Working with vulnerable families: a health visiting perspective

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foumal of Advanc ed Nursing 1996,23,912-918

Working with vulnerab le fam ilies a hea lth

visiting perspective

Jan e V A pp le to n BA{Hons) MSc RGN

RHV

PGCEA

Senior

Lecturer

m Nursing Division of Adult N ursing and Health Sciences Hillside

House The University of

Hertfordshire

Hatfield Campus

College

Lane Hatfield

Hertfordshire LIO

9AB England

Accepted for publication

1

June 1995

APPLETON J V (1996) Journal of Advanced Nursing 1 9 9 6 , 2 3 , 9 1 2 - 9 1 8

Working with vulnerable families a health visiting perspective

The aim of this p aper is to describe p art of the findings of a research stud y

wh ich explored th e health visitor's role in identifying and w orking with

vuln erable families in relation to child protection One objective of the stu dy

was to describe and analyse the work whic h health visitors und ertake w ith

vulnerable families aimed at preventing crisis, lU-health and child abuse Thi

paper outlines this aspect of the research and looks specifically at health

visitors' perceptions of their work and intervention s with vu lnerable families

and child ren Health visitors working m an inner city area and a suburban are

were sampled an d pilot work was undertaken in a third subu rban area Stage

one involved a postal survey of 102 health visitors, in w hich a response rate o

58 (57 ) was obtained Stage two involved 12 ln-dep th interviews with healt

visitors One major finding of this stud y highlighte d the fact that the health

visitor's role when w orking with v ulnerable families appears to be one of

diversity and conflict In the light of the cu rrent Nation al Health Service refor

it seems of paramou nt im portance that health visitors illustrate to others, both

managers and other health/social service professionals alike, the im portant

function of their work with these vulnerable groups This is essential to ensu r

that health visitors' work with v ulnerable families in relation to cbild p rotecti

IS

unde rstood and valued and that the needs of vulnerable families con tinue

be identified This pape r contributes to the knowledge base of health visiting

and raises some important issues for professional health visiting practice

TM TP nn TT PT Tri M visitor child protection specialists and/or health visi

manage rs (Health Visitors' Asso ciation 1994a, Cassidy

Recent comm entary reveals m any co ncern s about th e Day 1994, Laurent 1994) A ll these issues clearly ra

future of health v isitmg practice an d the general und er- major conce rns about the provisio n of services for vuln

funding of community nursing services m the United able groups and questions ultimately ans e about wheth

Kingdom (Sadler 1994) Press repor ts have highlighte d the the um versally available health visitmg service is imd

drop m num bers of students seconded to comm imity nurse threat

education courses as trusts implement funding cu ts, and For the purposes of this research paper vulnerable fam

the resulting problem s wh ich ensue from this (Cole 1994) les are identified as those families 'wh ere there are sev

A recent national survey of health visitors has drawn problems in the family giving cause for concern, but whe

attention to problems of health visitors working unde r sig- there is not enough evidence of actual or potential ha

nificant levels of stress, often with large caseloads and to the chil d/ch ildre n for social services to becom e direc

invariably with little access to clinical sup port from health invo lved' (Taylor James 1987) Sm ce hea lth visitors



Working with vulnerable families

one of the main professional groups who regularly have

contact with the preschool child and his/her parents, they

have a potentially ma]or role to play m lden tifyu^ vulner-

able families and preventing child abuse (Barker Percy

1991) In term s of child p rotectio n, the role of the h ealth

visitor IS to 'ob serve, as sess, record and refer' (Health

Visitors' As sociation 1994b) In terms of prev ention , health

visitors are well placed to identify vulnerable families so

that mcreased support cam be offered to these families and

preventive work conducted

However, this tj^e of preventive work can often go

unrecognized and be undervalued and practitioners have

long recognized the difficulties inherent in measuring pre-

ventive aspects of the health visiting service because of

the long-term natu re of much of the work (Campbell et al

1995,

Hall 1996) This pap er will describe one aspect of

the findings of a study which was undertaken to explore

health visitors' work with vulnerable families in relation

to child protection It will concentrate on health visitors'

