly indicates the need for particularly through the development of internal mentors to have adequate preparation for the role in coaches, so that even greater benefits can be achieved. addition to adequate clinical experience, so that they
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Courageous conversations: Part of any professional 2012). The fidelity measures, values and structures of relationship for the health visitor, be it with clients, the Family Nurse Partnership model have contributed colleagues, other professionals or managers, will involve to its success and identify it as an example of a “positive having courageous conversations whilst maintaining the practice environment”. relationship. Patterson (2002) describes it as learning Relational or nurturant support is a precondition for to use effective communication when it matters most. the effective deployment and acceptability of specific Developing professionals’ skills to enable them to problem-oriented or instrumental support at the level engage in effective ‘courageous conversations’ is a key of practice and at the level of promoting practitioner factor in developing ‘conflict resilient workplaces’ (State resilience. This precondition is summed up in the central Government of Victoria 2011). Conflict presents position afforded to ‘compassion’ within the proposed opportunities for people to strengthen their relationships framework for resilience. with themselves and others. Developing skills in managing ‘courageous conversations’ is one of Action learning:A number of aspects of action learning the components of the NHS Leadership Academy have been identified as important to its effectiveness. training programme. Facilitation skills are crucial to ensuring that individuals feel safe to engage with the action learning process, Relationship-based models of intervention: The but there are organisational challenges in supporting development of the relationship with the client is what people to develop these skills quickly. If it is to work makes the ‘real difference’ in improving outcomes for well, then action learning requires mutual commitment service users (Crowther and Cowan, 2011). “Making of each team member to participate. It should a difference” has been identified as a key motivating however be noted that participants can find it factor in influencing students’ decisions to enter health problematic to attend action learning sets as part of visiting (Whitaker et al, 2013). Having the ability to form their working day and additional space may need to be and model good relationships lies at the core of health created for them to work successfully. The prime focus of visiting practice, but there is evidence that organisational action learning is learning from, through and for action factors mean that it is difficult for health visitors in many and only derivatively related to support and resilience. areas of the country to develop relationships with their clients (Bidmead reported in Cowley 2013). There is Performance feedback: This is important to improve also evidence to suggest that this affects morale, job understanding and review progress. There can, satisfaction and professional self-esteem. There is a risk however, be barriers to feedback as individuals may of losing people from the profession if they feel unable fear being upset, and having their self-esteem and to “make the difference”. relationships compromised. Within performance feedback, multisource (360-degree) feedback can be Overwhelmingly large health visitor caseload size is a used to help employees improve and focus on their very important factor inhibiting the ability of the health development. As such, it is a starting point for the visitors to establish relationships with parents (Bidmead development of new skills, and as skills are worked reported in Cowley 2013). Bidmead found that pressures on over time, progress can be measured. It may lead of record keeping, less-qualified staff being deployed to successful behaviour changes within individuals, to take on work with families, lack of support from although it is not seen to benefit a team or organisation. managers to take on relationship work are also inhibiting After Action Review provides insights into performance, factors The CYPMHC state that, where health visitors are team work, leadership and culture and has been used unable to establish relationships with clients, valuable predominantly in analysing specific events to increase interventions and support, including a better awareness, generate understanding, facilitate behaviour understanding of the importance of attachment in change, learn and develop an action plan. In this their children’s development, will be reduced. It also process, staff take responsibility and this facilitates job means that early signs of mental health problems – satisfaction, engagement and retention for review their whether in the infant or the parent – may be missed, actions and making changes. increasing the risk of serious mental disorders, which are costly both in financial and human terms. Training Interagency/disciplinary groups: These can help in relationship-based models of intervention improves to clarify roles and responsibilities and contain the health visitor job satisfaction, competence, consistency, emotional impact of work. By using work discussion self-awareness, relationships with clients and colleagues, groups, Schwartz Centre Rounds® or compassion circles in addition to improved outcomes for children and experiences can be explored and reflected upon and families (Douglas and McGinty, 2001; Bashford and Seal participants can develop their understanding of
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institutional and inter-personal dynamics and the Compassion, self-compassion and compassionate possible emotional meaning of communications. resilience: There has been some research exploring Multidisciplinary forums where health professionals resilience in nursing and other professions (e.g. McCann meet monthly to reflect and acknowledge work-related et al. 2013; Hunter and Warren 2014, Adamson et al, psychological, emotional and social challenges should 2012; Wendt et al) but research relating to health be considered. visitors is limited (Lindley 2013, Hudson et al 2013). A consultative literature review, national survey and Peer support: Within the healthcare environment, peer scoping exercise led to the development of a resilient support has become a significant element in the delivery framework for health visiting. While resilience of quality care. However, it has rarely been defined in programmes for individuals can be effective it is the literature and its diverse application presents serious important to consider the context of health visiting methodological issues including difficulties in practice and address the structural and contextual interpretation and comparability. If the health visiting sources of stress that contribute to adversity. profession is to effectively incorporate peer relationships into support-enhancing interventions as a means to The idea of self-compassion as influential to professional improve quality care and health outcomes, it is essential resilience is a new development and one that is central that this concept be more clearly explained. In the iHV to the compassionate resilient concept of support. survey (2014), health visitors identified their peers as Building health visitors’ resilience is a complex process, a significant source of support. This includes informal/ which requires a preventative, compassionate, unscheduled peer support, indicative of a strength of strengths-based approach. health visiting’s professional culture. Peer support The resilience framework: The resilience framework is attributes in health visiting can be emotional, underpinned by compassion, and the principles of health informational and appraisal. The mechanisms and visiting and 6Cs are key components. An ecological benefits of peer support in health visiting and the approach to resilience incorporating individual, societal impact of mobile working on this source of support and environmental interaction and the capacities of warrants consideration. individuals to change structures through emancipatory Resilience: Resilience is a dynamic, developmental actions is recommended. Key factors which contribute process (Rutter, 2012, Cicchetti, 2010) which can be to resilience include professional identity, supportive defined as the ability to adapt, cope positively (Hunter relationships, supervision, work/life balance, spirituality, and Warren 2014), transform (Hart & Gagnon 2015) self-awareness including emotional insight, self and even thrive in adversity (Wendt et al 2011). It is -compassion, hope and learning opportunities. A range a dynamic process, which can be planned for, of models of support are included and provide a menu developed and practised. Context and process are of support to choose from. The framework is effectively important considerations (Cowley 2008). Although the delivered through compassionate and resilient context of health visiting practice can contribute to an leadership, interagency education and practice, and increased risk of adversity, many health visitors remain a skilled compassionate workforce. Through the resilient, and understanding what contributes to their process of developing the framework, the need for resilience is important. Key factors include professional further research has been identified. This includes identity, supportive relationships, supervision, work/life the need to understand how health visitors process balance, spirituality, self-awareness including experiences that are significant or traumatic and what emotional insight, self–compassion, hope and learning helps them cope. The impact of the work environment, opportunities. Culture is an important consideration in particularly in the light of an increase in mobile understanding resilience (Ungar 2008). Cultural norms working, warrants further study. This framework will influence how distress is expressed, which responses facilitate resilience with compassion such that health are regarded effective and which values and beliefs visitors thrive in their dynamic workplaces, develop a underpin these responses (Dutton et al, 2014). An strong professional identity and model resilience and ecological approach to resilience incorporating compassion in working with clients. Supporting the individual, societal and environmental interaction development of resilient health visitors who model and the capacities of individuals to change structures compassion will contribute to maximising health through emancipatory actions is recommended. outcomes and experiences for children, families and communities, building their own resilience.
71 Supporting Health Visitors and Fostering Resilience Literature Review
Recommendations
Policy makers, educators, managers and practitioners need to work together to identify, introduce and evaluate strategies to promote resilience and compassion, and supportive practice environments. This includes the development of compassionate business models.
Create narrative centres through the communities of practice and the iHV to enhance understanding about what contributes to health visitors’ compassionate resilience.
Leaders should promote workplace compassion through role modelling and encouraging work/life balance, facilitating nurturing, supportive relationships.
Implement practices to support compassion such as selection and socialisation processes, which facilitate noticing, feeling, sense-making and acting in a compassionate way.
Support the development of self-compassion in staff at all levels in an organisation using a strengths-based approach and providing education and training programmes.
Managers need to provide support, enabling and encouraging practitioners to develop relationships with their clients.
