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Projects 2007-09
Child and Family Health Nursing: Standardisation and Development of Clinical Practice

Child and Family Health Nursing: Standardisation and Development of Clinical Practice

A project officer will be employed to promote, coordinate and ensure competent, consistent CFHN clinical practice across HNE with an emphasis on the Northern and Manning Sectors.

Location to be advised but within HNE.

The project officer has Area wide responsibilities. The domains within the job description include responsibilities for providing:

Clinical leadership
Clinical Service and consultancy
Education
Research; and
Clinical services planning and development

Aims and objectives

Hunter New England (HNE) wide competent, standardised clinical practice and documentation in Child and Family Health Nursing (CFHN);
Provide education and support to ensure evidence based and standardised practice for CFHN across HNE with emphasis on northern geographical area;
Implementation of the draft NSW Health CFHN Practice Standards Framework, which include assessment of CFHN’s evidence based clinical knowledge and skills of . This project is led by the Nursing and Midwifery Office, NSW Health;
Coordinated procedure and guideline development and policy implementation across HNE CFHN;
Equity of access to clinical supervision of Child and Family Health Nurses across HNE;
Equity of access to a defined set of clinical resources;
Implementation of mechanisms to support Child and Family Health Nurses, in particular those in rural and remote areas and/or working as sole practitioners;
Implementation of strategies that improve networking among CFHN’s and enable equity of access to specific nursing education;
Strategic planning to improve the profile of CFHN issues particularly in the northern sector;
Provide a lead role in strategic service planning and implementation of issues of critical importance to the wellbeing of children. This includes: attending to issues regarding breastfeeding; Aboriginal child health; hip dysplasia; obesity; child health screening in accordance with the revised personal health record and assessing and managing children with chronic and complex health problems as well as children at risk of harm;
Provide a lead role in strategic service planning and implementation of issues of importance to the wellbeing of parents. This includes ensuring area wide approaches to the implementation of Safe Start and the NSW Health Breastfeeding policy;
Review of referral pathways and strengthening partnerships with internal and external partners.

Expected outcomes

Standardised CFHN clinical practice informed by recent literature, best practice and research;
Congruency and consistency of policy, procedure and guideline development and implementation in Child and Family Health Nurses in northern and southern HNE;
Standardised approach to clinical review;
Standardisation of resources and literature for nurses and parents;
Equity of access to clinical consultancy across HNE Health by CFHN’s;
Equity of access to clinical supervision among CFHN’s;
Competent, consistent CFHN clinical practice across HNE with an emphasis on the Northern and Manning Sectors through the implementation of Practice Standards
Identification of areas for research within CFHN

Key performance indicators

The success of the project will be measured by:

Evidence of systems developed to enhance communication and networking among: CFHN’s, Managers, CNC’s and internal and external partners;
50 % CFHN’s commence assessments of evidence based clinical skill assessments developed as part of the NaMO CFHN Practice Standards framework. These clinical skill assessments have been trialed as part of the pilot project in HNE;
Two – five (2-5) identified CFHN assessors in each sector in HNE for implementation of the CFHN Practice Standards Framework;
Evidence of consistent processes developed area wide for dissemination and implementation of policies, procedures and guidelines across HNE CFHN;
Evidence of consistent approach to prioritising, delivering and evaluating quality educational opportunities for CFHN’s;
75% staff attending education activities;
Evidence of standardisation of resource material and literature for nurses and parents;
50% CFHN’s access regular clinical supervision. HNE and Kaleidoscope has a commitment to the rollout of clinical supervision and there has been training workshops available throughout the area to increase the numbers of supervisors for staff. The project officer will seek opportunities and funding for further training of clinical supervisors if required

Progress

Introduction

At the end-February 2008, a Child and Family Health Clinical Nurse Consultant was seconded into the Project Officer Child and Family Health Nursing: Clinical Practice Standards position to commence set up of the project. The current project officer was officially appointed to the position in early July 2008.

