From normality to risk : a qualitative exploration of health visiting and mothering practices following the implementation of Health for all Children
King, Caroline Anne
The overall aim of this study is to explore how health visiting and mothering practices have been shaped by the implementation of Health for All Children (Hall). ‘Hall’ denotes a programme of work around child health surveillance and promotion published in four reports between 1989 and 2003. The fourth Hall report (Hall 4) marked a shift towards a more targeted approach to service provision, predominantly through the work of health visitors, yet aimed to meet the needs of all families with young children. The study explores how health visitors’ work practices have been shaped by this new policy context, including how it has influenced their relationships with families as well as the profession as a whole. It also examines the experiences of mothers, their relationships with health visitors, and how they negotiate and manage their children’s health and well-being. A review of Scottish policy reveals an early years agenda focused on risk and early intervention; and that community nursing has been at the centre of, and shown resistance to, a number of policy directives over the last decade. A review of the existing literature explores the relationship between evidence and Hall and identifies health visitors as the profession charged with its implementation. Literature on mothering and fathering exposes a focus on parenting in policy which belies the gendered nature of caring for children. The empirical study reported in this thesis is located theoretically in relation to the shifting emphasis in disciplinary practices shaping child health from normality to risk. The study uses a qualitative approach and took place within the Lothian region of Scotland. Initially, discussions with policy-makers and practitioners working in the early years, nationally and locally, were carried out to scope the context for the study. Semi-structured interviews with 16 health visitors and 20 mothers were then undertaken and analysed thematically, with the findings chapters shaped through an iteration between theory and grounded analysis of the accounts of the health visitors and mothers. The health visitors’ accounts reveal the changing nature and form of their knowledge and expertise and the implications of this for their practice and profession. The discussions of health visiting practice identify the important roles of observation and relationships work with families, in homes and clinics over time, and how these activities enable health visitors to construct knowledge of families. The interviews with mothers suggest a blurring between lay and professional knowledge where normality is defined by mothers themselves and through their relationships with health visitors. While the mothers work to construct themselves as morally adequate, attention to the stories mothers tell, and, in particular, the emotion in them, suggests that vulnerability can be experienced by any mother. This phenomenon sits in contrast to increasing attention by professionals placed on the monitoring and policing of ‘vulnerable’ families while opportunities for observation and relationships work diminish. The study concludes by exploring key conceptual issues. It considers shifts between normality and risk and how these are shaping how vulnerability is constituted through health visiting practice. In conjunction, it explores the implications of changing health visiting practices, for health visitors, as a profession. Finally, the scope for the health visiting profession to shape policy and practice are considered.