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The Journal of the Community Practitioners’ and Health Visitors’ Association COMMUNITY PRACTITIONER
September 2010 Volume 83 Number 9 www.commprac.com www.unitetheunion.org/cphva
Protecting IN THIS ISSUE NEW CPD MODULES: First with older adults this issue supported by Dettol Enough progress? Strategies to address staffing shortages Interdisciplinary training A health visitor-led eczema clinic Breastfeeding and medication Your rights to ask for time to train The NEW Cetraben bath additive dispenser for almost* complete control at bath time
– Easy-To-Use Optic Measure – Contoured Bottle Get the right dose every time Easy to grip and pour – Drip Resistant Neck – Transparent Packaging Prevents the bottle Patients can see when from becoming they need to order slippery and greasy a repeat prescription
* We’re sorry, but we can’t do anything about the kids!
Cetraben® Emollient Bath Additive. Abbreviated Product Information rash and erythema have been observed, in which case the product should be Please refer to Summary of Product Characteristics before prescribing. discontinued. Marketing Authorisation Numbers: Cetraben Emollient Bath Presentations: Bath additive – Clear liquid containing light liquid paraffin 82.8% Additive: PL 17320/0002. Basic NHS Price: Bath Additive – 500ml plastic w/w. Indications: Symptomatic relief of red, inflamed, damaged, dry or bottle £5.75. Legal Category: GSL. Date of Preparation: February 2010. chapped skin, especially when associated with endogenous or exogenous Further Information is available from: Genus Pharmaceuticals Ltd, Benham eczema. Dosage: Bath additive – Adults: Add one or two capfuls; Children: add Valence, Newbury, Berks, RG20 8LU. Cetraben® is a registered trademark. half/one capful to a warm water bath or apply with a wet sponge to wet skin Emollient bath additive before showering. Contra-indications: Hypersensitivity to any of the Adverse events should be reported. Reporting forms ingredients. Special Warnings and Precautions: Care should be taken if and information can be found at www.yellowcard.gov.uk. light liquid paraffin allergy to any of the ingredients is suspected. Care should also be exercised Adverse events should also be reported to Genus when entering or leaving the bath. Avoid contact with the eyes. Side Effects: Pharmaceuticals on 01635 568400. (Refer to the SmPC for full list) vary rarely, mild allergic skin reactions including Made to Measure Date of preparation: June 2010 GENUS CET0610761 01 CP Sep 10 Contents.qxd:Layout 1 19/8/10 11:31 Page 1
COMMUNITY PRACTITIONER
SEPTEMBER 2010: VOLUME 83, NUMBER 9
The journal of the Community Practitioners’ and Health Visitors’ Association Transport House, 128 Theobald’s Road, London WC1X 8TN FRONT COVER PHOTO: PHOTOLIBRARY CONTENTS T: 020 3371 2006 F: 0870 731 5043
UNITE/CPHVA MEMBERSHIP For membership-related enquiries from existing members of Unite/CPHVA, please Tel: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for contacts. To join Unite/CPHVA, apply online at: COMMENT CLINICAL www.unitetheunion.org 3 NHS: the faith to fight 39 Clinical papers JOURNAL SUBSCRIPTIONS Karen Reay June Thompson (For non-members of Unite/CPHVA) The need to become ‘political Early maternal affection and adult UK individual yearly rates: Payment by direct debit £90.00 clinicians’ to save the NHS coping skills Annual payment £99.50 Inequalities in mortality in Britain Student £69.50 greater today than in 1930s UK institutional yearly rate £105.00 NEWS & FEATURES Evidence-based guidelines are needed Rest of the world yearly rates: for nipple shield use Individual £104.00 Institutional £109.50 4 NEWS 41 Clinical update Subscription enquiries should be made to: Community Practitioner subscriptions, 12 Increasing staff numbers Wendy Jones, Sharon Breward Ten Alps Subscriber Services, Alliance Kin Ly Drugs and breastfeeding Media Limited, Bournehall House, Bournehall Road, Bushey WD23 3YG Are current strategies to T: 020 8950 9117 increase the workforce enough? [email protected] www.cphvabookshop.com REGULARS 36 Child eczema clinic PUBLISHERS Ann Francis 16 Letters Published on behalf of Unite/CPHVA by: Ten Alps Creative, One New Oxford Street, Developing a health visitor-led 43 Your rights at work London WC1A 1NU eczema clinic for under-fives T: 020 7878 2300 F: 020 7379 7155 Kate Oultram Scott Ford Managing director Time to train: your rights
ADVERTISING PROFESSIONAL 45 Resources James Priest T: 020 7657 1804 All professional papers have been double-blind 48 Network [email protected] peer reviewed prior to publication
PRODUCTION 19 Practice improvement, Ten Alps Creative (design and production) breastfeeding duration and ● NEW CPD MODULES: The first Williams Press (printing) health visitors of a new series of Unite/CPHVA © 2010 Community Practitioners’ CPD supplements (included with and Health Visitors’ Association Rachael L Spencer, Sheila Greatrex- this issue) addresses hygiene in ISSN 1462-2815 White, Diane M Fraser the home, supported by Dettol Community Practitioner is indexed in the Cumulative Index to Nursing and Allied 24 Emotional labour within ● LAR of the Year Award 2010 – Health Literature (CINAHL) and the Applied community nursing leadership 10 September deadline, see p27 Social Science Index and Abstracts (ASSIA). ● The views expressed do not necessarily Elaine Haycock-Stuart, Annual Professional Conference – represent those of the editor nor of Susanne Kean, Sarah Baggaley 20 to 22 October at Harrogate Unite/CPHVA. Paid advertisements carried International Centre, see p34 in the journal do not imply endorsement by 29 Protection of vulnerable adults: Unite/CPHVA of the products. ● Unite 4 Our NHS campaign – an interdisciplinary workshop see Comment on p3 and: GUIDE FOR CONTRIBUTORS Mary Rose Day, Eleanor Bantry- www.unitetheunion.org/health Community Practitioner welcomes White, Pauline Glavin relevant contributions. Articles on professional issues are double-blind peer reviewed and should be 2000 to 3500 words. Author guidelines are available from the editor. Submissions should be made in electronic format by email to: [email protected]
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EDITORIAL ADVISORY BOARD Gaynor Kershaw (chair) Health visitor, Heywood, Middleton and Rochdale PCT Obi Amadi Unite/CPHVA lead professional officer Maggie Breen Macmillan clinical nurse specialist – children and young people, Royal Marsden Hospital NHS Trust, Sutton Debbie Davison Health visitor, Surrey PCT PHOTOLIBRARY COMMENT Toity Deave Research fellow, Centre for Child and Adolescent Health, Bristol Wendy Deshpande Breastfeeding programme lead, Croydon Community Health Services Barbara Evans Unite/CPHVA Community Nursery Nurse Forum chair NHS: the faith to fight Gavin Fergie Unite/CPHVA professional officer for Scotland and Northern Ireland Margaret Haughton-James School nurse team leader and practice nurse, Practitioners need to become ‘political clinicians’ to save the NHS as a Lambeth PCT Avril Jones Research health visitor, joined-up entity, free at point of delivery and paid for by general taxation Gwent Healthcare NHS Trust Kay Kane Independent nurse advisor, community nursing The White Paper on the health service, put What is depressing about the coalition is Catherine Mackereth Public health lead – together in just six weeks, is the biggest that it was presumed that the Liberal mental health and wellbeing, Sunderland Teaching PCT onslaught on the founding principles of the Democrats would act as a brake on their Brenda Poulton Professor, Institute of NHS since its establishment in 1948. partners. In fact, the party of Lloyd Nursing Research and School of Nursing, County Antrim Giving the majority of the NHS budget George, Maynard Keynes and William Lesley Young-Murphy Acting director of to GPs – some £70billion – is an open Beveridge (the architect of the welfare community services and head of patient care, North Tyneside PCT invitation to private healthcare companies state) has its foot on the accelerator with to substantially increase the 4% of NHS the same ferocity as the Conservatives. EDITORIAL TEAM services that they currently provide. Their The rapidity of this ‘reform’ risks social Danny Ratnaike Editor cohesion, and as the state is pared down [email protected] first loyalty is to their shareholders, not to Jane Appleton Professional editor the ethos of the NHS. Decisions on hip Big Society is meant to take over, with [email protected] replacements at your local hospital could thousands of volunteers to emerge (from Kin Ly Assistant editor [email protected] be made by a company in the US Midwest. where?) to take over its responsibilities. T: 020 7878 2404 As its founder Aneurin Bevan said, the NHS ‘will last as long HONORARY OFFICERS as there are folk left with the faith to fight for it’ Lord Victor Adebowale President Angela Roberts Chair Alison Higley Vice chair Unite health sector members need to The state has been fundamental to health move beyond their everyday role as clini- and educational improvements over the PROFESSIONAL OFFICERS cians to become more political with a last century because the previous ad hoc T: 020 3371 2006 Obi Amadi Lead professional officer small ‘p’ – to be advocates for local needs, arrangements – heavily reliant on charities Gavin Fergie Professional officer for Scotland and to make the case for a unified and and private philanthropy – were inefficient. and Northern Ireland universal NHS, not only with managers, Up to 40% of army recruits to the Boer Rosalind Godson Professional officer for school health and public health but with MPs, opinion formers, patient War were unfit for service because of Dave Munday Professional officer and community groups and the media. rickets and other poverty-related diseases. What health secretary Andrew Lansley is This led to the 1903 Committee of COMMUNICATIONS Shaun Noble Communications officer proposing is untested, rushed, probably Physical Deterioration, which recom- [email protected] very expensive to implement and with no mended medical inspections for children guarantee that services to patients will and free school meals for the poor. LABOUR RELATIONS dramatically improve. The case for the state to have the over- Barrie Brown Lead officer for nursing Siân Errington Research/policy officer While the White Paper is hurried into riding responsibility for the nation’s health being with only cursory consultation, the is watertight, but it will have to be fought Conservative manifesto pledge of 4200 for. As its founder Aneurin Bevan said, the more health visitors appears to be parked in NHS ‘will last as long as there are folk left the slow lane. And what is happening to the with the faith to fight for it’. 2004 promise that every one of the 3300 For the Unite 4 Our NHS campaign, see: secondary schools in England would have a www.unitetheunion.org/health specialist school nurse by 2010 who would also look after the ‘feeder’ primary schools? Karen Reay We are light years away from achieving this. Unite national officer for health 04-10 CP Sept 10 News.qxd:Layout 1 19/8/10 11:37 Page 4
NEWS
NHS plans: ‘more privatisation’
Unite has stated that the NHS White Paper will result in more privatisation, amid fears over fragmentation and costs
The government’s NHS White Paper Equity GP consortia: private intervention drive down costs even more, especially as and excellence: liberating the NHS has been There are concerns that if GP consortia the Big Society welcomes private sector criticised by Unite as opening up the NHS encounter problems, it is likely that private intervention. This will mean that quality is to greater privatisation. companies would bid to run them. Unite compromised for cheapness.’ Unite national officer David Fleming Health Sector lead officer for nursing Barrie Even organisations that have welcomed stated: ‘This is an untested, expensive Brown stated: ‘There is every risk that Big Society are concerned. National Council Trojan Horse in political dogma that will private sector firms will step in where GP for Voluntary Organisations chief executive give private companies an even greater consortia get into difficulties, and experi- Stuart Etherington said: ‘The government stake in the NHS.’ ence in the US with the health maintenance must ensure that cuts do not disproportion- The union accused health minister organisation has shown that.’ ately hit the most vulnerable and scupper Andrew Lansley of backtracking on a pre- the chances of achieving the Big Society.’ election pledge that there would be no more There is every risk that major reorganisation of the health service. private sector firms will step Increase in social enterprises Unite assistant general secretary Gail The Department of Health (DH) has in where GP consortia get Cartmail added: ‘I do not believe this is announced that a further 15 social enter- what people voted for and my fear is that into difficulties prises will be set up through the Right to government will speed on before the public Request scheme. This is in addition to the realise what is at stake. That’s why I He added: ‘Public health initiatives could 16 created since the scheme was set up in encourage all Unite members to join us at be forgotten against all the other demands 2008, obliging PCTs to consider requests Westminster on 19 October, the eve of the and the turbulence caused by the biggest from staff to deliver services through a comprehensive spending review, and take reorganisation of the NHS since 1948. It social enterprise. part in the Trades Union Congress (TUC) could affect health visiting if GPs and Former director of Millmead Children’s Parliamentary Lobby.’ others expect health visitors to shoulder the Centre Partnership Frances Rehal stated: Further details will be available on the responsibility for developing the public ‘This model has helped to ensure that a Unite 4 Our NHS campaign website, see: health initiatives – they have the skills but very needy and socially marginalised www.unitetheunion.org/unite4ournhs will they have the resources?’ community in Millmead in East Kent has White Paper proposals to meet the been successfully engaged. It has enabled government’s aim to devolve power from Public to private and voluntary sectors parents and staff to become members of Whitehall to patients and professionals The government has also launched the Big the organisation and work together to include streamlining the NHS and getting Society programme to open up public come up with local solutions for local rid of ‘layers of bureaucracy’ by abolishing services to new providers such as charities, challenges. It enables local decision making all primary care trusts (PCTs) and strategic social enterprises and private companies. and local accountability.’ health authorities, developing GP consortia Unite national officer for community and She added: ‘I think social enterprises have instead with commissioning responsibili- not-for-profit sector Rachael Maskell a real part to play and they should be ties. The government states that it plans to stated: ‘The voluntary sector is being hit by looked at in the context of giving back ‘create the largest social enterprise sector in massive cuts to its funding – for example, power to local communities.’ the world by increasing the freedoms of Croydon Council has slashed 70% of its Gail Cartmail responded that Unite’s foundation trusts’, and affirms that all NHS voluntary sector budget. The coalition’s position ‘is firmly opposed to social enter- trusts will become foundation trusts. rampant drive for greater competition will prise for the delivery of NHS services – although they may be supported initially TUC Parliamentary Lobby for the best of reasons, the model fragments provision and lays the founda- Join Unite at the TUC Parliamentary Lobby on 19 October, tion for further privatisation.’ see: www.unitetheunion.org/unite4ournhs Cost of reorganising the NHS Although the DH stated that the reforms could cost up to £1.7billion, an editorial in the British Medical Journal estimated the cost to be between £2billion and £3billion, based on National Audit Office survey data. Barrie Brown stressed: ‘These costs will reduce the money and resources available
for protecting frontline services.’ PHOTOLIBRARY
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NEWS
A ‘forgotten generation’ 20 to 22 October, Harrogate International Centre Unite/CPHVA has warned of the long-term effects of public sector cuts, particularly to services that target children and young people. Unite/CPHVA professional officer Dave Munday stated: Conference: 007 party ‘There have been claims that the government wants to change phrases often used to describe health, for example from The theme for this year’s Unite/CPHVA annual professional “narrowing the gap” to “close the gap”. From the cuts that are conference party is James Bond and it will take place on the being inflicted on youth services, the government shows itself second night of conference. to be good on rhetoric but very poor on the reality of the Unite/CPHVA professional officer Gavin Fergie stated: ‘The situation. Universities are more oversubscribed than ever, UK conference is the one thing that all members should do while benefits are being slashed and support mechanisms as we only live once – don’t be a “Dr No” and come along. destroyed, creating a forgotten generation.’ It will be a real case of from Harrogate with love, and In a letter to all directors of children’s services, children’s memories of the conference are like diamonds minister Michael Gove announced plans to cut £169.5million – they are forever, even if some delegates capital funding from a range of youth services. These include the morning after the party have an reducing available funding from the youth capital fund by appearance for their eyes only.’ 50% and cancelling investment in school swimming pools as This year, a poster workshop will part of the Free Swimming programme. enable all candidates who submitted a In Scotland, an Independent Budget Review Panel has paper to display their posters in the exhibi- recommended a reduction of free and subsidised public tion hall and discuss their work with delegates. services, stating that 60 000 public sector jobs could be cut. Breakfast briefings will also be hosted by Unite/CPHVA professional officer Gavin Fergie stated: exhibition sponsors such as NHS Choices, whose ‘Proposals to consider reducing universal services will cause stakeholder manager Adam Harridence will talk professional anxiety among members who have fought long about using NHS Choices in practice. and hard to maintain these as the best route to identify vulnerability. Unite continues to engage in dialogue with the Scottish Government to seek solutions to the financial predicament that we collectively face.’ The panel said that free and subsidised public services had A First Choice Treatment been expanded ‘on a near universal basis’ but that continuing with them on that scale ‘is unlikely to be affordable’. It has For Nappy Rash called on the Scottish Government to review all free or Nappy rash is a common skin condition experienced by subsidised services and look at eligibility and the introduction most babies. As the first point of contact for new parents, of charges. community practitioners are In Northern Ireland (NI), a report commissioned by the ideally placed to offer valuable advice on both prevention and NI Council for Voluntary Action (NICVA) suggests that treatment. Always read the label £1.2billion-worth of spending cuts will need to be made over Morhulin is a dual action nappy rash cream containing zinc oxide, the next five years. The NICVA is worried that the cuts could a known barrier cream1, enhanced with the natural benefit of cod have a disproportionate impact on voluntary and community liver oil, which promotes the healing of wounds, whilst soothing organisations that deliver public services. and moisturising the skin. Cod Liver Oil also contains Vitamin A which contributes to its healing effects. Ahead of the UK-wide comprehensive spending review due on 20 October, Welsh first minister Carwyn Jones visited Morhulin is available in 50g and retails at £2.99 public sector staff in North and South Wales to ask them how services could be improved while reducing costs. e ob A comprehensive spending review has also been launched in For further information on nappy rash Jersey, and Unite and other unions have launched a public SS\ prevention and treatment, visit 1D www.morhulin.co.uk. The site contains consultation on it. Proposals include making £50million- K a section dedicated to healthcare worth of public service cuts by 2013. UDV our baby’s professionals, where an educational w mum, y As a ne In a letter leaked to The Guardian, home secretary and health and wellbeing will leaflet containing nappy rash advice
naturally be at the top ofte ,your so agenda. Your and baby’s delica skin is can be downloaded or ordered to equalities minister Theresa May warned chancellor George precious it’s important you take good distribute in your surgery. Additional care of it from top to toe. Osborne that spending cuts could widen inequalities: ‘There leaflets can be requested free of are real risks that women, ethnic minorities, disabled people charge by simply visiting and older people will be disproportionately affected. Women, www.leaflets2U.co.uk. for instance, make up higher number of public sector workers, and all four groups use public services more.’ The minister stressed that under equality laws it is a legal 1 requirement to consider this when forming any policies. www.nhs.uk 04-10 CP Sept 10 News.qxd:Layout 1 19/8/10 11:37 Page 6
NEWS
IN BRIEF... Arm’s length bodies streamlined
New educational supplements A number of government-funded arm’s length not happen, the CHRE should review how it can Unite/CPHVA has launched a new series of bodies (ALBs) in charge of quality improvement work efficiently.’ educational supplements that can be used to and public health will be abolished or have The HPA will be abolished support continuing professional development functions transferred to other organisations and its functions transferred to (CPD) portfolios, and the first is included with following a Department of Health review. a new Public Health Agency. It is this issue of the journal. Produced with Dettol, Affected ALBs include the Council for unclear how the Public Health the first one is about promoting hygiene. Healthcare Regulatory Excellence (CHRE), Agency will operate, though Health Protection Agency (HPA) and NHS details are expected to be Next issue: skincare CPD supplement Institute for Innovation and Improvement. published later this year. Johnson & Johnson is supporting Unite/CPHVA The CHRE will become self-funding, charging Some of the functions of the NHS in developing a second educational supple- a levy on the regulatory bodies that it oversees, Institute will move to the new NHS ment, which will be included in the next issue including the NMC. Unite/CPHVA lead profes- Commissioning Board, and the of the journal. It will provide an overview of sional officer Obi Amadi commented: ‘We hope government has said that it will identify what the latest evidence about infant skin care. that this change does not result in an increase in other functions could be delivered through the registrant fees. In order to ensure that this does creation of independent organisations. Unite general secretary election The deadline for nominations for the election of a new Unite general secretary is 12pm on 6 September. The ballot is expected to be held from 25 October to 19 November. Health visitors take on school-age
LAR of the Year nomination deadline workload: ‘consultation ignored’ The nomination deadline for this year’s Local Accredited Representative (LAR) of the Year Unite/CPHVA has been in contact with health the health visitors workforce to work across Award is 10 September. Award nominations minister Anne Keen to emphasise that a model the nought-to-11 age group.’ should be sent to Barrie Brown on email: being introduced in North Yorkshire will mean However, Unite/CPHVA stressed that the [email protected] or by post to: that health visitors will be expected to take on PCT has only 8.33 whole-time equivalent Barrie Brown, Transport House, 128 Theobald’s school nursing caseloads. school nurses, despite being the third largest Road, London WC1X 8TN. To access a form, Following previous reports, the minister had PCT in England. see: www.unitetheunion.org/cphva stated: ‘I am informed that health visitors are The model is due to be implemented this not being asked to take on the role of school month, despite an earlier consultation with NHS White Paper consultations nurses. As part of the assessment of children’s staff in which a majority said they were The Department of Health has launched four services at the primary care trust (PCT), health against it. Unite stated that an evaluation on consultations on elements of the NHS White visiting and school nursing have undergone a the use of the same model in NHS Harrogate Paper – developing the NHS Outcomes service modernisation. The service modernisa- suggested that health visitors did not have the Framework, giving local authorities a stronger tion included utilising the transferable skills of capacity to take on this extra work. role in supporting patient choice, putting local consortia of GP practices in charge of commis- sioning services, and proposals about founda- tion trusts. The consultation deadline is 11 Lansley’s healthy eating policies opposed October. For details, see: www.dh.gov.uk/en/ Healthcare/LiberatingtheNHS Unite/CPHVA is one of 30 could reduce obesity and help NMC alcohol and drug conviction policy organisations to sign a letter to children’s concentration.’ The NMC has introduced a new policy requiring health minister Andrew Lansley The joint letter calls for a meeting nurses and midwives who have received a expressing concerns about plans with the government in order to caution or conviction for an alcohol or drug to halt the extension of free share evidence. related offence to submit a medical assess- school meals, his criticism of Meanwhile, a report by the Centre ment when they reapply for registration. For Jamie Oliver’s healthy school for British Teachers has identified a details, see: www.nmc-uk.org/Registration/ meals campaign and proposals to need to engage families to adopt Staying-on-the-register/ and click on ‘Declaring allow commercial organisations to healthy lifestyles. While it police charges, cautions and convictions’. help fund Change4Life. acknowledged that school-based Unite/CPHVA professional officer programmes could be effective, it NI cervical screening from 25 Dave Munday stated: ‘Not expanding noted: ‘No intervention to date has found an The Department of Health, Social Services and free school meals shows that the government is effective means of engaging with families.’ Public Safety has announced that it will raise not true to its word on giving public health a It stated that schools alone will not be able to the cervical screening age from 20 to 25 in high priority. There is a wealth of evidence to reduce obesity, and the government should take Northern Ireland (NI) by January 2011. suggest that nutritionally balanced school meals action to develop family-based interventions.