Please note: the focus of the project officer’s initial work has been with the child and family health nurses and Centres in the Northern and LMNC region due to the identified lack of a CFH Clinical Nurse Consultant working in these regions. The Southern sector of HNE has two incumbent CFHN CNC positions.

Evidence of systems developed to enhance communication and networking among: CFHN’s, Managers, CNC’s and internal and external partners;

Establishment of HNE CFHN Collaborative Group

The project officer, with the support of Felicity Williams, Area Nurse Manager Professional Development, has developed an intranet site called the HNE CFHN Collaborative Group. This site, operated through myLink, is now used by CFH nurses and managers throughout HNE. The project officer is currently the moderator. To sustain participation on this forum, the incumbent Child and Family Health Nurse CNC's will share the moderator role. The site enables:

Online discussion forums to enable professional networking and communication, particularly among rural CFH nurses;

Review of draft CFHN clinical guidelines and policy compliance procedures;

Access to minutes of relevant Area CFHN meetings;

Advertising of courses and conferences via the Calendar function and News Forum;

Nurses to post clinical questions;

Access to new reports and documents;

Access to relevant web links.

The site went live in December 2008. There are currently 79 group participants from across the region. The project officer and CNC's are encouraging staff to use the site as a one stop shop for CFHN information and communication. The site was officially launched at the inaugural HNE CFHN Forum held on 29/6/09.

HNE Child and Family Health Nurse Managers and CNC's Committee
This committee (which was established prior to this project) continues to meet bi-monthly and provides a forum to address CFHN clinical and management issues. The project officer has been able to use this committee to flag significant rural/regional clinical issues and provide feedback to the managers and CNC's regarding aspects of the project. This communication and advocacy role related to clinical issues will be difficult to sustain however, in the absence of a dedicated CNC position for these clusters. Notwithstanding the need for a dedicated CNC position, it is noted that the new Temporary Full time (12 months), HNE Child and Family Health Nursing Service Development Coordinator position that the project officer has commenced in from 1July 2009, will be able to continue to attend this meeting and discuss ongoing issues for the rural regions for the next 12 months.
Child and Family Health Clinical Nurse Consultant Meetings
The Project Officer and both Southern sector CNC's have met regularly during the course of the project. The purpose of the meeting is to plan and coordinate delivery of CFHN education and clinical practice programs across HNE. The outcomes of the meetings have provided recommendations and actions for prioritisation and standardisation of education and clinical practice which are then tabled at the Area CFHN Managers Committee meetings. A CNC representative from the Northern and Manning clusters will be required in the longer term to continue this liaison.
Attendance at team meetings
The project officer has endeavoured to attend team meetings in the New England and Manning regions where possible to update and discuss CFHN clinical matters with staff. Again, this may not be sustainable without a designated full time CNC position to continue in this role.
HNE Child and Family Health Nurses Forum
The project officer was successful in developing a submission to Families NSW (Southern Sector) for financial support to hold the first HNE wide Forum for Child and Family Health Nursing. This successful forum was held on 29/6/09 at Muswellbrook. There were 108 participants.

The working group organised to plan the event was chaired by Trish Hannan, CFHN Nurse Manager Greater Newcastle. This small working group consisted of CFH managers and CNC's from across the area. The funding covered the costs of venue, catering as well accommodation for two nights for nurses and managers traveling from rural and remote areas to attend. The aim of the forum was to unite the service to discuss future plans and programs as well as promote networking and communication. There is a likelihood that this area wide forum will become an annual event. Analysis of the evaluations is underway.
Linking with Internal & External Partners
The project officer has established links with:
- Maternity Services: by working with the Area Clinical Midwifery Consultants on the Breastfeeding Central Collaborative Group as well as a submission to Area Executive for Lactation Consultant positions to be established across HNE.
- Mental Health Services: by working with Mental Health personnel and the CFHN CNC's on the development of Suicidal Risk Assessment education and resource tools for CFHN's
- HNE Nursing & Midwifery Services through collaboration with Felicity Williams, Area Nurse Manager: Professional Development on the CFHN Collaborative Group and Susan Brazil, Nurse Manager Practice Development for rural exchange funding.
- Urban Division of General Practice: through provision of an education session to a forum of practice nurses on the role of the CFHN, and the new developmental screening assessments in the Personal Health Record.