The development of internal coaching should be considered.
As a way to developing ‘conflict resilient workplaces’, health visitors should be encouraged to undertake training in ‘courageous conversations’.
Mentors working with student health visitors should be supported and prepared to undertake their role, and have adequate clinical experience to be confident to undertake the role.
A clear distinction should be made between the role of mentorship with students and the potential of mentorship for supporting resilience and development of established health visitors within the workforce, drawing upon work undertaken to develop mentorship for leadership development.
Every health visitor should be encouraged to access a form of supervision that includes the restorative function.
Health visitors should have access to relationship-based training programmes which develop strengths -based approaches.
The Family Nurse Partnership Model should be embraced as an example of a positive practice environment from which we can learn.
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Future research
In common with research on family support (Cutrona, 2000), this review has highlighted the diversity of support mechanisms of potential value to the resilience of health visitors, but also the difficulty of establishing ‘direction’ within the diversity of approaches available. The centrality of relational support and compassion as a renewed concern in nursing is promising in providing ‘direction’ within this diversity. Hart and Gagnon (2015) argue that there is a need to bring resilience research and practice development together. Understanding how practitioners process and understand significant or even traumatic experiences gives insight into coping styles and capabilities and how to strengthen these. A solutions-oriented approach to research on how healthy work environments contribute to resilience is needed, as much research is problem-oriented, e.g. does providing relaxing spaces enhance the quality of interaction between practitioners, does peer mentorship increase work satisfaction? Further research should be conducted on issues such as:
Evaluation of the effectiveness of resilience education programmes.
Evaluation of a bespoke compassionate resilience education and training programme.
The short and long-term impact of compassion on staff engagement, job performance and health outcomes.
Evaluation of how health visitors learn from compassionate experiences and how to apply this to future situations.
More research on organisational mechanisms and how individuals communicate their suffering.
The alignment of health visiting practice orientation with service organisation to build on the strengths of professional culture and the potential of support mechanisms to enhance protective factors.
Examination of cross-cultural differences at work, and consideration of whether all cultures are equally perceptive in noticing suffering and what is deemed acceptable to discuss at work.
73 Supporting Health Visitors and Fostering Resilience Literature Review
References
Abraham, A. (2011) Care and Compassion. Parliamentary and Health Service Ombudsman. Available at: bit.ly/1zUKute (Accessed 1.10.14).
Absolum, M. (2006). Clarity in the Classroom, Chapter 2. Auckland: Hodder Education.
Action for Happiness (2014) Doing Well from the Inside Out: A unique programme to build employee well-being and resilience and enhance performance. Available at: bit.ly/1z7gLud (Accessed 1.10.14).
Adams, C. (1998) The role of community practitioners and health visitors in the tier one CAMHS workforce. Unpublished. Presentation given at ‘The Future of CAMHS’ conference, 2009.
Adamson, C., Beddoe, L., Davys, A. (2012) Building Resilient Practitioners: Definitions and Practitioner Understandings. British Journal of Social Work, 1-20.
Admi, H. (1997). Nursing students’ stress during the initial clinical experience. Journal of Nursing Education, 36, 323- 327.
Algoe S,B., Fredrickson, B.L.,Gable S,L. (2013) The social functions of the emotion of gratitude via expression. Emotion. 2013 Aug;13(4),605-9.
Allen, J., Fairlough, G., Heinzen, B. (2001). The Power of Tale: Using narrative for organisational success. West Sussex: John Wiley & Sons Ltd.
Aston, L. Molassiotis, A. (2003): Supervising and supporting student nurses in clinical placements: the peer support initiative. Nurse Education Today 23(3), 202-210.
Atkins, P. W. B., Parker, S. K. (2012). Understanding individual compassion in organizations: the role of appraisals and psychological flexibility. Academy of Management Review, 37(4), 524-546.
Ausbrooks, A. (2011). Why Child Welfare Supervisors Stay, Journal of Religion & Spirituality in Social Work: Social Thought, 30(4), 358-384, DOI: 10.1080/15426432.2011.619901
Bambling, M., King, R., Raue, P., Schweitzer, R., Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research, 16(3), 317-331.
Barker,J.,Hodes,D.(2007) The Child In Mind: A Child Protection Handbook. Routledge: London
Barnett, J. E., Baker, E. K., Elman, N. S., Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38(6), 603-612. Available at: bit.ly/1CvJGKW
Barlow, J, Stewart-Brown S., Callaghan H., Tucker J., Brocklehurst N., Davis H. (2003). Working in Partnership: The development of a home visiting service for vulnerable families. Child Abuse Review, 12, 172-189.
Barlow, J., Davis, H., McIntosh, E., Jarrett, P., Mockford, C., Stewart-Brown, S. (2007). Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Archives of Disease in Childhood, 92, 229-233.
74 Supporting Health Visitors and Fostering Resilience Literature Review
Barnes, J., Ball., M., Meadows, P., Howden, B., Jackson A., Henderson, J., Niven, L. (2011). The Family Nurse Partnership in England . Department of Health.
Bashford, E., Seal, J. (2012). A case study explaining the changing way we work with families through delivery of the Family Partnership, Department of Public Health.
BBC, (2014), Beyond Belief. Available at: bbc.in/1yAfdG5, May.
Beck, D., Srivastava, R. (1991). Perceived level and sources of stress in baccalaureate nursing students. Journal of Nursing Education, 30, 127-133.
Becker, M., Neuwirth, J. (2002). Teaching strategies to maximize clinical experiences with beginning nursing students. Journal of Nursing Education, 41, 89- 91.
Bell, M., Coen, E., Coyne-Nevin, A., Egenton, R., Ellis, A., Moran, L. (2007) Experiences of an action learning set. Practice Development in Health Care, 6(4), 232-241
Bendelow, G. (2009). Health, Emotion and The Body. Oxford: Polity Press.
Berry, C. (2014) Wellbeing in Four Policy Areas Report by the All-Party Parliamentary Group on Wellbeing Economics. New Economics Foundation.
Bigwood, P. (2013). Using Restorative Supervision to Improve Clinical Practice and Safeguarding Decisions, Department of Health.
Bidmead, C., (2013). Health visitor/parent relationships: a qualitative analysis. Appendix 1. In: Cowley, S., Whittaker, K., Grigulis, A., Malone, M., Donetto, S., Wood, H., Morrow, E., Maben, J. (Eds.), Appendices for Why Health Visiting? A Review of the Literature about Key Health Visitor Interventions, Processes and Outcomes for Children and Families. National Nursing Research Unit, King’s College London. Available at: bit.ly/1tlMmJb
Bion, W. R. (1962) Learning from experience. London: William Heinemann.
Board, M., Symons, M. (2007) Community matron role development through action learning. Primary Health Care, 17(8): 19-22.
Bolt, JE (2005). The future of executive development. San Francisco: Executive Development Associates.
Booth, A., Sutton, A., Falzon, L., (2003). Working together: supporting projects through action learning, Health Information and Libraries Journal. 20 (4), 225 – 231.
Botham, J. (2013). What constitutes safeguarding children supervision for health visitors and school nurses? Community Practitioner, 86(3), 28–34.
Bowlby, J. (1988). A Secure Base. London: Routledge.
Brandt, R. (2013). Calling In a Coach, SHRM Human Resources Magazine, September , 54-55.
Brocklehurst, N., Barlow, J., Kirkpatrick, S., Davis, H. & Stewart-Brown, S. (2004). The contribution of health visitors to supporting vulnerable children and their families at home. Community Practitioner 77, 175-179.
Brooks, N; Moriarty, A. (2009): Implementation of a peer-support system in the clinical setting Nursing Standard, 35-39.
75 Supporting Health Visitors and Fostering Resilience Literature Review
Brown, B. (2012). Daring Greatly: how the courage to be vulnerable transforms the way we live, love, parent and lead. London. Penguin Books Ltd.
Browne, K., Jackson, V., (2013). Community intervention to prevent child maltreatment in England: evaluating the contribution of the family nurse partnership, Journal Public Health 35 (3), 447-452.
Brunero, S., Stein‐Parbury, J. (2008). The effectiveness of clinical supervision in nursing: an evidenced based literature review, Australian Journal of Advanced Nursing, 25 (3), 86.
