Ethical tensions associated with the promotion of public health policy in health visiting: a qualitative investigation of health visitors' views

Aim: To explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients. Background: Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions. Methods: A total of 17 semistructured individual interviews covering participants' experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach. Findings: Health visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors' sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors' professional values and ability to develop relationships with clients could have numerous adverse implications.