50 % CFHN’s commence assessments of evidence based clinical skill assessments developed as part of the NaMO CFHN Practice Standards framework. These clinical skill assessments have been trialed as part of the pilot project in HNE;

There are a number of reasons why this performance indicator has not been met. These assessments are included as part of the NSW Health CFHN Professional Practice Framework which has only just been endorsed by Debra Thoms, Chief Nurse, Nursing and Midwifery Office at NSW Health in April 2009. It has been important to wait for the release of this final document as well as the release of the revised NSW Child and Family Health Nurse Association Inc (CAFHNA) Competencies. The CAFHNA competencies although finalised, have not yet been made available.

There was a significant delay in the education and assessment component of the skill assessments being developed and uploaded onto the electronic myLink program on the HNE intranet due to local issues related to the allocation of specific course codes. This issue is now resolved and the courses are being developed.

In July 2008, the project officer conducted workshops discussing the CFHN Professional Practice Framework with nurses and managers in LMNC as well as the Northern Clusters. Information about the Framework was again discussed by the project officer and Jennifer Reed, CFHN CNC Upper & Lower Hunter at the HNE CFHN Forum held in June 2009.
In May 2009, the project officer coordinated the submission to the HNE Nurse and Midwife Strategy Program 2009-2010 for $45,000 to pilot the CFHN Professional Practice Framework in three HNE clusters. The title is “Piloting the NSW Health Child and Family Health Nursing Professional Practice Framework in HNE Health: Implementation and Evaluation”. It is anticipated that this pilot project will assist in identifying issues related to the implementation of the Framework and develop processes to ensure sustainability.
Two – five (2-5) identified CFHN assessors in each sector in HNE for implementation of the CFHN Practice Standards Framework;

Greater Newcastle and Lower Hunter have 2-3 identified assessors in each cluster. The three sites selected to implement the pilot (see 2 above) also each have 2-3 assessors nominated. All assessors will require information and education about the role of the assessor. This information and education package is being developed at a State wide level and has been included as part of the proposed pilot.
Evidence of consistent processes developed area wide for dissemination and implementation of policies, procedures and guidelines across HNE CFHN;

A HNE CFHN Policy, Procedure and Clinical Practice Guidelines working group was established in August 2008. The group has representation from each cluster and meets monthly via teleconference.

Please refer to accompanying document: Status of CFHN Policy Compliance Procedures and Clinical Practice Guidelines- July 09 version, which outlines the progress of the working group. Three clinical guidelines have been circulated for consultation and comment with one more in draft. There are three draft clinical procedures also under development. These draft documents are available also on the HNE CFHN Collaborative Group for comment by CFHN and managers area wide.

Support has been given by managers for the working group to continue to meet at the conclusion of the project.
Evidence of consistent approach to prioritising, delivering and evaluating quality educational opportunities for CFHN’s;
On commencement of the project, an initial 12 month education plan for CFHN was developed by the project officer and CFHN CNC's The priorities of the education program were to meet the education needs of CFHN's in implementing new health promotion and screening programs required following changes to the Personal Health Record (PHR), and in response to recent NSW Health policy directives. Education workshops were available in key locations across Northern, LMNC and Southern clusters and were consistent with education programs being delivered state wide in CFHN.

An example of this performance indicator is that by end of July 2008, all CFHN's across HNE had access to an educational update in the use of the Parents Evaluation of Developmental Status (PEDS) and Ages and Stages Questionnaire (ASQ). CFHN's are now able to use both screening tools with families. The PEDS is part of every child health check in the PHR from 6 months of age. The ASQ and ASQ: Social Emotional is used dependent on the parents’ responses on the initial PEDS screen. The ASQ had not been implemented in most parts of HNE prior to these updates, and there has been inconsistent practice in the use of the PEDS across the area. The education will be reinforced with the implementation of area wide clinical procedures (see 4 above).