Bryar, R., Kendall, S., Mogotlane, SM. (2012) Reforming Primary Healthcare: A Nursing Perspective. Available at: bit.ly/1D4Fsbp. Accessed 17.12.14.
Burleson BR., Albrecht TL., Sarason IG. (1994) Communication of Social Support, Sage, Thousand Oaks, CA.
Canham, H. (2000) Exporting the Tavistock Model to Social Services: Clinical Consultative and Teaching Aspects. Journal of Social Work Practice. 14(2), 125-133
Cardno, C. (2007) “Leadership learning: the praxis of dilemma management”, International Studies in Educational Administration, 35(2), 33-50.
Cardno, C., Piggot-Irvine, E. (1997). Effective Performance Appraisal: Integrating Accountability and Development in Staff Appraisal. Auckland: Longman.
Centre for the Advancement of Interprofessional Education (CAIPE) (2012). Comments on the Draft Care and Social Bill October 2012. Available at: bit.ly/1JBQqsT Accessed 3.11. 2014.
Chade-Meng Tang (2012) Search Inside Yourself: increase productivity, creativity and happiness. London: Collins.
Chambers, C. and Ryder, E. (2009) Compassion and Caring in Nursing. London: Radcliffe Publishing Ltd.
Chapman, L. (2013) A ‘roll-on, roll-off’ preceptorship pathway for new registrants, Nursing Management (UK) 20(2), 24-26.
Cheater, FM. (2001) An evaluation of a local clinical supervision scheme for practice nurses. Journal of Clinical Nursing Jan;10(1),119-31.
Children and Young People Mental Health Coalition, Policy Briefing Paper 1. Health Visitors.
Cho, Y., Egan, TM. (2009) Action Learning Research: A Systematic Review and Conceptual Framework, Human Resource Development Review, 8(4), 431 -462.
Cicchetti, D. (2010) Resilience under conditions of extreme stress: a multilevel perspective. World Psychiatry, 9, 145-154.
Clutterbuck, D. (2004), Everyone Needs a Mentor; Fostering talent on your organisation, Fourth Edition, Chartered Institute of Personnel and Development (CIPD).
Cobb, S. (1976) Social support as a moderator of life stress, Journal of Psychosomatic Medicine, 38 (1976), 300–314.
Coghlan, D., Brannick, T. (2005). Doing action research in your own organization (2nd ed).Thousand Oaks, CA: Sage.
76 Supporting Health Visitors and Fostering Resilience Literature Review
Cohen, S., Syme, SL., (1985) Issues in the study and application of social support. In: Cohen, S., Syme, S.L. (Eds.), Social Support and Health. Academic Press, Toronto.
Cohen S., Gottlieb B., Underwood L.G. (2000) Social relationships and health in S. Cohen, L.G. Underwood, B. Gottlieb (Eds.) (2000) Social Support Measurement and Intervention: A Guide for Health and Social Scientists, Oxford University Press, Toronto.
Condon, P., Desbordes, G., Miller, W., Desteno, D. (2013) Meditation increases compassionate responses to suffering. Psychological Science, 24, 2125-2127.
Cosley, BJ., McCoy, SK., Saslow, LR., Epel, ES. (2010) Is Compassion for others stress buffering? Consequences of compassion and social support for physiological reactivity to stress. Journal of Experimental Social Psychology 46, 816-823.
Cowley, S. (2008). Developing and measuring resilience for population health. African Health Sciences, 8(5), 41-43.
Cowley, S., Whittaker, K., Grigulis, A., Malone, M., Donetto, S., Wood, H., Morrow, E., Maben J. (2013). Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families National Nursing Research Unit, King’s College Available at : bit.ly/1tlMmJb
Cox, A. (1993) Befriending young mothers, British Journal of Psychiatry, 163 (1993), 6–18.
Crowther, K., Cowen, G. (2011). Effective Relationships with Vulnerable Parents to Improve Outcomes for Children and Young People: Final Study Report, York Consulting.
Currie, K., Biggam, J., Palmer, J., Corcoran, T. (2012) Participants’ engagement with and reactions to the use of on-line action learning sets to support advanced nursing role development, Nurse Education Today, 32(3), 267-272.
Cutrona, CE. (2000) Social Support Principles for Strengthening Families In Canavan, J., Dolan, P., Pinkerton, J (Eds) Family Support: direction from diversity (Ch 5) Jessica Kingsley. London.
Daloz, L. (1986). Effective Teaching and Mentoring. San Francisco, ca: Jossey-Bass Publishers.
Darling, LAW. (1984). What to Do About Toxic Mentors. Journal of Nursing Administration, 15, 43-44.
Davis, H., Spurr, P. (1998). Parent counselling: an evaluation of a community child mental health service, Journal of Child Psychology and Psychiatry,39, 365-376.
Davis, H., Rushton, R. (1991). Counselling and supporting parents of children with developmental delay: A research evaluation. Journal of Mental Deficiency Research, 35, 89-112.
Davis, H., Tsiantis, J. (2005). Promoting Children’s Mental Health: The European Early Promotion Project (EEPP). International Journal of Mental Health Promotion 7, 4-16.
Day, DV. (2000). Leadership development. Leadership Quarterly, 11, 581-613.
Day, C., Davis, H. (2009) The Family Partnership Reflective Practice Handbook. London: CPCS. de Haan, E., de Ridder, I. (2006). Action learning in practice. Consulting Psychology, Journal: Practice and Research, 58, 216-231.
77 Supporting Health Visitors and Fostering Resilience Literature Review
De Loo, I. (2001). New thoughts on action learning. Journal of European Industrial Training, 25, 229-234.
De Loo, I. (2002). The troublesome relationship between action learning and organisational growth. Journal of Workplace Learning, 14, 245-255.
De Loo, I. (2006). Action and organisational learning in an elevator company. The Learning Organization, 13, 204-214.
Dennis, CL. 2003, Peer support within a health care context: a concept analysis. International, Journal of Nursing Studies, 40(3), 321–332.
Department of Health/HMG. (2011). No Health Without Mental Health: a cross government mental health outcomes strategy for people of all ages. Available at: bit.ly/1F8legM . Accessed 1/8/14.
Department of Health (2012). Compassion in Practice. Available at: bit.ly/1IBveUj. Accessed July 2014.
Department of Health, DH. (2013). Improving Children and Young People’s Health Outcomes: a system wide response. Available at: bit.ly/1CvKUG3 (Accessed 9.6. 2013).
Department of Health/ Business in the Community (2009). Emotional Resilience Toolkit. Available at: bit.ly/163vSdV Accessed 1.8.14.
Devlin, A., Mitcheson, J. (2013). An Evaluation of Three Models of Health Visiting Practice Teaching in the East of England, Journal of Health Visiting, 1(10), 574 – 581.
Dewar, B., Sharp, C. (2006). Using Evidence: how action learning can support individual and organizational learning through action research, Educational Action Research, 14 (2), 153-159.
De Zulueta, P. 2014. Compassionate resilience- why we need it in healthcare. Human Values in Healthcare Forum. Summer Update pp.2
Dickerson, S., Kemeny, M. (2004) Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130, 355-391.
Dilworth, R.L., Willis, J. (2003). Action learning: Images and pathways. Malabar, FL: Krieger.
Dixon-Woods, M., Baker, R., Charles, K., Dawson, J., Jerzembek, G., Marin, G., Mccarthy, I., McKee, L., Minion, J., Ozieranski, P., Williars, J., Wilkie. P., West, M. 2013. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.BMJ Quality and Safety. Available at : bmj.co/1CKpJjO. Accessed 10.10.14.
Dobbin, A. (2014) Burnout or fired up? British Journal of General Practice. October, 497-498.
Donetto, S., Malone, M., Hughes, J., Morrow, E., Cowley, S., Maben, J. (2013) Health Visiting: Inform the Development of UK Health Visiting Practice and Services (Department of Health Policy Research Programme, ref. 016 0058), National Nursing Research Unit.
Douglas, H., Ginty, M. (2001). ‘The Solihull Approach: changes in health visiting practice’ Community Practitioner,4 (6), 222-224.
Douglas, H., Brennan, A. (2004). Containment, Reciprocity and Behaviour management: Preliminary evaluation of a brief early intervention (the Solihull Approach) for families with infants and young children The International Journal of Infant Observation. 7 (1)9-107.