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NEWS
ADVERTISEMENT NE Lincolnshire ballot: Breastfeeding is best for babies* no NHS option The Child NutritionCOLUMN Unite has criticised a ballot of NHS North East Lincolnshire Q&A staff, because it fails to ask if they want to stay in the NHS, but only whether they want to work for a social enterprise or a consortia of GPs. Q What advice should I give to a Unite regional officer Dave Monaghan said: ‘If the trust’s mother planning to raise her management is allowed to push through either of the two baby as a vegan? options proposed it will result in the NHS becoming a A vegan diet excludes all animal products, marketing brand to enable lots of private companies, often A including red meat, poultry, fish, eggs, milk and honey. Infants raised on such a diet are at risk of from North America, to make billions of pounds in profits.’ energy, protein, iron, zinc, fat soluble vitamins, B12, B2 He added: ‘It will mean hundreds of dedicated nurses and and calcium deficiencies.1 Alternative protein sources include pulses and nuts. However, these are both high care professionals will not be working for the NHS any more. in fibre, which may bind to certain minerals (particularly In some cases, not all services will be taken on by the new iron) and reduce their bioavailability. It is therefore extremely challenging to raise a baby on a vegan diet2, employer – leaving huge questions over the provision of major and the Food Standards Agency does not recommend a services in the area, such as the unit to assess and rehabilitate vegan diet for a baby.3 Rosan Meyer, If parents do want to raise their baby on a vegan Paediatric Dietitian patients before they return to their own homes with support.’ diet, it is recommended that they seek the advice of a Unite’s local campaigns have resulted in trusts abandoning registered dietitian to assess the growth, macro and micronutrient status of the child. It is recommended that plans to transfer services to social enterprises, including breast or formula feeding should continue until 1 year of age. Most vegan children Sandwell Community Healthcare Services, where 67.2% of staff are fed a soy formula which is enriched with nutrients. It is important that vegan babies should not be given nutritionally deficient homemade/unmodified soy voted against the move, and Shropshire County Primary Care milks before the age of 1. Additionally, a multivitamin is recommended between Trust, which has instead made recommendations to form a 6 months of age and 5 years, and in most cases vegan babies also require B12 supplementation. Special attention should be given to iron, zinc and essential fatty community foundation trust with NHS Telford and Wrekin. acids (especially DHA). As oily fish is not consumed, additional oils like rapeseed, Unite has said there are issues with foundation trusts, but that flax and linseed may be required.4 this is better than a social enterprise. Does breastfeeding nutrition advice For campaign details, see: www.unitetheunion.org/unite4ournhs Q differ for mothers of multiple births? Breastfeeding for multiple births is, in principle, the same as for single births. A Research has shown that the volume of breast milk produced is directly related to the weight of the infant, thus allowing for sufficient production of Welfare reforms: milk for more than one baby. However, to achieve this, the breastfeeding mother has to ensure sufficient nutrient intake of 500–600kcal per baby per day on top of her normal requirements. Also, there may be an increased need for vitamins and minerals, and in particular iron, calcium and vitamin D may be a concern5 for those ‘detrimental impact’ breastfeeding. If there is an increased need, and the diet is not sufficient in these micronutrients, supplementation may be suggested.
Two analyses of a Department of Work and Pensions (DWP) Can health professionals give report on the impact of proposals to changes to housing benefit Q information about formula if asked? have predicted negative outcomes for disadvantaged and The World Health Organization and United Nation Children’s Fund UK A Baby Friendly Initiative ensures that if a mother chooses to bottle feed, vulnerable groups. minimum standards for her care apply. This includes ensuring that mothers Unite/CPHVA professional officer Gavin Fergie stated: ‘The know how to prepare a bottle feed and obtain general information on formula feeds. 5 government continues to publish proposals that have a detri- However, information can only be provided if requested by the parent. mental effect on those most vulnerable in society. Any public References: health nursing student would be able to discuss the detrimental 1. Wolfe S, 2007. Children from Ethnic Minorities and Those following Cultural Diets. In V Shaw and M Lawson, eds. Clinical Paediatric Dietetics. 3rd ed. Oxford: Blackwell Publishing. Ch. 28. impact that this can have on health. It is a pity that such profes- 2. Kirby M et al. Pediatr Clin North Am 2009; 56: 1085-1103. sional opinion seems missing from these policy decisions. 3. Food Standards Agency. Your baby. Feb 2010. 4. Flidel-Rimon O et al. Semin Neonatol 2002; 7: 231-9. Members need to become involved in the on-going national and 5. UNICEF UK Baby Friendly Initiative. http://www.babyfriendly.org.uk/pdfs/baby_friendly_information_leaflet. pdf [Accessed April 2010]. local debate over these and similar ideas to provide the measured, articulate professional challenge to such proposals.’ The National Housing Federation stated that housing benefit Call on our expertise: cuts would equate to £624 a year, and calculated that those For more information on child nutrition affected would include 431 000 women and 178 000 people with please visit www.aptamilprofessional.co.uk disabilities. The Trades Union Congress stated the largest cuts or call our careline on 08457 623 676 This column is brought to you in association with Aptamil would be in London, where 159 370 families would see their This column represents the independent views of the author housing benefit cut by £22 a week. *Important Notice: Breastfeeding is best for babies. Breast milk provides babies with the best source of Other proposals from the DWP include combining the current nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial income-related benefits and Tax Credit systems, bringing out- bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s of-work and in-work support together, and supplementing health. Infant formula and follow on milks should be used only on the advice of a healthcare professional. monthly household earnings through credit payments.
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NEWS
IN BRIEF... Evidence to Munro Review
ContactPoint shuts down Unite/CPHVA has submitted its evidence to the same way that younger children do, and we have ContactPoint has shut down and healthcare Munro Review highlighting the importance of a duty to protect them from harm. But because professionals will no longer be able to school nurses and community nursery nurses as there are fewer school nurses, it means that there access it. The government has announced its well as health visitors in safeguarding vulnerable are fewer opportunities to engage and advise intention to develop an alternative approach children from harm. older children. Evidence suggests that when to help identify whether a colleague is It states that members have highlighted a lack children know their school nurse, then they use working or has previously worked with the of improvements to local practice since the them very well.’ same vulnerable child. The Department for publication of Lord Laming’s second review, The safeguarding young people report by the Education is assessing the feasibility and and draws attention to low numbers of qualified Children’s Society, NSPCC and University of affordability of its plans and intends to staff: ‘Unite continues to highlight the deterio- York found that 8700 young people aged 10 to provide an update in the autumn. ration in the number of health visitors in 15 became the subject of a child protection plan England and the slow growth in the number of in the 12 months up to 31 March 2009. Neglect Sexual health checker for women school nurses.’ was the most common reason, followed by NHS Direct has launched an online sexual Unite/CPHVA has said that the lack of emotional abuse. Young health and symptom checker for women. The qualified school nurses means that vulnerable people had huge difficulties health and symptom checker covers a wide school-age children are not getting the protec- in disclosing maltreatment, range of symptoms and problems, such as tion services that they need. and there was a major gap in sexually transmitted diseases, menstrual problems, loss of sex drive, and pain when In response to a report on protection services research knowledge about urinating or during intercourse. To access this for teenagers, and which concluded that there their maltreatment. and other symptom checkers, please see: were insufficient protection services for 14- to The report’s authors called www.nhs.uk/nhsdirect 17-year-olds who have been victims of abuse of on Professor Munro to neglect, Unite/CPHVA lead professional officer consider changes that need to DPPI one-day conference Obi Amadi commented: ‘Older children still fall be made to protection services Disability, Pregnancy and Parenthood under the protection of the Children’s Act in the for older children. International (DPPI) will be hosting a one-day conference themed ‘Empowering physically disabled parents during pregnancy and Pension review birth’. The conference is free to attend and Early intervention will take place on 14 October at Wesley's Chapel, 49 City Road, London EC1Y 1AU. For review planned independence further information and to book a place, Tel: 0800 018 4730 or email: [email protected] The government has commissioned a review questioned into early intervention that, in addition to NMC Welsh language consultation assessing best models for early intervention, Unite has submitted its evidence to the The NMC has launched a consultation on its will look at how services could be funded by Independent Public Service Commission draft Welsh language scheme, which aims to non-government organisations. (IPSC) review of public service pensions that facilitate the use of the Welsh language in its Unite/CPHVA Health Visitor Forum chair questions its independence. communications. The draft document lays out Maggie Fisher stated: ‘I am not entirely Unite joint general secretary Derek Simpson plans for how it intends to implement the convinced that it is necessary to conduct a stated: ‘The first stage of the commission’s scheme in written and telephone communica- review of what we already know. There is work has been described as “interim”, but it is tion, public meetings and publications, and this is expected to come into effect from already a wealth of evidence that concludes clear from the terms of reference that, in fact, January 2011. The consultation deadline is that early intervention services are effective.’ the first report will be required to make a final 16 October. To take part and to access the She added: ‘There appears to be another judgement on whether there is a case for consultation document, see: www.nmc-uk.org/ motive, and it seems that the key aim is to change. Otherwise, it could not begin to make Welsh-language-scheme-English-translation/ look at how it could be funded by other recommendations for the short-term savings sectors. Where will this non-government the government is clearly keen to realise.’ WellChild ABPN Scholarship funding come from? We know that the He added: ‘Unite questions the independence The Association of British Paediatric Nurses voluntary sector is strapped for cash and of this commission and whether it can resist (ABPN) and charity WellChild have come threatened by increased cuts, so one can only the forceful lobby wishing to drastically erode together to offer a £1000 scholarship to assume that they are looking toward the the modest pensions of millions of public nurses to improve their care for children in private sector, and this will only lead to further sector workers.’ the community. The application deadline is fragmentation and privatisation of the NHS.’ Unite’s evidence argues a number of points, 30 September. For further information and to The review will be chaired by Labour MP including that public service pensions are access an application form, please see: Graham Allen. An interim report is due to be proportional to pay and earned by service and www.abpn.org.uk/site/scholarships/ published at the end of January 2011 and the that higher pensions reflect reward for a long 293/scholarships.aspx final report in May. career in public service.
8 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9
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NEWS
Action on Health Visiting workshop: model of practice
As part of a series of events to develop the asked delegates to give an example of Action on Health Visiting programme, situations where things went wrong in Unite/CPHVA held a one-day workshop practice – it could be situations regarding last month looking at the development of safeguarding and developmental problems a health visiting model of practice. – and then asked them to work through Unite/CPHVA professional officer Obi the model to identify whether the outcome Amadi stated: ‘We are working with the would be different.’ it right for children and families, Department of Health (DH) to develop a Unite/CPHVA professional officer Dave and DH Family Nurse Partnership model for health visitors to use in their Munday added: ‘There was resounding implementation lead Ann Rowe day-to-day practice.’ support from members regarding the gave an overview of the model She added: ‘We have worked with model of practice. There was some discus- and how it could be used to frontline practitioners, researchers, sion about how it could be useful for deliver the Healthy Child programme for academics and safeguarding professionals clinical supervision – but in terms of deliv- nought- to five-year-olds. in terms of testing it and getting it right – ering any sort of clinical supervision, then The workshop, themed ‘From principles we are almost there.’ this model has got to go hand in hand to practice: contributing to a model of The model is still being developed and with one of the key planks of the Action practice for health visiting’, forms part of full details will be available in the coming on Health Visiting programme, which is to the second phase of the Action on Health months, but delegates at the workshop had get more health visitors in place.’ Visiting programme, which is looking at a chance to test the model. Obi stated: ‘The Obi gave an overview of the joint developing a health visiting framework for model of practice was well received. We Unite/CPHVA and DH document Getting improvements in practice. Action on Health Visiting events overview
Unite/CPHVA Research Forum feasibility of using parallel categories Partnership implementation lead Ann member Karen Whittaker and statements for these different forms Rowe and Centre for Parent and Child attended a number of the of healthcare practice. Support director Crispin Day. Here, For some, the assumption that a participants looked in detail at the ‘craft Action on Health Visiting nursing position was a viable starting of health visiting’. This redressed the events that have been held so point for exploring health visiting imbalance created by previous far and provides an overview practice was a basic flaw in this process, workshops, where health visiting practice and prevented the unique nature of had been considered from a nursing During 2010, the Action on Health health visiting practice to be exposed. As standpoint. Attention was given to devel- Visiting programme has built on the a consequence, pinpointing health visiting oping a way of explaining the ‘how’ of ambitions highlighted in the Getting it practice within each nursing framework health visiting through the creation of an right for children and families guide by presented difficulties and progress in illustrated model of practice for preven- giving further consideration to the these three workshops was slow. tive health visiting services. It is antici- dimensions of health visiting. The fourth workshop was dedicated to pated that this model – and the Early in the year, practitioners, the topic of leadership and how this accompanying information detailing the managers, commissioners and might feature as a chapter within the E- theoretical base, essential skills, qualities, academics attended a series of four Learn for Health, Healthy Child attributes and technical expertise workshops to consider health visiting programme (HCP). This was felt to be a required by practitioners – will be careers, preceptorship and leadership. potentially useful resource to support helpful for articulating the health visiting The NHS Nursing Careers framework learning across the workforce, though it contribution to the HCP. and the Preceptorship Framework for was acknowledged that it alone would be The next stage is to pilot the model Nursing were used as templates to insufficient to address leadership issues with practitioners. This took place in explore the requirements for supporting within health visiting services. London last month (see above) and a sustainable health visiting workforce. The more recent Action on Health subsequent events around the country This proved challenging and partici- Visiting activities have been organised as are being planned for the autumn. pants debated the congruence between ‘Deep Dive’ events jointly facilitated by For details of future events, see: health visiting and nursing roles and the Department of Health Family Nurse www.unitetheunion.org/cphva
10 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 Bio-Oil® is a skincare oil that contains a combination of natural oils and vitamins, together with the breakthrough ingredient PurCellin Oil™. It was developed in 1987 and is today the number one selling scar and stretch mark product in 12 countries. It is available at pharmacies at the recommended price of £8.95. For comprehensive product information please visit bio-oil.com. Bio-Oil® is a product of Union Swiss, successfully treating skin since 1954.
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NEWS FEATURE
Increasing staff numbers Strategies are being pursued to increase the workforce, but are they enough?
Kin Ly assistant editor
Last September, the journal reported on will dramatically increase the recruitment Rita states: ‘There is already recognition the true scale of the health visiting crisis in to these programmes.’ that if you are a graduate, then you can London, and since then many NHS organ- complete the nurse education programme isations have made pledges to increase Return to practice in two or three years. The assumption is staffing numbers. NHS London and NHS East Midlands that if you are a graduate, then you have In May, NHS London launched a health have developed a three-month return-to- that ability to learn at a quicker pace. visiting strategy providing several other practice pilot programme. In London, this There is still 50% theory and 50% practice, routes into the profession and there is a will start in September and in January at and the person would have student status focus from the government to provide City University London and Bucks New and supernumerary status.’ 4200 more health visitors, though it is University. In the East Midlands, the NHS London is also working with not clear how this is to be delivered. programme will begin this month at the community service providers in the capital Additionally, some organisations such as University of Northampton. in order to progress with its plans to NHS Cornwall have been looking at other develop a career framework for CNNs to home visiting solutions with the develop- If all relevant NHS access nurse training and subsequent ment of local training pathways for staff organisations follow health visitor training. nurses into health visiting and/or school nursing, and Unite has been working to this strategy, then it could Everyone must follow suit ensure that these are safe and appropriate. become an adequate solution Although NHS London’s strategy and the Although the Welsh Assembly government’s pledge on additional health Government has committed to employing These two SHAs aim to get 60 health visitors have been welcomed by one named school nurse in every visitors back into practice, and those Unite/CPHVA, there are still examples secondary school, the target of providing enrolled on the course will have their where services are suffering because of a one school nurse for every secondary in course fees paid and be entitled to a lack of health visitors. England remains far from being met. bursary of £1000 to cover expenses. Unite/CPHVA professional officer Dave NHS Sutton and Merton health visitor Munday stresses: ‘If all relevant NHS More than one route Janet Neale, who completed a return-to- organisations follow this strategy, then it NHS London’s health visiting strategy practice course after being away from the could become an adequate solution. But includes a return-to-practice campaign, a profession for 10 years (see Box 1), says: the problem is that only pockets of areas fast-track entry route and career frame- ‘I think health visitors who are a bit more are doing something proactive about it.’ works for community nursery nurses mature, not necessarily in age but in terms In NHS Waltham Forest, which has (CNNs) to get them to a level where they of having more life experience, will come longstanding problems with recruitment can access registered nurse training. back with a wider vision.’ and retention, the health visiting situation Unite/CPHVA strategic alliance profes- She adds: ‘Health visiting is the best job has worsened according to Unite/CPHVA sional officer Rita Newland states: ‘We are that I have ever done and I am absolutely local accredited representative (LAR) encouraged to see that NHS London is delighted to be back in the field. What is Elaine Baptiste. taking a multifaceted approach to increas- most rewarding is the satisfaction that I She says: ‘If you add up the number of ing the number of health visitors in the have done a good job, and that they health visitors who have left and those profession. However, there is an urgent genuinely appreciate it.’ who are going to leave, the total loss is 10 need for the strategy to also include a whole-time equivalent (WTE) health review of the funding systems that support Fast-track into health visiting visitors. We do not have anywhere near health visitor education programmes.’ NHS London states that the development enough staff to cope with the complex She adds: ‘Currently, funding is allocated of its fast-track route is ‘progressing well’. issues in the area.’ on an annual basis from the strategic It is shortlisting applicants for the course, Despite that the trust has confirmed that health authorities (SHAs) to the NHS which will begin later this year at King’s there will be no vacancy freezes and that organisations, and is very vulnerable when College London. they are recruiting to all health visiting budgets are cut in situations of financial The SHA confirmed that the programme vacancies, their workload has increased. downturn. We encourage NHS London to would be made up using existing Elaine states: ‘To add to our usual create a stable funding system as part of curricula, including the two-year postgrad- workloads, social services have reported the strategy that allows NHS organisations uate diploma in nursing and one-year more cases of domestic abuse – it seems to and higher education institutes to invest in specialist community public health nurse me to have increased five-fold – but we do these programmes over time, because this (SCPHN) course. not have the health visiting staff to cope.’