perceptions of their role with vulnerable families and

illustrates the diversity and confhct which the role

encompasses

RESEARCH DESIGN

This broadly qualitative study was undertaken in two

stages Health visitors working in an inn er city area and a

suburban area were targeted and pilot work was under-

taken in a third subu rban area Stage one involved a postal

survey of 102 health visitors, m which a response rate of

58 (57 ) was obtamed Stage two mvolved 12 ln-depth

interviews with h ealth visitors Stage one of the study

enabled the researcher to gain an understandmg of health

visitors' work with vulnerable families at field level, by

surveymg a number of health visitors working m con-

trastmg areas It was plan ned tha t data gained from the

postal survey would inform the mterview schedule used

in stage two and provide an mterview sample

Methodological issues relating to this study have been

documented in greater detail m an earlier paper

(Appleton 1994)

FINDINGS AND ANALYSIS

A marked feature of the analysis of this study is that the

health visito r's role is one of diversity an d conflict Thes e

two separate concepts link together and present a picture

of health visitors trying to function withm the constraints

of large caseloads, limited tune and dwindlmg resources

In their work with families with young children the key

aim of the health visitor is to identify those children m

need (Children Act 1989) and to work with families to

reduce stress and enable families to cop>e What is clear

from the findings of this research study is the fact that

health visitors are spendu^ a lot of their worktime

Time Resoufx;e

Being realistic

Figure

The health visitor's role with vulnerab le families role

diversity and conflict

working with vulnerable groups to prevent deterioration

m health and family crises from occumng, however, a lot

of this work is going unrecognized by managers and other

professionals

The analysis of this research study indicates that health

visitors have four key yet diverse roles to play with vulner-

able families (see Figure 1) These are

1 identification of vulnerability,

2 support agent,

3 referral agent, and

4 reluctant monitor

Quite possibly role diversity may well be a direct

response to the comp lexity of the concept of vulnerability

(Appleton 1994) Evidently whichever role the health visi-

tor IS pursuing, she/he must be realistic m the pursuit of

goals These roles and the confiicts whic h health visitors

seem to be facing will be discussed m this paper m con-

junction with the principles of health visiting (Council for

the Education and Training of Health Visitors 1977)

Assessm entAdentification of vulnerab le families

and chi ldren

The assessment of vulnerable families was discussed m

detail in an earlier pape r (Appleton 1995) However, the

findmgs suggest that the assessment of vuhierabihty is

a complex and multifactonal process and has to take

acco unt of the fact that the co ncep t itself is ambiguous and

transient

It's so multifactonal, there's so many things you have to base it

all on

(HV54)

In the three areas utilized m this stud y different official



/

V Appleton

cntena/guidehnes were available to health visitors to

assist them m the identification of vulnerable famihes

Furthermore, despite the presence of official health

authority/trust guidelines, a large proportion of the h ealth

visitors admitted to using their own professional judge-

ments m the assessment of vulnerable families This cer-

tainly contrasts with muc h of the previous literature wh ere

the majority of research has focused on health visitors' use

of checklists/screening tools m making a ssessments of vul-

nerable families as opposed to an examination of the

health visitor's own assessment process (Woods 1981, Fort

1986, Hills et al 1990, Taylor 1 991 , Walker & Crapper

1995) (This IS des pite the fact that man y chec klists an d

screening tools are highly dubious in their validity )

In using their own clinical judgements to assess vulner-

ability, the analysis of the data m the study mdicated the

presence of six key interrelating factors w hich hea lth visi-

tors use in the assessment process in identifying vulner-

able families The se are (a) know ledge of families/the

community, (b) reflection-on-action (Schon 1987), (c) situ-

ations/famihes which cause the health visitor increased

anxiety/concern, (d) the health visitor's own knowledge

base and expenence, (e) the past history of a family, and

(f) gut feelings /instinct (reflection-in-action (Schon 1983))

Health visitors have a very important role to play in case-

finding and this role was discussed by virtually all ques-

tionnaire respon den ts and interviewees Dmgw all et

al

(1983) and Taylor Tilley (1990) have discussed m depth

the health visitor's role m case-findmg and the pro-

fessional rivalnes which can exist between health visitors

and social workers However, vnth m this research study a

number of health visitors were obviously very concerned

about the ethical dilemmas associated with the identifi-

cation of vulnerable families and the lack of resources to

offer these families

I also think it's quite frustrating because having identified a vul-

nerable child or children or famihes in need of support — when

there's very httle you can offer them it's raising people's

expectations and I think that's very unfair

(HV39)