In a second example, the CNC's from Tresillian and Karitane had jointly developed an education package called ‘Responsive Settling Guidelines’. The CNC's from both institutions provided this education to all HNE CFHN’s in 2008. Additionally, all nurses received an introduction to the ‘Keys to Care giving’ education program from the Mid North Coast CFH CNC. Both education programs focus on the importance of responsive and sensitive care giving by the parent and enable the nurses to build skills to foster this important facet of parenting knowledge and skill.

More recently, the CFHN's from across the area have participated in workshops on Vision Surveillance and State-wide Eyesight Preschooler Screening (StEPS) and the roll out of Body Mass Index (BMI) screening. A meeting has been held with mental health staff regarding roll out of suicide risk assessment training which is mandatory education and was a high priority of the nurses on the recent Needs Analysis questionnaire (see below).

An area wide CFHN Education and Clinical Supervision Needs Analysis was completed in January 2009. The report provides a baseline of CFHN employment details, stage of nursing career and skill building, years of CFHN experience, qualifications and education completed in the workplace, perceived education needs, preferred mode of learning, special topics of interest and suggestions for education and support. The information from the Needs Analysis was tabled with the HNE Nurse Manager group in February 2009 as well as reported and circulated to nurses and managers. In consultation, the CNC's plan to use the information to assist with planning and delivery of education over the next 18 months.
A highlight of this project was the opportunity to coordinate a two day education program for 8 rural nurses to attend. This education program was organised and delivered by CFHN clinical nurse specialist staff in Greater Newcastle. The project officer was able to use project funds to replace salary for one CNS (Karen Johnson) to organise and evaluate the two days; and obtain rural nursing exchange funding to cover the accommodation and meal expenses of the rural nurses. The rural nurses were staff new to CFHN who had not had the opportunity to attend formal orientation in their area (again due to the lack of a designated CNC position). There were many positive benefits for both the rural nurses and the CNS staff and it is hoped that the networks established will continue to provide support to these isolated nurses.
75% staff attending education activities

In 2008/09, it is estimated > 90% of CFHN's attended standardised programs of education across HNE. Planning and delivery of all education programs now occurs at an area level. All education programs include an evaluation component. The four Northern clusters and Manning will need a dedicated CNC position to continue providing equity of ongoing delivery of education in HNE or a similar funded option.
Evidence of standardisation of resource material and literature for nurses and parents;
The Project Officer completed an audit of resources held at HNE Child and Family Health Centres at the commencement of the project. The audit was conducted to obtain a baseline of equipment held at Centres in order to determine current resource needs, inform minimum standards of equipment required at Centres and work toward equity of access to resources for nurses across the Area. 60 centres replied to the audit from a possible 69 = 87% response rate. The audit report was circulated via the Children, Young People and Families Clinical Network to CFHN managers and nurses.

It is important to note that the audit list contains an ‘ideal’ list of resources and identifies the essential equipment required. Information from the audit was used to inform purchases made by the project officer with project funds. The project officer also conducted site visits to the majority of CFH Centres in the Northern and LMNC to gather more information about nurses’ working environments and access to resources.

The established CFHN Policy, Procedure and Clinical Practice Guidelines Policy group has commenced nominating best practice resource material and literature and websites for nurses and parents. The first example of this is standardisation of the information that parents’ receive about infant sleep and settling. This information is available to all staff via the online CFHN Collaborative Group.
This process will be sustained with the ongoing work of the group.
50% CFHN’s access regular clinical supervision. HNE and Kaleidoscope has a commitment to the rollout of clinical supervision and there has been training workshops available throughout the area to increase the numbers of supervisors for staff. The project officer will seek opportunities and funding for further training of clinical supervisors if required

Results from the HNE CFHN Education and Clinical Supervision Needs Analysis provided some information on the uptake of clinical supervision (CS) across the area. Of the 56 respondents, 22 (39%) accessed regular CS. This result was concerning as attendance at CS is part of Area Health Service responsibility in the Supporting Families Early package requirements (NSW Health, 2008, p.43). The Needs Analysis also tabled information on the respondents’ mode of clinical supervision, the health personnel providing CS and information about the respondents’ concerns related to CS. The report indicated that the majority of respondents would like more education on CS, in particular, the program Getting the most out of Clinical Supervision which can be included in education plans for the area.