12 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 12-13 CP Sep 10 Newsfeature.qxd:12-13 CP Feb 09 News_NEWv6.qxd 19/8/10 11:40 Page 13
NEWS FEATURE
‘The course was excellent and provided me with adequate Box 1. Returning to practice: Janet Neale training to return to practice. We had to compile a portfolio, ‘I qualified as a health visitor in 1982, and in 1997 I left health attend study days, and complete 150 hours of practical work, visiting and went to live and work in the US. When I moved back which involved the invaluable guidance and support of a mentor. to the UK in 2007, I wanted to get back into health visiting – but ‘Going back into practice for the first time was like putting on an e over. after 10 years away, I felt that my health visiting days wer old familiar shoe, and it was so exciting going back in the field! As Trends had changed and there are so many degree students now my mentor said, “The skills and knowledge are already there, it is that I wasn’t too sure how I would compare to them. But after simply a case of making sure that you are up to date”. talks with my family, friends and colleagues, who all told me that I ‘I’ve noticed so many changes. There are much more child would be wasting all my valuable skills if I didn’t go back, I protection cases now. We do not do as many developmental ofession. decided to find my way back into the pr checks, and sometimes you think “Is this as good a service as it eturn to practice ‘Unfortunately, information about how to r once was?” But I guess times have changed and resources are wasn’t easily available. Courses were not advertised and a lot of different, so we just have to try and give as good a service as we people did not know of their existence. If I hadn’t used my initia- can with what we’ve got – and we do! tive, I wouldn’t have known about it at all. I decided to contact my ‘Years ago we visited families more, now we have to sell ourselves ector for children’s GP practice and was told to contact the dir and the service at the first visit to empower them to come to clinic eturn-to- services, who gave me positive encouragement to do a r and children’s centres to seek help. Earlier qualified health visitors rey, and I have practice course. I enrolled at the University of Sur have a strong basis of knowledge to add to the team.’
never looked back. PHOTOLIBRARY
Widespread problems will increase health visitor numbers in the urgent appointments, and are worried that Other areas across England are also still autumn, and that health visitors need to be things are slipping through the net. We’re suffering from staffing problems. An encouraged to stay or return to the asking the trust to follow the recommen- Ofsted report about safeguarding services workforce. This goes completely contrary dations of Lord Laming and the Healthy in Birmingham stated: ‘Significant invest- to what is happening in some organisa- Child programmes appropriately.’ ment has been made across the three tions, where they are actively getting some Unite has stated that there is a job freeze primary care trusts (PCTs) to tackle health visitors to leave by making it very and no cash to recruit school nurses or longstanding difficulties in recruiting and difficult to work in this environment, health visitors in North Yorkshire. retaining health visiting staff, but this has saying that they are freezing posts or Unite/CPHVA LARs have developed a yet to have a demonstrable impact.’ encouraging them out of the door.’ petition against the reduction of health Salford safeguarding services, which had visitors and school nurses in the area, previously been criticised by Ofsted as Health visitors and school-age care which is supported by Netmums, and are ‘inadequate’, have since been found to School nurse numbers appear to vary calling for more signatures, see: have made insufficient improvements. widely, with optimism in some areas but www.surveymonkey.com/s/YC3NTJD Ofsted noted: ‘Despite the shortage of health visitors being asked to take on NHS Hounslow, which previously stated health visiting staff, caseloads have been school nurse caseloads in others. that it had difficulty recruiting school nurse reorganised to ensure that work with University of Wolverhampton SCPHN students, continues to experience the same children and young people with a child course leader Sarah Shewin states: ‘Student problems. The trust has confirmed that it protection plan is prioritised. A recent school nurse numbers here are very has only been able to recruit health visitor audit carried out by Salford Safeguarding healthy. We are expecting approximately 22 students: ‘NHS Hounslow is sponsoring Community Board found that, while new school nursing students to start in four student health visitors for 2010 to reports from health visitors and school September from across the west midlands 2011, though we advertised for both health nurses mostly provided good chronolo- and this may increase to 24 – we are visitor and school nurse students.’ gies, not all had a clear and concise waiting for that to be confirmed.’ It could be a few years before we see any analysis of strengths and risks.’ However, due to a severe shortage of notable increase in health visitor and It also stated that the identification and school nurses in NHS North Yorkshire and school nurse numbers, since the pool of management of risk when children are York, health visitors will be expected to qualified SCPHNs is so small. Although referred to social care services is still not take on school nursing caseloads this there is optimism with the new fast-track consistent. Referring to public sector cuts, month. Prior to the trust’s decision to route, it would still take a couple of years Dave comments: ‘Health minister Andrew adopt this model, a consultation with staff before students qualify through it. Both Lansley has promised that frontline was carried out that suggested that the fast-track and return-to-practice services will be protected, so I would majority were against this, but this has programmes, while positive, have not been question whether local organisations are apparently been ignored. developed for school nursing. taking any instruction from that. I’m still Unite/CPHVA LAR Sarah Hughes states: meeting members who are facing service ‘Nothing is being done to increase school For more information cuts, and when we ask managers why they nurse numbers. There are only 8.33 WTE For return-to-practice courses in are proceeding with that in light of what is school nurses for whole of North London, please see: being said about frontline services, they Yorkshire. There needs to be better recog- www.london.nhs.uk/hvreturntopractice are saying that they must cut costs and this nition of the different roles that we play.’ For the East Midlands return-to-practice is how they are going to do it.’ NHS Haringey has adopted this model, course, email: [email protected] He adds: ‘Ministers Anne Milton and and according to feedback from staff there, For the fast-track course, see: Sarah Teather have made comment at a the move has not been positive. Sarah www.kcl.ac.uk/schools/nursing/ visit to Grove Children’s Centre last month states: ‘Health visitors have had to cancel fasttrack that they will announce plans of how they their appointments to make it to more
September 2010 Volume 83 Number 9 COMMUNITY PRACTITIONER 13 21194_Apt Ingre DPS Ad_New Abacus_Com Prac_AW:1 17/3/10 19:07 Page 1
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IMPORTANT NOTICE: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breast fed. The decision to discontinue breast feeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breast feeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to Journal: Community Practitioner a babies health. Infant formula and follow up milks should be used only on the advice of Size: 297 x 420 mm Bleed: 3 mm Supply as hi-res PDF Job No: 21194 a healthcare professional.
CP Sept 10 14 Aptamil.pdf 1 23/08/2010 09:54 16 CP Sep 10 Letters.qxd:Layout 1 18/8/10 15:59 Page 16
LETTERS
Acknowledging not-for-profit service providers
Regarding the PCTs ignore ballot results news item in July’s their PCT or NHS hospital trust. They were able to focus on journal, I write as a health visitor and CPHVA member with achieving change in key healthcare areas. Their experience and over 25 years’ experience of working in the public sector. I set knowledge of public health, community development, working up a community mutual organisation (type of social enterprise) with hard-to-reach families, evidence-based practice and their in a very deprived community in Millmead on the outskirts of willingness to challenge the status quo all helped ensure that we Margate. This community had not been able to benefit from developed services that made a difference to local children and statutory service provision, provided through the regular families. As part of a larger integrated team, the health staff hierarchical, service-led, standardised approaches. The were ‘freed up’ to use their extensive knowledge and skills to community members had little confidence in statutory service bring about positive changes in the Millmead area. provision and felt sceptical that agencies would ever be able to The model has been running for over five years. It is now a provide the services that parents felt they and their children Sure Start children’s centre and is contracted by Kent County needed. It was very apparent that if we as a local Sure Start Council to deliver children’s centre services. Funding has been programme were going to make a significant difference to agreed up to March 2011. It has not been privatised. It is an people’s lives on the estate, then we needed a model of gover- effective service provider that places meeting the needs of the nance that parents and children felt part of. local community at the heart of the programme. We developed a community mutual where parents are paid-up Since the general election, there is a lot of uncertainty about (£1) members and where staff are also eligible to become future funding of public services and how services will be members. The programme provided a wide range of services remodelled. This uncertainty is experienced by community including health visiting and midwifery. It provided services in mutuals alongside other service providers in the statutory and ways that made sense to local parents. The model also enabled third sectors. Community mutuals like Millmead have a lot in parental input in relation to the commissioning of services to common with statutory service providers. They are all not-for- meet local needs. Parents were readily able to tell us what they profit organisations that invest in service provision. Let us work and their children needed. Through parental involvement and together to fight for services for children and families irrespec- the inclusion of local knowledge in the planning cycle (health tive of the governance model used. Commitment to supporting visitors, midwives and speech and language therapists), we were children and families is what we all have in common. Evidence able to evidence an increase in breastfeeding rates at birth from shows that large hierarchical organisations are unable to ‘bend’ 27% to 60%, a decrease in teenage births by about 60% over an to provide flexible services to support communities like eight-year period and a significant reduction in hospital admis- Millmead. Let us acknowledge this and move on. sions for young children under four years. The health visitor and midwife who were seconded onto the programme were Frances Rehal able to work in different ways than how they would operate in Director of Millmead Children’s Centre Partnership Ltd
August’s cover image without using a picture of a child in such a ensured there was a supportive environment As a group of health visitors who have negative format. to protect her from being affected negatively. valued our journal and held it in high However, you are right that we cannot Ann Burke Health visitor, Leeds regard, we were very alarmed to see the know the precise circumstances – the only front cover of our recent issue. I am sure Thank you both for getting in touch to feed assurance we have is that the image is from we are not alone in finding the image it back about this and share your concerns. a reputable source, and that a proper release portrays to be disturbing, and while we I am sorry to hear that anyone found this form was signed on the model’s behalf. appreciate that the child involved was image to be offensive and upsetting, since I am discussing this further with Unite/ undoubtedly well protected, as we are that certainly was not the intention. CPHVA professional officers to ensure that assured children exploited ‘in the movies’ As much as we want to produce striking we are taking these issues into sufficient for entertainment are, we can’t help but and effective covers, we do endeavour to consideration when choosing journal images. wonder what effect it had on this child, for ensure that we are responsible in how we do Danny Ratnaike Editor little purpose. Not usually ones to be this and that they do not conflict with what ‘picky’ but feel uncomfortable about this. Unite/CPHVA stands for, and to this end all covers are approved by Unite/CPHVA. Kathy Ashdown Health visitor, Weymouth Say something! The effect of being involved in producing I am writing to express my concern images or entertainment on children is also Send letters of up to 300 words via email: regarding the picture on the journal an important and serious issue, and one that [email protected] or by post to: depicting a child with a knife in her hand. would be of special concern to our readers. Community Practitioner, Ten Alps Creative, I do not feel that this is an appropriate I would hope and expect that in posing for One New Oxford Street, London WC1A 1NU picture, and feel that depicting a child with this still photograph, the girl would have a knife in her hands is offensive and simply been asked to pose rather than act upsetting. There are other ways in which out or imagine herself in a distressing you could have expressed your concern scenario, and that those responsible for her
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PROFESSIONAL
Practice improvement, breastfeeding duration and health visitors
Introduction to supporting change in health care, Rachael L Spencer MSc, BSc, RGN, RHV, RNT There is evidence of a growing number of having originated within the nursing Senior lecturer in nursing, University of Lincoln methods aimed broadly at improving profession over two decades ago.4 Practice practice, particularly within health care. A improvement is ‘concerned with creating Sheila Greatrex-White RN, PhD, MEd, CertEd, DipN recent systematic review of interventions transformational cultures of effectiveness, Lecturer in nursing, MSc course director and ERASMUS that promote the duration of breastfeeding for the purposes of delivering person- co-ordinator, University of Nottingham revealed a dearth of literature in the fields centred, evidence-based health care. It uses of training and education of healthcare systematic approaches and skilled facilita- Diane M Fraser PhD, MPhil, BEd, MTD, RM, RGN professionals and breastfeeding counsel- tion to develop practitioners, teams, Professor and head of division of midwifery, lors, in addition to that relating to practices, workplaces, organisations and University of Nottingham evidence-based practice or practice communities’ (p240).5 improvement initiatives.1 The literature identifies a number of Abstract Breastfeeding is a key public health contextual and cultural factors that have an The primary purpose of practice improvement is to priority. A recent evidence-based review2 impact upon practice improvement. These improve clinical practice through changing the behaviour of healthcare professionals. found that a history of breastfeeding was include organisational structure, the Breastfeeding is a key public health issue, conferring associated with a reduction in the risk of expertise of practice improvement facilita- benefits associated with both infant and maternal acute otitis media, non-specific gastroen- tors, the context of practice settings and health, yet breastfeeding rates in the UK and Ireland teritis, severe lower respiratory tract infec- workplace culture. There are also a number are among the lowest in Western Europe. tions, atopic dermatitis, asthma (in young of challenges to the concept of practice In this paper, the ways in which practice improvement children), obesity, type-1 and 2 diabetes, improvement. These include multiple can be utilised to enhance both efficiency and childhood leukaemia, sudden infant death perspectives that may lead to a lack of effectiveness are described, using a case study of the syndrome and necrotising enterocolitis. focus, and the tendency for initiatives to be potential contribution of health visitors to increasing For maternal outcomes, a history of only weakly linked to strategic outcomes breastfeeding duration in primary care in order to lactation has been associated with a and the modernisation agenda.4 It has also illustrate this in clinical practice. reduced risk of type-2 diabetes and of been suggested that the involvement of breast and ovarian cancers.2 Ip et al2 also managers in practice improvement is Key words found that the early cessation of breast- crucial to the successful implementation of Practice improvement, health visitors, breastfeeding feeding or a decision not to breastfeed its processes and the sustainability of were associated with an increased risk of outcomes.4,6,7 It is beyond the scope of this Community Practitioner, 2010; 83(9): 19-22. maternal postpartum depression. The paper to critically analyse all of these World Health Organization’s Global factors in detail, but key barriers to imple- strategy for infant and young child feeding3 menting available evidence for best describes essential interventions to practice in relation to improving practice promote, protect and support exclusive in breastfeeding will be discussed later. breastfeeding. While improved maternity services help to increase the initiation of Breastfeeding context exclusive breastfeeding support through- A review of evidence has demonstrated that out the health system is required to help on a population basis, exclusive breastfeed- mothers to sustain it. ing for six months is the optimal way of This paper describes the ways in which feeding infants.8 Thereafter, infants should practice improvement can be utilised to receive complementary foods with enhance both efficiency and effectiveness, continued breastfeeding up to two years of using the potential contribution of health age or beyond. The existing Public Service visitors to increase breastfeeding duration Agreement for England aims to see levels of in primary care as a case study to illustrate breastfeeding prevalence at six to eight this in clinical practice. weeks as high as possible.9 International initiatives have been insti- Approaches to practice improvement gated over the past 25 years in an effort to Practice improvement (also known as increase breastfeeding rates.3,10,11 The practice development) is a broad term that public health White Paper Choosing health: is used to describe particular approaches making healthy choices easier,12 Every child
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matters13 and National Service Framework attention. Furthermore, there has been an Moreover, the failure of healthcare practi- for children, young people and maternity assumption among some health visitors tioners to provide consistent, adequate and services14 have re-emphasised the impor- that breastfeeding promotion in terms of appropriate postnatal support and tance of initiatives to support breastfeed- positioning, demand feeding, cues that an education has been suggested by a number ing. These governmental policies provide a infant is hungry and night-time feeding are of authors27-29 as one reason that may powerful context for local action to all part of the remit of the midwife.21 contribute to the early cessation of breast- improve public health outcomes for Against this background and the imple- feeding. Studies have identified a paucity of children and their families. Despite these mentation of the latest Health for all pre-registration training for specific initiatives, breastfeeding rates in the UK children22 recommendations, the role of groups of healthcare professionals – and Ireland are among the lowest in health visitors in breastfeeding requires GPs,30,31 nurses26 and midwives.32 Western Europe, and indeed worldwide.15 further exploration. There has been recent Participants in both Smale et al’s31 and Successive surveys by the Office of debate on the lack of clarity about public Wallace and Kosmala-Anderson’s25 studies National Statistics have shown that the health models and approaches to working, reported feeling ill-prepared to support incidence and prevalence of breastfeeding and use of the terms ‘health visitor’ and breastfeeding women. These barriers are all in the UK have increased since 1990. ‘public health nurse’ are often used inter- potentially amenable to change through However, there is a noticeable drop from changeably.23,24 It has been suggested that practice improvement. initiation rates during the early weeks. In this confusion contributes to a lack of The Education Sub-Committee of contrast to other European countries with clarity on their workload prioritisation and Unite/CPHVA has expressed concerns to median durations of breastfeeding of five potential for improving practice.23 A the NMC that breastfeeding education for months or over, the median rate in the UK decrease in numbers of health visitors those undertaking health visitor training is one month.16 The reasons that mothers being recruited, trained and employed remains inconsistent across the UK.33 give for stopping breastfeeding suggest further adversely affects the extent to which Smale et al’s31 study into the provision of that few of them gave up because they they can engage in practice improvement. breastfeeding education found that health planned to, particularly those giving up One of the few studies examining the role visitors who were interested in breastfeed- before four months.15 While improved of health visitors in supporting breastfeed- ing pursued specific additional breastfeed- maternity services help to increase the ing has been published recently. ing training rather than relying upon their initiation of exclusive breastfeeding, Conducted in Glasgow, the study suggests standard initial training, which was support throughout the health system is that babies who are breastfeeding at the described by participants as ‘variable’ or required in order to help mothers sustain first routine health visitor contact at 10 ‘just the basics’ (p108).31 Furthermore, exclusive breastfeeding. days were twice as likely to be breastfeed- those practitioners who developed an ing at the second routine health visitor interest in breastfeeding were not viewed as Role of health visitors in breastfeeding contact at six weeks if the health visitor the norm but as zealots who were ‘evangeli- Skilled support for breastfeeding women had received training in breastfeeding in cal’ and ‘fanatical’ (p109).31 The literature increases the duration of breastfeeding.17,18 the previous two years.19 These results on practice improvement identifies The UNICEF UK Baby Friendly Initiative remain significant after controlling for workplace culture as one of the factors that in the community provides a recognised socioeconomic variables. This observa- has an impact upon its success. There are and accredited framework for routine tional study of routine practice is of profound implications that, if this view practice across NHS community trusts in particular interest, since it examines the perpetuates throughout the health service, England to increase duration of breastfeed- health visitor’s role in supporting breast- then promoting and supporting breastfeed- ing for all women. feeding in one of the most deprived cities ing will be perceived as an activity within While health visitors have had a role in in Europe. There is thus potential for the specific remit of a minority of practi- promoting and supporting breastfeeding health visitors to develop and improve tioners. Challenging the culture of health since the development of the profession in practice, contributing to increasing breast- visitors in their views of breastfeeding and the early decades of the 20th century, there feeding duration in primary care and the their role in supporting women to breast- is little evaluation of their impact on requirement for advice and support feed is a key requirement for practice intention and duration,1 and recent for breastfeeding issues, including feeding improvement to succeed. research suggests that they do not generally a growing infant and anticipation of The ability to understand why healthcare receive adequate training on return to work. professionals give the advice they do is breastfeeding.19 The role, function and central to understanding the perpetuation scope of practice of the midwife is estab- Practice improvement requirements of variations in breastfeeding advice. Data lished in statute, and encompasses care in Research has identified a number of from a qualitative study undertaken by the postnatal period for not less than 10 barriers to the role of health visitors in Simmons34 found that conflicting advice days and up to 28 days.20 There is a breastfeeding support, including: had a detrimental effect on mothers who plethora of research conducted by ■ Knowledge deficits among practitioners chose to breastfeed. Inconsistency is mostly midwifery-qualified researchers concern- ■ Ambivalent attitudes and organisational evident as inaccurate information, and the ing the role of the midwife and breastfeed- cultures that do not support breastfeeding authoritarian way in which healthcare ing. Conversely, the role of the health ■ Inadequate skills and low levels of self- practitioners may communicate to women visitors in breastfeeding promotion and efficacy (personal confidence) in appears to worsen the inconsistencies that continuation seems to have received sparse supporting breastfeeding women.25-27 exist.34 Problems related to perceived
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insufficient milk, painful nipples and The key drivers to achieve practice improve- professional training in terms of increased refusal of the baby to suck or latch have ments would include: knowledge, attitudes, practices and confi- been documented widely and can all be ■ Appropriate training and education dence.36 Dykes37 suggests that controlled alleviated by appropriate positioning and ■ A change in the culture and practice trials should be undertaken to evaluate attachment of the baby at the breast, and of health visitors working within specific programmes of education in unrestricted feeding. In addition, insuffi- community settings. relation to providing appropriate support cient milk is the most common reason Voluntary breastfeeding counsellors with and increasing breastfeeding duration. given by women for stopping breastfeeding high standards of practical training built Health visitors caring for mothers who are between one week and four months.15 into their curricula give invaluable support, breastfeeding need specialist skills by the but they should not be expected to fill the provision of specialised breastfeeding Improving practice gaps in health service provision, education educational opportunities. For example, this Cape and Barkham35 emphasise improve- and training. A meta-analysis of six trials could be in providing support and advice ment in practice through the identification identified that World Health Organization/ for breastfeeding the growing infant and and change of behaviours and activities that UNICEF training courses were effective for anticipation of returning to work. It would result in effective health care in terms of meeting patient needs. This ensures that Box 1. Examples of practice improvements poor or inappropriate practices such as those described above are addressed, and ■ Antenatal visits from health visitors including discussion about the reasons for that bad practice is eliminated. There is breastfeeding, disadvantages of bottle-feeding, practicalities of breastfeeding and potential for health visitors to develop and social issues such as embarrassment and support – in Hull, this resulted in increased improve practice, thus contributing to breastfeeding duration among the health visitor’s caseload38 increased breastfeeding duration in primary ■ Telephone helpline to provide breastfeeding specific support and problem solving from care. Given the current debates regarding a healthcare professional the health visiting profession, practice ■ Baby Cafés provide mothers with a drop-in facility to relax, feed their baby, meet other improvement initiatives in relation to its mothers and provide access to healthcare professionals for advice, in addition to potential contribution to supporting breast- resources such as loanable or reduced cost breast pumps and a feeding bra-fitting service feeding and therefore increasing breastfeed- ■ Social marketing to establish the views and opinions of local mothers, their partners, ing duration would seem particularly healthcare professionals and local businesses about breastfeeding timely, and warrant further exploration.