In order to fulfil the activity 'searching for health needs'

health visitors must have the opportunity to search for,

identify and assess vulnerable groups (Dmgwall &

Robinson 1993) It wou ld app ear that with over half of the

interviewees commenting on the effects of a reduction m

the home visiting service, it was therefore seen as likely

that some vulnerable families/children w ould not be ident-

ified Indee d Buttigieg (1995, cited in

HVA Association

News

1995) has recently stressed that targeting health visit-

mg services only at famihes with identified needs could

put vulnerable children in danger

The recent re-exammation of the principles of health

visiting has highlighted the need to stimulate awareness

of health n eeds , not only at the client level but also at the

level of health service managers and at a national le

amongst policy-makers (Tw inn & Cowley 1992) In

latter cases the pnnciple is being applied so that tho

who are responsible for providing services are aware

unmet needs in their areas Evidently this aspect of

pn nc iple is very important to this research which revea

that health visitors were finding unmet needs when th

highlighted the identification of 'other' vulnerable fam

ies In fact, eight (67 ) of the mterv iew ees talked ab

identifying 'other' vulnerable families, that is, those fam

ies which th e health v isitors identify as being vulnerab

but who do not fall into the health auth on ty/tru st's crite

of vulnerability This is clearly further evidence whi

indicates the lack of validity of the checklists/guidelm

yet It may also represent the non-legitimation of

concept of vulnerability

For many health visitors confiicts exist around t

differences between professional judgements and offic

guidelines Control by managers is an appa rent issue

that it IS likely that field health visitors and health auth

les/trusts have different agendas for identifying vuln

ability The appa rent non-legitimation of the concept

vulnerability seems to refiect its ambiguity and 'invi

bility ' Cowley (1991) has previo usly identified the k

issues for establishing legitimacy of a con cept Evide n

an ambiguous c oncep t such as vulnerabilify is unlikely

have much legitimacy m the current National Hea

Service (NHS) business climate where recent legislati

does not allow hidden needs to be readily identified a

does not easily accommodate ambiguous health nee

(Twmn & Cowley 1992) Cynically, it appears easier

Ignore these ambiguous needs within the purchaser/pr

vider ideology

In fact It IS extremely significant that health visitors

identifying these 'other' vulnerable families an d m anage

have to be aware of the professional conflicts that this c

cause health visitors This research supports Tw inn

Cowley (1992) who state that 'm many areas there is

clear route for health visitors to pass on information abo

the health needs they become aware o f The research

argues that health visitors must impress on managers t

identification of unmet needs and the importance

climcal judgements in the assessment process

Support agent

Offering vulnerable families support was an area discusse

by 40 (69 ) of the questionn aire respond ents and 1

(83 ) of the interviewees and is obviously viewed b

health visitors as a very important part of their work an

clearly takes up a large prop ortion of their time In th

study support included such actions as offenng an acces

ible health visiting service, boosting parenting skills an

parents' esteem, encouragement, advocacy, providin

advice for clients and working m partne rship w ith client



Working with vulnerable fam ilies

I feel that the health visitor should make every effort to support

these families through the difficult penod as much as is possible

and through continuous assessment, helping them to meet the

needs as they arise and aiming at getting these famihes to look at

their situation and become self sufficient m dealing with it, and

this S how I base my work with vulnerable families

(HV6)