78 Supporting Health Visitors and Fostering Resilience Literature Review
Douglas, H. (2010). Supporting emotional health and wellbeing: the Solihull Approach, Community Practitioner, 83(8), 22-5.
Douglas, H., Whitehead, RE. (2005). Health Visitors’ experiences of using the Solihull Approach. Community Practitioner 78(1),20-23.
Downie, C., Basford, P. (2003). Mentoring in Practice, A Reader. London: University of Greenwich.
Duffy, K. (2003). Failing Students: A Qualitative Study of Factors that Influence the Decisions Regarding Assessment of Students’ Competence in Practice. London: Nursing and Midwifery Council.
Dutton, JE., Workman, KM., Hardin, AE. 2014. Compassion at Work. Annual Review of Organisational Psychology and Organisational Behaviour, 1,277-304.
Edmonstone, J. (2008) Action learning as a developmental practice for clinical leadership. International Journal of Clinical Leadership, 16(2),59-64.
Ellis, A., Dryden, W. (2007). The Practice of Rational Emotive Behavior Therapy (2nd ed.); New York, Springer Publishing.
Emmons, RA., Stern, R. (2013). Gratitude as a psychotherapeutic intervention. Journal of Clinical Psychology. Aug; 69(8), 846-55.
Eng, E., Young R. (1992) Lay health advisors as community change agents, Family Community Health, 15, 24–40.
Epstein, R.M., Krasner, M.S. (2013). Physician resilience: what it means, why it matters, and how to promote it. Academic Medicine. Mar; 88(3), 301-303.
Feildon, S. (2005). Literature Review – Coaching effectiveness; a Summary, NHS Modernisation Agency Leadership Centre.
Fischer, M., Webb, C. (2008). What do midwifery mentors need? Priorities and impact of experience and qualification. Learning in Health and Social Care, 8(1), 33-46.
Foot, J., Hopkins, T., (2010). A glass half full: How an asset approach can improve community health and wellbeing, London: Improvement and Development Agency.
Fraiberg, S., Adelson, E., Shapiro, V. (1975). Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child & Adolescent Psychiatry, 14(3), 387-421.
Frankl, V. (2006). Man’s Search for Meaning. An Introduction to Logotherapy. Boston, MA: Beacon Press.
Frameworks for Change (2014). Could compassion Circles change the NHS? Available at: bit.ly/1wzoVr3. (Accessed 1.1.15)
Francis R. (2010) Independent Inquiry into care provided by Mid Staffordshire January 2005-March 2009. London, The Stationery Office.
Fredrickson, BL. (2001). The Role of Positive Emotions in Positive Psychology. The Broaden-and-Build Theory of Positive Emotions. American Psychologist, 56 (3), 218- 226.
79 Supporting Health Visitors and Fostering Resilience Literature Review
Friborg, O., Hjemdal, O., Rosenvinge, J., Martinussen, M. (2003) A new rating scale for adult resilience : what are the central protective resources behind healthy adjustment? International Journal of Methods in Psychiatric Research 12(2) 65-77.
Frost, N. (2005). Professionalism, partnership and joined-up thinking. Research in Practice. Available at: bit.ly/1C2rmb5. Accessed 2.10.14
Germer, C. (2009) The Mindful Path to Self-Compassion: freeing yourself from destructive thoughts and emotions. London. The Guildford Press.
Gilbert, P. (2010) The Compassionate Mind: a new approach to life’s challenges. London: Constable.
Gilbert, P., McEwan, K., Matos, M., Rivis, A. (2011). Fears of compassion: Development of three self-report measures. Psychology and Psychotherapy: Theory, Research and Practice 84, 239–255.
Gibb, J. R. (1961). Defensive communication. Journal of communication, 11(3), 141-148.
Giblin PT. (1989) Effective utilisation and evaluation of indigenous health care workers, Public Health Reports, 104 (1989), 361–368.
Gillard, S., Gibson, SL., Holley, J., Lucock, M. (2014) Developing a change model for peer worker interventions in mental health services: a qualitative research study. Epidemiol Psychiatr Sci. Jul 3:1-11.
Gingiss, PL. (1993) Peer coaching: building collegial support for using innovative health programs. Journal of School Health. 63 (2), 79-85.
Gladwell, M. 2013. David and Goliath: Underdogs, Misfits, and the Art of Battling Giants. New York, Little Brown Book Company.
Goodrich, J. (2011) Schwartz Center Rounds: Evaluation of UK Pilots. King’s Fund, London.
Goodrich, J. (2012) Supporting hospital staff to provide compassionate care: do Schwartz center rounds work in English hospitals? Journal of Royal Society of Medicine, 105(3), 117-22.
Goldsack, T., Hall, K. (2010). Mellow Parenting Evaluation - August 2008 (final version completed September 2010), Doncaster Educational Psychology Service, Wheatley Children’s Centre.
Gopee, N. (2008). Mentoring and Supervision in Healthcare. London: Sage.
Gray, M., Smith, L. (2000). The qualities of an effective mentor from the student nurse’s perspective: Findings from a longitudinal qualitative study, Journal of Advanced Nursing, 2000, 32(6), 1542-1549.
Gray, B. Smith, P. (2009) Emotional labour and the clinical settings of nursing care: the perspectives of nurses in east London. Nurse Education in Practice 9 (4), 253-261.
Graybeal, C. (2001). Strengths-based social work assessment: Transforming the dominant paradigm, Families in Society: The Journal of Contemporary Human Services, 82, 233-242.
Greenhalgh, T. (2013) The Compassionate Organisation. British Journal of General Practice,481.
80 Supporting Health Visitors and Fostering Resilience Literature Review
Hamrin, V., Weycer, A., Pachler, M. (2006): Evaluation of peer-led support groups for graduate nursing students. Journal of Nursing Education 45(1), 39-43.
Hardacre, J., Keep, J., (2003). From intent to impact: developing clinical leaders for service improvement, Learning in Health and Social Care. 2(3), 169 – 176.
Hart, A., Heaver, B. 2013. Evaluating resilience-based programs for schools using a systematic consultative review Journal of Child and Youth Development, 1 (1) 27-53.
Hart, A., Gagnon, E. (2015) Uniting resilience research with an inequalities agenda: Towards a fifth wave? Unpublished paper: Work in Progress, University of Brighton, Brighton.
Haydock, D., Mannix, J., Gidman, J. (2011). CPT’s perceptions of their role satisfaction and levels of professional burnout, Community Practitioner, 84 (5), 19-23.
Healthcare Commission (2007) Investigation into outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells. London, Healthcare Commission.
Health Education England. (2011). Health Visiting Programme: Guidance and FAQs for the Education Initiative – Continuing Professional Development for Health Visitors.
Helgesson V.S., Gottlieb B. (2000) Support groups in S. Cohen, L.G. Underwood, B. Gottlieb (Eds.) (2000) in Social Support Measurement and Intervention: A Guide for Health and Social Scientists, Oxford University Press, Toronto.
Hewison, A., Sawbridge Y. (2014) Nursing is hard emotional work-why is this ignored? In What does the future hold for the NHS, Health Services Management Centre, Birmingham, 26-27.
Hewison, A., Sawbridge Y. (2012) Nursing Leaders need backing and support to reclaim care. Nursing Times 108 (7) 7.
Hewison, A., Gale, N., Shapiro J. (2012) Co-production in research: some reflections on the experience of engaging practitioners in health research. Public Money and Management 32 (4), 297-302.
HMG (2010) White Paper: Healthy Lives, Healthy people: Our strategy for Public Health in England. Available at: bit.ly/1BkOsXx ( Accessed 1.10.14)
House, JS. (1981) Work Stress and Social Support, Prentice-Hall, Englewood Cliffs, NJ.
Hölzel, B.K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S.M., Gard, T., Lazar, S.W. (2011). Mindfulness practice leads to increases in regional brain grey matter density. Psychiatry Research: Neuroimaging, 191 (1): pp. 36-43. Available at: 1.usa.gov/1H7o77Q Accessed 2.9. 2014.
Hubbard, C., Halcomb, K., Foley, B., & Roberts, B. (2010). Mentoring: A nurse educator survey. Teaching and Learning in Nursing, 5(4), 139-142.