Guidelines for authors Articles are considered for publication on the under- district nurses. Relevant figures, tables and images are References standing that they are not being offered to any other welcomed, though original work on paper is submitted Please check that all journal and have not been published or accepted else- at the owner’s risk. Electronic images should be at least references are complete where. All manuscripts should be submitted, with full 300dpi resolution. and accurate prior to author contact details, directly to the editor Danny submission. References should Ratnaike by email: [email protected] as a Professional papers should be between 2000 and be set out in the Vancouver style and Microsoft Word document attachment (.doc file). 3500 words in length, and are subject to double-blind should not exceed 35 in number. Authors should keep a copy of any material that they peer review. The first page should contain the following submit for publication. information only: title of article, first name and surname Editing of author(s), their qualifications and details of positions The editor reserves the customary right to style and Presentation and house style held, and the number of words in the article (including shorten material accepted for publication. All articles should include a clear title for the article, abstract and references). This should be followed by an name of author(s), qualifications and details of position unstructured abstract of 150 to 200 words, and up to Publication held, and the number of words in the article (including five key words or terms that reflect the article’s subject The editor reserves the customary right to determine the any references). In spelling, where either ‘s’ or ‘z’ can be and focus accurately. priority and time of publication. Due to the large num- used, please use ‘s’. Numerals one to nine should be Research articles should be arranged in the usual order ber of articles received, publication may be delayed, written out in full, 10 and over typed as figures. Percent of introduction, study aim or purpose, methods (includ- though every effort is made to publish within nine should be written as %. Unfamiliar terms should be spelt ing ethical approval and considerations), results, discus- months of acceptance. out in full when first used, followed by the abbreviation sion, implications and recommendations, conclusion, Authors of articles willl receive one complimentary copy in brackets. Quotation marks should be single, except references and acknowledgments. of the journal following their publication. for quotes within quotes. Capital letters should not be used for terms like ‘health visitor’ or ‘nurse’. Clinical updates are usually 1400 words in length, should be referenced and review management issues Danny Ratnaike editor Article content and length within a particular clinical area. Tel: 020 7878 2404 Articles need to be written with our readership in mind E: [email protected] – health visitors and school nurses and their team Other features are 700 or 1400 words in length (one Jane Appleton professional editor members, including community nursery nurses, as well or two printed pages) and their content should be dis- Tel: 01865 482606 as community children’s nurses, practice nurses and cussed with the editor prior to submission. E: [email protected]
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seem obvious that practice improvement Key points focusing on this area is vitally important. Examples of different practice improve- ■ Breastfeeding duration rates in the UK are among the lowest in Western Europe ments to support breastfeeding and increase ■ Health visitors are ideally placed within community settings to support duration rates are available (see Box 1). breastfeeding duration ■ Specific approaches are advocated to improve health visitors' practice in an effort to Conclusion increase breastfeeding duration rates Breastfeeding is a key public health issue. ■ Systematic review evidence shows that These approaches include the provision of specialist education and training in addition support from healthcare professionals can to a change in the workplace culture have a positive effect on the duration of breastfeeding. However, there is also approach toward developing models and organizations. Journal of Nutritional and evidence of a significant lack of knowledge approaches to working for family-centred Environmental Medicine, 2002; 12(3): 255-64. 17 Renfrew MJ, Dyson L, Wallace L, D’Souza L, and skills relating to breastfeeding among health visitors. McCormick FM, Spiby H. The effectiveness of health healthcare professionals. It would seem that the potential of interventions to promote the duration of breastfeeding: systematic review. London: National Institute for The primary purpose of practice practice improvement approaches to Health and Clinical Excellence, 2005. improvement is to improve clinical practice further the support provided by health 18 Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers: a systematic review. Paediatric through changing the behaviour of health- visitors for breastfeeding duration would and Perinatal Epidemiology, 2003; 17(4): 407-17. care professionals. In relation to breastfeed- be a vital and timely contribution to the 19 Tappin D, Britten J, Broadfoot M, McInnes R. The ing promotion and support, it has been public health agenda. effect of health visitors on breastfeeding in Glasgow. International Breastfeeding Journal, 2006; 1: 11-9. suggested that a shortage of appropriate 20 NMC. Midwives rules and standards. London: NMC, 2004. education and training in breastfeeding is References 21 Carlisle D. Breastfeeding friendly. Community Practitioner, 2008; 81(2): 101. one reason why the UK breastfeeding rate is 1 Renfrew MJ, Dyson L, Wallace LM, D’Souza L, 22 Hall DMB, Elliman D (Eds.). Health for all children among the lowest in Europe. The failure of McCormick F, Spiby H. Breastfeeding for longer: what (fourth edition). Oxford: Oxford University, 2003. works? Journal of the Royal Society for the Promotion of 23 Carr SM. Refocusing health visiting: sharpening the healthcare practitioners to provide consis- Health, 2005; 125(2): 62-3. vision and facilitating the process. Journal of Nursing tent, adequate and appropriate postnatal 2 Ip S, Chung M, Raman G, Chew P, Magula N, DeVine Management, 2005; 13(3): 249-56. D, Trikalinos T, Lau J. Breastfeeding and maternal and support and education has been suggested 24 Smith MA. Health visiting: the public health role. infant health outcomes in developed countries. Journal of Advanced Nursing, 2004; 45(1): 17-25. by a number of authors as one reason that Rockville, Maryland: Agency for Healthcare Research 25 Wallace LM, Kosmala-Anderson J. Training needs may contribute to the early cessation of and Quality, 2007. survey of midwives, health visitors and voluntary- 3 World Health Organization. Global strategy for infant sector breastfeeding support staff in England. breastfeeding, therefore highlighting a need and young child feeding. Geneva: World Health Maternal and Child Nutrition, 2007; 3(1): 25-39. for practice improvement in this area. Organization, 2003. 26 Battersby S. Midwives embodied knowledge of breast- 4 McCormack B, Dewar B, Wright J, Garbett R, Harvey The literature on practice improvement feeding. MIDIRS Midwifery Digest, 2002; 12(4): 523-6. G, Ballantine K. A realist synthesis of evidence relating 27 Spear HJ. Breastfeeding behaviors and experiences of identifies a number of contextual and to practice development: executive summary. Edinburgh: adolescent mothers. American Journal of Maternal cultural factors that impact on practice NHS Quality Improvement Scotland, 2006. Child Nursing, 2006; 31(2): 106-13. 5 McCormack B, Titchen A. Critical creativity: melding, 28 Dennis C. Breastfeeding initiation and duration: a improvement. These include the context of exploding, blending. Educational Action Research, 1990 to 2000 literature review. Journal of Obstetric, practice settings and workplace culture. 2006; 14(20): 239-66. Gynecologic, and Neonatal Nursing, 2002; 31(1): 12-32. 6 Leeman L, Baernholdt M, Sandelowski M. Developing 29 Manhire KM, Hagan AE, Floyd SA. A descriptive The existing culture is one in which health a theory-based taxonomy of methods for implement- account of New Zealand mothers’ responses to open- visitors may be viewed as authoritarian and ing change in practice. Journal of Advanced Nursing, ended questions on their breast feeding experiences. 2007; 58(2): 191-200. inconsistent, those who pursue an interest Midwifery, 2007; 23(4): 372-81. 7 Dewing J. Implications for nursing managers from a 30 Burt S, Whitmore M, Vearncombe D, Dykes F. The in supporting breastfeeding are viewed as systematic review of practice development. Journal of development and delivery of a practice-based breast- ‘zealots’, and some practitioners perceive Nursing Management, 2008; 16(2): 134-40. feeding training package for general practitioners in the 8 World Health Organization. Nutrient adequacy of UK. Maternal and Child Nutrition, 2006; 2(2): 91-102. breastfeeding promotion as not being part exclusive breastfeeding for the term infant during the 31 Smale M, Renfrew MJ, Marshall JL, Spiby H. Turning of their role remit. first six months of life. Geneva: World Health policy into practice: more difficult than it seems. The Organization, 2002. case of breastfeeding education. Maternal and Child In order to achieve practice improve- 9 Cabinet Office. PSA Delivery Agreement 12: improve Nutrition, 2006; 2(2): 103-13. ments in breastfeeding support, appropri- the health and wellbeing of children and young people. 32 Cantrill RM, Creedy DK, Cooke M. Midwives’ ately trained and educated breastfeeding Norwich: HMSO, 2008. knowledge of newborn feeding ability and reported 10 World Health Organization. Innocenti Declaration on practice managing the first breastfeed. Breastfeeding support networks are needed that include the protection, promotion and support of breastfeeding. Review, 2004; 12(1): 25-33. voluntary and professional members to Geneva: World Health Organization, 1991. 33 Community Practitioner. Breastfeeding education incon- 11 World Health Organization. International code of sistencies add to concerns. Community Practitioner, 2008; support women to initiate and maintain marketing of breast-milk substitutes. Geneva: World 81(4): 5. breastfeeding, in addition to a change in Health Organization, 1981. 34 Simmons V. Exploring inconsistent breastfeeding advice: 12 Department of Health. Choosing health: making healthy two. British Journal of Midwifery, 2002; 10(10): 616-9. the culture and practice of health visitors choices easier. London: Department of Health, 2004. 35 Cape J, Barkham M. Practice improvement methods: working within the community. It is a 13 Department for Education and Skills. Every child conceptual base, evidence-based research, and fundamental requirement that health matters. London: Department for Education and practice-based recommendations. British Journal of Skills, 2003. Clinical Psychology, 2002; 41(3): 285-307. visitors should be able to demonstrate the 14 Department of Health. National Service Framework for 36 Britton C, McCormick FM, Renfrew MJ, Wade A, knowledge and skills of breastfeeding to children, young people and maternity services. London: King SE. Support for breastfeeding mothers. Cochrane Department of Health, 2004. Database of Systematic Reviews, 2007; (1): CD001141. enable mothers to make fully informed 15 Bolling K, Grant G, Hamlyn B, Thornton A. Infant 37 Dykes F. The education of health practitioners support- choices on infant feeding, and therefore feeding survey 2005. London: Stationery Office, 2007. ing breastfeeding women: time for critical reflection. 16 Nicoll A, Thayaparan B, Newell M, Rundall P. Maternal and Child Nutrition, 2006; 2(4): 204-16. fulfil the objectives of public health policy. Breast feeding policy, promotion, and practice in 38 Department of Health. Good practice and innovation There is a need for a co-ordinated Europe: results of a survey with non-governmental in breastfeeding. London: Department of Health, 2004.
22 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 BREASTFEEDING IS BEST FOR BABIES
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Emotional labour within community nursing leadership
Introduction embedded within the organisational norms Elaine Haycock-Stuart PhD, RHV, RM, RGN Recent policy and reforms in the UK place and structures. Thus arguably, emotion Senior lecturer, University of Edinburgh emphasis on leadership in the NHS for management takes place in nursing work18 achieving quality health care.1-9 The strate- and recent reforms are adding new dimen- Susanne Kean PhD, MSc, RN, DipN gies and policy frameworks indicate the sions and complexity. Collegial emotional Research associate, University of Edinburgh valued traits of leaders and make reference labour19 is one particular type of to outstanding and excellent leaders.10 emotional labour identified in nursing Sarah Baggaley BSc, SCM, RHV, RGN However, it is asserted that it is the work. While there is evidence of emotional Lecturer and health visitor practitioner, ordinary leaders that sustain much of the labour in nursing work,18-21 there is little University of Edinburgh transformation in organisations.11-15 evidence of how this presents within the Developing leadership capacity in community nursing context. Abstract community nursing is seen as key to Recent months have seen great emphasis on leader- Purpose ship within the UK. Unlike politicians, leaders of achieving healthcare goals, as care shifts community nursing have little support from aides and from hospitals to the community and This paper reports the key theme of advisors as they grapple with the implementation of leadership skills are essential to this trans- emotions in leadership, which emerged policy agendas. This paper gives insight into some of formation in the vision of community from a research study that aimed to: the emotions involved in leading community nursing to nursing.16 As a consequence, new leader- ■ Identify how leadership is perceived and meet some of the recent NHS policy agendas, such as ship roles have emerged within community experienced by community nurses shifting the balance of care. The focus of this paper nursing. Essentially clinical- and practice- ■ Examine the interaction between recent aims to examine emotions in leadership, particularly focused nurses are taking on new leader- policy and leadership development in collegial emotional labour within community nursing. ship roles and responsibilities. community nursing. Qualitative interviews with 12 leaders of community nursing pointed to the current trials and tribulations of Background Method undertaking a leadership role in community nursing. Currently, there is a lack of research about The wider study used qualitative methods The nurse leaders indicated how they undertook leadership in community nursing, and a involving semi-structured interviews with surface acting to mask their emotions, to maintain a dearth of evidence about the impact of 39 community nursing service staff. The dignified and professional demeanour with colleagues. adopting leadership approaches in study reported here is based on data from Interviews with nurse leaders highlighted the tensions community nursing. 12 community nurse leaders within this in their roles and that they often felt unsupported. Few Leadership is very much a social process sample from three health boards in community nurse leaders had access to emotional that has to contend with power relations Scotland. The interview schedule was support in their leadership role unless they became and the consequent potential for conflict, developed from a review of the literature. stressed and unwell. A recommendation is that which will require emotion management Questions were focused on how leadership support through coaching or mentorship should be in the workplace.17 Bolton18 suggests that in community nursing is experienced and made available for people in leadership positions ‘emotion management may be carried out conceptualised by nurse leaders. whether new, experienced, senior or junior due to the according to professional norms’ (p63) as Participants were recruited by cascading challenges of the role. professionals undertake difficult social email information about the study to them Key words interactions in accordance with achieving through the nurse directors. Data were Leadership, community nursing, management, emotions their work objectives. Within the social digitally voice recorded and transcribed context of the wider organisations’ verbatim, and were managed within the Community Practitioner, 2010; 83(9): 24-7. cultural norms, individuals – for example, NVivo 8 software following written nurse leaders in the NHS – undertake consent from all participants. Emotions in emotion management. leadership emerged as one key theme in the For some aspects of nursing work, the analyses and forms the focus of this paper. boundaries between friend and colleague The nurse leaders at Agenda for Change or friend and client or patient can become band 7 and above with a designated leader- blurred, needing skills of ‘emotional ship role (see Table 1) were purposefully zoning’17 for successful social interactions drawn for in-depth data analysis of this in the workplace. Workplace emotions are theme. The three health board research and reflected through the interpretations of the development departments and the research individual nurse’s relationships, which are ethics committee approved the study.
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Findings and discussion acting indicates how the nurse leaders feel Table 1. Sample of nurse Emotion and decision making the need to mask their true emotions in Shifting the balance of care from hospital to order to meet their own goals or those of leader participants community settings is a clear policy agenda the organisation. Surface acting by nurses Role Number within the NHS, and leadership roles are involves the wearing of a mask to maintain 16 instrumental in realising this. Several a professional demeanour in the hospital Team leader 5 nurses in leadership roles within the ward setting,23 and it would seem that Lead nurse 3 community spoke of how challenging similar practices are required within different elements of implementing change community nursing in order to navigate Acute care managers for 1 community sector were to meet the new agenda of shifting the the social vagaries. balance of care. This team leader alludes to In a different health board area, this Assistant nursing director 1 a lack of understanding in acute services assistant nursing director explains how she Director of nursing 2 when negotiating the smooth transition of developed her mask to the extent that she patients into the community with acute likened it to almost becoming a ‘Stepford Total 12 care colleagues: wife’, alluding to the level of masking and Because nobody ever thinks about controlling of emotions: within her role and how she felt that she is community and I think... like there was day So, I suppose some of the big things I’ve read ultimately letting junior colleagues and surgery there, the girl from the renal unit, about leadership and what makes a good patients down in favour of her obligations there was somebody from – I’m trying to leader is around that being visible, being to attend meetings: think where else – I said, ‘So, say when you’ve positive, being decisive without kind of too I would say to the staff nurse, well I’ll do this got to empty these beds of a day... and the overly directive and listening. So what I try to patient, this patient and this patient and then patients no longer want to be shipped from do in this role, having come from a nurse something would crop up and my boss would [area A] to [area B] and they decide just to consultant role which was a leadership one say, well you have to come to this meeting, take their own discharge without services... before, is to demonstrate some of those behav- and then I would have to say to the staff so, when you’re emptying your beds every iours every time I’m with the community nurse, ‘I can’t do these patients, I’ve got to go’. day’ – and they’re just laughing and I think... nurse managers. I mean, not – I mean, you And I felt that was letting her down, you (team leader 1.3). don’t want to look – that you’re not a know. And I just hated that feeling of letting The team leader’s frustration at this lack ‘Stepford wife’ or anything, but at the same people down, really (team leader 1.1). of understanding and forward planning of time be realistic, but at the same time to try It was evident in the data that team her acute care service colleagues becomes and even when I’m not feeling like being like leaders felt a moral commitment to evident when she is referring to their that, to try and do it [laughs] (assistant patients and their junior colleagues, but ‘laughing’. The lack of understanding of nursing director 2.1). also obligated to senior colleagues and the how acute care colleagues’ behaviour affects Arguably, the masking of emotions and tasks they requested them to undertake. community nurses led to her frustration, keeping up appearances can be hard work The team leaders often felt trapped within while at the same time she has little power emotionally, but it can also be integral to the new leadership role. These concerns to make them see what the impact of their the role and protective of the emotional expressed by nurses in leadership roles can behaviour is – this then requires her to demands of the job,23 and necessary to be interpreted as shifting from the sacred to manage these emotions. meet some of the challenges of the leader- the profane.23 The profane is the obligato- This team leader can be understood to be ship role. It is evident that for many nurse ry world of social roles, such as responding ‘emotionally present and fully engaged’ leaders, they felt constrained as to when to the senior leaders requests to attend (p24)23 with the dilemmas of shifting the they could be their authentic self, explain- meetings, while the personal is the sacred, balance of care, but utilises a professional ing how they often concealed their true involving their commitment to patients demeanour to negotiate her passion across feelings and self. Many described skilled and junior colleagues’ concerns and the table with her acute service colleagues. performances as social actors to achieve maintaining good relationships. The data The team leader felt frustrated, though she their work goals, often involving high levels suggest that leadership roles presented kept her emotions in control for the of emotion management. many moral dilemmas, and nurses in meeting, but spoke with passion – under- different leadership roles often felt unsup- taking surface acting22 with colleagues in Managing emotions at work: a balancing act ported in their challenging work. order to move the meeting forward. Several of the nurses in leadership roles Despite the team leader’s frustration referred to experiencing moral dilemmas in Feeling unsupported and taking the flack evident above, she is remaining profession- their work, leaving them emotionally Several of the new team leaders expressed al. Bolton23 argues that such a professional challenged and with a feeling that they had that they had felt unsupported and indeed demeanour distances nurses from distress- let people down. New team leaders – often undermined by senior colleagues on ing and demanding elements of their work, in particular those with a clinical occasions leaving them ‘out on a limb’: yet the data from this study suggest that component to their leadership role – felt I have to say, we have felt unsupported and I emotional management of this nature can challenged in balancing clinical time with think the whole of the team, all the team be burdensome for some nurse leaders. patients and their need to attend meetings. leaders have experienced that at some time. Analysis of data where team leaders The following team leader explained how That you feel like you’re out on a limb (team describe what can be interpreted as surface she experienced these moral dilemmas leader 1.2).
