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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 trialled 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.

1. Evidence of systems developed to enhance communication and networking among: CFHN’s, Managers, CNC’s and internal and external partners;
   
   Area CFH Nurse Managers and CNCs Committee
   Prior to the project commencing, a HNE CFH Nurse Managers’ Committee had commenced meeting on a bi-monthly basis. The two CFH Clinical Nurse Consultant positions from HNE Southern Sector and the project officer joined this committee at the April 2008 meeting. This committee provides a forum for enhancement of communication among the CFH nurse manager and CNC groups as well as a focal point for the planning of education and service delivery and discussion of CFHN related issues. The project officer is able to assist with representation of CFHN clinical matters from the Northern sector.
   
   Clinical Nurse Consultant Meetings
   The Project Officer and both Southern sector CNCs have commenced meeting monthly. The purpose of the meeting has initially been to plan and coordinate delivery of CFHN education programs across HNE but also incorporates planning for standardisation of clinical practice. The expected outcomes are action plans for prioritisation and standardisation of education and clinical practice which can be tabled at the Area CFH Nurse Managers Committee meetings.
   
   Development of Area CFHN Shared Network Drive
   The project officer obtained permission from the managers at the above committee to develop a shared network drive for use by CFH Nurses and managers across HNE. The shared drive will be used to provide area wide access to relevant CFHN policies, procedures and guidelines. It can also provide easy access to journal articles, minutes of relevant meetings and standardised literature for nurses and parents. There are no associated costs to the creation or use of a shared network drive.
   
   Use of HSNet (Human Services Network) or MyLink (Moodle) software
   The project officer has had discussions with the Area Nurse Manager: Professional Development regarding the development of electronic discussion forums that are available via NSW Health intranet free of charge. The discussion forums would be for professional use only and can enable networking and communication particularly among rural CFH nurses. The sites can advertise courses and conferences; nurses can post clinical questions and access documents that have been uploaded to the site. HS Net can also be accessed state wide by other CFHNs. If actioned, the project officer would be the moderator.
   
   CFHN Cluster Meetings
   In the Greater Newcastle cluster, CFHN’s meet on a monthly basis at a geographical cluster level for planning and networking. The project officer is discussing this concept with nurses and managers in the Northern sector during site visits to Centres. Feasibility, access and impact on workloads are being considered due to geographical distances between centres.
   
2. 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 trialled as part of the pilot project in HNE;
   
   A recommendation made to the NSW Health Nursing and Midwifery Office in the September 2007 Report of the Pilot to Introduce the CFHN Practice Standards into the workplace was to appoint a short term project officer. One of the objectives of the project officer was to transfer the knowledge components of the clinical skill assessments into an electronic, interactive format instead of the current requirement of an oral assessment of knowledge. To date the project officer has not been appointed.
   
   As it is unlikely that a NaMO Project Officer will be appointed, the NCHN CFHN Project Officer has commenced working with the HNE Nurse Manager Professional Development to transfer the knowledge component of the clinical skills onto MyLink (Moodle) software. Moodle is a software program that can be used to develop education courses and assessments. An estimated time of six months is anticipated for this data transfer and setup of electronic courses. Once established, the information will be centralised and easily accessible for nurses and managers via the intranet. The software is free to use. It will be a requirement that the nurses will first complete the knowledge component of the assessments prior to completing the practical assessment of a clinical skill. The NSW Health CFH CNC Network is assisting the project officer with the content of the assessments.

   It is also crucial for the success of this element of the NCHN project that planning, education and discussion occurs with all CFH nurses and managers. The project officer is currently discussing the framework with nurses and managers in LMNC and two workshops are planned with nurses from the Northern sector at the end of July 2008.
   

3. 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. For reasons outlined above in (2), this performance indicator has not yet been targeted for action. Further education and discussion with nurses is required across LMNC, Upper Hunter and each cluster in the Northern sector before expressions of interest are called for assessors. There is a clear criteria developed to meet assessor requirements.
   
   Also, in consultation with Professor Cathrine Fowler, Tresillian Chair in Child and Family Health at the University of Technology Sydney, the NSW Health CFH CNC Network is developing an education package for clinical workplace assessors. It is not deemed currently feasible for all clinical assessors to undertake the Certificate IV Workplace Training and Assessment course unless it is more easily accessible and affordable in the workplace. The CFH CNCs will provide this education package to nominated CFH assessors.
   