As mentioned in the June 2008 report, the majority of child and family health nurses from Greater Newcastle, Lower and Upper Hunter and the Lower Mid North Coast access monthly group clinical supervision (CS). However, due to the relatively small numbers responding to the above survey, it was unclear what the level of CFHN access and uptake of CS was across the whole region. Therefore, a Mapping Exercise of the access and uptake of CS by HNE CFHN's was completed by the project officer in April 2009. Currently, 71% of HNE CFHN's attend regular clinical supervision.

As a follow up of this CS Mapping Exercise, both the rural nurses not currently in CS, and the managers that attend the HNE CFHN NM meeting, agreed to a trial of monthly clinical supervision via teleconference. This method of CS provision is cost effective and sustainable. The project officer is currently organising this trial.

Discussion

Issues

There are a number of issues that continue to affect the clinical support of child and family health nurses across the region. These issues were mentioned in the previous project reports dated June 2008 /January 2009. An update of progress on these issues is provided below:

Home Visiting/Scope of Practice:
There is inconsistent application of the NSW Health home visiting ‘whereabouts’ policy across the Area. At some sites, the movement of nurses through the day is tracked but there is no fail-safe method of ensuring nurses’ back to base safety at the end of the day. Reliability of mobile phone reception when home visiting is an ongoing issue for rural nurses.

There are inconsistent approaches in the conduct and content of a universal home visit with parents. This was also identified in the recent 2008 HNE CFHN Service Review. A recommendation from the CFHN Service Review is for the CFHN service to focus and articulate the scope of nursing practice; and, develop a policy compliance procedure to define primary health care in the context of working with vulnerable families. The role of the new CFHN Service Development Coordinator position will be to facilitate the actions from the CFHN Service Review.
Lack of Standardised Orientation Process:
As mentioned in previous reports, there is a lack of equity and standardisation of orientation and mentorship processes across HNE CFHN services. Orientation is a critical element in ensuring that there is standardised clinical practice and availability of clinical support and mentoring for new nursing staff to the specialty. It is particularly important for this specialty due to the independent and isolated nature of child and family health nursing practice. Routine orientation and mentorship programs are currently available only in Greater Newcastle and Lower and Upper Hunter CFHN Services where there are CNC's present.

This issue has been tabled at the Area CFHN Manager’s group. After the success of the recent two day rural nurse education update held in Newcastle, it was agreed by the Greater Newcastle CFHN service that new rural nursing staff could join in the GNS orientation program when available. Rural staff would need the support of their managers and access to subsidised accommodation and travel for this method of orientation to work. This still leaves a gap, however, in the ongoing clinical support and mentorship of new and existing rural CFHN's in the four Northern and Lower Mid North Coast clusters. There is an ongoing need for a designated CNC position in the Northern and LMNC clusters. This issue has been identified in the HNE CFHN Service Review Action Plan.
Inequity in access to CNS and Mentoring workshops
These workshops are generally held in Newcastle which due to geographical distances, makes them largely inaccessible to nurses in the rural clusters. This education was rated as a high priority by respondents on the recent Education and Clinical Supervision Needs Analysis. A recommendation is that these workshops are held in the Northern and LMNC sectors to redress this imbalance.
Nurses / midwives undertaking CFHN role without CFHN qualification
In some rural areas, nurses and midwives without a child and family health nurse qualification are undertaking the role of the child and family health nurse. Note that this does not include that group of nurses employed in the rural Clusters who are currently undertaking their postgraduate CFHN qualification.