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The leadership roles were considered Certainly, in reflecting on her behaviour grounded in nursing practice and challenging in many ways by different nurse this team leader related her emailing congruent with their own values and belief leaders, and many of them explained how practices as being commonplace among system. The moral dilemmas arose when they regularly encountered and managed other senior nurses in leadership roles leadership work challenged this value and emotions about conflict with colleagues – within the organisation. belief base that originally attracted many to indeed some saw this as the main aspect of However, not all nurses in leadership community nursing. their role, as these team leaders explain: roles experience burn out as a result of the As this nursing director states, when there I think basically [the lead nurse] wants me to stress of their work. This director of is respect and humanity in nursing work it be an interface so that she doesn’t have to deal nursing described her leadership role as a is a much treasured and valued asset: with any difficult situations or conflict from resilience role. Different levels of resilience I do think that people are doing extraordi- the coal face, really (team leader 1.1). have been related to the success of leaders nary things, and I think from where, where I thought, well this is somebody who’s at the in leadership roles:17 I’m trying to come from – my brand of same level as me who’s creating this problem, So it’s a kinda resilience role, although there nursing and, and leadership, we’re trying to I’m gonna discuss it with [the lead nurse], was many times I would have a dark night of position those skills and abilities and the but it was very much left at my door (team the soul thinking, ‘I’m never gonna get them way people work and it is about – some of leader 1.2). together’, but I just kept on, you know, the stuff’s about respect for one another, I Avoidance of conflict by senior nurse moving them forward and, you know... mean, not even anything that, you know, leaders meant that the new, less experienced (director of nursing 1.1). just about human kindness and behaviours team leaders experienced the conflict Work-life balance has been associated with (director of nursing 1.2). instead. Goldman24 refers to such a leader’s different levels of resilience and the ability Collegial emotional labour19 relating to behaviour as toxic leadership. With no of leaders to sustain leadership roles.17 In conflict seems to be rife in community coaching, the team leaders considered this addition, developing supportive infrastruc- nursing work, and requires emotion element of their work to be emotionally tures such as through coaching can support management to achieve the goals of the draining, and this had led to early burn out people in leadership positions with regard NHS organisation. Humanity, the core of among some nurse leaders. Prolonged to the challenging aspects of their decision nursing work, needs to be brought to the surface acting with colleagues, to move making. However, it became evident in this fore of nursing leadership work too. forward on negotiations when there is study that only a couple of the nurse leaders conflict, can be seen to contribute to burn had such a support mechanism in place, Implications for practice and education out. It has been argued that deep acting despite recognition of its value. Challenges from conflict and emotion contributes to burn out,17,25 but data from management mean that community this study suggest that prolonged surface Tribulations and human kindness nursing leaders need to be supported acting with colleagues is also related to Much of the emotion management through coaching and mentoring burn out. The emotional challenges reflect described by the nurse leaders related to approaches, even when they become more the lack of culture of supporting leadership challenging situations and conflict with experienced in leadership roles. Few roles within community nursing systems. colleagues. Yet there are many people community nurse leaders in this study had undertaking leadership roles in community access to emotional support in their leader- Emotional injury: stress nursing, and some have been doing it for ship role unless they became stressed and Several of the nurses in leadership roles quite some time. As this team leader points unwell. Nursing education, with a focus on described emotional injuries17 such as out, community jobs are dynamic and leadership development, needs to consider stress in relation to their work as they fell interesting, and while people often latch on the emotion work that leadership in into a commitment trap. When emotion to the negative aspects of the work, good different settings entails. Nursing is often management fails and stress becomes things do come of these roles: considered emotionally challenging work overwhelming, ill health is experienced: But it’s a shame, because I think community due to caring for patients. This study Before I was ill, I have to say – I would be jobs are very good jobs to have. They can be highlights some of the system-created emailing at 11 o’clock at night or at very varied, very satisfying and all the rest of emotional challenges of leading a weekends... I was very doubtful about every- it, but people moan so much about them community nursing workforce. Building thing I was doing, you know, ‘Is this a correct (team leader 1.1) inner resilience along with appropriate decision? Are we going the right way down Nurses in the community and those in enabling mechanisms is essential for good this route? Do you think I could do that?’... nursing leadership positions enjoy a level of coping in leadership roles. There is a need (team leader 1.2). autonomy of practice found in few other for developing better communication This team leader described her crisis of areas of nursing work within the NHS. The systems for good working relations to identity, questioning her own personal and opportunity to undertake leadership roles support colleagues for positive leadership shared values and beliefs that lead to combined with direct patient care involving experiences. A culture of supporting our internal personal conflict, culminating in individuals and families is another aspect of own is needed in community nursing, as illness. It is suggested in the literature that community nursing work highly valued by opposed to the ‘tendency to eat its young’.26 burn out is largely due to organisation- the nurse leaders – that is not to say that it wide practices and norms, yet is often was not without challenges. The opportuni- Conclusions treated as individual pathologies rather ty to work with patients and families There are significant trials and tribulations than organisational structural dilemmas.25 enables team leaders in particular to feel in community nursing leadership work.
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Conflict is evident in everyday work, and Key points emotion management is undertaken to navigate the social terrain within the profes- ■ Leadership within community nursing involves emotional management, which can be 22 sional feeling rules of nursing. A core understood as collegial emotional labour aspect of the community nursing leadership ■ Community nursing leaders need to support new and less experienced leadership roles role is surface acting, to negotiate the ■ Community nursing needs to organise mentoring and coaching in leadership roles for challenges of organisational change to meet support and development NHS policy agendas and personal work goals of the nurse leaders. Surface acting22 in emotion work is not without dangers. Institute Scotland, which made this 13 Stanley D. In command of care: toward the theory of Personal conflict of the leader’s own values research possible. congruent leadership. Journal of Research in Nursing, 2005; 11(2): 132-44. and identity can become challenged 14 Yukl G. Leadership in organizations. Boston: Pearson through the process of managing emotions References (Global Edition), 2010. 15 Collinson D. Rethinking followership: a post-struc- in nursing work to meet organisation goals. 1 Antrobus S, Kitson A. Nursing leadership: Influencing turalist analysis of follower identities. The Leadership Collegial emotional labour19 is evident in and shaping health policy and nursing practice. Quarterly, 2006; 17: 179-89. Journal of Advanced Nursing, 1999; 29(3): 746-53. 16 Department of Health. Shifting the balance of power: leadership roles in community nursing, 2 Department of Health. nGMS. London: Department the next steps. London: Department of Health, 2002. often requiring extensive surface acting with of Health, 2003. 17 Fineman S. Understanding emotion at work. London: 3 Scottish Executive. Visible, accessible and integrated Sage, 2003. nursing colleagues to meet individual care: report of the Review of Nursing in the Community 18 Bolton SC. Emotion management in the workplace. leader’s and NHS policy agendas. in Scotland. Edinburgh: Scottish Executive, 2006. Basingstoke: Palgrave, 2005. 4 Department of Health. Knowledge and Skills 19 Theodosius C. Emotional labour in health care: the A culture of improved communication Framework. London: Department of Health, 2003. unmanaged heart of nursing. London: Routledge, 2008. and support is needed within the leadership 5 Department of Health. Liberating the talents: helping 20 Smith P. The emotional labour of nursing. London: process. The current culture and systems of primary care trusts and nurses to deliver the NHS Plan. Macmillan, 1992. London: Department of Health, 2002. 21 Huynh T, Alderson M, Thompson M. Emotional labour community nursing are more managerial 6 Scottish Executive. Partnership for care: Scotland’s health underlying caring: an evolutionary concept analysis. and less leadership focused, and at odds White Paper. Edinburgh: Scottish Executive, 2003. Journal of Advanced Nursing, 2008; 64(2): 195-208. 7 Scottish Executive. Delivering for health. Edinburgh: 22 Hochschild AR. The managed heart. London: with the current policy context, rendering Scottish Executive, 2005. University of California, 1983. leadership as rhetoric in current 8 Scottish Executive. Delivering care, enabling health. 23 Bolton SC. The hospital: me, morphine and Edinburgh: Scottish Executive, 2006. humanity: experiencing the emotional community on community nursing systems. 9 Donaldson L. Safe high quality health care: Investing Ward 8. In: Fineman S (Ed.). The emotional organisa- in tomorrows leaders. Quality in Health Care, 2001; tion: passions and power. Oxford: Blackwell, 2008. 10: 8-12. 24 Goldman A. Destructive leaders and dysfunctional Acknowledgments 10 Scottish Government. Delivering quality through organizations. New York: Cambridge University, 2009. The authors thank the participants who leadership. Edinburgh: Scottish Government, 2009. 25 Tracy SC. Power, paradox, social support and prestige. 11 Binney G, Wilke G, Williams C. Living leadership: a In: Fineman S (Ed.). The emotional organisation: took part in the research for giving freely of practical guide for ordinary heroes. Harlow: Prentice passions and power. Oxford: Blackwell, 2008. their time and thoughts in relation to the Hall, 2009. 26 McKenna H, Keeney S, Bradley M. Nurse leadership 12 Stanley D. In command of care: clinical nurse leader- within primary care: the perceptions of community focus of this research, and acknowledge the ship explored. Journal of Research in Nursing, 2006; nurses, GPs, policy makers and members of the public. financial support of the Queen’s Nursing 11(1): 20-39. Journal of Nursing Management, 2004; 12(1): 69-76.
LAR of the Year Award 2010 Branches invited to nominate local accredited representatives
Unite/CPHVA is calling for nominations for this year’s LAR of the Year Award, which is due to be presented at the Unite/CPHVA Annual Professional Conference 2010 in Harrogate on 20 to 22 October.
Branches are encouraged to nominate suitable candidates for this important annual award, using the nomination form available via the Unite/CPHVA website, see: www.unitetheunion.org/cphva
All nominations must be returned by 10 September by email to: [email protected] or by post to:
Barrie Brown, Unite/CPHVA, 128 Theobald’s Road, London WC1X 8TN
September 2010 Volume 83 Number 9 COMMUNITY PRACTITIONER 27 BREASTFEEDING IS BEST FOR BABIES ADVERTISEMENT FEATURE
The latest ESPGHAN opinion on the composition of preterm formulae
Latest ESPGHAN1 2009 opinion
* ESPGHAN states “In conclusion, there is not enough available evidence suggesting that the use of probiotics or prebiotics in preterm infants is safe. Efficacy and safety should be established for each product. We conclude that the presently available data do not permit recommending the routine use Recommendations for SMA Gold Cow & Gate of prebiotics or probiotics as food supplement in preterm/LBW formula Prem 1 Nutriprem 12/ Latest Opinion – Aptamil Preterm3 1 preterm infants” ESPGHAN 20091
Meets the current ESPGHAN opinion * ** “It is concluded that there on prebiotics in preterm infants ✓ ✓ ✗ is not sufficient evidence Meets the current ESPGHAN opinion to generally recommend on nucleotides in preterm infants ✓** ✓ ✗ addition of nucleotides to 1 Long-chain polyunsaturated preterm infant formulae” fatty acids (LCPs) ✓ ✓ ✓
Reduced lactose level (lactose:glucose polymer ratio) ✓ 50:50 82:18
Low osmolality (mOsmol/kg H O) ✓ 272 370 2
Nutrients such as sugars, amino acids, salts, minerals do not readily The Committee on Nutrition of the American Academy of Pediatrics diffuse across membranes, increasing the length of time in an has considered the risks associated with hyperosmolar feedings infant’s immature gastrointestinal system. The number of these and has recommended 400 mOsmol/kg as the recommended safe nutrients contributes towards the feed’s osmolality osmolality for infant formula8
When feeds are hyperosmolar, they have been shown to empty The latest Tsang guidelines recommend that hyperosmolar more slowly from the stomach than isotonic solutions,4, 5 and are feeding should be avoided, but do not provide a maximum level associated with an increased risk of nausea, vomiting, diarrhoea, of osmolality for low-birthweight (LBW) formula9 gastroesophageal refl ux1 and have also been linked with necrotising enterocolitis (NEC) (infl ammation of the gut)6,7 SMA has the lowest osmolality of all the preterm/LBW formulas in the UK & ROI but still while providing a nutritionally complete low birthweight formula that is in line with the latest Tsang guidelines9
For more information on the SMA Gold Prem Range, visit www.smahcp.co.uk or www.smahcp.ie
IMPORTANT NOTICE: Breast milk is best for babies. This product must be used under medical supervision. SMA Gold Prem 1 is a special formula designed for the particular nutritional requirements of preterm and low birthweight babies who are not solely fed breast milk.
References: 1. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. Enteral Nutrient Supply for Preterm Infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010; 50:1-9. Full report: http:links.lww.com/A1480 2. Cow & Gate Nutriprem 1 Datacard (04/07). URL: www.in-practice.co.uk, accessed online 27th November 2009. 3. Milupa Aptamil Preterm Datacard. September 2008. 4. Pereira-da-Silva L et al. Osmolality of preterm formulas supplemented with non-protein energy supplements. Eur J Clin Nutr 2008; 62: 274-8. 5. Costalos C et al. Gastric emptying of Caloreen meals in the newborn. Arch Dis Child 1980; 55:883-885. 6. Fenton T. Not all osmolality is created equal. Arch Dis Child 2006; 91: F234. 7. Book L et al. Necrotizing enterocolitis in low birthweight infants fed an elemental formula. J Pediatr 1975; 87: 602-5. 8. American Academy of Pediatrics and Committee on Nutrition. Commentary on breast-feeding and infant formulas included proposed standard formulas. Pediatrics 1976; 57: 278-285. 9. Tsang R et al. Nutrition of the preterm infant, scientifi c basis and practical guidelines; second edition. Digital Educational Publishing Inc, 2005; Cincinnati, Ohio ZGP0031/01/10
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Protection of vulnerable adults: an interdisciplinary workshop
Introduction within any relationship where there is an Mary Rose Day MA, BSc, RPHN, RM, RGN, DipMan Government policy nationally and interna- expectation of trust which causes harm or Nursing and midwifery course co-ordinator, tionally1-4 recognises that the risks of elder distress to an older person or violates their University College Cork, Ireland abuse and self-neglect are increasingly human and civil rights’ (p25).1 Eleanor Bantry-White MPhil, MSW, BSocSc complex and growing problems in society. This definition is adopted from the Lecturer in social work, University College Cork, Ireland These distinct phenomena pose challenges UK’s Action on Elder Abuse,13 and has for the protection and welfare of older also been adopted by the World Health Pauline Glavin DipCouns, BASoc, CQSW people. Both elder abuse and self-neglect Organization.2 A number of categories of Senior social worker, Health Service Executive, Ireland may occur in institutional or community abuse are recognised within this definition settings however the majority of referrals including physical abuse, sexual abuse, Abstract This paper reports on the development, delivery, come from within the community. Under- psychological abuse, financial or material content and student evaluation of a comprehensive reporting and poor detection of both elder abuse and neglect or acts of omission and 1 elder abuse and self-neglect workshop for public abuse and self-neglect increase risks of discriminatory abuse. health nursing and social work students. The workshop mortality and morbidity.5-8 International studies estimate the preva- provided an interdisciplinary shared learning experi- The complexity of cases can present many lence of abuse in the community at between ence for the students to prepare them for their critical ethical challenges and dilemmas on confi- 1% and 5% of the population aged 65 years role in safeguarding vulnerable adults. dentiality, safety, self-determination, and older. However, these figures are The aim of the workshop was to increase knowledge, choice, beneficence, non-maleficence and regarded to be an underestimate. awareness and understanding of roles and responsibil- decision making capacity.9,10 Primary care Approximately 2.6% to 5% of older people ities and critical practice problems in the prevention teams and a multidisciplinary approach are living in the community may suffer elder and management of elder abuse and self-neglect. key in addressing elder abuse and self- abuse at any specific time.8,14,15 The shared learning approach provided clarity on roles neglect, since no single discipline has all the Age Action estimates that 14 400 to 24 000 and responsibility, valuing and respecting the contri- expertise. Different attitudes, beliefs and of Irish people over the age of 65 years have bution of each team member. philosophies can exist between profession- been abused, though Protection Services for The importance of building communication and trust als11 and using shared learning opportuni- Older People (PSOP) in Ireland received with team members and clients was seen as critical. ties can help to improve relationships and only 1840 referrals in 2008 and 1870 in Through case studies and group discussion, assess- understandings across disciplines. The 2009.5 The perpetrator can be any person ment and practice skills were developed and importance of empowerment, teamwork, who is in a position of trust, such as an awareness heightened on the complexity of the critical partnerships, intersectoral collaboration, employee, family member or neighbour. practice problems and ethical issues. and interdisciplinary education to influence One in four cases are under-reported due to health and wellbeing is well recognised. As poor knowledge, diversity in recognition, Key words future leaders, public health nurse (PHN) embarrassment, fear of consequences and Elder abuse, self-neglect, interdisciplinary training, and social work students need skills, denial by older people.4,16 shared learning knowledge and competence to detect, Self-neglect is not included in the defini- Community Practitioner, 2010; 83(9): 29-32. manage resolve and prevent elder abuse and tion of elder abuse in Ireland, the UK, self-neglect.2,4,5,11,12 Europe or Australia and is not mandated The purpose of this paper is to describe a for reporting purposes, since it does not collaborative interdisciplinary workshop occur within a relationship of trust.1 This on elder abuse and self-neglect that was differs from the US, where self-neglect is used to prepare PHNs and social workers included in the definition of elder abuse in in Ireland as future members of communi- some states.17 Self-neglect can be inten- ties of practice. tional or non-intentional (see Table 1) and has been defined as ‘the inability (inten- Elder abuse and self-neglect tional or non-intentional) to maintain Aging populations and multiple co- socially and culturally accepted standards morbidities will increase vulnerability and of self-care with the potential for serious risk for elder abuse and self-neglect and consequences to the health and wellbeing pose significant challenges for health and of the self-neglecters and perhaps even to social care services.9 In Ireland, elder abuse their community’ (p16).18 has been defined as: ‘A single or repeated act The concept of self-neglect is complex or lack of appropriate action occurring and there is no standardised national or
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Table 1: Differentiating factors between intentional and health and social care professionals in the management of elder abuse and self-neglect non-intentional self-neglect nationally.1,4,26,27 However, evidence suggests that community nurses, PHNs and Intentional Non-intentional senior social workers are challenged by Lifestyle Cognitive impairment (such as dementia) ethical issues and dilemmas, the complexity Choice Functional impairment of cases, and inadequate knowledge and Maintaining control Psychiatric illness (such as depression) skills, making interventions difficult.10,27 Personality type Substance abuse (such as alcohol abuse) Interdisciplinary education and training Fear of institutionalisation Major life stressor have been highlighted as key factors for effective identification and prevention.
