Health Visitor Workbook
Student:
Placement:
Mentor
1
Why have a work book?
It is an NMC requirement that you complete a set amount of clinical hours while
on placement. These hours must consist of practice based experience or
education relating to your area of practice. It is appropriate for you to partake
in theory work whilst on placement however you must be able to link this theory
to practice and have evidence of work undertaken while you are in your practice
area.
Because of the nature of the work in a Health visiting environment it is likely
that there will be time when your mentor will be doing activities that you will
not be enable to engage in. This is not an opportunity to go home as you will not
be able to achieve your clinical hours. The workbook has been provided in order
to give ideas and activities of experiences that you can take advantage of while
you are in the community setting and will provide you with evidence to show your
mentor in order to get your hours and competencies signed off.
Make the most of your Health visiting placement, never again in your training
are you going to get an opportunity to understand a community and the health
care within it as well as you can when with the HV.
2
INTRODUCTION
This placement will see you being based with a health visitor. Though in recent
years, HV’s can enter the profession via a direct route of academic education
and training, HV’s are predominantly registered nurses who have undergone
extensive further training and education in child health, health promotion and
taking forward public health initiatives within the community setting.
They work as part of an extensive multi-disciplinary primary health care team,
providing a flexible, dynamic and health focused service to individuals, families
and the wider community. They offer evidence based advice and provide
practical help with the aim of promoting good health and preventing illness. The
role also encompasses tackling the impact of social inequality on health, working
closely with at-risk or deprived individuals and families. Their unique position
within the primary health care team allows them to offer this service within the
family home and within locally run clinics.
During your placement you will be given the opportunity to spend time with
other health professionals that make up the primary health care team, who
practice from specialist and outpatient clinics located outside the main teaching
hospitals. This will allow you to gain a greater understanding of the role of
health promotion together with disease management and prevention from the
community's perspective.
It is hoped that you will thoroughly enjoy your placement with the health
visiting service. We trust that you embrace this opportunity to achieve
professional as well as personal objectives, remembering you can speak to your
mentor at any time to ensure you gain the most from your community placement.
Please note, there may be times when your mentor is not available, in this case
you will be allocated to another.
3
Health visitors: Specialist Community Public Health Nursing
Health visitors are public health nurses formally registered as Specialist
Community Public Health Nursing (SCPHN) (NMC 2004); their public health
remit and activities are identified as;
"Specialist community public health nursing aims to reduce health inequalities by
working with individuals, families, and communities promoting health, preventing
ill health and in the protection of health. The emphasis is on partnership
working that cuts across disciplinary, professional and organisational boundaries
that impact on organised social and political policy to influence the determinants
of health and promote the health of whole populations".
(Nursing and Midwifery Council 2004)
The Principles of Health Visiting
The work of the health visitor is categorised by 4 domains referred to as ‘The
Principles of Health Visiting’ (CETHV 1977) (Figure 1.1). These domains
encompass 10 key principles of public health practice (NMC 2004) aimed at
health promotion and health maintenance, the prevention of ill-health and the
reduction of risk factors that might undermine health. The health visitor
deploys these functions amongst the general population, with individuals,
families and the wider community. Rapport and collaboration are essential and
therefore intentional requirements of the health visitor’s work. They are
central not only to relationships with the client group but also with lay and
professional agencies whose purpose and expertise can be drawn upon in the
fullest pursuit of public health.
4
Figure 1.1: The Principles of Health Visiting
Health Visiting Domain
Public Health Principle
(Principle)
Search for health needs

Surveillance and assessment of the population’s
health and wellbeing
Stimulation of

Collaborative working for health and wellbeing
awareness of health

Working with and for communities to improve
needs
Influence on policies
health and wellbeing

affecting health
Developing health programmes and services and
reducing inequalities

Policy and strategy development and
implementation to improve health and wellbeing

Research and development to improve health
and wellbeing
Facilitation of health

enhancing activities
Promoting and protecting the population’s
health and wellbeing

Developing quality and risk management within
an evaluative culture

Strategic leadership for health and wellbeing

Ethically manage self, people and resources to
improve health and wellbeing
(Nursing and Midwifery Council 2004)
5
Health visitors work to raise awareness of the link between health and lifestyle
through information, advice and advocacy. Essential to this work is evidence
based knowledge not only of the interplay between health and wellbeing and
environmental forces but also of the idiosyncratic strengths, deficits and needs
of individuals and groups. Health visitors therefore undertake screening of
individuals and the general population. They are required to collate, analyse and
interpret information in order to respond appropriately to those at risk, in need
of support and services and to minimise harm.
Health Visitors work to a core programme which focus on 6 High impact areas

Transition to parenthood and the early weeks including early attachment
(see section on child development)

Maternal mental health (PND) (see section on child development).