Working openly w ith families and being very clear about

the health visitor's role is very important if the support

which the health visitor can offer is gomg to be effective

Empowerment and enabling families to make mformed

decisions was an area discussed by over half the health

visitors, yet health visitors seemed realistic in their views

that this was sometimes hard to achieve Interesbngly over

half the sample stated that the only home visiting they

completed was for new births, developmental checks and

extra inp ut for vuln erable families All other contacts w ith

children and families were made in clinics

The amount and quality of support which a health visi-

tor can offer a vulnerable family is likely to decrease as

caseloads increase in size There was a consensu s of opi-

nion that undoubtedly many vulnerable children/families

were being missed, m that they w ere not being identified

in the first place an d clearly if the am oun t of hom e visiting

S

cut back further th en the problem wou ld be exacerbated

Home visitmg was viewed by the health visitors as an

important factor m identifying vulnerab ility Man y hea lth

visitors felt dissatisfied with the service they were able to

offer £ind the researcher noted that 11 (92%) of the inter-

view sample appeared demoralized

I feel very dissatisfied with the service I give because I feel that

well over a third of my time is spen t on clencal, it's a very vulner-

able area, for an awful lot of my families I now do a new birth

visit and then see people m clinic so I feel there's no way that

I give anything like the service to the families you know, I've said

that about supporting but it's very limited

(HV42)

This health visitor felt that in most cases all she was

able to do was to identify the fact that families are vu lner-

able and

sometimes dole out leaflets and things about what's normal devel-

opment but lots of these families need lots and lots of inpu t and

you feel quite helpless

(HV42)

Interestingly only nine (16%) of the questionnaire

respondents talked about having a health promotion or

educative role with vulnerable famihes, this may reflect

the lack of time or the fact that it is impossible to discuss

health issues w hen feunilies have mu ltiple social problems

which nee d to be addressed Realistically health visitors

find It inappro priate to address h ealth enh ancing activities

when vulnerable famihes are often facing multiple social

and other problems

It seems of paramount importance to find ways of meas-

uring and evaluating health visitors' work with v ulnerable

families, yet interviewees' views about the feasibility of

this were mixed

eferral agent

In pursuit of the fourth principle of health visiting, 'the

facilitation of health enhancing activities' (Council for the

Education and Training of Health Visitors 1977), health

visitors have traditionally acted as a resource for clients,

offering accurate and relevant information about health

issues, as well as providing a major supportive service,

empowermg parents and boosting their self-esteem and

confidence levels Tw mn & Cowley (1992) highlight the

many circumstances which inhibit health enhancing

beha viour and they state there is 'a clear need for facili-

tatio n to focus on changing the circum stances or situation

m which people live, rather than concentrating solely on

individual behaviour and knowledge' A key assumption

has been that adequate resources will be available for

hea lth visitors to refer clients on to However a striking

feature of this stud y is that althou gh 40 (80%) of the ques-

tionnaire respondents and 10 (83%) of the interviewees

saw their role as being a referral agent and facilitator/mobi-

lizer of other services and resources, in reality resources

for vulnerable families/children are just not available

I mean the problem is that the resources are not really there

(HVIOJ

Health visitors continually described situations of

unm et needs Where resources are available, many he alth

visitors were extremely concerned that m future GP fund-

holding purchasers may not be willing to make referrals

and buy services for vulnerable clients because of the

expense involved This is obviously a very worrying situ-

ation and likely to be exacerbated because of the neb ulous

nature of vulnerability, as well as its non-legitimation m

the present NHS Several health visitors discussed the

importance of documentmg ineffective referreds and

reporting to managers the existence of unm et n eeds

Lack of resources c ontinu es to result m the hea lth visitor

being the sole support agent for the majority of vulnerable

families Table 1 illustrates health v isitors' perception s of

the resou rces available for vulne rable families Althoug h

it IS possible that the que sbon naire respo ndents did n ot

identify all resources available to vulnerable families m

their area, it is likely that health visitors mentioned those

resources most frequently available With the exce ption of

family centres all other resources appear to be available

on a limited basis Differences m he alth visitors ' perce p-

tions of what services are available even in one area are

evident and are likely to anse from the fact that health

© 1996 Blackwell Science Ltd,

Journal of Advanced Nursing

23, 912-918

9 1 5



/ V Appleton

Xflhle Rftfiourcfis av ail ab le

for vulnerable families as

reported by 58 health visitors

Family centres

Community psychiatnc nurse

Local authority playgroups/day

nursenes

Portage

Family aid workers/home help

Counsellors

Special needs team/services for

handicapped children

Homestart

Child guidance/child and family

centre

Local authority sponsored

childmmder/playgroup place

Health visitor child protection

specialist

Speech therapist

Voluntary agencies

Interpreters/link workers

Miscellaneous

Resources

available

(n = 58)

30

5

19

9

14

12

1 1

18

18

6

2

4

9

1

2 1

Available

( )