Box 1. Workshop learning objectives PHN and social work education in Ireland PHNs in Ireland are geographically based ■ Understand and discuss definitions, risk, protective factors and prevalence of elder abuse generalist nurses who provide primary, and self-neglect secondary and tertiary care to individuals, ■ Critically explore roles and responsibilities of PHNs, social workers, senior social workers, families and communities across the life PSOP and multidisciplinary team members in elder abuse and self-neglect span. An important element of this role is ■ Critically evaluate policy, procedures, directives and responsibility in cases of elder abuse identifying and assessing vulnerable people 28 and self-neglect at risk of elder abuse and self-neglect. PHN students are registered general nurses ■ Analyse, explore and discuss ethical dilemmas associated with elder abuse and self-neglect with many years practice experience when ■ Critically discuss ways to enhance assessment and problem-solving skills using a shared they undertake the one year full time learning approach postgraduate training programme, which is a registerable qualification.29 PHNs are international definition.19 Some researchers Interdisciplinary working is essential as is a the main source of referral to PSOP. view self-neglect as a distinct multidisciplinary team approach to assess- In Ireland, social workers work with syndrome,20,21 while others believe it to be ment, involving clients and carers in individuals, families and groups who are a number of symptoms that can be linked decisions where possible, and this will experiencing social, economic or to a number of mental and cognitive direct the interventions that need to be put emotional challenges.30 They work with disorders.22,23 Consultations to primary in place. Freedom, self-determination, vulnerable older adults across a range of care services Scotland in 2007 to 2008 person-centred care, competence, capacity, primary care and acute services including identified 166 older people per 100 000 of confidentiality, beneficence, non-malefi- the PSOP. Social work education in Ireland population with a diverse range of self- cence, preservation of family, safety and provides a generic statutory qualification. neglect diagnoses.24 In 2008, PSOP protection of the clients are some of the On entry to the postgraduate social work categorised 359 (20%) referrals in Ireland issues and dilemmas that present daily to two-year full-time programme at as self-neglect, but there were wide varia- health and social care professionals.4,9 University College Cork, students have a tions in identified cases across regions.5 The England and Wales have a Protection of theoretical grounding in the social sciences established risk factors for self-neglect are: Vulnerable Adults (POVA) list and this is and practice experience with diverse ■ Advancing age (older than 75 years) included as an element of training across groups.31 Evidence suggests that ■ Mental health problems some trusts.25 In the Republic of Ireland, a community nurses, PHNs and social ■ Cognitive impairment number of policy guidelines and web workers need interdisciplinary training to ■ Dementia resources are in place to support and guide develop competencies.10,32 ■ Frontal lobe dysfunction ■ Depression Box 2. Case study: self-neglect (fictional) ■ Chronic illness ■ Nutritional deficiency Mary is an 80-year old frail woman who lives on her own in a rural area. In her house ■ Alcohol and substance abuse there are 15 or more cats. The house smells of cat excrement and urine. The floor is ■ Functional and social dependency often wet and dirty. The cats sleep and walk on the table among her crockery, food and ■ Social isolation (loner, recluse, poor personal items. The house is dark, since she refuses to have the curtains opened to social networks). allow in sunlight. She mixes up day and night, and eats very little. She has fallen in the Elder abuse and self-neglect can occur in a past and was admitted to hospital, often self discharging in opposition to medical advice. She has also refused to take a shower and the offer of assistance in taking a variety of settings – home, hospital, contin- shower. Over the last 10 years, she has also refused assistance from health and social uing care, nursing homes, sheltered care services. She has no immediate family. housing and day care. Abuse does not Mary’s father died when she was a child, and her mother was unable to care for her due occur in isolation, but is linked to the to hard times. As a result, she was admitted to an orphanage when she was five years individual’s history, personality, relation- old. Mary has very stark memories of her years there, where she suffered physical ships, family circumstances and living abuse, humiliation and a continuum of punishment. environment, or a combination of these.
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Elder abuse and self neglect workshop Key points The PHN and social work educators collab- orated with the senior social worker, PSOP ■ Ageing populations, chronic illness and disability will increase risk and vulnerability to and Health Service Executive South to elder abuse and self-neglect develop the workshop. The aim of the elder ■ Elder abuse and self-neglect are complex phenomena and a multidisciplinary and abuse and self-neglect workshop was to multi-agency response is key increase knowledge and awareness for ■ Educators need to include interdisciplinary shared learning approaches in the curriculum working with people experiencing elder abuse and self-neglect, with specific and education of professionals on elder abuse and self-neglect learning objectives (see Box 1). The workshop took place in February from individual groups stimulated discus- elder abuse and self-neglect. Students’ 2010, when both PHN (n=10) and social sion, and the senior social worker and awareness and knowledge of professional work (n=15) students had completed two educators encouraged students to think assessment, capacity and decision-making practice placements. The mix of presenta- beyond actions, to the significant elements issues were enhanced. Students described tions, online reading resources, bibliogra- of the work in particular, developing the importance of gaining a ‘collaborative phy, case studies (see Box 2), mixed group relationships and building trust. The real understanding’, but acknowledged that this discussions, facilitation and feedback by case examples enabled the senior social process presented both benefits and three facilitators supported critical analysis worker to share some of the outcomes and challenges. Students reported benefits as and discussion in order to deepen under- challenges of each individual case. including greater understanding of roles standing about professional approaches Reflection on group process provided and responsibilities, importance of (knowledge, values and skills) used in students with insight into the strengths and communication, and valuing and respect- prevention, detection, intervention and on- challenges of working collaboratively.33 ing the contribution of each team member. going management of cases. The challenges identified were time The workshop was delivered in two parts Student evaluation management, the fact that ‘there are no over two weeks (see Table 2). Part two was At the end of part two, all students easy solutions’, and dilemmas involved facilitated by three people – a PHN, social completed evaluation sheets and an open with balancing self-determination and work educator and senior social worker for discussion explored students’ experiences choice with risk and protection. PSOP. A senior social worker took the lead and learning following participation in the and provided context from a clinical workshop in order to guide its future devel- Team approach practice perspective and gave each small opment. Student evaluation of the Small groups facilitated discussion and mixed group of around five students two workshop appeared to be very positive, and gave clarity about the roles and responsi- case studies drawn from caseloads (after the key issues that emerged were – bilities of PHNs, social workers, senior ensuring anonymity). This aimed to knowledge development, team approach social workers and wider team members. enhance students’ practice skills in relation and ethical challenges. The significant issues identified were the to working collaboratively, exploring ‘relationship of trust with vulnerable individual and professional beliefs, values, Knowledge development adults’ and the need ‘to pace’ the assess- philosophies, roles and responsibilities, The workshop provided students with a ment and intervention processes. Students problem solving and risk assessment, and good understanding and knowledge of recognised the centrality of the team to identify possible interventions. Feedback international and national perspectives on approach, while acknowledging that social workers and PHNs are located in different Table 2. Workshop structure places within health and social care systems. PHN students’ views of the role of Content Format Process social workers were captured: The advocacy role, promoting self-determi- Part one (week Overview of defini- Formal presentation, Developing a shared one) tions, prevalence, reading materials learning forum for nation, the autonomy of clients. Two hours antecedents, risk and and supporting knowledge synthesis The PHN students’ view was that this protective factors, documentation online enabled social workers to ‘step back’ from policy, legislation, Informal group exclusively focusing on adverse risks to interdisciplinary discussion assessment, recognising the preferences and wishes of assessment tools vulnerable adults. Social work students and interventions acknowledged that philosophy, ethos, Part two (week two) Examination of Group-work on case Active experiential training, caring and beliefs make it difficult Four hours case studies of studies in small learning for PHNs to ‘walk away’ from a case of self- elder abuse and groups Critical analysis and neglect where the person has refused inter- self-neglect Assessment and problem-solving vention, because of their beliefs and ‘duty intervention planning exercise of care’ toward clients. Social work Structured large- students identified with the need for PHNs group feedback to maintain their relationships with the wider family network.
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Ethical challenges cases of elder abuse and self-neglect. More 12 National Council on Ageing and Older People. Review Students appeared able to identify, reflect awareness of elder abuse and self-neglect at of the recommendations of ‘Protecting our future’: report of the Working Group on Elder Abuse. Dublin: upon and work through the ethical issues family and population level will assist in Stationary Office, 2009. raised by elder abuse and self-neglect in the detection and reporting of cases.14 13 Action on Elder Abuse. What is elder abuse? Action on Elder Abuse Bulletin, 1995; (May-June): 11. particular, balancing protection with self- There needs to be more educational prepa- 14 Comijs H, Pot AM, Smit JH, Bouter LM, Jonker C. determination. Students were facilitated to ration and skills development in the area of Elder abuse in the community: prevalence and conse- quences. Journal of the American Geriatric Society, work through the complexity of cases: elder abuse and self-neglect, especially 1998; 46: 885-8. Need to stand back from the drama... details interdisciplinary education to support best 15 Biggs S, Manthorpe J, Tinker A, Doyle M, Erens B. of the abuse or the complexities of the kinship practice.10 Training needs to recognise that Mistreatment of older people in the United Kingdom: findings from the first national prevalence study. relationships involved. professionals have varied approaches and Journal of Elder Abuse & Neglect, 2009; 21(1): 1-14. The importance of building trust and of skills in working in cases of elder abuse.11 16 Akaza K, Bunai Y, Tsujinaka M, Nakamura I, Nagai A, Tsukata Y, Ohya I. Elder Abuse and neglect: social recognising the challenges involved in There is a paucity of evidence on the problems revealed from 15 autopsy cases. Legal implementing change with vulnerable impact of educational initiatives that Medicine, 2003; 5(1): 7-14. 17 Teaster PB, Dugar TA, Otto JM, Mendiondo MS, Abner people was acknowledged. address the identification, management EL, Cecil KA. The 2004 survey of state adult protective and prevention of elder abuse. A study services: abuse of adults 60 years of age and older. Conclusion and recommendations needs to be undertaken that examines the Washington DC: National Center on Elder Abuse, 2006. 18 Gibbons S, Lauder W, Ludwick R. Self-neglect: a Population ageing means that more people impact of interdisciplinary education elder proposed new NANDA diagnosis. International are living longer with more ill health, abuse and self-neglect workshop on the Journal of Nursing Terminologies and Classification, 2006; 17(1): 10-8. making them more vulnerable to elder subsequent knowledge, skills, attitudes and 19 Dyer CB, Heisler CJ, Hill CA, Kim LC. Community abuse and self-neglect, which can occur behaviour of professionals. Finally, the approaches to elder abuse. Clinics in Geriatric Medicine, 2005; 21(2): 429-47. across a variety of settings. Elder abuse and authors hope that these findings will 20 Naik AD, Burnett J, Pickens-Pace S, Dyer CB. self-neglect are often unrecognised or at a stimulate discussion and the sharing of Impairment in instrumental activities of daily living chronic stage when identified, increasing experiences. The workshop is the first step and the geriatric syndrome of self-neglect. The Gerontologist, 2008; 48: 388-93. mortality and morbidity. Abusers can be and more work is underway to develop the 21 Pavlou MP, Lachs MS. Could self-neglect in older family members, neighbours, staff or any programme, which is intended to run on adults be a geriatric syndrome. Journal of the American Geriatric Society, 2006; 54: 831-42. persons in positions of trust. an annual basis for students. 22 Halliday G, Banerjee S, Philpot M Macdonald A. Student evaluation of the workshop was Community study of people who live in squalor. The Lancet, 2000; 355: 882-6. very positive. Students gained increased References 23 Dyer CB, Goins AM. The role of the interdisciplinary understanding and knowledge of elder 1 Department of Health and Children. Protecting our geriatric assessment in addressing self-neglect of the abuse and self-neglect. Evidence suggests future: report from the working group on elder abuse. elderly. Generations, 2000; 24(2): 23-7. Dublin: Stationery Office, 2002. 24 Information and Statistics Division. Practice team that the education of professionals in the 2 World Health Organization. Missing voices: views of information annual update (2007 to 2008). Edinburgh: recognition of elder abuse and self-neglect older persons on elder abuse. Geneva: World Health NHS National Services Scotland, 2009. Organization, 2002. 25 Department of Health. Protection of Vulnerable Adults is a first step in primary prevention and 3 Department of Health. No secrets: guidance on devel- scheme in England and Wales for adult placement effective leadership is a requirement for oping and implementing multi-agency policies and schemes, domiciliary care agencies and care homes: a practical guide. London: Department of Health, 2004. effective practice.34 The innovative shared procedures to protect vulnerable adults from abuse. London: Stationery Office, 2000. 26 Irish Nurses Organisation. Old Vulnerable and learning approach and teaching methods 4 National Centre for the Protection of Older People. abused. World of Irish Nursing, 2004; 12(10): 18-20. Elder abuse and legislation in Ireland. Dublin: National 27 National Centre for the Protection of Older People. were seen by students to provide for a more Education and training. Available at: www.ncpop.ie/ Centre for the Protection of Older People, 2009. index.php?uniqueID=5 (accessed 13 August 2010). in-depth reflection and critical analysis of 5 Health Service Executive. Open your eyes: elder abuse service 28 Clarke J. Public health nursing in Ireland: a critical roles and responsibilities of social workers, developments. Dublin: Health Service Executive, 2008. overview. Public Health Nursing, 2004; 21(2): 191-8. 6 Gill TM. Elder self-neglect: medical emergency or PHNs and team members. Students identi- 29 An Bord Altranais. Requirements and standards for marker of extreme vulnerability. Journal of the fied with a team approach, valued joint public health nursing education programmes. Dublin: American Medical Association, 2009; 302(5): 517-8. An Bord Altranais, 2005. working, building relationships of trust and 7 Hurley M, Scallan E, Johnson H, DeLa Harpe D. Adult 30 National Social Work Qualification Board, Irish working in partnership with clients, carers, service refusers in the greater Dublin area. Irish Association of Social Workers. Social work as a career. Medical Journal, 2000; 93(7): 208-11. Dublin: National Social Work Qualification Board, families and communities. Case studies 8 Mowlam A, Tennant R, Dixon J, McCreadie C. UK study Irish Association of Social Workers, 2009. allowed students to explore the complexity of abuse and neglect of older people: qualitative findings. 31 Dempsey M, Halton C, Murphy M. Reflective learning London: National Centre for Social Research, 2007. and individuality of each case in the context in social work education: scaffolding the process. 9 Day MR. Self-neglect: a challenge and a dilemma. Social Work Education, 2001; 20(6): 631-41. of best practice, policy and legislation. Archives of Psychiatric Nursing, 2010; 24(2): 73-5. 32 Damron-Rodriguez JA. Developing competence for It is recognised that health and social care 10 Day MR, McCarthy G, Leahy-Warren P. Professional nurses and social workers. American Journal of views on self-neglect: an exploratory study. Irish Nursing, 2008; 108(9): 40-6. professionals such as PHNs and social Journal of Medical Science, 2009; 178(8): S286. 33 Latucca L, Creamer E. Learning as professional practice. workers are central and have key roles in 11 Yaffe MJ, Wolfson C, Lithwic M. Professions show New Directions for Teaching and Learning, 2005; 102: 3-11. different enquiry strategies for elder abuse detection: 34 Perel-Levin S. Discussing screening for elder abuse at the identification, assessment, prevention Implications for training and interprofessional care. primary health care level. Geneva: World Health and on-going management and support of Journal of Interprofessional Care, 2009; 23(6): 646-54. Organization, 2008.
The Unite/CPHVA website has been redesigned to Unite/CPHVA provide easier access to the association’s many valuable online professional resources. website See: www.unitetheunion.org/cphva
32 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 IMPORTANT NOTICE: BREASTFEEDING IS BEST FOR BABIES formula withNEW LIPIL* improved
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References: 1. Morale SE, et al. Early Hum Dev.2005;81:197-203, 2. Hoffman DR et al. Abstract FASEB J. 2003;17:A727-A728, 3. Birch EE et al. Dev Med Child Neurol. 2000;42:174-181, 4. Birch EE et al. Early Hum Dev. 2007;83:279-284
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NutramigenLipil_AD_B_Sept_Iss_2.indd 1 05.08.10 15:12 Unite/CPHVA Annual Professional Conference Healthy Family, Healthy Child
The Unite/CPHVA annual conference • Annual Professional Forum • Poster Workshops is the principal event where we come (members only) • CPHVA Education & Development together to address the key challenges and • Fringe Meetings Trust AGM opportunities we face as professionals. • Civic Reception Find the inspiration and interaction you • Celtic Meetings Highlights include: need to refresh your professional vision • Breakfast Briefings • Large Exhibition and discover what you can bring back to • Community Nursery Nurses’ • Masterclasses your workplace. Register online today Professional Symposium www.neilstewartassociates.com/sh269
Ministerial address: Keynote speakers: Speakers Include: Anne Milton MP Lord Victor Carol Landry Parliamentary Under Secretary Adebowale International Vice-President at of State for Public Health President, CPHVA Large, United Steelworkers’ Union, USA
UK Public Health Professor Laura George Hosking Serrant-Green Founder, Chief Executive Professor of Community and Public and Research Co-ordinator, Health, University of Lincoln and WAVE Trust Visiting Professor, University of West Indies
Who should attend Public health professionals from the NHS, local • Community nursing and health visitors recruitment • District nurses government and education including: professionals • Voluntary agencies • Health visitors • Professional practice leads • Midwives • School nurses Other professionals engaged in the public health • Social workers • Community nurses agenda including: Education and research • Community nursery nurses • Practice nurses • Public health researchers • Community practitioners • Child & adolescent mental health services • Leads in public and community health NHS management • Children’s centre managers Other organisations engaged in the public health • Directors of nursing and public health • GPs agenda, including: • NHS directors and heads of human resources • Practice nurses • Commercial companies • NHS business managers • Paediatric nurses • Pharmaceutical companies • NHS trust strategy directors • Adult mental health services • Third sector support organisations Annual Professional Conference 2010 Wednesday 20th - Friday 22nd October 2010 Harrogate International Centre, Harrogate
Sponsored by: Free Internet Access! Pampers® has kindly sponsored free internet access for all visitors. Computer stations will be dotted around the exhibition hall and a café area will allow you to sit down to access wireless on your own equipment too.
