In recent years there has been greater emphasis placed on nursing research. The Chief Nursing Officer for England launched the first ever research strategic plan for nursing in November 2021, which aims to create a people-centred research environment that empowers nurses to lead, participate in and deliver research, so that research is fully embedded in practice and professional decision-making, for public benefit (NHS England, 2021).
Health visitors play an important role in contributing to this national agenda (Baldwin et al, 2024a), which is also reflected in the new Nursing and Midwifery Council (NMC) Standards of Proficiency for Specialist Community Public Health Nurses (NMC, 2022). While the need for health visitors to lead research may be more widely recognised, creating an enabling environment for research to take place and supporting health visitors to participate in research is less often reported.
The ADBB study
ADBB stands for the Alarm Distress Baby Scale, an observation tool for identifying social withdrawal in babies aged from birth–24 months (Guedeney and Fermanian, 2001). The ADBB study was a mixed-methods feasibility and acceptability study using the Alarm Distress Baby Scale (ADBB) in universal health visiting practice in England (Baldwin et al, 2023). This study, carried out by the Institute of Health Visiting (iHV) in partnership with the University of Oxford, and funded by The Royal Foundation of The Prince and Princess of Wales, took place over a 10-month period between May 2023 and March 2024.
Ethical approval was obtained from the Departmental Research Ethics Committee (DREC) at the University of Oxford. It involved training 25 health visitors across two sites in the use of either the ADBB or the modified version of the scale, m-ADBB (Matthey et al, 2013) and subsequently collecting quantitative and qualitative data from health visitors and service managers to inform the study findings. The full study report can be accessed here: https://bit.ly/4a7z2hT.
This article discusses the journey of the Hull 0–19 Integrated Public Health Nursing service (one of the participating sites) and shares the strategies used to engage staff, and the benefits of participating in research as well as the learning from the overall experience.
The Hull 0–19 Integrated Public Health Nursing service
In 2022 the Hull 0–19 Integrated Public Health Nursing service contract was awarded to Humber Teaching NHS Foundation Trust. The service was ready for re-investment, and the staff who had undergone the Transfer of Undertakings Protection of Employment rights (TUPE) reported that they were motivated and positive about change, but exhausted following the impact of the COVID-19 pandemic, years of under recruitment and changes to organisational leadership of the service.
As part of the re-investment into the new Hull 0–19 service, a new position of a Specialist Health Visitor in Perinatal and Infant Mental Health was included in the service model. A training needs analysis identified the field of infant mental health as an area to prioritise to develop the knowledge, skills, and competencies across the workforce. Furthermore, a decision was made to invest into the newly commissioned Hull 0–19 service with the inclusion of a clinical psychologist offering consultation, supervision, and training within the service.
It is well documented that early relationships set a template for how babies begin to think about themselves, and others (Parent-Infant Foundation, 2020) – they are fundamental to infant mental health. Young babies need sensitive, responsive adults to help them to bring difficult emotions under control (for example, through soothing them when they cry). Parents' responses shape how babies experience their emotions and also how they learn to regulate and express them (Parent-Infant Foundation, 2020).
The city of Kingston-Upon-Hull, commonly referred to as Hull, is categorised as the 13th (of 75) ‘Start for Life’ most deprived area, using the Income Deprivation Affecting Children Index list, and is often higher when using other measures. Based on the Hull 2023 Children and Young People, Emotional Wellbeing and Mental Health: Health Needs Assessment results, one in 18 (5.5%) 2–4-year-olds are likely to have a mental health issue – in Hull that equates to 528 children (Thrive Hull, 2023). The impact of poor mental health is cumulative, and can begin in pregnancy and in the early years (Thrive Hull, 2023). Poor mental health in childhood is also more prevalent in families living with stress factors such as conflict, substance misuse, parental mental illness, exposure to trauma and severe poverty (Parent-Infant Foundation, 2020).
The Hull 0–19 service was approached by the iHV to consider taking part in the ADBB study due to its interest in developing the workforce around perinatal and infant mental health (PIMH), coupled with the introduction of the PIMH specialist health visitor post into the newly commissioned service. While this request from the iHV was met with enthusiasm, it was also acknowledged that the service was in its first year of transformation, where health visitors continued to manage large and challenging caseloads and the PIMH specialist health visitor had only just been appointed. There were a number of other competing priorities to consider and participating in research was simply an aspirational priority for the service at this point.
To explore whether taking part in the research would be possible, meetings were arranged with senior managers, the Trust research team and importantly the commissioners. Enthusiasm was building, and although it was important to be attentive to different aspects of service delivery; namely, stability of the key performance indicators and the impact on staff workload if the team was to participate in the research study. With all this taken into consideration … we said yes!
Initial engagement with health visitors
Health visitors within the Hull 0–19 service were invited to take part in the ADBB study by an expression of interest. Details of the study were sent to all health visitors, giving information about the ADBB tool and the purpose of the study. The expectations for commitment to undertake training on the use of the ADBB tool and collecting data were made clear from the outset. There was a good initial response, and very quickly 10 health visitors were recruited to take part in the ADBB study. The staff were enthusiastic at the prospect of being involved in the research, what it might add to their practice and how it could enhance their work with families. Furthermore, this was the first time that the health visitors had been given the chance to be involved in research in practice, mainly due to lack of opportunity and workload.
