BUILDING RESILIENCE IN HEALTH VISITOR STUDENTS FOR COPING WITH ADVERSITY IN PRACTICE PENELOPE LINDLEY A thesis submitted in partial fulfilment of the requirements of the University of Brighton for the degree of Doctor of Education April 2015 Abstract Health Visiting (the specialism of public health nursing focusing on families and children) has been under threat over the last decade, with a considerable reduction in staff establishment. This has contributed to discrepancies in practice between broad public health standards, against which health visitor education is validated, and the reality of practice that is dominated by safeguarding (child protection) work. Negative workplace experiences have coincided with this reduction in staff numbers, include growing workloads, diminishing resources, and significant organisational change. Encountering such adversity in practice can impact negatively on the functioning and wellbeing of a newly qualified health visitor. Studies drawing on a number of salutogenic concepts and theories have identified orientations and abilities that promote the capacity to withstand adversity, and the notion of ‘practitioner resilience’ is established within the literature. However, there is a lack of research examining the whole experience of student learning and the means by which this may enhance practitioner resilience. The research question underpinning this study was: How do student health visitors’ experiences in higher education and practice settings contribute to the development of their capacity to respond to the tensions between expectation and reality in their practice role? In addressing this question the study explores students’ expectations of their new role and the reality of their experience, and the learning that contributed to the development of the capacity to respond to this reality. Case study methodology rooted in a critical realist perspective allowed for the analysis of the complex, non-linear relationships between what students bring to learning, what they experience and what causes these experiences. Course documents provided the context of the planned curriculum. Data were collected from twelve participants through two series of three activity-based focus groups conducted at the beginning, middle and end of their 52-week full-time course, and semi-structured interviews carried out with six participants in the final 2 months of the same year. The longitudinal nature of data collection allowed for triangulation of data and an iterative approach to both data collection and analysis. A conceptual web of learning for practitioner resilience, drawing on resilience and transformative learning theory, emerged from initial literature review and preliminary data collection, providing a framework for data analysis. Significant differences emerged between student expectation and experience of the health visitor role. Participants experienced greater complexity than expected, a lack of continuity with clients, a predominant focus on high risk safeguarding, a lack of autonomy in the role, and a lack of opportunity for health promotion and ‘upstream’ public health work. For some the reality of the role was “shocking”, and the emotional impact of exposure to poverty and deprivation was widely identified. However, motivation to ‘make a difference’ was increased through this exposure, and commitment to the role grew over the year. An initial preoccupation with instrumental learning gave way to the emergence of communicative learning as being central to the development of practitioner resilience. The process of ‘surviving the course’ modelled behaviour that was seen to support resilience in practice. Learning from observation of others, and reflection, helped participants to identify positive and negative influences on resilience in themselves and in their teams. This study makes an original contribution to the field through the development of a conceptual framework combining resilience and transformative learning theory, and the application of this framework to learning for practitioner resilience. The conceptual web of learning, depicting the complex process of development of practitioner resilience, supports a social theory of resilience. The study supports the contention that resilience can be learnt through professional education, contributing new knowledge regarding how this has been achieved during a course leading to a professional qualification. The study adds to the small volume of research carried out with students and contributes new insights into the development of resilience as part of a process of transformative learning. Team dynamics and leadership are confirmed as being key to individual and team resilience, with positive outcomes emerging from practice contexts that are open, honest and trusting. 2 Blank 3 Table of Contents ABSTRACT .............................................................................................................. 2 LIST OF FIGURES ................................................................................................... 10 LIST OF TABLES .................................................................................................... 10 ACRONYMS AND DEFINITIONS ................................................................................. 11 ACKNOWLEDGEMENTS ........................................................................................... 14 DECLARATION ....................................................................................................... 15 1. INTRODUCTION .................................................................................................. 16 1.1 Influences from Professional Background ............................................................ 16 1.2 Context of the Health Visitor Role ........................................................................ 17 1.3 Original Contribution to the Field .......................................................................... 19 1.4 Why this is an Important Issue for Health Visitor Education ................................. 19 1.5 Influence of Sustainability and Employability Agenda ........................................... 20 1.6 The Reason for the Focus on Resilience .............................................................. 21 1.7 Inclusion of the Education Theory Perspective ..................................................... 22 1.8 Research Aims ..................................................................................................... 23 1.9 Research Question .............................................................................................. 23 1.9.1 Sub-questions ............................................................................................... 24 1.10 Insider Researcher Perspectives........................................................................ 24 1.11 Summary ........................................................................................................... 27 2. LITERATURE REVIEW ......................................................................................... 29 2.1 Introduction .......................................................................................................... 29 2.2 Search Strategy ................................................................................................... 30 2.3 Theoretical Underpinning for the Study ................................................................ 31 2.3.1 Relevance of Salutogenic Concepts .............................................................. 31 2.3.2 Resilience Theory ......................................................................................... 34 2.3.3 Transformative Learning Theory ................................................................... 40 2.4 Practitioner Resilience ......................................................................................... 45 2.4.1 Experience of Adversity in Professional Practice ........................................... 45 2.4.2 Defining and Understanding Practitioner Resilience ...................................... 46 2.4.3 Practitioner Resilience as a Process in Organisational Systems ................... 57 4 2.4.4 Education and the Promotion of Practitioner Resilience ............................... 60 2.5 Summary ............................................................................................................. 62 3. METHODOLOGY ................................................................................................. 64 3.1 Introduction ......................................................................................................... 64 3.2 Establishing an Ontological and Epistemological Position ................................... 64 3.3 Critical Realism ................................................................................................... 65 3.4 Consideration of Alternative Theoretical Frameworks .......................................... 69 3.5 Application of Critical Realism to the Study Design ............................................. 71 3.6 Critical Realism and Case Study Methodology .................................................... 71 3.6.1 Definition of a Case Study ............................................................................ 72 3.6.2 Case Study as a Methodology ...................................................................... 73 3.7 Research Methods .............................................................................................. 75