Hudson, C., Hart, A., Dodds, P. (2014) Towards an ecologically based intervention to grow professional resilience, The Second World Congress on Resilience: from person to society, Timisoara, Romania. Conference proceedings.
Hunter, B., Warren, L. (2013), Investigating Resilience in Midwifery: Final report, Royal College of Midwives.
81 Supporting Health Visitors and Fostering Resilience Literature Review
Hunter, B., Warren, L. 2014. Midwives’ experiences of workplace resilience. Midwifery. 2014 Aug; 30(8) 926-34. doi: 10.1016/j.midw.2014.03.010.
ICN (2007) cited in World Health Professions Alliance (2008) Positive Practice Environments for Health Care Professionals. Factsheet p.2 Available at: bit.ly/1ysaxkV
Institute of Health Visiting (iHV) (2014 ) Institute of Health Visitors Making the most of Health Visiting Survey.
Institute of Health Visiting (iHV/HEE) (2015) National Induction Framework. Available at: www.ihv.org.uk
Institute of Health Visiting (iHV/HEE) (2015) National Preceptorship Framework . Available at: www.ihv.org.uk
Irons, C. (2013) The science of compassion: evolutionary, neurophysiological and psychological perspectives. Journal of Holistic Healthcare 10(3), 10-16.
Jackson, C., Thurgate, C. (2011): Action learning: maximising learning in the workplace. British Journal of Healthcare Assistants, 5(9), 454-456.
Jackson, D., Firtko, A., Edenborough, M.,(2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity : a literature review . Journal of Advanced Nursing, 60(1), 1-9.
Jackson, E. (2008) Work discussion groups at work: applying the method p51-p72. In Rustin, M. Bradley, J. (ed) Work Discussion: Learning from Reflective Practice in Work with Children and Families. London: Karnac Books.
Jarvis, J. (2004). Coaching and buying coaching services. A guide. London: CIPD. Available at: bit.ly/1zGIlSI
Johnson, C. (1998). The essential principles of action learning, Journal of Workplace Learning. 10(6/7), 296 – 300.
Jones, M., Johnston, D. (1997). Distress, stress and coping in first year student nurses. Journal of Advanced Nursing, 26, 475-482.
Joyce, B., Showers, B. (1982) The coaching of teaching. Educational Leadership. 40,1, 4-10.
Karamally,F. (2013) Compassion in Business.Available at: bit.ly/1yLAoJF ( accessed 1.12.14)
Kelton, M. (2014). Clinical Coaching an Innovate Role to Improve Marginal Students, Nurse Education Practice, Nov 3;14 (6), 709-13.
Kenyon, L., Peckover, S. (2008). ‘A Juggling Act’: an analysis of the impact of providing clinical placements for pre-registration students on the organisation of community nursing and health visiting work. Nurse Education Today, 28(2), 202-9.
King, J. (1999). Giving Feedback. British Medical Journal [online] Available at: bmj.co/1yMoiLp [ Accessed 29 November 2014].
King’s College London (2014) Press release Friday 23 May. Supporting NHS staff at work: could Schwartz centre rounds hold the key to happier, healthier workforce and enhance compassionate care? Available at bit.ly/1wzpf92. Accessed 10.1.15.
King’s Fund (2014). Developing compassionate leadership through mindfulness. Available at: bit.ly/1wyyhcR. Accessed 12.9.14.
82 Supporting Health Visitors and Fostering Resilience Literature Review
Kinnell, D, Hughes, P. (2009). Mentoring Nursing and Healthcare Students. London: Sage.
Kirkland, M. (1998). Stressors and coping strategies among successful female African American baccalaureate nursing students. Journal of Nursing Education, 34, 5-12.
Kleehammer, K., Hart, L., Keck, J. (1990). Nursing students’ perceptions of anxiety producing situations in the clinical setting. Journal of Nursing Education, 29, 183-187.
Kless, J. (1989). Use of a student support group to reduce students stress in a nurse anaesthesia program. AANA Journal, 57, 75-77.
Konig, S., Gluck, J. 2013. Gratitude is with me all the time: how gratitude relates to wisdom. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 1-12.
Kline, N. (2005) Time to Think: An Imperative of Behaviour, Not Time. Available at: www.timetothink.com. Accessed 1.11.5.
Klugar, A., DeNisi, A. (1996) The effects of feedback interventions on performance: A historical review, meta-analysis and preliminary feedback theory. Psychological Bulletin, 119, 254-285.
Kubler-Ross, E. (1969). On Death and Dying. New York: Macmillan.
Kuhn, J. S., Marsick, V. J. (2005). Action learning for strategic innovation in mature organizations. Action Learning: Research and Practice, 2, 27-48.
Lakey, B., Cohen, S. (2000) Social support theory and measurement in S. Cohen, L.G. Underwood, B. Gottlieb (Eds.) (2000) Social Support Measurement and Intervention: A Guide for Health and Social Scientists, Oxford University Press, Toronto.
Lam, SF., Yim, PS., Lam, TWH. (2002) Transforming school culture: can true collaboration be initiated? Educational Research. 44 (2), 181-195.
Lambert, VA., Lambert, CE., Itano, J., Inouye, J., Kim, S., Kuniviktikul, W., Ito, M. (2004). Cross- cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). International Journal of Nursing Studies, 41(6), 671-684. Available at: bit.ly/1BvdANZ
Lazarus, RS. (1991).‘Progress on a cognitive-motivational-relational theory of emotion’, American Psychologist, 46, 819-834.
Leadership in Compassionate Care Programme Team (2012) Leadership in Compassionate Care Programme: Enhancing Patient Care by promoting compassionate practice Final Report, Edinburgh Napier University and NHS Lothian.
Learmonth, A. (2005) Action learning as a tool for developing networks and building evidence-based practice in public health. Action Learning: Research & Practice, 2(1), 97-104.
Leary, J., Gallagher, T., Carson, J., Fagin, L., Bartlett, H., Brown, D. (1995). Stress and coping strategies in community psychiatric nurses: A Q-methodological study. Journal of Advanced Nursing, 21, 230-237.
Levinson et al (1978) The Seasons of a Man’s Life. New York: AA Knopf.
83 Supporting Health Visitors and Fostering Resilience Literature Review
Lim, J., Hepworth, J., Bogossian, F. (2011). A qualitative analysis of stress, uplifts and coping in the personal and professional lives of Singaporean nurses. Journal of Advanced Nursing, 67(5), 1022-1033.
Lindley, P. (2013). Practitioner Resilience: Building resilience in health visitor students for coping with adversity in practice. Resilience Forum Presentation. Available at: bit.ly/1vFrVkR Accessed 30.7.14
Linley, PA. & Joseph, S. (2004) Positive change following trauma and adversity: a review. Journal of Traumatic Stress, 17(1), 11-21.
Lloyd Jones M (2005) Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. Journal of Advanced Nursing. 49, 2,191-209.
Maben, J. (2008) Employee engagement and retention in the nursing workforce: a case study of an inner London acute trust. London: King’s College and London School of Hygiene and tropical Medicine.
Maben, J., Peccei, ER., Adams, M., Robert, G., Richardson, A., Murrells, T., Morrow, E. (2012). Exploring the relationships between patients’ experiences of care and the influence of staff motivation, affect and wellbeing. NIHR. bit.ly/1JBUdq6 Accessed 21-01-15
Machin, AI., Pearson, P. (2014): Action learning sets in a nursing and midwifery practice learning context: A realistic evaluation, Nurse Education in Practice, 14 (4), 410-416.
Macleod, J., Nelson, G. (2000). Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review, Child Abuse and Neglect, 24 (9), 1127-49.
Marlow, N. et al. (1998). Randomised trial of parental support for families with very preterm children: Avon Premature Infant Project. Archives of Disease in Childhood, 79, 4-11.
Marquardt, MJ. (2004). Optimizing the power of action learning. Palo Alto, CA: Davies-Black.
Marquardt, MJ., Leonard, HS., Feedman, AM., Hill, CC. (2009). Action learning for developing leaders and organizations: Principles, strategies, and cases. Washington, DC: American Psychological Association.
Marsick, V., O’Neil, J. (1999). The many faces of action learning. Management Learning, 30, 159-176.
Martyn, C. (1997). Distress, stress and coping in first-year level student nurses. Journal of Advanced Nursing, 32, 66-74.
Maslow, A. 1971. The Farther reaches of Human Nature. Harmondsworth: Penguin.