Conference at a glance Day One: 20th October Day Two: 21st October Day Three: 22nd October Economic and demographic impacts Sustaining positive change in the community: Sustaining positive change - on practitioners flourishing - not failing - families influencing the future 10:30 Annual professional forum - 08:00 Breakfast briefings 08:00 Registration, refreshments, exhibition and Unite/CPHVA members only 08:00 Registration, refreshments, exhibition and networking 12:30 Annual conference networking 09:00 Plenary session three 13:30 Plenary session one 09:00 Plenary session two 10:30 Refreshments, exhibition and networking 15:20 Refreshments, exhibition and networking 10:20 Refreshments, exhibition and networking 12:20 The Nick Robin Memorial Lecture 15:30 Local Accredited Representatives’ workplace 11:45 Concurrent sessions 13:15 Conference summation training session (by invitation only) 11:45 Community nursery nurses’ professional symposium lunch, exhibition and networking 16:00 Masterclasses 12:45 Lunch, exhibition and networking 14:00 Close of conference 17:30 Conference closes 13:15 CPHVA Education and Development Trust AGM Open to all Unite/CPHVA members 19:30 Local Accredited Representatives’ reception (by invitation only) 14:00 Concurrent sessions 14:00 Community nursery nurses’ professional symposium Full agenda details are available at 15:00 Refreshments, exhibition and networking www.neilstewartassociates.com/sh269 15:30 Debate 16:30 Concurrent sessions 17:30 Fringe meetings 19:30 Conference party Exhibitor list • The Royal College of Paediatrics and • Lansinoh • Interest Group for Parenting and Family • Hipp Organic Child Health • Forum Group Support • PromoCon • NHS Choices • Stiefel, A GSK Company • Department of Health – Nutrition Team • ‘Now We’re Talking’ • Dr Browns Natural Flow • Genus Pharmaceuticals • Education and Resources for Improving • Parents 1st • Johnson’s Baby • Bounty Childhood Continence (ERIC) • CPHVA Trust • Mead Johnson Nutrition • Reckitt Benckiser - Dettol • The Anaphylaxis Campaign • NMC • Harlow Printing • One Plus One • British Journal of School Nursing • NSPCC • Malem Medical • Reckitt Benckiser - Bonjela • Pampers® • NHS Immunisation Information • International Association of • Sudocrem • Consumer Financial Education Body Infant Massage • Alliance Pharmaceuticals
Call Mark Baker on 020 7324 4330 to discuss exhibition and sponsorship opportunities
Register online: www.neilstewartassociates.com/sh269 or call 020 7324 4330 36-37 CP Sep 10 Francis.qxd:Layout 1 18/8/10 16:13 Page 36
FEATURE Child eczema clinic Developing a health visitor-led eczema clinic for children aged under five years to educate and support families in managing the condition
Ann Francis Specialist community practitioner continued to rise while resources have and weaning to minor ailments, including public health nursing – health visitor, visibly decreased. These conditions skin conditions such as atopic eczema. The NHS Luton Community Services account for about 15% of a GP’s clinics are usually very busy, with up to 80 workload.5 Atopic eczema can have a children seen within the two hours that Health care is a complex and rapidly significant negative impact on the quality the clinic is open. This allows a limited changing business. To deliver the best of life of the children affected, parents and amount of time to explain to parents how possible care to patients, it is essential that carers. Community-based healthcare to treat and manage their child’s eczema.12 the evidence is readily available to inform professionals need to understand the rapid practice.1 It is not simply about adapting changes that are occurring in the under- Health visitor-led eczema clinic to change, but identifying the need for, standing of eczema and its management.6,7 Over the past four or five years, I have and initiating improvements in care. The developed a personal interest in eczema. NHS Next Stage Review final report2 I wanted to use the This stems from my time working with the details a change in the focus of the NHS knowledge and experience district nursing team – a time of leg ulcers, from quantity to quality, to empower pressure sores and varicose eczema. That patients, offer more choice and increase that I had gained to interest was fervered when I moved to opportunities to influence their care. make a positive impact children’s services and on to becoming a health visitor. I wanted to use the Health visitors and leadership Commissioners, providers and health knowledge and experience that I had Health visitors are increasingly required to planners need information about the gained to make a positive impact on undertake project work using a range of prevalence and incidence of skin condi- people’s lives, especially for the children methodologies. As a consequence, prepara- tions, available services and their effective- and their families in the locality.12 tion for this role requires personal and ness. Informed decisions can then be taken During health visitor-led child health professional development within the to ensure high quality care, wherever it is clinic sessions, I became increasingly aware domain of leadership and management. provided and whoever provides it.8 of how many parents asked advice about In order to take on new roles and the condition of their child’s skin. For responsibilities, there is a need to look at Eczema in children many, this clinic is their first contact point new ways of working. Theoretical princi- The impairment of quality of life caused by for help and advice, having been given its ples can be defined as part of practice childhood eczema may be greater than or details by the health visitor in the postnatal development, focusing on improving client equal to other common childhood diseases period. The child may be prescribed care, transformation of the context and such as asthma and diabetes – it is a major emollients by their GP, but not given suffi- culture of care, adopting a systematic chronic childhood disease.9 Eczema affects cient information about creams or applica- approach to effective practice change, and five million children and adults in the UK tion. Others are not aware that their child ensuring that development is a continuous every year – around one in five children has eczema and have many questions. process that focuses on the nature of the and one in 10 adults. There is no cure, but These parents need time to discuss their facilitation needed to enable change to there are many ways in which discomfort child’s condition more fully, and it soon occur. This principle can be applied to and distress can be minimised, enabling became evident that the time available to change in the way we manage childhood them to live as normal a life as possible.10 give beneficial advice and support in a busy atopic eczema in the community. Atopic eczema is the most common type child health clinic was inadequate. and tends to develop during childhood, Skin disease and primary care usually running in families and closely Running the clinic Skin diseases affect between one-third and linked with other atopic allergic conditions In March 2008, the eczema clinic opened one-quarter of the population at any one such as asthma and hay fever. It develops for the first time, for children with mild to time, with 60 000 referrals to secondary early in childhood during the first year of moderate atopic eczema. Health visitors care in 2001 to 2002.3 In primary care, life, at a time when families are often still throughout Luton who felt that their 80% of the workload encompasses eczema, in contact with health visitors.11 families would benefit were invited to send psoriasis and acne, with atopic eczema Parents can attend child health clinics referrals. The families would then be sent being the most common inflammatory run in health centres and now in children’s an individual 30-minute appointment. skin disease of childhood.4 The demand centres, seeking advice from the health During the appointment, parents are for dermatology care in the UK has visitor on a variety of topics, from feeding educated on the management of their
36 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 36-37 CP Sep 10 Francis.qxd:Layout 1 18/8/10 16:13 Page 37
FEATURE
child’s eczema – the use of emollients and care, we are keen to start new services with empowers families to manage care more products such as corticosteroid creams, the belief that they are needed and what effectively. However, in this economic bath oils and ointments, their correct clients want. We can then find that clients crisis with the NHS being transformed, we application and amounts that should be do not turn up for appointments or come have to fight to keep such valuable used, as well as environmental factors and to sessions. With the eczema clinic, as services going. The new White Paper states food allergies. These parents benefit from health visitors we had listened to what that the government plans to build on the an individualised information session. The mothers were saying to us when they came legacy of Lord Darzi and improve quality idea of patient educational sessions is to seek advice at health clinics, and as a and healthcare outcomes, ‘ensuring that supported by the National Institute for team we did something positive about it. the focus is always on what matters most Health and Clinical Excellence guidelines In the two years that the clinic has been to patients and professionals’ (p21).16 that were released in December 2007.13 in operation, we have achieved a 98% At present, referrals are received only The clinic at first was run on a fortnight- attendance rate, with clients rarely from members of the health visiting ly basis, but due to the high volume of cancelling appointments. The eczema service, but with increased staffing levels referrals it soon became evident that this clinic continues to be successful, though in and investment this service has the would need to become weekly. This change the current climate of staffing and potential to receive and manage referrals was implemented in May 2008. financial constraints it is now running on from GPs and other community-based a two-weekly basis once again. healthcare professionals. Benefits for parents The majority of parents who bring their It is often revealed that References child to the clinic do not fully understand 1 Leng G. Basing decisions on the evidence. environmental factors Independent Nurse, 2009; 19: 42. why their child has eczema. They have 2 Department of Health. High quality care for all: NHS Next often been prescribed emollients by their are exacerbating Stage Review: final report. London: Stationery Office, 2008. 3 Action on Dermatology. Action on dermatology: good GP and are of the opinion that the creams the condition practice guide. London: Department of Health, 2003. 4 Dermatology Workforce Group. Models of integrated will eradicate that condition completely. service delivery in dermatology. London: Department When the skin condition remains the same In 2009, I was privileged to receive the of Health, 2007. 5 Buchanan P, Courtenay M. Topical treatments for after using the creams, they conclude that GP National Enterprise Award, sponsored managing patients with eczema. Nursing Standard, the creams do not work and return to the by the Royal College of General 2007; 21(41): 41-50. 6 Watkins P. Using emollients to restore and maintain GP for a different cream. Practitioners, under the category of skin integrity. Nursing Standard, 2008; 22(41): 51-7. 7 Watkins P. Atopic eczema in children: clinical guidelines During the discussion with the parents, it Primary Care Nursing for Innovation for for daily practice. Primary Health Care, 2008; 18(8): 41-6. is often revealed that environmental the work done in setting up and running 8 Schofield J. Updated dermatology health care needs assessment. Dermatology Nursing, 2009; 8(2): 20-5. factors are exacerbating the condition, the eczema clinic. 9 Wright J. Coping with atopic eczema. Journal of such as bed-sharing, non-cotton clothing Community Nursing, 2006; 21(5): 30-3. 10 Chiodo B. Eczema: an overview. Journal of or family pets. As a nurse prescriber, I also Conclusion Community Nursing, 2002; 16(9): 46-9. 11 Robinson J. Managing atopic eczema in childhood: have the option to prescribe an appropri- Health visitors strive to build relationships the health visitor and school nurse role. Community ate treatment if deemed necessary. and give support to parents and families Practitioner, 2008; 81(6): 25-8. 12 Department of Health. Facing the future: a review of the Parents are given an information pack re- during the first five years of their child’s role of health visitors. London: Stationery Office, 2007. emphasising what has been said, and leave life. This gives us the potential to have a 13 National Institute for Health and Clinical Excellence. Atopic eczema in children: Management of atopic eczema armed with much needed knowledge and significant impact on health issues from in children from birth up to the age of 12 years. London: National Institute for Health and Clinical Excellence, 2007. understanding to manage their child’s an early age. The health visitor-led eczema 14 Department of Health. Providing care for patients with eczema in a more positive manner. clinic is an initiative that continues to be skin conditions: guidance and resources for commissioners. London: NHS Primary Care Contracting, 2008. successful because it is what parents want 15 Department of Health. Modernising nursing careers: Benefits for GP surgeries and need. It affords the time to explain setting the direction. London: Stationery Office, 2006. 16 Department of Health. Equity and excellence: liberat- As the parents have a better understanding and discuss their child’s condition and ing the NHS. London: Department of Health, 2010. of their child’s eczema after attending the clinic, they become less anxious about the Box 1. Outcomes of the health visitor-led eczema clinic condition. Once they begin the new regime, the eczema improves and they no ■ Parents receive information and practical advice on managing their child’s condition longer need repeated appointments at ■ By enabling health visiting staff to refer clients to the service, it allows them extra their GP surgery, freeing up appointments time to give parents advice during busy clinic times for those seeking more acute care. ■ Reduces the need for repeated GP appointments, this vacates appointments at busy GP surgeries for those seeking more acute care14 Outcomes and challenges ■ Cost effective to the NHS regarding frequent prescriptions and by incorrect applica- There have been numerous positive tion of topical medications outcomes from running the clinic – for ■ Staff assisting with the clinic increase clinical knowledge and become more children and their families, but also for the competent with prescribing skills15 health visitors and colleagues (see Box 1). ■ Satisfaction and reduced anxiety for parents through better management of their One of the challenges when setting up a child’s eczema new service is the question of whether ■ Reduces the need for costly referrals to a dermatologist consultant or specialist people will come. In the field of health
September 2010 Volume 83 Number 9 COMMUNITY PRACTITIONER 37 Calm skin. Peaceful night.
Applied regularly, the patient friendly formula of Diprobase will hydrate, soothe and calm eczematous skin1, helping to reduce night-time itching and scratching.
Diprobase Prescribing Information Uses: Diprobase Cream and Ointment are emollients, with moisturising and protective Contra-indications: Hypersensitivity to any of the ingredients. Side-effects: properties, indicated for follow-up treatment with topical steroids or in spacing such Skin reactions including pruritus, rash, erythema, skin exfoliation, burning sensation, treatments. They may also be used as diluents for topical steroids. Diprobase hypersensitivity, pain, dry skin and bullous dermatitis have been reported with product products are recommended for the symptomatic relief of red, inflamed, damaged, use. Package Quantities: Cream: 50g tubes, 500g pump dispensers; Ointment: dry or chapped skin, the protection of raw skin areas and as a pre-bathing emollient 50g tubes. Basic NHS Costs: Cream: £1.28 (50g), £6.32 (500g); Ointment: for dry/eczematous skin to alleviate drying effects. Dosage: The cream or ointment £1.28 (50g). Legal Category: GSL. Marketing Authorisation Numbers: Cream: should be thinly applied to cover the affected area completely, massaging gently 0201/0076; Ointment: 0201/0075. Further information available upon request and thoroughly into the skin. Frequency of application should be established by the from Schering-Plough Ltd, Shire Park, Welwyn Garden City, Herts, AL7 1TW. physician. Generally, Diprobase Cream and Ointment can be used as often as required. Date of Revision: November 2009. Tried. Trusted. Diprotected. Please refer to the full SPC text before prescribing this product. Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Schering-Plough Drug Safety Department on +44(0)1707 363773. Code: DIP/10-665d Date of preparation: January 2010 References: 1. Diprobase SmPC www.diprobase.co.uk
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CLINICAL PAPERS
Inequalities in mortality in Britain Early maternal affection greater today than in 1930s Thomas B, Dorling D, Davey Smith G. Inequalities in premature mortality in Britain: and adult coping skills observational study from 1921 to 2007. BMJ, 2010; doi:10.1136/bmj.c3639 (22 July 2010).
The level of inequalities in premature mortality between different areas of Britain is now greater than at any time since comparable records began and could become worse, researchers have found. Mortality inequalities have persisted over many years and recent government efforts to reduce them have not had any great impact as yet. Health inequalities have widened over the past 10 years, reflecting those in wealth and income. To report on the extent of inequality in premature mortality as measured between areas of Britain, researchers analysed mortality data for England, Wales and Scotland. Statistics for the population aged under 75 from 1990 to
Maselko J, Kubzansky L, Lipsitt L, Buka S. Mother’s affection at eight months predicts 2007 were used, and those aged under 65 from 1921 to 1939, 1950 emotional distress in adulthood. Journal of Epidemiology and Community Health, 2010; to 1953, 1959 to 1963, 1969 to 1973 and 1981 to 2007. doi:10.1136/jech.2009.097873 (26 July 2010). Geographical inequalities in age-sex standardised rates of High levels of maternal affection to infants at eight months are mortality below age 75 increased every two years between 1990 to associated with significantly lower levels of emotional distress 1991 and 2006 to 2007 without exception. During this period, the in adult offspring, a study has found. Despite a growing poorest were 1.6 times more likely to die prematurely than the consensus that levels of parent-child warmth and affection most affluent in 1990 to 1991. By 2006 to 2007, those worst-off seem to moderate the stress response and make children more were twice as likely to die prematurely than the most affluent. The resilient to frustration, distress and other difficulties, there is last time that inequalities were almost as high as they are now was little longitudinal data with objective assessment during infancy in the lead up to the economic crash of 1929 and depression of the and sustained adult follow up. To examine the association 1930s. The researchers conclude: ‘Although life expectancy for all between objective assessments of mother-infant nurturing at people is increasing, the gap between the best and worst districts is eight months and symptoms of distress in middle adulthood, continuing to increase. The economic crash of 2008 might precede US researchers used data from a birth cohort of the National even greater inequalities in mortality between areas.’ Collaborative Perinatal Project (follow-up mean age=34, final n=482). Infant-mother interaction quality was rated by a Evidence-based guidelines are psychologist during routine developmental assessment. At the end of each session, the psychologist completed an assessment needed for nipple shield use Eglash A, Ziemer A, Chevalier A. Health professionals’ attitudes and use of nipple shields for of how well the mother had coped with her child’s develop- breastfeeding women. Breastfeeding Medicine, 2010; 5(4): 147-51. mental tests and how she had responded to their performance. The amount of affection and attention she gave to her child was Nipple shields are used readily for term and near-term infants in also categorised, ranging from ‘negative’ to ‘extravagant’. Adult their first week of life, as well as for pre-term infants despite many emotional functioning was assessed (average age=34) with the concerns regarding their safety, a US study has concluded. Their use validated Symptom Checklist-90, capturing specific elements, is controversial among healthcare professionals. Nipple shields have such as anxiety and hostility, as well as general levels of distress. been extolled for their role in overcoming breastfeeding difficulties At eight months one in 10 interactions (n=46) were charac- and maligned for reduced milk supply leading to undernourished terised by a low level of maternal affection toward the infant. infants, as well as shield addiction. Despite being used by breastfeed- Most (n=409) were characterised by normal levels, and the ing women for centuries, professional guidelines for their use have remaining 27 by very high levels. When the specific elements never been developed. To determine healthcare professionals’ most of the checklist were analysed, those whose mothers had been common reasons for and against their use, a web-based anonymous observed to be the most affectionate at eight months had the survey was advertised in 2009 via an internet list to physicians and lowest levels of anxiety, hostility and general distress. There allied health professionals specialising in breastfeeding management. was a more than seven-point difference in anxiety scores Subjects were asked about their most common reasons for using between those whose mothers had displayed low or normal nipple shields, their most common concerns, and what they typically levels and high levels of affection. This pattern was seen across hear from breastfeeding women who have used them. all elements of the checklist – the higher the mother’s warmth, Of 490 participants who completed the survey, 92% had used the lower the adult’s distress. High levels of maternal affection nipple shields in their practice. The most common reason for use are likely to facilitate secure attachments and bonding, say the was to help the infant latch and nurse before 35 weeks, and 38% authors. This not only lowers distress, but may also enable a used nipple shields in infants at between 35 weeks’ gestation and child to develop effective life, social and coping skills, which three days of age. Respondents rated ‘lack of follow-up by those will stand them in good stead as adults. These findings suggest introducing the nipple shield’ as their greatest concern. The most early nurturing and warmth have long-lasting positive effects frequently expressed maternal response was that ‘they are helpful’. on mental health well into adulthood. Evidence-based guidelines are needed, say the researchers, as are prospective studies on their impact on breastfeeding.
September 2010 Volume 83 Number 9 COMMUNITY PRACTITIONER 39 39-40 CP Sep 10 Clinpaps.qxd:Layout 1 19/8/10 11:44 Page 40
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IN BRIEF...
Late pre-term births and the risk of Vitamin E and reduced risks of respiratory illness dementia and Alzheimer’s
The Consortium on Safe Labor. Respiratory morbidity in late preterm births. JAMA, 2010; 1 Devore E, Grodstein F, van Rooij F, Hofman A, Stampfer M, Witteman J, Breteler M. 304(4): 419-25. Dietary antioxidants and long-term risk of dementia. Arch Neurol, 2010; 67(7): 819-25. 2 Mangialasche F, Kivipelto M, Mecocci P, Rizzuto D, Palmer K, Winblad B, Fratiglioni L. Babies born between 34 and 37 weeks’ gestation are much more High plasma levels of vitamin E forms and reduced Alzheimer’s disease risk in advanced likely to have respiratory illness compared to infants born at age. Journal of Alzheimer’s Disease, 2010; 20(4): 1029-37. full term, according to a report. To assess short-term respirato- Consuming more vitamin E through the diet appears to be ry morbidity in late pre-term births compared with term births, associated with a lower risk of dementia and Alzheimer’s US researchers from the Consortium on Safe Labor looked at disease (AD) suggesting vitamin E may help prevent cognitive data of 233 844 deliveries between 2002 and 2008 – 19 334 late deterioration in elderly people, according to the conclusions of pre-term and 165 993 term neonates were included in the two recent studies.1,2 Oxidative stress – cell damage from analysis. Late pre-term birth was defined as delivery between oxygen exposure – is thought to play a role in AD development. 340/7 and 366/7 weeks’ gestational age, while term birth was To study consumption of major dietary antioxidants relative to defined as 370/7 to 406/7 weeks’ gestational age. Late pre-term long-term risk of dementia, researchers in the Netherlands births were compared with full-term births for resuscitation, assessed 5395 participants aged 55 years and older who did not respiratory support and respiratory diagnosis. have dementia between 1990 and 1993.1 Over an average of 9.6 For neonates who were born at 34 weeks, the odds of respira- years of follow up, 465 developed dementia and 365 of those tory distress syndrome (RDS) were increased 40-fold, and that were diagnosed with AD. After adjusting for other potentially risk decreased with each advancing week of gestation until 38 related factors, the one-third of individuals who consumed the weeks. Even for those born at 37 weeks, the odds of RDS were most vitamin E (median=18.5mg per day) were 25% less likely still three times greater than that of a 39- or 40-week birth. to develop dementia than the one-third who consumed the There was no difference in respiratory morbidity in 38-week least. The authors conclude that higher intake of foods rich in versus 39- to 40-week infants. The researchers suggest that vitamin E may modestly reduce long-term risk of dementia and further research is needed to determine if it may be useful to AD. In the second study,2 Swedish researchers investigated the use steroids to promote foetal lung maturity beyond the current association between plasma levels of eight forms of vitamin E standard of 34 weeks, or if it may be useful to use medications and incidence of AD among the 232 oldest individuals in a to stop premature labour in women beyond 34 weeks to population-based setting. After six years of follow up, 57 AD maintain pregnancy for longer. cases were identified. Subjects with higher blood levels of all vitamin E forms had a reduced risk of developing AD. In Gestational diabetes: recurrence risk conclusion, high plasma levels of vitamin E are associated with in subsequent pregnancies a reduced risk of AD in advanced age, say the authors.
Getahun D, Fassett M, Jacobsen S. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol, 2010; doi:10.1016/j.ajog.2010.05.032 (13 July 2010). No increase in seizures after DTaP Huang W-T, Gargiullo P, Broder K, Weintraub E, Iskander J, Klein N, Baggs J; Vaccine Safety Women with a history of gestational diabetes mellitus (GDM) Datalink Team. Lack of association between acellular pertussis vaccine and seizures in early childhood. Pediatrics, 2010; doi:10.1542/peds.2009-1496 (19 July 2010). have an increased risk of recurrence in subsequent pregnancies, say US researchers. GDM is associated with higher rates of pre- The diphtheria-tetanus-acellular pertussis vaccine (DTaP) does eclampsia, birth trauma and future risk of type-2 diabetes. For not appear to increase a child’s risk of seizures, according to a the neonate, GDM is associated with a higher risk of retrospective analysis from the US Vaccine Safety Datalink macrosomia and hypoglycaemia. The researchers examined the project. The analysis included 433 654 children aged six weeks recurrence risk of GDM in a subsequent pregnancy using to 23 months, who received approximately 1.3million doses of longitudinally-linked records to study women with first two DTaP over 10 years. A seizure event (febrile or afebrile) was and first three singleton pregnancies. Risks of GDM in the defined by ICD-9-CM diagnoses assigned to an in-patient or second pregnancy among women with and without previous emergency department (ED) setting. The exposed period was GDM were found to be 41.3% and 4.2% respectively. The composed of a predefined four person-days after each DTaP recurrence risk of GDM in the third pregnancy was stronger dose. Overall, there were about 7200 seizures requiring ED or when women had GDM in both prior pregnancies. The authors hospital care. In adjusted analyses, the seizure incidence was no conclude that a pregnancy complicated by GDM is at increased higher within four days after vaccination than during other risk for subsequent GDM, and say early detection and initiation times. The authors point out that the previously used, whole- of treatment is important because unrecognised or untreated cell pertussis vaccine (DTP) had been associated with an gestational diabetes is likely to lead to adverse maternal and increase in febrile seizures, but conclude that DTaP is not foetal outcomes. associated with acute seizure events.