51 72

8 62

32 76

15 52

24 14

20 69

18 97

31 03

31 03

10 34

3 45

6 9

15 52

1 72

36 21

Resources

not

mentioned

(n = 58)

28

53

39

4 9

4 4

4 6

4 7

4 0

4 0

52

56

54

4 9

57

37

N ot

menU

( )

48 28

9 1 3 8

67 24

84 48

75 86

79 31

8 1 0 3

68 97

68 97

89 66

96 55

93 1

84 48

98 28

63 79

authorities/tmsts cover large geographical areas,

and

a

resource which is available at one end of the borough, may

not be available to families living in a different part

Many health visitors talked about the need to docum ent

ineffective referrals, firstly m order to identify to manage-

ment that unmet needs are still there and secondly to do

'the protecting y our back bit' (HV 56) Nettleton (1991)

identified health visitors 'covering their backs' in his study

and remarked that it was 'acknowledged as a reality with

some regret as a retrogressive defence agamst the stresses

of pressu re of wo rk' (Nettleton 1991) Worrymgly, at the

other end of the scale one health visitor did not bother

making referrals to social services m the majonty of cases

because of the likelihood of them not taking any action

and the time involved m m aking referrals To a certain

extent th e hea lth visitor ap{>ears to be slip ping into danger-

ous practice and realizes this

and things that I would have rung social services about and

wanted help and intervention w ith maybe 6 or 7 years ago now I

might not necessanly even inform social services because I think

wha t are they going to do about i f But in a sense then I wo nder

IS that dangerous practice''

(HV42)

The referral agency which health visitors continually

complamed about was social services and this supports

earlier resea rch findmgs (Taylor & TiUey 1989, Gilardi

1991, Nettleton 1991) Health visitors were clearly very

concerned about the lack of social work input with so

vulnerable families

and sometimes you can get stuck — you can't get any h

People don't recognize what you see Because social services

being pressured all the time, they can't cope So they don 't w

to see the needs that we're finding out in other families

(HV

Quite clearly social workers are only involved m mi

mal preventative w ork and will generally only get involv

with v ulnerable families once a crisis/abuse ha s occurr

This supports the findmgs of Taylor James (1987) w

found there was a failure on the part of social services

pick up cases that should have been their responsibili

Thus a very common feature is that the health visi

appears to be the sole professional supporting vulnera

families Many health visitors appe ar angry and frustra

over the lack of social services inp ut w ith families, parti

larly in those areas of 'high concern' often described

'grey areas' All interviewees w ith the exception of o

complained of low morale and the fact that other p

fessionals give hea lth visitors little creden ce T

researcher found the health visitors generedly stressed a

frustrated This was clearly a group of professionals w

were struggling to even begm to facilitate the pnnciples

health visitmg due to the effects of very hmited resourc

As health visitors are often the sole profession

mvolved with vulnerable femuhes many seemed to be



orking with vulnerable families

confhct with their own roles as health promoters, several

even appeared to he taking on a social work role, albeit

reluctantly They are evidently trymg to bndg e the gap of

lack of resou rces, as Potryku s (1990), Nettleton (1991) and

De La Cuesta (1992) have previously identified, and this

creates enormous role conflicts and reuses many impli-

cations for the man agement and practice of health visitmg

Many social services departments are overstretched and

under great stresses following the changes of the

Commumty Care Act (Department of Health 1990) and

increasing demands of The Children Act (Department of

Health 1989) Thu s health visitors find they cannot con-

centrate on health issue s with vulne rable families because

of the multiple social problems that many families are

faced with Wh en the health visitor is the sole professional

offering input to vulnerable families, inevitably bound-

aries will merge

I mean I think anything you do to give a family extra resources,

copmg mechanisms or whatever you're working towards child

protection And tha t's why you know i t's very difficult to say to

make a dividing line as to when health visiting stops and when

social work should continue, because I think at the moment I

thmk health visitors go over into social work and prevention of

child abuse hugely

(HVIO)