Breastfeeding (initiation and duration)

Healthy weight (to include nutrition and physical activity)

Health and wellbeing at 2 years old (development of the child two year
old review (integrated review) and support to be ‘ready for school’)

Managing minor illness and reducing accidents (reducing hospital
attendance and admissions)

Identify and read the policies/reports (Summary) that support the
direction for health visiting and discuss the positive impact of this
work with your Health Visitor.
E.g Building a Brighter Future: The Early Years and Childcare Plan
Health of Children and Young People - Wales report
6
Schedule of Growing Skills
Schedule of Growing Skills (SGS) is an invaluable tool for professionals who need to
establish the developmental levels of children. The individual assessment can be used at
any time with children from birth to 5 years, enabling professionals to assess them as and
when appropriate and convenient.
SGS provides a reliable ‘snapshot’ of a child’s developmental level, including areas of
strength and potential delay. It examines nine key areas, all of which were developed from
Mary Sheridan’s STYCAR sequences:

Passive Posture

Active Posture

Loco-motor

Manipulative

Visual

Hearing and Language

Speech and Language

Interactive Social

Self-Care Social.
By using colourful and engaging toys like building blocks, a doll, pegs and shapes, the
assessment makes the tasks feel like playtime to the child, allowing professionals to
observe and assess reactions while the child ‘plays’. Each record form allows for up to four
assessments of any one child, providing a clear indication of progress over time. For those
that require further assessment, subsequent record forms can be utilised. A simple
scoring system highlights developmental areas where children might potentially have a
delay, indicating where referral might be necessary.
7
 Get involved in a developmental check!! How does the
Health Visitor Assess each of the above areas?
Ref: http://www.gl-assessment.co.uk/products/schedule-growing-skills
8
Community Profile
Get together with other students based with Generic and flying start Health
Visitors in your area. It may be appropriate for you to gather information in
pairs and then feed back as a group in order to develop a detailed Community
profile.
Definitions
Community
Neighbourhood
Why do a community Profile
A community profile is an attempt to describe a particular community or
neighbourhood. It uses a variety of different techniques to build up a picture of
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the community from a number of perspectives. The purpose for doing a
community profile is for the student nurse to gain a greater understanding of
what a community consists of, what services are required by that community and
why it has or has not been identified as needing extra funding for certain
projects. It should include a health needs assessment and explore socioeconomic factors and health issues to find what conditions are most prevalent
within the area and how they impact on the community.
Doing this profile early on in you placement will assist you in having a greater
understanding of what are the needs and drivers for your community. It will
also assist in orientating you to your new area.
The community profile should be address ethnicity, health, poverty, age, gender
of the population of an area taking into account the co-morbidities and common
conditions in that area and thinking about why this may be.
While collecting information for your Community profile, think carefully about:

Your professional appearance and how this will affect what information
people give you.

Your professional attitude

Introducing yourself

Communication skills

Informed consent of participants.

