Previous research has identified variables such as; skill and knowledge (16); personal experience of parenting (8); work setting (17); professional experience (17, 19); child and family focused training (18, 19); and time and workload (17) as having a significant effect on professionals FFP. However, many of these findings were shown to be non-significant factors in the present study. A potential explanation may lie in the variation and adaption of the FFMHPQ used in the present study compared to previous research.
Many previous studies (8, 16, 18) utilised the original FFMHPQ without psychometric evaluation and have continued to use subscales despite poor reliabilities (8, 9, 16, 17). It was on this basis that an exploratory factor analysis was conducted for the study discussed in this paper (see 31). Due to alterations following psychometric evaluation, the scale utilised in the present study is distinctive from both the original study and successive studies employing the FFMHPQ. This may have resulted in differing effects and relationships between the variables and FFMHPQ scores (dependent variable). Furthermore, there were some differences in how the present study and previous studies utilised the FFMHPQ in the analysis. While the present study calculated a total score of all items (n = 20) for the dependent variable, previous studies totalled and averaged individual subscale scores (8, 9, 16, 17). As previously discussed, scores were not based on the same factor structures. Thus, the analysis (t-tests and ANOVA) in the present study is distinctive from previous work. Finally, previous studies have largely explored FFP within a sample of mental health professions, as opposed to health visitors, potentially explaining differing findings. Due to the differences in the FFMHPQ factor structure, approaches to the analysis, and differing populations, it may be difficult to draw comparisons from previous findings to the present study.
Despite differences with previous FFP literature, the health visiting literature nevertheless suggests that factors such as time, and workload impact practice (32). Results using independent t-tests found that health visitors who had face to face contact with partners and children, and those that supported the partner had a significantly higher mean score on the FFMHPQ, than those that did not. However, frequency of visits (daily, weekly, monthly or yearly) had no effect on FFMHPQ scores. This suggests that health visitors’ FFP is not dependent on workload and quantity of visits, instead it is dependent on the quality of the visit and who they have contact with.
Within the UK, health visiting caseloads are at an all-time high (32). The Community Practitioners and Health Visitors Association (CPHVA), a UK organisation, recommend that health visitors can safely manage a maximum caseload of 250 families (32). However, as evidenced through the present research, caseloads can be well above this limit i.e. maximum of 333. In addition to increasing caseloads, there is also greater complexity within caseloads, evidenced by the high numbers of mothers with mental illness (see Table 1). These factors have been linked to a lack of time spent with families which has been shown to be a significant barrier to effective FFP (16). Despite high caseloads, 55% of health visitors met with families daily or weekly, and 35% visited families on a monthly basis. Indicting, that caseload size did not affect time spent with families, nor did time spent with families affect FFP. Further suggesting that effective practice is dependent on quality and content of visits and not quantity of time spent with families.
The analyses examined whether health visitors’ professional knowledge would have a significant effect on FFMHPQ scores. In the ANOVA, training had a significant effect on FFMHPQ scores, with those who had family focused, substance misuse, and domestic violence training having significantly higher scores. Training (specifically family and child focused training) has similarly been shown to be a significant predictor of FFP in previous studies with mental health nurses (18). However, within the sample there were varying rates of training received. For example, only 9% of the sample had received family focused training, while 75% had received child focused training. These findings call into question why so few health visitors are receiving family focused training, when it remains a policy recommendation (33).
The final hypothesis examined whether personal or professional experiences had a significant effect on FFP. ANOVA revealed that personal experience of mental illness had a significant effect on FFMHPQ scores, however variables such as, age, parental status, time since registration, and being in a specialist position had no effect on FFMHPQ scores. Health visitors’ personal experiences can influence their identity as a professional (24). In addition, there is some evidence to suggest that personal traits such as empathy (34) sense of coherence (35), conscientiousness, and emotional stability (36) are factors which influence practice.
Among health visitors in Australia, personal experience of mental illness was associated with a deeper understanding of service users with mental illness (25, 26). However, the present findings suggest that health visitors with personal experience of mental illness are less family focused. Many of the studies that explore professionals with personal experience of mental illness, report that professionals use this experience to guide practice with the service user (25, 37, 38). Professionals in these studies used their experience to build rapport, trust, and relationships with the service user (37, 39, 40), viewing themselves as more authentic (41), and credible (25). However, these studies did not explore how these experiences lead to a deeper understanding of the needs and impact beyond the service user (i.e. partner, children, grandparents), highlighting the limited existing research in this area. Thus, this study offers a unique examination of the influence of health visitors personal experience of mental illness on their understanding of the wider family. Accordingly, caution must be taken when assuming shared experience, such as mental illness, will automatically lead to better practice for all members of the family.
While the findings found that time since registration did not have a significant effect on FFP, the wider literature suggests the contrary. Indeed, there are models of nursing practice that specify that professional expertise and development is a linear process that is dependent on time (42, 43). The more experienced (in years) the nurse, the better the quality of care for patients (44). However, for some, these models are too limiting, and argue that the concept of expertise has been oversimplified, in that it is not solely dependent on time nor is it linear (45). Furthermore, when stating that years in practice leads to better quality of care for service users, it is unclear who constitutes a service user. For example, in health visiting the mother and child are considered to be the primary patients/service users, while the other family members (partner) are not. It is possible that time since registration does improve quality of care for the mother or child, however, not for all family members equally. Thus, as the care of the mother and child improves, FFP decreases. However, with limited and contrary research in this area, it is difficult to determine a definitive explanation for this result.
Methodological Considerations And Limitations
The FFPMHQ was a self-report tool and was thus subject to social desirability bias. While efforts were made to minimise this (e.g. participation was anonymous), the possibility of its influence exists. The sample size comprised 47% of the total available population of health visitors in NI. While this is lower than the ideal, this sample still met the underlying assumptions for our analyses and was in excess of that suggested by the power calculation. This cross-sectional study took place within the UK which is subject to country specific policies and practices. It is therefore likely that the lack of definition of FFP (27) will mean that these guiding policies will differ from those of other countries, which could therefore limit the generalisability of these findings.