McAllister, M., McKinnon, J. (2009) The importance of teaching and learning resilience in the health disciplines: A critical review of the literature. Nurse Education Today 29,371-379.
McCann, C. M., Beddoe, E., McCormick, K., Huggard, P., Kedge, S., Adamson, C., Huggard, J. (2013). Resilience in the health professions: A review of recent literature. International Journal of Wellbeing, 3 (1), 60-81.
McCormack, B., Dewing, J., Breslin, L., Coyne-Nevin, A., Kennedy, K., Manning, M., Peelo-Kilroe, L., Tobin, C. (2009). Practice development: realising active learning for sustainable change, Contemporary Nurse 32 (1-2), 92-104.
McDonald, G., Jackson, D., Wilkes, L., Vickers, M.H. (2012) A work-based educational intervention to support the development of personal resilience in nurses and midwives. Nurse Education Today, 32, 378-384.
84 Supporting Health Visitors and Fostering Resilience Literature Review
McGonigal, K. (2013). How to make stress your friend. Ted Talk Video online. Available at bit.ly/1KtIZ5E. Accessed 1.9.14.
McKimm, J. (2009) Giving effective Feedback. British Journal of Hospital Medicine, March, 70(3), 158-161.
McNamara, MS., Fealy, GM., Casey, M., O’Connor, T., Patton, D., Doyle, L., Quinlan, C. (2014). Mentoring, coaching and action learning: interventions in a national clinical leadership development programme, Journal of Clinical Nursing. Sep; 23 (17-18): 2533-41. doi: 10.1111/jocn.12461. Epub 2014 Jan 7.
McVeigh, H., Ford, K., O’Donnell, A., Rushby, C., Squance , J. (2009). A framework for mentor support in community-based placements, Nursing Standard, 23(45), 35-41.
Mental Health Foundation. (2007). Arts, Creativity and Mental Health Initiative. Participatory Arts Self Evaluation Approach Project Report. London. Mental Health Foundation.
Mental Health Strategic Partnership (2013). Building Resilient Communities: Making every Contact Count for Public Mental Health, Available at: bit.ly/18qmd2O.
Menzies-Llyth, I. (1960). Social systems as a defence against anxiety: an empirical study of the Nursing Service of a General Hospital. Human Relations. 13,95-121.
Millera, S. (2002). Mentoring Students and young people: a Handbook of Effective Practice. London:Kogan Page.
Milford, R., Kleve, L., Lea, J. and Greenwood, R. (2006). A pilot evaluation study of the Solihull Approach’ Community Practitioner; 79: 11, 358-362.
Moore, T., Adams, M., Pratt, R. (2013). ‘A service evaluation on the Solihull Approach training and practice’ Community Practitioner, 86 (5), 26-27.
Morris-Day, N. (2014) Setting out: reflections of a newly-qualified health visitor, Community Practitioner, 87(1), 37.
Morton, S. (2013). What support do health visitor mentors need? Community Practitioner, 86 (8) 32-35.
Myall, M., Levett-Jones, T., Lathlean, J. (2007). Mentorship in contemporary Practice: the experiences of nursing students and practice mentors. Clinical Nursing Journal 17(14),1834-42.
National Institute for Health and Clinical Excellence. NICE. (2009) Depression: the treatment and management of depression in adults. NICE Clinical Guideline 90. London: NICE.
National Nursing Research Unit (2013) Does NHS staff wellbeing affect patient experience of care? Available at bit.ly/16LpUii. Accessed 12.10.14
Neff, K. (2011). Self-Compassion, Self-esteem and Wellbeing. Social and Personality Psychology Compass. 1-12.
Neff, K., Germer, C. (2013). A pilot study and randomised control trial of the mindful self-compassion program. Journal of Clinical Psychology, 69, 28-44.
Neff, K. D., Lamb, L. M. (2009). Self-Compassion. In S. Lopez (Ed.), The Encyclopedia of Positive Psychology, 864-867). Blackwell Publishing.
NHS Confederation (2014) All Together Now: Making Integration Happen. Available at: bit.ly/1ENPOO4. Accessed 1.12.14.
85 Supporting Health Visitors and Fostering Resilience Literature Review
NHS Elect (2014) Developing Resilience in Self and Others. Available at: bit.ly/1x3brd0. Accessed 23.9.14.
NHS Employers (2014a). Guidance on prevention and management of stress at work. Available at: bit.ly/1Ep4fei. (Accessed 1.12.14).
NHS Employers (2014b)). Values Based Recruitment. Available at: www.nhsemployers.org. Accessed 1.12.14.
NHS England (2014) National Health Visiting Service Specification, (2014/15). Available at: bit.ly/1D4Kpkn Accessed 1.12.14.
NHS Leadership Academy (ND) The Leadership Academy and 360 degree feedback. bit.ly/1H7qpUz accessed 14.01.15
NHS Staff Survey. (2013). Available at: bit.ly/15KhpTY.
Nowack, K. (2005) Longitudinal evaluation of a 360 degree feedback program: Implications for best practices. Paper presented at the 20th Annual Conference of the Society for Industrial and Organizational Psychology, Los Angeles, March 2005.
NSPCC. (2013) Research Briefing: Vicarious trauma: the consequences of working with abuse, NSPCC research briefing.
Nursing and Midwifery Council. (2008a) The Prep Handbook, (NMC: London).
Nursing and Midwifery Council. (2011a), Circular 26/2007, (NMC: London).
Obholzer, A., Roberts, V.Z. (1994) The Unconscious at work: individual and organizational stress in the human services. London: Routledge.
Oldknow, H., Gosling, J., Etheridge, K., Williamson, K. (2014): Role of peer support workers in care services for young people, Learning Disability Practice, 17 (6), 28-30.
Olds, DL., Hill, PL., O’Brien, R. (2003). Taking preventive intervention to scale: the nurse–family partnership, Cognitive Behavioural Practitioner, 10 (4), 278-90.
Olds, D., Henderson, C., Eckenrode, J. (2002). Preventing child abuse and neglect with prenatal and infancy home visiting by nurses. In: Browne KD, Hanks H, Stratton P, editors. Early Prediction and Prevention of Child Abuse: A Handbook. Chichester: Wiley; 2002,165-83.
Omansky, GL. (2010). Staff nurses’ experiences as preceptors and mentors: and integrative review. Nurse Management, 18(6), 697-703.
O’Neil, J., Marsick, V. J. (2007). Understanding action learning. New York: AMACOM.
Otway, C. (2001): Informal peer support: a key to success for nurse prescribers. British Journal of Community Nursing 6 (11), 586-591.
Oxford Mindfulness Centre, (2014) Mindfulness and Depression. Available at: bit.ly/1zUOt9i Accessed 1.19.14
Pagana, K. (1998). Stresses and threats reported by baccalaureate students in relation to an initial clinical experience. Journal of Nursing Education, 27, 418- 424.
86 Supporting Health Visitors and Fostering Resilience Literature Review
Patterson, K., Grenny, J., McMillan, R., Switzler, A. (2002). Crucial Conversations: Tools for Talking when Stakes are High, McGraw Hill.
Palsson, M., Hallberg, I.R., Norberg, A., Bjorvell, H. (1996). Burnout empathy and sense of coherence among Swedish district nurses before and after systematic clinical supervision. Scandinavian Journal of Caring Sciences. 10 (1), 19‐26.
Partnership for Occupational Safety and Health in Healthcare (2012) Health and Wellbeing in Healthcare Settings. Available at: www.nhsemployers.org. (Accessed 1.12.14).
Pedler, M. (2002). Accessing local knowledge. Human Resource Development International, 5, 523-540.
Pedler, M., Burgoyne, J., Brook, C. (2005). What has action learning learned to become? Action Learning: Research and Practice, 2, 49-68.
Persinger, J. (2012) An Alternative to Self-esteem: Fostering self-compassion in Youth. Communique, 40(5), 20-23.
Peterson, U., Bergstrom, G., Samuelsson, M. (2008): Reflecting peer-support groups in the prevention of stress and burn-out: randomized controlled trial. Journal of Advanced Nursing, 63(5), 506-516.
Petersen, C., Seligman, MEP. (2004). Character strengths and virtues: A handbook of classification, Oxford: Oxford University Press.