Being prepared

What are the relevant questions and why?
10
Suggestions for collecting your information
Census information
Census information normally provides the basic skeleton for any community
profile. Information is available on a wide range of key statistics, e.g. age,
ethnicity, employment and health. These are often collated to provide a figure
for other key figures such as a number of single parent households and a
number of pensioners living alone. Census figures are available from a
government website – www.statistics.gov.uk and local authorities often do useful
work on them, which is posted on their websites. Data is available at various
levels: national, regional, local authority and ward. It is also available at the
smaller scale of so-called output areas. This can be very useful for identifying,
for example, the nature of a particular estate, but it is less readily available and
requires considerably more work.
Other official statistics
The government collects a wide range of statistics and is increasingly making
this available at a neighbourhood level. The most useful are the deprivation
statistics these figures are available from a government website –
www.statistics.gov.uk. Maps may be available from CANDL or from the local
authority. Other sources for useful statistics are the police, housing offices
and the Health Authority (public health).
Doctor’s surgery
Speak to the practice manager and ask for the surgery statistics. I.e. how many
patients are from what age groups? What are the issues particular to that
area? What are the most prevalent diseases? Etc……
11
Using maps
Drawing up a map of your neighbourhood is generally an indispensable part of
doing a community profile. These can be produced in a variety of ways – hand
drawn, traced from large-scale maps available in libraries. Maps can then be
annotated with relevant local information such as key buildings, demographic
concentrations and anything else which seems significant. A good map makes an
excellent display, especially when used together with photographs.
Mapping techniques
Mapping in this sense is drawing together a list of the institutions and groups
which serve an area – from council offices to community groups. This can
provide a useful starting point for the interviewing discussed below.
Documentary research
It is always worth trying to find out what has been written about the area
previously. The local library is generally the best place to start. The council and
other organisations may also have various reports and profiles.
Observation
It is always worth walking the streets of your neighbourhood at different times
of the day and making a note of what you see. Use can also be made of
photographs.
Surveys
Surveys are perhaps what people first think of when wanting to understand the
community. They can have value, but are very labour-intensive, often requiring a
team of volunteers or students. Some limited door knocking can be a useful way
of getting a flavour of an area.
12
Snowball interviewing
A more useful way of talking to people face-to-face and putting some flesh on
your statistical bones can be to identify key people in the community – the local
policeman, local councillors, head teachers and health visitors, for example.
These professions should also be balanced with local residents such as chairs of
tenants associations and other locally active people. As you talk to people they
will often suggest others that it might be worth talking to – hence the term
snowball interview. You should check with your statistics, however, that you are
meeting a cross-section of the whole community and not missing out, for
example, a significant ethnic minority.
Making sense of the data
Although it might at first seem daunting, it is not that difficult to get together
a lot of data about an area. What really counts however is making sense of this
data and why it matters to you– comparing different bits of data and seeing how
they support or contradict each other. Getting a group together to reflect on
the data is a good idea.
13
Writing a Profile
Present the Profile in as you see fit. Maybe split it in to sections on
Environment, Health, Culture, Services etc. Think about who could use it and
when it may come in handy. Could your HV team use it to identify suitable
support groups for their families?
Making the Most of a Profile
Doing a community profile is a lot of work, so it is worth thinking hard about how
to make the most of it. Below are a few pointers:

Make sure you leave enough time to present it in an appropriate and
appealing way

Make the most of contacts gained through doing the profile ask if you
can spend time with them to find out more about their role?

How could you use this profile to enhance your community placement?

The best profiles are participatory, where people get involved in the
process and this follows through into greater understanding of the area
and the potential for taking action.
14
Health Promotion
Taking Action
Previously, in this work book you and your colleagues took part in developing a
community profile. Following on from that profile you should be able to identify
an issue that is pertinent to your area. This does not have to be a child based
issue. If you are an adult branch nurse choose an adult issue but think carefully
how it may affect the family, an unborn child or the health of children and
adults within the household.

Create a health promotion leaflet or poster that acknowledges this
problem and suggests solutions of coping mechanism for the family or
those involved in promoting health in your community.
15
Multi disciplinary Team working
Part of a Nurses role is to understand the roles of the wider multidisciplinary
team and how they fit into the patient journey. The best way to do this is by
spending time with these professionals getting to know their remit and role.

Arrange to spend a day with each member of the community
Primary Health Care team.

Following each visit construct a brief job description for each
member of the team and a discription of when they would be
involved with the family.