Although this issue mainly occurs during leave relief periods for the incumbent CFHN, there has been a perception by some non child and family health managers that the role can be filled / backfilled by generalist nurses or midwives. There is also often a lack of qualified CFHN staff available in the smaller centres for managers to use to cover leave relief. The Supporting Families Early package states that ‘the provision of home visiting by a maternity discharge service does not meet the requirements of a universal health home visit’ (NSW Health, 2008, p.27). The knowledge and skills required to complete the range of assessments and meet the information and support needs of new parents in their child’s early years is outside the scope of practice of generalist nurses and midwives. This issue has been discussed at the HNE CFHN manager group.
Lack of a Clinical Nurse Consultant Position
As mentioned throughout this report, the lack of a clinical consultant positions in five of the eight HNE clusters will continue to adversely impact on the nurses’ access to clinical support, education and quality improvement processes. This issue has been recommended for action on the recent HNE CFHN Service Review Action Plan.

Challenges

The challenges within this project were:

Due to the geographical distances and scope of the project, the Project Officer did not have the capacity to provide the necessary ongoing face to face clinical support to child and family health nurses across the Northern and LMNC region, particularly in relation to orientation. As mentioned, there are insufficient clinical consultant positions to provide ongoing clinical support and mentoring in these regions after the conclusion of this project.
The delay in finalisation of the NSW Health CFHN Professional Practice Framework postponed the roll out of the clinical skill assessments during the project timeframe.
Likewise, there was an unexpected delay in the establishment of the online education and assessment program.
The available timeframe of this project was shortened to 16 months instead of the anticipated 2 year timeframe.

Achievements

The resource audit and site visits to centres highlighted particular gaps in essential nursing resources across the region, particularly in the 4 Northern clusters. There were some project funds available in 2008 to purchase a set of resources for the CFHN service. As a result, the HNE CFHN Service received:
- Eleven (11) purpose built Clinical Examination Benches. This was highlighted as a priority as nurses at these Centres in the Northern clusters were using benches at incorrect heights &/or widths to examine infants, for example meeting tables, outdoor tables, patient beds and examination couches;
- Sixty-five (65) books Birth To Five Years: Your Child’s Development (2008) by developmental specialist Mary Sheridan were purchased as a standardised reference tool in every Centre to assist CFHN's across HNE in accurately screening infants and children at routine child health checks. This is particularly important since PEDS and ASQ screening has commenced;
- Ten (10) The Breastfeeding Answer Book texts were purchased for Northern and LMNC CFH Centres as a reference tool to assist nurses working with breastfeeding mothers. The same text is available in all Centres across the Southern sector;
- Twenty (20) portable Wedderburn Infant Length Measure Mats; As universal health home visiting is a major part of every CFHN’s role, this equipment was prioritised for purchase as the resource audit indicated that many centres did not have access to an infant measure mat;
- Twenty (20) Wedderburn Infant Scales Bags; similarly, the resource audit indicated that nurses did not have access to a dedicated safe carry bag to carry infant scales into parents’ homes.
  
  Additional project funds were available in mid 2009. Purchases included:
- Twelve (12) sets of stand on scales for older children
- Twenty-five (25) Developmental Dysplasia of the Hip DVD's (RCH, Melbourne) were purchased for distribution to the main centres in each cluster. This DVD will be required when nurses complete the education requirements for the infant health surveillance clinical skill assessment.
- Thirty (30) Getting to Know You DVD's from the NSW Institute of Psychiatry. This DVD is to be used during parent groups and other education opportunities to facilitate parent learning about infant cues.
- Specific equipment and resources purchased for Centres at Boggabilla and Toomelah. These centres did not receive assistance with project funds in 2008 as child and family health nurses were not working in those locations at the time. There is a very great need in these communities for skilled, resourced child and family health nurses.
Completion of the HNE CFHN Education and Clinical Supervision Needs Analysis Report.
Coordination of the successful two day education program for rural nurses held in April 2009.
The establishment and roll out of Area wide CFHN education programs
Establishment of the online, HNE CFHN Collaborative Group
Establishment of the HNE CFHN Policy, Procedure and Clinical Practice Guidelines working group.
Successful submission to Families NSW to hold the first HNE CFHN Nurses Forum on 29/6/09.
Coordination of submission to Nurse and Midwife Strategy Fund Program 2009-2010 to pilot the implementation and evaluation of the NSW Health CFHN Professional Practice Framework.