Proctor, B. (1986) Supervision: A Co-operative Exercise in Accountability in: Marken, M., Payne, M. (eds.) (1986). Enabling and Ensuring - supervision in practice National Youth Bureau, Council for Education and Training in Youth and Community Work, Leicester, UK.
Puckering, C. (2004). Mellow Parenting: An intensive intervention to change relationships. The Signal. Newsletter of the World Association for Infant Mental Health, 12(1), 1-5. January – March.
Puckering, C., Rogers, J., Mills, M., Cox, A. D., Mattsson-Graff, M. (1994). Process and evaluation of a group intervention for mothers with parenting difficulties. Child Abuse Review, 3(4), 299–310.
Puckering, C., Evans, J., Maddox, H., Mills, M., Cox, A. D. (1996). Taking control: A single case study of mellow parenting. Clinical Child Psychology and Psychiatry, 1 (4), 539–550.
Puckering, C., Mills, M., Cox, A. D., Maddox, H., Evans, J. (1999). Improving the quality of family support; Mellow Parenting: An intensive intervention. Final report, Department of Health.
Puckering, C. (2004). Mellow Parenting: An intensive intervention to change relationships. The Signal. Newsletter of the World Association for Infant Mental Health, 12 (1), 1-5. January – March 2004.
Puckering, C., Evans, J., Maddox, H., Mills, M., Cox, A. D. (1996). Taking control: A single case study of mellow parenting. Clinical Child Psychology and Psychiatry, 1(4), 539–550.
Pulsford, D., Boit, K., Owen, S. (2002). Are mentors ready to make a difference? A survey of mentors attitudes towards nurse education. Nurse Education Today, 22 (6), 439-46.
Puura, K., Davis, H., Cox, A., Tsiantis, J., Tamminen, T., Ispanovic-Radojkovic, V., Paradisiotou, A., Mantymaa, M., Roberts, R., Dragonas, T., Layiou-Lignos, E., Dusoir, T., Rudic, N., Tenjovic, L. & Vizacou, S. (2005). The European Early Promotion Project: Description of the Service and Evaluation Study. International Journal of Mental Health Promotion, 7, 17-31.
87 Supporting Health Visitors and Fostering Resilience Literature Review
Ralph, RO., Lambric, TM., Steele, RB.(1996). Recovery issues in a consumer developed evaluation of the mental health system. Presentation at 6th Annual Mental Health Services Research and Evaluation Conference, Arlington, VA, February, 1–13.
Raelin, JA. (2007). Toward an epistemology of practice. Academy of Management Learning and Education, 6, 495-519.
Raelin, JA. (2008). Work-based learning. San Francisco: Jossey-Bass.
Raelin, JA., Raelin, JD. (2006). Developmental action learning. Action Learning: Research and Practice, 3, 45-67.
Rapp, C., Saleebey, D., Sullivan, PW. (2008). The future of strengths-based social work practice, in Saleebey D (ed) (2006) The strengths perspective in social work practice, (4th Ed) Boston: Pearson Education
Revans, RW. (1971). Developing effective managers. New York: Praeger.
Revans, RW. (1982). The origins and growth of action learning. London: Chartwell-Bratt.
Revans, RW. (1998). ABC of action learning. London: Lemos & Crane.
Reynolds, M., Vince, R. (2004). Critical management education and action-based learning. Academy of Management Learning & Education, 3, 442-456.
Richardson, J., Ainsworth, R., Allison, R., Billyard, J., Corley, R. and Viner, J. (2008) Using an action learning set (ALS) to support the nurse and allied health professional consultant role. Action Learning: Research & Practice, 5(1), 65-77.
Riley, K. Gibbs,D. (2013) Heartmath in UK Healthcare: Does it add up? Journal of Holistic healthcare, 10(1), 23-28.
Robinson, D., Miller, L., Rickard, C. (2013). The Family Nurse Workforce: A Study for the Family Nurse Partnership National Unit, Institute for Employment Studies.
Robinson, J. (1982) Evaluation of Health Visiting. London. Council for the Education and Training of Health Visitors.
Robinson, V. M. J., Hohepa, M., Lloyd, C. (2009). School leadership and student outcomes: Identifying what works and why – Iterative Best Evidence Synthesis Programme. Wellington: Ministry of Education. Chapter The knowledge, skills and dispositions involved in effective educational leadership.
Robinson, V. M. J., Lai, M. K. (2006). Problem-based methodology: Research for the improvement of practice. Oxford: Pergamon Press and Robinson.
Rocha, T. 2014. The Dark Night of the Soul. Available at: theatln.tc/1Ep4plV. Accessed 1.10.14.
Rook K.S. (1984) The negative side of social interactions: impact on psychological well-being, Journal of Personality and Social Psychology, 46 (1984), pp. 1097–1108.
Rooke, J., Altounyan, C., Young, A., Young, S. (2007). Doers of the word? An inquiry into the nature of action in action learning. Action Learning: Research and Practice, 4, 119-135.
Rosenberg, M. (2013). Nonviolent Communication: A Language of Life: Life-Changing Tools for Healthy Relationships (Nonviolent Communication Guides), Puddle Dancer Press.
88 Supporting Health Visitors and Fostering Resilience Literature Review
Rustin, M. (2008) Work discussion: some historical and theoretical observations, p3-21. In Rustin, M. Bradley, J. (ed) Work Discussion: Learning from Reflective Practice in Work with Children and Families. London: Karnac Books.
Rutter, M. (2012) Resilience as a Dynamic Concept. Development and Psychopathology 24, 335–344.
Ryan, RM., Deci, EL. (2000). Self-determinism theory and the foundation of intrinsic motivation, social development, and well-being. American Psychologist, 55, 68-75.
Sadler, DR. (1989). Formative Assessment and the Design of Instructional Systems. Instructional Science, 18, 119-144.
Sanders, MR., Dadds, MR. (1993). Behavioural Family Intervention. Needham Heights, MA: Allyn and Bacon.
Sapolsky, RM. (2004) Why Zebras Don’t Get Ulcers: The Acclaimed Guide To Stress, Stress Related Diseases, and Coping. 3rd Ed, New York: St. Martin’s Griffin.
Sargeant, J., Mann, K., Ferrier, S. (2005) Exploring physicians reactions to multisource feedback: perceptions of credibility and usefulness .Medical Education. 39,497-504.
Sawbridge, Y., Hewison, A. (2014) Making compassionate care the norm starts with our staff. Health Service Journal, 25th July, 1-3. (bit.ly/1CvOobw).
Sawbridge, Y., Hewison. A. (2013) Thinking about the emotional labour of nursing-supporting nurses to care. Journal of Health Organization and Management 27 (1), 127-133.
Sawbridge, Y., Hewison, A. (2012) Taking action on poor practice. Nursing Standard 26 (30), 62-63.
Sawbridge, Y., Hewison A (2011) Time to care? Responding to concerns about poor nursing care. Health Services Management Centre Policy Paper 12. HSMC, University of Birmingham, Birmingham. ISBN 9780704428874
Sawbridge, Y., Hewison, A., Tinline, G. (2014) Time to Care? Report of an action research project to examine the feasibility of introducing the Samaritans volunteer support system in acute NHS hospital wards. University of Birmingham, Birmingham. Available at bit.ly/1ysdRN4
Sawbridge, Y., Hewison, A. ( 2011) Time to care? Responding to concerns about poor nursing care. Policy paper 12. University of Birmingham. Health Services Management Centre.
Sayer, L. (2013) Production of Community Nursing - the journey of professional socialisation: a grounded theory’s of community nurse practice teachers, Unpublished PhD Thesis.
Schore, AN. (2001). Effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Journal of Infant Mental Health; 22 (1-2), 7-66.
Shapiro, C., Meyers, A., Toner, C. (undated). Family justice clinical guide. Available at: bit.ly/1DfhMRB
Senge, PM. (1990). The fifth discipline. New York: Doubleday.
Sekerka, LE., Chao, J. (2003) Peer coaching as a technique to foster professional development in clinical ambulatory settings. Journal of Continuing Education in the Health Professions 23,1, 30-37.