Please fill in the visiting contact list at the back of this work book
following your visit.
16
Case study
Find a patient that has been involved with the health service and talk to
them about their journey and which Health Professionals have been involved
so far. Write down your observations and thoughts.
17
Child Protection and Safe-guarding
Safeguarding children is a key priority for the Welsh Government and for local
agencies. We want to ensure that policies and practices across Wales, both at
national and local level, deliver the best outcomes for children in terms of
protecting them and safeguarding their welfare.
Following Lord Laming’s report into the death of Victoria Climbié a revised
framework for tackling child abuse through legislation, guidance and new
structures was established.
1. What are the recommendations that have come from this piece of
work?
2. How will this affect your actions as a qualified nurse?
18
Scenario 1
A mother starts to shout at a toddler in reception. She calls her a ‘stupid cow’
and gives her a hard slap.
1. Is this any of your business?
2. How would you respond?
Scenario 2
A 6 year old attends to have several teeth removed. He is very thin, his hands
feel cold, he is grubby, unkempt and uncommunicative. You remember
performing a number of extractions on his brother a few months ago.
How do you respond?
Scenario 3
A woman patient attends the surgery with 2 young children. She has facial
bruising and a missing tooth. She tells you that her partner did it but pleads
with you not to tell anyone.
How would you deal with this disclosure?
19
Domestic Abuse
Domestic abuse affects people from all walks of life, and from all cultural, social
and ethnic backgrounds, the well off as well as the poor. It affects those in
work and those out of work, the young and the old, in all parts of Wales. There
is significant overlap between the abuse of women and the abuse of children.
Where children live in a home where domestic abuse takes place there is a risk
of harm. To witness or to be aware of abuse and threats or violence is highly
detrimental to children of any age, including the very young. They could also be
at risk of, or subjected to, serious systematic abuse themselves. (Welsh
Assembly Government, Tackling Domestic Abuse: The All Wales National
Strategy 2005).
The Reality of Domestic Abuse:
Research indicates:
• Domestic abuse is the largest cause of morbidity in women aged 19-44,
greater than war, cancer and motor vehicle accidents ;( Flood-Page and Taylor
2003).
• Domestic abuse accounts for nearly one quarter of all recorded violent crime
in the UK; (Stanko)
• Throughout England and Wales one incident of domestic abuse is reported to
the police every minute ;(Ibid)
• Still, because domestic abuse is hidden it is under-reported and thus underrecorded ;( ibid)
20
Domestic Abuse Quiz
How many women experience domestic abuse in their lifetimes?
a. 1 in 100
b. 1 in 10
c. 1 in 4
How many men experience domestic abuse in their lifetimes?
a. 1 in 100 b.
b. 1 in 50
c. 1 in 9
In the UK, approximately how many women a year are killed by a current or
ex-partner?
a. 10
b. 100
c. 200
On average, how long does it take for a woman to leave an abusive
relationship?
a. 3 years
b. 7 years
c. 10 years
Are women more / less at risk in the month after leaving a violent
relationship?
More
Less
Domestic abuse usually decreases if a woman is pregnant?
True
False
21
How many times is a woman likely to experience physical violence before
reporting it?
a. 3 times
b. 23 times
c. 35 times
How many women live in a refuge in any one day?
a. 3,000
b. 5,000
c. 7,000
Approximately what percentage of children on the child protection register
in England and Wales, have lived with domestic abuse?
a. 45%
b. 65%
c. 85%
What percentage of people would report their neighbour if they witnessed
them kicking an animal?
a.25%
b. 50%
c. 75%
What percentage of people would report their neighbour if they witnessed
them kicking their partner?
a. 25%
b. 50%
c.75%
Answers at back of booklet
Source: http://www.idas.org.uk/uploads/File/resources/quiz.pdf
22
Immunisations
The World Health Organization (WHO) acknowledges that immunisation is one of the
most effective health investments, estimated at preventing between two and three
million deaths each year. See: World Health Organization: immunization. It is now
seen as the most cost effective of health care activities and is a recognised critical
element of preventive care around the world (Plotkin et al., 2008).
Nurses have a major role in advising and promoting immunisation, as well as
administering vaccinations not only within the childhood immunisation programme but
also those for adults, including travel vaccines and the annual influenza vaccination
campaign.
All vaccines given as part of the recommended immunisation programme in the UK, as
stipulated in the Department of Health’s immunisation against infectious disease Green
Book (DH, 2013), are provided free of charge through the NHS. The process for ensuring
the vaccines reach all those who need them is complex; it requires close liaison between
commissioners, health boards and providers, and health protection experts. An effective
immunisation service depends on staff being suitably skilled and qualified. This is
necessary to ensure vaccinations are given safely and vaccine wastage minimised. Also,
public and professional confidence is critical to the success of the national immunisation
programmes. Public confidence in vaccines is frequently challenged, particularly when there
are controversies about the safety and necessity of vaccines. It is therefore essential
that all professionals involved with immunisation be confident, knowledgeable and up to
date. They are then in a position to give clear, consistent, accurate advice, and explain the
benefits and risks of vaccines appropriately and effectively. Many staff, including some
from non-clinical backgrounds, are involved in the process of immunisation. This process
23
includes the administration of the vaccine, as well as supporting and advising parents or
patients on which vaccines are recommended and the reasons why.