This appears to substantiate the findings of

De

La Cuesta

(1992) who descnbes health visitors taking on 'fange

activities' (De La Cuesta 1992) She desc ribes finnge work

as 'when health visitors are confronted with gaps in

resources or services they attempt to respond to them by

filling or bridging them and this is the essence of fringe

work' (De La Cuesta 1992) The evide nce m this s tudy

describes health visitors trying to bridge the gap of lack of

resources by doing others' work Interestmgly this also

supports the findings of Potrykus (1990) who found that

health visitors are often called to 'step mto the breach left

by social worke rs simp ly not the re' N ettleton (1991)

terms it 'assuming responsibilities for others' and also

descnbes health visitors being forced mto a social work

role wh ich he terms 'social work by proxy' Clearly if

health visitors are bndging the gap between health visitmg

and social work it creates enormous role conflicts, as

Taylor Tilley (1989) have previously identified

In this stud y ma ny of the he alth visitors believed strongly

that without the health visiting profession the numbers on

the Child Protection Register would mcrease dramatically

A number of health visitors also believed that families con-

tmue to prefer mput from health visitors rather than social

workers, this hmts at the professional nvalry identified by

Dmgwall et al (1983) and Taylor Tilley (1990)

A lot of famihes are apprehensive about making contact with

social services but will contact health visitors for advice

(HV9)

All

Some of them

None of them

Not sure

Not applicable

1

35

20

1

1

Table Social worker allocation to vulnerable family

No of health visitors Health visitors

1 72

60 34

34 49

1 72

1 72

The interview data indicated that for all the health visi-

tors the majonfy of their wo rktime is spen t with vu lnerab le

families For this group of hea lth visitors, social workers

had m inimal inpu t with vulnerable families Table 2 illus-

trates social worker allocation to questionnaire respon-

dents' vulnerable famihes/children as reported by the

health visitors participating in the study

Reluctant monitoring role

The diversity of the health visitor's role and the ensuing

conflicts are again illustrated m the health visitor's reluc-

tant momtonng role, which has previously been high-

lighted in the hterature (Mayall Foster 1989) Of the 50

questionnaire respondents who commented on the health

visitor's role with vu lnerab le famihes, 22 (44 ) talked

about havmg a momtonng role of families m conjunction

with the ir suppo rtive role Clearly for the majority of

health visitors they played a 'reluctant momtonng role'

This may be because health visitors are being forced to fill

the gap in service which quite clearly social workers are

not providing

C O N C L U S I O N S

This research hats taken a step forward in illustrating the

important role which health visitors play in working with

vulnerable families in relation to child protection

Unfortunately the importance of health visitors' preven-

tive work m this area is often unacknow ledged and is cer-

tainly overshadowed hy an emphasis on routine child

health surveillance and other quantifiable asjjects of the

service There wo uld ap pear to be a false sissumption tha t

much of the work which indeed health visitors are under-

taking with v ulnerable families is bemg a ttnbuted to social

service departments This is an issue wh ich rapidly need s

to be recogmzed and addressed by the government and by

health/social service departments

This paper has bnefly descnbed the development of a

'health visiting assessment process', which illustrates the

key steps m health visitors' decision making Professional

judgements have been shown to be extremely important

m assessing vulnerability, despite the emphasis still



/ V ppleton

placed on checklists/guidelines, and this is clearly an area

of health visitmg which needs further investigation The

study suggests that health visitors have four key inter-

related yet quite diverse roles to play with vulnerable fam-

ilies identification of vulnerability, support agent, referral

agent, and a reluctant monitoring role The analysis illus-

trates that the health visitor's role m dealing with vulner-

ability

IS

one of diversity and conflict It has been suggested

that role diversity may be a direct response to tbe com-

plexity of vulnerability Role conflict appears to result

from the lack of other resources for vulnerable groups

Finally the research has stressed that health visiting is

currently facing considerable role conflict and control It

IS essential that if health visitors are to maintain pro-

fessional goals and credibility, they must not fall into the

trap of being viewed as a 'Jack of all trades' Health visitors

must not be lured mto providing others' services simply

because they do not exist This has tremendous impli-

cations for practice and is an issue which needs to be

addressed by both health and social services

Acknowledgements

Many thanks to my supervisor Dr Sarah Cowley,

Department of Nursing Studies, King's College, University

of London, for her guidance with this study, and to the

health visitors who participated m the study Thank you

also to the Smith and Nephew Foundation for their finan-

cial support dunng this research

References

Appleton

J

V (1994)