4. Evidence of consistent processes developed area wide for dissemination and implementation of policies, procedures and guidelines across HNE CFHN;
   
   By the end August 2008, the project officer plans to have established an Area wide CFHN policy, procedure and clinical guidelines working group (WG). This has not occurred to date due to the delay in the formal appointment of the project officer to the position. The aim of the WG will be to identify and develop where necessary, a core set of policies, procedures and guidelines to assist with governance of CFHN practice across HNE. Consultation will occur with the Area Nurse Manager committee, CYPF Network and relevant external partners.
   
   The area shared drive will be used as the central storage for these documents. The Kaleidoscope website will also be used.
   
5. Evidence of consistent approach to prioritising, delivering and evaluating quality educational opportunities for CFHN’s;
   
   The project officer will develop an education needs assessment to determine the area wide perceived education needs of HNE CFHNs. This has not been done previously for this nursing specialty and will be used to provide a baseline of CFHN qualifications and education attained in the workplace, years of experience in the specialty, and inform planning and delivery of future education programs. It is envisaged that the assessment will be distributed to nurses and managers in August 2008 with a report completed by October 2008.
   

   
   As mentioned, an initial 12 month education plan for CFHN is being developed by the project officer and CNCs. The priorities of the education program is to meet the education needs of CFHNs 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. The education workshops will be available in key locations across Northern and Southern clusters and are consistent with education programs being delivered state wide in CFHN.

   By the end of July 2008, all CFHNs across HNE will have had access to an educational update in the use of the Parents Evaluation of Developmental Status (PEDS) and Ages and Stages Questionnaire (ASQ). CFHNs will be 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 has 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.

   The CNCs from Tresillian and Karitane have jointly developed an education package called ‘Responsive Settling Guidelines’. The CNCs from both institutions are booked to provide this education for all CFHN’s in the four (4) Southern clusters in August 2008 and in November 2008 to nurses from the four (4) Northern clusters. Additionally, all nurses will receive an introduction to the ‘Keys to Caregiving’ 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. Evaluation tools have been developed.
   

6. 75% staff attending education activities
   
   As discussed in (5), the majority of nurses across all clusters will be accessing standardised education activities from July 2008. The information obtained from the education needs assessment will assist in informing the preferred methods of providing education programs in future across HNE.
   
7. Evidence of standardisation of resource material and literature for nurses and parents;
   
   The CFHN Project Officer has conducted an audit of resources held at HNE Child and Family Health Centres. 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. The audit is completed. 60 centres replied to the audit from a possible 69 = 87% response rate. The audit report is available now to be circulated via the CYPF Network to CFHN managers and nurses. It is important to note that the audit list contains an ‘ideal’ list of resources as well as identifying the essential equipment required.
   
   

   Information from the audit was used to inform purchases made by the project officer with project funds. The project officer has 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.
   
   Once established, the Area CFHN Policy and Procedure working group will assist in the identification of best practice information literature for parents in order to develop standardisation of written material for parents.
   

8. 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
   
   The majority of Child and family health nurses from GNS, LH, UH and LMNC access monthly group clinical supervision (CS). There is a peer support model of CS provided for some CFHNs from the Tablelands and McIntyre clusters. There is also a project officer appointed in the Peel cluster to develop a nursing clinical supervision culture.
   
   However, none of the child and family health nurses from the Mehi Cluster and few nurses from the Tablelands or Peel cluster are currently accessing regular formal clinical supervision. The project officer is undertaking site visits and consultations with nurses and managers across the Northern sector to find solutions to this issue. The project officer has also consulted with the Peel Cluster Project Officer: Clinical Supervision regarding access issues for nurses and solutions to finding appropriate supervisors in the rural areas.

Discussion

Since the commencement of the project, the Project Officer has visited 21 Child and Family Health Nursing Centres across the Northern clusters and LMNC and travelled approximately 4500 kms. It has been important to meet as many child and family health nurses and managers as possible and discuss the project objectives and clinical practice issues. The Project Officer has also attended a number of team meetings across the region.