Initially, some health visitors had reservations as they felt there was a lack of specialist services or interventions available locally to refer families if the ADBB/m-ADBB scales highlighted concerns. However, through further discussion and supervision, various options for onward support and intervention from within the 0–19 service and wider services across the partnership were identified. This included the recently enhanced offer around infant mental health within the local Family Hubs to support parent–infant relationships. This helped to reassure the staff and built confidence in them participating in the study and using the ADBB/m-ADBB as required.
Additionally, some health visitors were concerned about having enough time to undertake the training involved and commit to the expectations around data collection, especially given the large workloads in the service. Practitioners had good support from senior managers and were reassured that they would be supported where capacity issues arose to facilitate participation. The Humber Teaching NHS Foundation Trust as an organisation is committed to research and actively encourages and supports all staff to get involved in research in practice at all levels.
The Trust's Research Strategy outlines three overall priorities:
The Hull 0–19 leadership team are equally passionate and supportive of research in practice and value the contribution that it can make to service delivery and outcomes for local communities. The senior leaders in the service have been actively involved in the Yorkshire and Humber Community of Practice for Research (https://ihv.org.uk/our-work/ihv-projects-and-evaluation/current-projects/yorkshire-and-humber-community-of-research-practice-0-19-project/). This helped to provide a space where practitioners were encouraged to participate and felt like they had permission to take part in research.
Study implementation
The 10 health visitors recruited to participate in the study attended a 2-hour online workshop delivered by the iHV to introduce the feasibility study and the ADBB/M-ADBB tool. This was followed by a half-day online training session on the use of the tool, which was delivered by Humagogie training centre (ADBB training providers). Following this, the iHV arranged online meetings for clinicians across the two sites to come together to ask questions and think together about use of the tool at the routine 6–8-week health visitor review and also how the data would be collected and fed back to the iHV research team. This provided a good opportunity to explore potential barriers, troubleshoot and develop a robust process of data collection.
The study required health visitors to use the m-ADBB at all 6–8 weeks mandated contacts, following training (Baldwin et al, 2024b). The health visitors reported that they were easily able to incorporate this into their everyday practice and attributed this to the tool requiring a relatively short training programme alongside it being used at a routine contact. This helped to facilitate the health visitors' participation in the study.
To ensure that the health visitors had access to support in practice, the specialist health visitor in perinatal and infant mental health, and another health visitor within the team, had undertaken more in-depth training on the full ADBB. This meant that health visitors could access support directly from clinicians in the team who had extended knowledge and skills in using the tool in addition to having more specialist knowledge around infant mental health and parent-infant relationship; support was also provided through an online forum facilitated locally. This enabled practitioners to feel supported and confident in using the tool and knowing what to do next if concerns were identified.
Outcomes for the Hull 0–19 Health Visiting Service
Participation in this research study has benefited individual health visitors, the 0–19 health visiting service, the organisation as well as the local community. For health visitors it has meant:
For the service/organisation it means:
For the community, benefits include:
The ADBB has added to health visitors' knowledge and skills repertoire in observing and interpreting babies' social cues and communication (Baldwin et al, 2024b). This enables early identification of babies experiencing distress associated with adverse or challenging family circumstances, so that appropriate support can be offered as early on as possible.
Taking part in the ADBB study has provided a great opportunity to raise awareness of the importance of prioritising infant mental health and supporting families to access interventions that promote the parent-infant relationship.
Furthermore, having Her Royal Highness The Prince of Wales spearheading the ADBB research project has attracted a lot of interest from the media, services and organisations in the field of early childhood and Infant mental health. This has helped to shine a spotlight on the importance of a positive experience in early childhood and the vital role of the health visitor in supporting this.
The Hull 0–19 Health Visiting Service were invited to take part in media coverage on the ADBB study for the BBC's One Show when the study was in progress to coincide with Infant Mental Health Week in June 2023. Following this, further filming was undertaken by The Royal Foundation of The Prince and Princess of Wales and Sky News for the publication of the study findings in April 2024.
This provided a great opportunity to showcase health visiting in Hull and highlight the value of positive infant mental health, alongside the importance of supporting families to access timely interventions to support the parent–infant relationship.
Reflections and implications for health visiting services
The journey of research participation shared in this article demonstrates that, despite the challenges and initial concerns, this has been an extremely rewarding experience for all involved, as demonstrated in the reflections in Box 1.
Participating in research has been rewarding on so many different levels. It is hoped that sharing the experience of our research journey will encourage other health visiting teams to get involved in research. This not only benefits the local health visiting service but also raises the profile of our profession. By being open to research, creating an enabling environment for research and embracing opportunities to participate in research, we can make important contributions to the national research agenda and the evidence base for health visiting interventions.
The Hull 0–19 service is grateful to have been selected to take part in this study and feel very proud of their contribution to such an important area of practice. It has stimulated interest within the service in research and helped to break down some of the barriers associated with participation in research in practice, such as time, opportunity, and academic experience.