Locate the current Childhood immunisation/ inoculation schedule.

Choose a vaccine and list the uses, side effects, contra indications

Find a news reports on situations when immunisations have been brought in
to question?

What were the implications?
24

Observe your HV mentor gaining informed consent from a parent regarding
immunisation of their child. What skills were used?

Which inoculations are not routinely part of the schedule but are offered
in certain circumstances?
25
Feeding
Midwives, health visitors and trained volunteers or peer supporters can all offer
information and practical help with breastfeeding. Peer supporters are mothers who
have breastfed their own babies and have had special training to help them support
other mothers. Talk to your Midwife or health visitor about the help that is available
in your area.

Collect information on Breastfeeding and weaning

What are the World Health Organisation recommendations for Breast feeding?

What does breast milk contain that makes it so good?

What are the benefits of breastfeeding?

How can you promote fathers bonding with Baby if being breastfed?

What are the current recommendations for Weaning?
26
The Equality Bill
Equality legislation offers mothers stronger protection when
breastfeeding. Equality legislation will make it clear that it is unlawful to
force breastfeeding mothers and their babies out of places like coffee
shops, public galleries and restaurants. For further information go to
www.equalityni.org

What are the common problems with Breast feeding and suggest some solutions
for these problems?

Observe the way your health visitor gives new mums information and support
with Breast feeding. Below is a space for you to reflect on this experience.
Once you have gathered this information ask your HV if they feel comfortable
with you giving advice to a new mum?
Reflection on Breast feeding advice
27
Medicines and breastfeeding
Many illnesses, including depression can be treated while breastfeeding without
harming the baby. Small amounts of whatever medicines taken will pass through
the breast milk to the baby. Medicines that can be taken while breastfeeding
include:

most antibiotics

common painkillers such as paracetamol and ibuprofen (but not aspirin)

hay fever medicines such as Clarityn and Zirtek

cough medicines (provided they don’t make you drowsy)

Asthma inhalers and normal doses of vitamins.

some methods of contraception but not all.
It’s fine to have dental treatments, local anaesthetics, injections (including
mumps, measles and rubella (MMR), tetanus and flu injections) and most types
of operations. You can also dye, perm or straighten your hair, use fake tan and
wear false nails.
Medicines for minor ailments when breastfeeding
• Make sure the medicine is safe to take when breastfeeding.
• Watch baby for side effects such as poor feeding, drowsiness and irritability.
For more information go to www.breastfeedingnetwork.org.uk/
drugline.html, or call the Drugs in Breast milk Helpline on 0844 412 4665.

List some drugs that should not be taken during pregnancy and breast feeding.
28
Mental health and Health Visiting
During the first week after childbirth, many women get the ‘Baby blues’.
Symptoms can include feeling emotional and irrational, bursting into tears for no
apparent reason, feeling irritable or touchy or anxious and depressed. These
symptoms are probably caused by the sudden hormonal and chemical changes
that happen after childbirth. They are perfectly normal and usually last for only
a few days.
Postnatal depression
Sometimes, though, the baby blues just will not go away. Postnatal depression is
thought to affect around 1 in 10 women (and up to 4 in 10 teenage mothers).
Although it’s very common, many women suffer in silence. Postnatal depression
usually occurs two to eight weeks after the birth, although it can happen at any
time up to a year after your baby is born. Some of the symptoms, such as
tiredness, irritability or poor appetite, are normal when you have just had a
baby, but these are usually mild and don’t stop you leading a normal life. With
postnatal depression, you may feel increasingly depressed and despondent, and
looking after yourself or your baby may become too much.

What are the main signs of Post natal depression?