Issues

A number of concerning clinical issues have been revealed during site visits to the Northern and LMNC regions. At this stage, the project officer is still gathering site visit information so solutions to these issues at a whole service level have not yet occurred. Where an immediate risk was noted, the individual nurse/Centre and manager have been consulted and solutions found. An outline of these issues follow:

Home visiting policy compliance:
There is an inconsistent application of the NSW Health home visiting ‘whereabouts’ policy across the Northern and LMNC clusters. At many 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. This is extremely concerning due to the large geographical areas covered, inconsistent mobile phone coverage and isolation that nurses face in many rural areas. Each nurse has been asked to follow up this issue with her line manager and it will be raised as a concern at the next CFHN Managers’ meeting. At one centre, the nurse’s whereabouts were not traceable at all through the day. This was alerted to the nurse’s manager and mechanisms are now in place to ensure the nurse’ safety when home visiting.

Isolated Centres:
The Werris Creek CFH Centre was identified as being isolated with no landline for use by the nurse. Following consultation with the CFHNs and their manager, the Werris Creek CFH Centre has been transferred to the local hospital site.

Lack of Use of Personal Protective Equipment:
It has been identified that there is inconsistent use of gloves by CFHN’s during infant examinations across the Area. In a number of clusters, none of the nurses use protective eyewear or aprons when there is a risk of body fluids exposure. Nurses at all centres have been asked to commence using gloves and source protective eyewear and aprons via their manager. The project officer recommends using a CFHN policy compliance procedure to address this issue at a whole of area level. Again, this issue can also be discussed at the Area CFH Nurse Manager meeting. Use of personal protective equipment such as protective eyewear and aprons requires a significant practice change for child and family health nurses.

Orientation Process:
From discussions with nurses and managers at Centre site visits it is apparent that there is a lack of standardisation of orientation processes across CFHN services with many sites not having any formal orientation process for new CFHN staff. Orientation is a critical element in ensuring that there is standardised clinical practice and availability of clinical support for nurses.

There are some examples of mentoring of new staff by experienced CFHNs in the local area. However, there is no identified position to provide orientation and ongoing clinical support to the CFHNs across the whole of Northern and LMNC clusters.

Likewise, there are no specific resource manuals for relief staff to orientate them to the Centre and community in which they work (it is acknowledged that relief staff are scarce in rural areas).

Lack of CFH Clinical Nurse Specialists:
There are very few child and family health clinical nurse specialists across the Northern and LMNC clusters. CNS staff are a key group in nursing and are viewed as the resource persons in the specialty. The CNS group assists with mentoring new staff and students, identifying clinical issues, development of clinical standards and quality projects etc. The lack of CNS staff may indicate the lack of advocacy and clinical career opportunity present for this specialty group of nurses. Following discussions about CNS positions with CFH nursing staff during site visits, a nurse at one site is now submitting an application for regrading.

A recommendation is that a number of CNS workshops are held in the Northern and LMNC sectors to redress this imbalance (most workshops are currently held in Newcastle). The project officer has consulted the Nurse Manager Professional Development about this issue.

Challenges

The challenges within this project are:

• The distances required to travel to provide one on one clinical support to CFHNs across the Northern and LMNC region
• There are also numerous individual CFHN managers across each cluster that are required to be consulted regarding nursing practice issues.
• The local General Practitioner has also been identified by rural nurses as either an ally or a challenge/barrier to the provision of effective care to parents and infants. One major exception to this was evidenced with the relationships developed by the transitional nurse practitioner (who is also the child and family health nurse) at one remote site. The NP role in CFHN is recommended as a possible model for consideration in the more isolated rural areas where families have difficulty accessing health care.

Achievements

The resource audit and site visits to centres highlighted particular gaps in essential nursing resources across the region but particularly in the Northern clusters. There were some project funds available to purchase a set of resources for the CFHN service. As a result, the area CFHN service will benefit from the purchase of:

• 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 well known developmental specialist Mary Sheridan were purchased as a standardised reference tool in every Centre to assist CFHNs 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.

This equipment will assist in standardising equity of access to resources across the region.

Lessons Learned

The project officer has learned to book fewer site visits per day when outreaching to rural nurses and Centres. The nurses appreciate the opportunity to have a one on one consultation about child and family health clinical practice issues and require at least 1½ - 2 hours per centre to allow enough time for discussion. Nurse managers have also been present at these meetings where possible. Those nurses who are working as sole practitioners in isolated rural settings want their practice affirmed as they are currently unable to benchmark against anyone. The CFHN Practice Standards Framework implementation will assist with this clinical support and affirmation of practice.

For more information contact:

Eileen Guest
Clinical Nurse Consultant, Child And Family Health Nursing
Kaleidoscope Greater Newcastle Sector
02 4924 6171