89 Supporting Health Visitors and Fostering Resilience Literature Review
Sinclair, A., Fairhurst, P., Carter, A., Miller, L. (2008). Evaluation of Coaching in the NHS, Report 455, NHS Institute for Innovation and Improvement, April 2008, ISBN: 978-1-85184-397-8, pp. xiv + 100
Skills for Care (2014) Values Based Recruitment. Available at: bit.ly/1De2JYA. Accessed 6.11.14
Smither, J., London, M., Reilly R (2005) Does performance improve following multisource feedback? A theoretical model, meta-analysis and review of empirical findings. Personnel Psychology, 58, 33-66.
Smither, J. et al (2003) “Can working with an executive coach improve multisource feedback ratings over time? A quasi-experimental field study.” Personnel Psychology, 56, 23-44.
Smither, J., Walker, AG. (2004) Are the characteristics of narrative comments related to improvement in Multirater Feedback Ratings overtime?Personnel Psychology; 89, 575-581.
Smock, S.A., et al (2008) Solution-focused group therapy for Level I substance abusers, Journal of Marital and Family Therapy, 34 (1), 107–120.
Stamm, B. H. (2010). The concise ProQOL manual. Pocatello, ID: ProQOL.org, 2nd Ed.
State Government Victoria (2011), Developing Conflict Resilient Workplaces- A how-to guide for creating more positive workplaces in the Victorian not-for-profit sector. Published by the Office for the Community Sector.
Stewart, MJ., Tilden, V. (1995) The contributions of health care science to social support International Journal of Nursing Studies, 32 (1995), 535–544.
Stuart, C.C. (2007). Assessment, Supervision and Support in Clinical Practice. Second edition. London: Elsevier.
Svinicki, M., McKeachie, W. J. (2011). McKeachie’s Teaching Tips: Strategies, Research and Theory for College and University Teachers. Wadsworth: Cengage Learning.
Tavistock and Portman NHS Foundation Trust (2015) ‘Training course outline: Psychoanaytic observational studies’ Retrieved from Online Web site: bit.ly/1CdA8pi. Accessed 12.1.15.
The American Psychological Association (2014) The Road to Resilience. Available at: bit.ly/1Gktfjk. Accessed on 3.10.14.
The Point of Care Foundation (2014) Staff Care; How to engage staff in the NHS and why it matters. Available at bit.ly/1wzpf92. Accessed 10.1.15.
Thompson, R., Arnkoff, D., Glass, C. (2011) Conceptualizing Mindfulness and Acceptance as Components of Psychological Resilience to Trauma. Trauma Violence Abuse October, 12 (4), 220-235.
Thorpe, G., Moorhouse, P., Antonella, C. (2009) Clinical Coaching in Forensic Psychiatry An Innovative Program to Recruit and Retain Nurses Journal of Psychosocial Nursing 47 (5).
Turbitt, U. (2012), Safeguarding Children Supervision: Development and Implementation of a Regional Approach In Northern Ireland, HSC Public Health Agency (Presented to BUSCPAN conference April 2012).
Tusaie, K., Dyer, J. (2004) Resilience: A Historical Review of the Construct. Holistic Nursing Practice.Jan/Feb,3-8.
90 Supporting Health Visitors and Fostering Resilience Literature Review
Tushman, M., O’Reilly, C. (2007). Research and relevance: Implications of Pasteur’s Quadrant for doctoral programs and faculty development. Academy of Management Journal, 50, 769-774.
Tushman, M. L., O’Reilly, C. A., Fenollosa, A., Kleinbaum, A. M., McGrath, D. (2007). Relevance and rigor: Executive education as a lever in shaping practice and research. Academy of Management Learning & Education, 6, 345-362.
Ungar, M. (2008) Resilience Across Cultures. British Journal of Social Work, 38,218-235.
Vanek, C. (2013) Guide to 360 reviews – what is a 360? How do you administer 360 feedback? Available at: bit.ly/1y3Amc8. Accessed 12.1.15.
Vince, R. (2003). The future practice of HRD. Human Resource Development International, 6, 559-563.
Vince, R. (2004). Action learning and organizational learning: Power, politics and emotion in organization. Action Learning: Research and Practice, 1, 63-78.
Waddell, DL., Dunn, N. (2005) Peer coaching: the next step in staff development. The Journal of Continuing Education in Nursing. 36 (2), 84-9.
Walker, J., Andrews, S., Grewcock, D., Halligan, A. (2012) Life in the slow lane: making hospitals safer, slowly but surely, Journal of the Royal Society of Medicine, 105, 283–287.
Walsh, K., Nicholson, J., Keough, C., Pridham, R., Kramer, M., Jeffrey, J. (2003). Development of a group model of supervision to meet the needs of a community health nursing team. International Journal of Nursing Practice, 9(1),33‐39.
Walsh, D. (2010). The Nurse Mentor’s Handbook: Supporting Students in Clinical Practice. Oxford: Oxford University Press Reviews.
Wendt, S., Tuckey, MR., Prosser, B. (2011) Thriving, not just surviving, in emotionally demanding fields of practice. Health and Social Care in the Community. 19(3),317-325.
West, M., Lyubovnikova, J. (2013) Why teamwork matters: enabling health care team effectiveness for the delivery of high quality patient care. In Developing and enhancing teamwork in organizations. Salas, E., Tannenbaum, S., Cohen, D. & Latham, G. (eds.). San Francisco: Jossey-Bass, 331-372.
Wills, TA. (1985) Supportive functions of interpersonal relationships. In: Cohen, S., Syme, S.L. (Eds.), Social Support and Health. Academic Press, Toronto.
Wills, T., Shinar, O. (2000). Measuring perceived and received social support. In: Cohen, S., Underwood, L.G., Gottlieb, B. (Eds.), Social Support Measurement and Intervention: A guide for Health and Social Scientists. Oxford University Press, Toronto, 86.
Wilson, L. (2008) Practical Teaching : A Guide to PTLLS & CTLLS. London; Cengage Learning.
Willmott, H. (1994). Management education: Provocations to debate. Management Learning, 25, 105-136.
Walia, S. (2014). “Leadership development through action learning sets: An evaluation study”. Nurse Education in Practice, 14 (6), 612.
Wilson, V., McCormack, B., Ives, G. (2008) Developing healthcare practice through action learning: individual and group journeys. Action Learning: Research & Practice, 5 (1), 21-38.
91 Supporting Health Visitors and Fostering Resilience Literature Review
World Health Organization (1998). Health Promotion: Milestones on the Road to a Global Alliance. Author, Geneva.
World Health Professions Alliance (2008) Positive Practice Environments for Health Care Professionals. Factsheet p.1 Available at: bit.ly/1ysaxkV Accessed 12.1.15.
Young, S., Nixon, E., Hinge, D. (2010): Action learning: a tool for the development of strategic skills for Nurse Consultants? Journal of Nursing Management, 18(1), 105-110.
Warne, T., McAndrew, S. 2008. Painting the landscape of emotionality: colouring in the emotional gaps between theory and practice of mental health nursing. International Journal of Mental Health Nursing, 17, 108-115.
Wave Trust (2013) Conception to age 2 – the age of opportunity. Croyden. Wave Trust. bit.ly/1DN99hS Accessed 20.1.2015.
Wave Trust (2014)The 1001 Critical Days - The Importance of the Conception to Age Two Period. Croyden. Wave Trust. Available at: bit.ly/1uZAb66 Accessed 20.1.2015.
Weng, HY., Fox, AS., Shackman, AJ., Stodola, DE., Caldwell, JZ., Olson, MC., Rogers G.M., Davidson RJ. (2013) Compassion Training Alters Altruism and Neural Responses to Suffering. Psychological Science, 24(7), 1171–1180.
White, M. (2013). Building a Resilient Organisational Culture, UNC, Kenan Flagner Business School, UNC Executive Development.
Whitmore, J. (2002). Coaching for performance. (3rd ed.) London: Nicholas Brealey Publishing.
Whittaker, K., Grigulis, A., Hughes, J., Cowley, S., Morrow, E., Nicholson, C., Malone, M., Maben, J. (2013). Start and Stay: The Recruitment and Retention of Health Visitors. National Nursing Research Unit. Kings College London. bit.ly/1tlMmJb
Wickremasinghe, N. ( 2014). Compassionate Leadership Training. bit.ly/1BvoZNQ
Wickremasinghe, N. (2014). Is that All There Is? Self Compassion and the Imperfect Life, Middlesex University: Doctorate Thesis: Ashridge Business School.
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