The

concept

of

vulnerability

m

relation

to

child protection health visitors' perceptions foumal of

Advanced Nursing 20, 1132-1140

Appleton

J V

(1995) Health visitor assessment of vulnerability

Health Visitor 68(6), 228-231

Barker

W

Percy P (1991J Health visiting und er scru tiny Health

Visitor 64(1J, 12-15

Campbell F , Cowley S Buttigieg M (1995) Weights and

Measures Outcomes and Evaluation in Health V isiting Health

Visitors' Association, London

Cassiday J Day M (1994J Breaking point Nursing Times

9O(47J, 20-21

Council for the Education and Training of Health Visitors (1977)

An Investigation into the Pnnciples of Health Visitmg

CETHV, London

Cole A (1994) Staffing cau se for concern Health Visitor 67(10),

332-333

Cowley S (1991) A grounded theory of situation and process in

health visiting Unpublished PhD thesis, Brighton

Polytechnic, Brighton

De La Cuesta C (1992) Marketing the service, basic social progress

in health visihng Unpuhhshed PhD thesis. University of

Liverpool, Liverpool

Department of Health (1989) An

Introduction to the Children

1989

HMSO, London

Departm ent of Health (1990)

NHS and Commumty Care Act,

HMSO, London

Dmgwall R Robinson K M (1993) Policing the family? H

visiting and public surveillance of private behavior hi

He

and Wellbemg Reader (Battle A

,

Gott

M ,

Jones

L

Side

eds), Macmillan, Basingstoke,

pp

165-173

Dingwall

R

, Eekelaar

J

& Murray

T

(1983)

The

Protectio

Children State Intervention and Family Life Basil Blackw

Oxford

Fort A (1986) The spider's w eb The Health Service foumal

558-559

Gilardi J (1991) Child protection in a South London dist

Health Visitor 64(7), 225-227

Hall D M

B

(ed ) (1996) Health for all Children Report o

Third Joint Working Party on Child Health Surveillance

edn OUP, Oxford

Hills A , Parson S A Turner B (1980) Health visiting prion

Nursing Times Community Outlook) 9(10j, 295-299

Health Visitors' Association (1994a)

Cause

for

Concern

Analysis of Staffing Levels and Training Plans in Health Visi

and School Nursing HVA, Lon don

Health Visitors' Association (1994b)

Protecting

the

Child

—

HVA Cuide to Practice

and

Procedures

HVA, London

HVA Association News

(1995) Children Universal service un

threat

Health Visitor

68(1), 6

Laurent C (1994) Survey Over-worked and under-valued

He

Visitor 67(11), 373

Mayall B Foster M (1989)

Child Health Care Living W

Children, Working For Children

Heinemann Nursing, Oxf

Nettleton R J (1991) Support and supervision of health visi

dealing with child abuse Unp ublished MSc thesis. Univer

of Manchester, Manchester

Potrykus

C

(1990)

The

p n ce

of a

child's life Health Vis

63(7), 217-217

Sadler

C

(1994) Child protection

Is

working together fal

ap a r f Health Visitor 67(8), 259-260

Schon D A (1983) Th e Reflective Practitioner How Professio

Think m Action Basic Books, New York

Schon D A (1987) Educating the Reflective Practitioner Jo

Bass, San Francisco

Taylor S L (1991) Can the health visiting service be targe

Unpublished BSc thesis. Associate College, Leice

University, L eicester

Taylor S James D (1987) Children at risk the changing ro

the health visitor Health Visitor 10(60), 329-33 0

Taylor S Tilley N (1989) Health visitors and child protec

confhct, contradictions and dilemmas Health Visitor

273-275

Taylor S Tilley N (1990) hiter-agency conflict in child a

work — reducing tensions between social workers and he

visitors

Adoption

and

Fostering

14(4), 13-17

Twinn S Cowley S (1992)

Th e Principles of Health Visitin

Re-Examinatwn

Health Visitors Association, London

Walker M & Crapper E (1995) Identifymg families of conc

Primary Health Care

5(2), 12-14

Woods J (1981) A practical approach to preventing child ab

Health Visitor 54, 281 -283

Working with vulnerable families: a health visiting perspective

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