What advice is given to women suffering with Post natal depression?
29
Puerperal psychosis
This is an extremely rare condition, affecting only one or two mothers in every
thousand and is more common in mums who have severe mental illness or have a
past history of severe mental illness, or if there is a family history of prenatal
mental illness. Puerperal psychosis is a serious psychiatric illness, requiring
urgent medical or hospital treatment. Usually, other people will notice the
mother acting strangely. Women suffering from puerperal psychosis should be
admitted to a specialist mother and baby unit so they can be treated without
being separated from their baby. Most women make a complete recovery,
although this may take a few weeks or months.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) can occur on its own or alongside
postnatal depression. It’s not clear why women develop PTSD, but there may be
a link between the condition and feeling ‘out of control’ and/or being very
frightened during the birth. Sometimes women worry that they might die, or
that their baby might die.
The symptoms include:
• Flashbacks
• Nightmares
• Panic attacks
• feeling emotionally ‘numb’
• sleeping problems
• feeling irritable or angry, and/or
• Irrational behaviour.
The Association for Post-Natal Illness and www.netmums.com
30

What communication skills do you feel would be important when
dealing with mums experiencing these problems?
31
Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy (DDP) was originally developed by
psychologist Daniel Hughes as an intervention for children whose emotional
distress resulted from earlier separation from familiar caregivers. It is a
treatment approach for families that have children with symptoms of emotional
disorders, including complex trauma and disorders of attachment. These
“disorders” are often exhibited in extremely challenging behaviours, usually the
result of a “fight, flight or freeze” reaction to overwhelming levels of anxiety
and stress.
DDP principally involves creating a "playful, accepting, curious, and empathic
(PACE)" environment in which the therapist attunes to the child’s "subjective
experiences" and reflects this back to the child by means of eye contact, facial
expressions, gestures and movements, voice tone, timing and touch, "coregulates" emotional affect and "co-constructs" an alternative autobiographical
narrative with the child.
DDP therapy also makes use of cognitive and behavioural strategies to achieve
therapeutic goals. As explained in the paragraph above, the extremely
challenging behaviours exhibited as a result of traumatic early experiences are
usually experienced by the child at an emotional rather than cognitive level. As
such, the child is unlikely to be able to adequately process these difficulties at
a purely cognitive or rational level, hence the benefit of an approach such as
DDP.
DDP is effective because of its reliance on and development of a shared
understanding, experience and “emotion” between therapist and child, caregiver
and child, and therapist and caregiver. The process of maintaining this shared
32
experience and emotion allows for mutual or “dyadic” regulation of emotion
between child and therapist so that the child feels a sense of safety and
security and can therefore safely experience the feelings associated with past
traumas, allowing for integration of these experiences rather than dissociation
of the feeling and memory.
This training is currently being rolled out to health Visitors in Wales. Find a health
visitor that has had this training and if possible speak to them about the benefits of
DDP.
 Explain the terms below in relation to DDP

Emotional Regulation/Proximity

Reflective Functioning

Trans-generational responses.

Attunement
33
Suggested Reading
 Hall, D. M., & Elliman, D. (Eds.). (2006). Health for all children: revised
fourth edition. Oxford University Press.
Hall, D., Cole, T., Elliman, D., Gibson, P., Logan, S., & Wales, J. (2008). Growth
monitoring. Archives of disease in childhood, 93(8), 717-718.
Becker-Weidman, A., & Hughes, D., (2008) (Manuscript accepted for
publication). “Dyadic Developmental Psychotherapy: An evidence based
treatment for Children with complex trauma and disorders of attachment.”
Briere, J., & Scott, C., (2006), Principles of Trauma Therapy, Thousand Oaks,
CA: Sage Publications.
Hughes, D., (2006), Building the Bonds of Attachment, 2nd.Edition, NY: Rowman
& Littlefield.
Hughes, D., (2007), Attachment-Focused Family Therapy, NY: Norton.
Perry, B., & Szalavitz, M., (2006), The Boy who was raised as a dog, NY: Basic
Books.
Quiz answers
Answers
C
C
B
B
More
False
C
C
B
C
B
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Contact List
While you are on placement you will meet other professionals that will be willing to
share their time and knowledge with you. Please complete the list below and pass it
to your mentor so that others can make contact with these professionals.
Name
Role
Address
Contact
Comments
number
35