Clinical papers was compiled by June Thompson
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CLINICAL UPDATE
Drugs and breastfeeding
When mothers are asked Box 1. Scenario: a distraught mother to stop breastfeeding while on medication You meet Stephanie at the clinic. She has struggled hard to establish breastfeeding having encountered cracked nipples and mastitis within the first four weeks. However, in recent weeks breastfeeding has been going well. Stephanie loves it and baby Ellie is a Wendy Jones happy, flourishing and contented baby. Drugs in Breastmilk Helpline pharmacist and Stephanie tells you that she saw Dr Hepworth yesterday for her six-week postnatal registered supporter, Breastfeeding Network check. She told her that she was tired and had become rather tearful during the appoint- Sharon Breward ment. Dr Hepworth suggested she was showing signs of postnatal depression and Infant feeding co-ordinator, Betsi Cadwaladr prescribed citalopram 10mg. She told Stephanie that she should stop breastfeeding, as University Health Board and UK vice chair, the drug could alter baby Ellie’s brain cells. Association of Breastfeeding Mothers Stephanie is distraught, her self-confidence is really low and she had thought that What do you do if a mother on your breastfeeding was the one thing holding her together, seeing Ellie so happy and thriving. caseload tells you that her GP has told her to Dr Hepworth had suggested that someone else could bottle-feed the baby overnight, but stop breastfeeding in order to have a medical Stephanie is a single mum with no support around her, so this is not an option. condition treated (see Box 1)? Do you: She has been told to stop breastfeeding, she is scared for her baby, scared of the drug – ■ Help her to stop breastfeeding – the pharmacist who dispensed it told her she might feel worse before she feels better – and permanently or temporarily she needs to stay on it for six months after she feels better. Is it addictive? Must she take ■ Suggest she sees another GP it? What formula can she use? Must she use formula? Stephanie sits in clinic and sobs. ■ Seek out information on the safety of ■ Has Dr Hepworth helped Stephanie? ■ What are you going to do now? the drug passing through breastmilk and discuss options with the GP Appropriate information Awareness and understanding ■ Refer the mother to alternative sources The BNF2 advises that drugs are almost All health visitors receive on-going training of information. invariably unlicensed for use during breast- on the benefits of breastfeeding to mother With larger and widespread caseloads, it feeding. This does not necessarily imply a and child. Your trust may be seeking Baby may not be easy to approach a GP to discuss risk, merely that the manufacturers have Friendly accreditation.10 Journals have such a scenario, and questioning their advice not included safety in lactation as part of frequent articles on breastfeeding and may feel outside of your remit as a health their licensing application and have not formula feeding, and health visitors are visitor. This article aims to help you decide undertaken clinical trials. Specialised texts seen by mothers as experts on child how to do this with good results for all. and reference sources provide information nutrition. However, the Australian paper9 on studies that have been reported, along confirmed the finding of a 1995 UK Advocacy and breastfeeding with pharmacokinetic information that study11 that much of a GP’s response to An important role for any trained nurse is facilitates assessment of safety.3-7 The BNF infant-feeding queries is based on the to act as the patient’s advocate. In addition, for Children8 provides information on drug knowledge and experience that they gained all healthcare professionals involved in the levels passing into breastmilk, along with while raising their own children. What if care of mothers and babies should protect, the licensed or unlicensed use in children. those children were born in the late 1970s promote and support breastfeeding. The results of a questionnaire sent to and 1980s, when breastfeeding initiation While nutritionally adequate, infant doctors in Australia9 has highlighted the was at its low point? formula can never replicate the myriad of need for simple, reliable, current informa- biological factors of breastmilk that confer tion to aid prescribing decisions in more Ethical responsibilities health advantages for mother and baby. complicated scenarios, citing antidepressant Prescribing medication may lead to early Breastfeeding is undoubtedly the best way use as an example. cessation of breastfeeding, often as a result for babies to be fed, it is the biological of subtle messages from healthcare profes- norm and formula-feeding is a clinical Enough time sionals if not overt instructions.12 In most intervention. The Department of Health1 GPs may lack time within a clinical consul- prescribing scenarios, GPs are aware of recommends that babies should be exclu- tation to seek out and evaluate informa- their responsibilities to a vulnerable third sively breastfed for six months, and beyond tion on levels of a drug passing into party in the discussion – the baby.9 In as part of a weaning diet until mother and breastmilk – together with how old the prescribing outside of license application, baby decide to stop. baby is, how often it is feeding and how the practitioner has to take ultimate So why might a GP recommend that a important breastfeeding is to the mother – responsibility for the use of the medication. mother stops breastfeeding in order for her on top of making a diagnosis and prescrib- To do so without full information and to take medication? ing decision. experience would be unethical. However,
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CLINICAL UPDATE
how ethical is it to halt or stop breastfeed- attempts to provide the information or decide how important it is to carry on ing due to perceived risks of a medication dismisses it, choosing to stay within breastfeeding. The Breastfeeding Network when the risks of formula feeding are clear? licensed indications? What if the mother is Drugs in Breastmilk Helpline7 took 170 now so scared that she is giving her baby calls from healthcare professionals and What can the health visitor do? ‘tainted’ milk that she no longer wants to mothers during May 2010 – an unprece- If you assist the mother to stop breastfeed- breastfeed, perceiving formula as ‘safer’? A dented volume – and many were the result ing as she has been advised, you are suggested letter (see Box 2) may be of a recommendation to stop breastfeeding helping her to follow the GP’s instructions adapted for use – while direct contact may following the prescription of a drug. – be that by pumping and dumping her be preferable, it can help to know that Mothers calling this voluntary helpline are milk for a period and re-establishing her there is good information to back up your counselled and supported to make the supply subsequently, or by cessation of her standpoint as the mother’s advocate. decision that is right for them having been supply. That sounds fairly unthreatening, provided with information on the available but consider a scenario in which you have How ethical is it to halt studies and safety data. Healthcare profes- helped a mother to stop feeding her six- or stop breastfeeding sionals are given written information week-old. She subsequently finds out that wherever possible to share with the mother there was sufficient information suggesting due to perceived risks and prescriber. However, the discussion that it is safe to take the medication during of a medication? should still take place as to why the GP, lactation. In the meantime, the baby has nurse or pharmacist chose to advise the developed an allergic reaction to cow’s If you suggest that the mother consults mother to stop breastfeeding and how this milk formula, is displaying symptoms of another GP, presumably because they may may be changed in the future. If the eczema and is generally unsettled. be more supportive of breastfeeding, you mother chooses to carry on breastfeeding Providing information from additional may undermine the mother’s confidence but not to tell the GP or to lie about her sources to the mother and GP enables in her care provider, and you may wish to breastfeeding, an opportunity is lost – but multidisciplinary working to facilitate the consider the ethics of such action. how many times does this happen? treatment of the mother’s condition and However, the mother’s opinion regarding support on-going breastfeeding. this should be respected. Conclusion By giving the mother information on Consider how you could change your Addressing challenges sources she may use to determine whether practice so that mothers are empowered You may have difficulties accessing the the drug is safe for her to take during and facilitated to continue breastfeeding, practice due to time or geographical breastfeeding, you are putting the onus on despite needing a particular medication. constraints. What if the GP rebuffs your her to assess the safety of the drug and to By working proactively, seeking out infor- mation and ensuring that priority is given Box 2. Suggested letter: medication for a lactating mother to the importance of breastfeeding, health visitors have an important contribution to make in supporting mothers to continue Dear Dr ...... Re Name ...... Baby ...... breastfeeding through challenges posed by Address ...... Date of Birth ...... illness and medication. I have seen the above named mother, who is currently breastfeeding. I understand that you advised her to stop breastfeeding whilst taking ...... References Locally we are working to increase the initiation and prevalence of exclusive breastfeeding 1 Department of Health. Breastfeeding your baby. Available in line with local and national policies. at: www.breastfeeding.nhs.uk (accessed 23 June 2010). 2BNF. British National Formulary. Available at: You may not be aware of the recommendation within NICE maternal and child nutrition www.bnf.org (accessed 23 June 2010). guidelines (www.nice.org.uk/PH11) that: 3 Sweetman SC (Ed.). Martindale: the complete drug reference (35th edition). London: Pharmaceutical, 2006. ■ Health professionals and pharmacists who prescribe or dispense drugs to a breastfeeding 4Hale T. Medications and mothers’ milk (14th edition). mother consult supplementary sources – for example, the Drugs and Lactation Database Amarillo, Texas: Hale, 2010. (LactMed) www.toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT – or seek guidance from the 5 US National Library of Medicine. LactMed. Available at: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT UK Drugs in Lactation Advisory Service (www.ukmicentral.nhs.uk/drugpreg/guide.htm) (accessed 23 June 2010). ■ Health professionals should discuss the benefits and risks associated with prescribed 6 UKMi Central. UK Drugs in Lactation Information and medication and encourage the mother to continue breastfeeding, if reasonable to do so. Advisory Service. Available at: www.ukmicentral.nhs.uk/ drugpreg/guide.htm (accessed 23 June 2010). In most cases, it should be possible to identify a suitable medication which is safe to take 7 Breastfeeding Network. What is the Drugs in Breastmilk during breastfeeding by analysing pharmokinetic and study data. Appendix 5 of the British Helpline? Available at: www.breastfeedingnetwork.org.uk/ National Formulary should only be used as a guide as it does not contain quantitative drugs-in-breastmilk.html (accessed 23 June 2010). 8BNF. BNF for Children. Available at: www.bnfc.org data on which to base individual decisions (accessed 23 June 2010). ■ Health professionals should recognise that there may be adverse health consequences 9 Jayawickrama HS, Amir LH, Pirotta MV. GPs’ decision- for both mother and baby if the mother does not breastfeed. They should also recognise making when prescribing medicines for breastfeeding women: content analysis of a survey. BMC Research that it may not be easy for the mother to stop breastfeeding abruptly – and that it is Notes, 2010; 3: 82. difficult to reverse. 10 UNICEF UK. Best practice in community health-care I recognise that the above medication is outside of its licence application for use during services. Available at: www.babyfriendly.org.uk/ page.asp?page=71 (accessed 23 June 2010). breastfeeding. However I attach further information, from the above reference sources, for 11 Jones W, Brown D. The medication vs breastfeeding your consideration. If you have any queries, I can be contacted on ...... dilemma. Br J Midwifery, 2003; 11: 550-5. Thank you. 12 Anderson PO, Pochop SL, Manoguerra AS. Adverse drug reactions in breastfed infants: less than imagined. Clinical Pediatrics, 2003; 42(4): 325-40.
42 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 43-44 CP Sep 10 YRAW.qxd:Layout 1 19/8/10 11:48 Page 43
YOUR RIGHTS AT WORK Time to train: your rights
Am I eligible to request time to train? Staff now have the right to request time to train from Eligibility for the right to request time to train is only available to their employers, and while this does not oblige them employees who have completed a minimum of 26 weeks’ service. to provide it, it does provide a framework to make a The following are not eligible to exercise the right: case for training and to ensure that this is heard fairly ■ Agency workers ■ People of compulsory school age ■ 16- or 17-year-olds who have an entitlement to reasonable paid Have you heard that training is usually the first thing to go if time off work to achieve an NVQ level 2 (or equivalent), unless resources are cut? One-third of employers do not train their they have already achieved that standard employees, and up to 10million workers receive no job-related ■ 16- to 18-year-olds who have a duty to participate in training training at all. Conversely, have you also heard it said that ‘organi- or education to attain an NVQ level 3 (or equivalent), unless sations cannot afford not to invest in training staff when times are they have already achieved that standard tough’? Despite this paradox, a new statutory right allows ■ Members of the armed forces. employees to make a request to their employer for time to train. Although there are restrictions on the eligibility of employees who Since 6 April 2010, under the statutory scheme, organisations may exercise this right, union representatives can encourage with 250 or more employees have obligations to respond to employers to consider requests from all staff, perhaps as part of individual requests for time to train. From April next year, those their first six months with the organisation or an induction with fewer than 250 employees will also have to do the same. period. Learning representatives can signpost ineligible staff The statutory scheme works in a similar way to the right to toward other opportunities to develop their skills, either through request flexible working. It is hoped that the right to request time union learning routes or at local colleges or community groups. to train will have the same impact in terms of employment policies and practice, and that up to a million workers may get What training or learning can I request? new training opportunities over the next three years. In order to make a request for time to train under the statute, there are certain criteria that must be met. You must apply in Equality of access to training for all? writing. There is a template letter on the government website (see: There is no doubt that inequality exists in access to training www.direct.gov.uk/timetotrain) that can help to make sure that all within health organisations. Lower-qualified, lower-paid workers the required information is included in the request: are four times less likely to receive regular training at work than ■ The subject of the training course or study those who already hold qualifications or are in higher-paid roles. ■ Where and when the training or study will take place, and for An interesting exercise for representatives would be to ask their what length of time trust or board for a breakdown of training budget spend, by role ■ Who provides the course, education, or supervises the study or department. Other inequalities might be highlighted if the same (college, awarding body, self-study programme) analysis could be done, for example, by gender or ethnic group. If ■ Whether it leads to a recognised qualification your organisation cannot – or will not – provide this, then a ■ How the education, training or study will make the individual union-led staff learning survey will probably be quite revealing. more effective at work or improve the organisation’s performance. The training must help the member of staff to develop skills that Managers always refuse requests for training! are relevant to their job, workplace or business. This fits in well While employers are able to put forward a legitimate business case with the NHS Knowledge and Skills Framework (KSF) – that an to refuse an individual or group of staff time to train, this is one individual’s competence to carry out their role, including meeting area where trade union representatives can be influential, persua- their objectives, can only be achieved with the support of the sive and work in partnership to seek viable solutions. organisation. It also aligns with the four pledges under the NHS Employers are now obliged by law to give proper consideration Staff Constitution on training and support to staff. to requests for training during working time. Union representa- The training must help staff to improve their job performance, tives, especially learning representatives, can support colleagues by which in turn should improve the performance of the ‘business’ giving them information and helping them to achieve the confi- or department, and in turn, the trust or board. It is therefore dence to exercise their right. useful to include references to the Quality, Innovation, Representatives who negotiate with their organisation are also Performance and Prevention initiative when you are making a well placed to promote the use of the right, and to make sure it is case for training. Again, this also reflects the cascade of organisa- included in policies and collective learning agreements for all tional objectives filtering down to department, team and individ- staff. Unions can also negotiate with employers on paying for job- ual level. It makes sense for all staff to be contributing to related courses and time taken off for training. Employers are not higher-level aims such as excellent patient care, reducing waste obliged to pay for these, but it is good common practice. Any and efficient use of scarce resources. These are all arguments to organisation or business will benefit directly from supporting a use that could help persuade decision-makers to agree to the time well-trained, motivated, competent and confident workforce. for training.
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YOUR RIGHTS AT WORK
We’re so understaffed, there’s no time for training! My request has been turned down! Unfortunately, if no training takes place, the situation probably Your employer must respond to your written request within 28 will not improve – in fact, it could get worse. It is short-term days (though 14 days is more helpful, and could form part of a thinking not to train staff or allow them to learn. Learning how to local agreement on training applications). In the meantime, they do something new, or more effectively or efficiently, could help may arrange a meeting to discuss the detail of the request before them become a more flexible, skilled and productive member of giving approval or rejecting your application. You may be the team. Fire-fighting, backlogs and staff stress levels cannot expected to provide more information about how the course will improve without strategic consideration of the learning and be paid for, or what arrangements you would need to make. You training needs of individual or collective team members. have the right to be accompanied by a union representative if you However, planning time for training is essential. Although wish. Holding a meeting can delay this part of the procedure by difficult, planning gives managers and the rest of the team the up to another 14 days. opportunity to cope with the time when an individual is away If the employer rejects your application, giving a valid business learning or studying. That is why it is important to make it clear reason, then you can appeal in writing within 14 days, giving the how long the training will take, on which days and when. It is the grounds for your appeal. Again, it will be helpful if there is a manager’s responsibility to meet the elements of capacity and meeting to offer solutions to the reason for refusal, and you have capability (specific dimension G7 in the KSF), but this is easier the right to be accompanied by your union representative. when they have all the relevant information. It will be useful to gather as much information, facts and Experienced colleagues can benefit both themselves and the counter-arguments as you can if you want to appeal. individual who is training, by becoming a mentor or peer super- Demonstrating flexibility, compromising or offering beneficial visor. They will be meeting elements of their own continuing suggestions will be most persuasive in turning the decision around. professional development, as well as core dimensions of the Referencing organisational objectives is probably most powerful, KSF like people and personal development, quality and such as improving part of the patient’s ‘journey’, or helping the service improvement. department or team save time, money or reduce waste.
There’s no money for training with all the cuts! Only once a year? If you make a request for time off to train, you have to indicate The statute makes provision for only one formal request per year how you suggest that the cost of the training could be met. from an individual. However, union representatives can negotiate There are many reasons why investing in training actually learning agreements that offer more favourable terms for individ- contributes to the financial viability of a business, and it is no ual or collective requests to be included in organisation policies. different for public sector organisations. Less waste, fewer mistakes or compensation payments, reduced repetition or dupli- Further reading and resources cation of effort, and fewer sick days taken by staff feeling stressed Check whether your organisation has a learning or training can all result if they feel competent and confident at what they do. agreement or study policy, which should be available for all staff There is also ample research to support these claims. on the intranet. If not, ask your manager, learning and develop- Although the employer is not required to pay for the time or the ment team, practice educator or human resources colleagues. training course itself, there may be ways of negotiating for an A really easy to understand guide The right to request time to organisational contribution. train: a guide for trade union representatives is available from When requests for paid time (and paid training courses or Unionlearn – see: www.unionlearn.org.uk/righttorequesttraining resources) are successful, it is useful for representatives to include The Campain for Learning website has useful resources and these as best practice when negotiating on learning agreements information, including an overview of the right for time off to and policies in the future. train and a mini-guide. See: www.campaignforlearning.org.uk If your organisation already has a good study leave policy, or arrangements for paid time off or paying for certain courses, Kate Oultram make sure they are referred to clearly in your letter of application. Unite Health Sector organiser Where the organisation has no existing arrangement for paying for training or time off, or you anticipate an objection, it is worth using the ‘investment in staff leading to improvement for the organisation and the patients’ argument – that everyone can benefit. There may be money available from public funding, for: ■ Apprenticeships ■ Staff who have not yet achieved level 2 NVQ or equivalent ■ Level 3 NVQ or equivalent for those aged under 25 years who have not reached that level before ■ Strategic health authorities (SHAs) in England or individual health boards or trusts may hold public money for provision of education or training for specific groups of staff. Examples are monies from the Skills Funding Agency and European Social Fund, or Multi-Professional Education and Training monies.
44 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9 45 CP Sep 10 Resources.qxd:Layout 1 18/8/10 16:19 Page 45
RESOURCES
The good sleep guide: for you and your baby Interpreting needs (third edition) Angela Henderson, Hawthorn (2010) ISBN: 9781907359002, £7.99 Making sense of child and family assessment: how to interpret children’s needs This short paperback is aimed Duncan Helm, Jessica Kingsley (2010) at parents of babies aged from ISBN: 9781843109235, £19.99 nought to 18 months. The author is a mother of two and a The focus of this book is analysis. psychology graduate who Assessment of children and young became interested in sleeping people’s needs is routine in all difficulties following her own childcare professions, and reports personal experience of this. are often made up of observations The book is divided into seven and facts. However, this book sections. Sections 1 and 2 helps demonstrates that it is the analysis parents to decide if they have a of the information gathered that sleep issue. The next two informs effective decision-making sections provide sound preven- to improve outcomes for children tative advice and suggestions on where babies should sleep and young people. and the provision of a safe sleeping environment. Sections 5 Examples from many serious case reviews are used, and and 6 focus on infants aged over six months who wake the author relates theory to practice by the effective use of regularly at night, and provides a question and answer section practice development exercises and scenarios in boxes of things that need attention before embarking on a sleep throughout. Although the primary audience appears to be training programme. The sleep programme outlined here is social care workers, it is very relevant to health visitors and based on the controlled crying method. The last section school nurses – I found myself applying the concepts to covers frequently asked questions and discusses possible many cases from my own previous health visiting practice. reasons why the programme may have been unsuccessful. Chapter 1 begins with an interesting review of models of The appendices cover weaning a baby off night feeds, decision-making and frameworks for assessment. While the understanding and coping with crying, an alternative to chapter gained my attention immediately, it became rather controlled crying (a graded leaving approach better known as repetitive and theoretical, ending with a two-page summary. gradual retreat), allergy deficiency and diet, and mothers Observation and seeking information is the topic of working outside the home. There is a sleep diary for parents Chapter 2. The need to consider different viewpoints is to copy, a short list of further help and a limited reading list. highlighted and the chapter cumulates in considering how to When reading this book, I alternated between feeling that it manage the data that has been collected. Chapter 3 looks at was excellent and being irritated by it, especially when different ways of gathering information and how it is used, in research was mentioned but then not cited or referenced. particular by different agencies. The scenario exploring the Sweeping generalisations about controlled crying and the decision-making process in referring a child to social care is long-term effects that crying may have on a baby are made: one in which every health visitor and school nurse will relate. ‘There is no risk in allowing him to cry at night during a Explanations of how decisions are developed are discussed sleep programme and this is the method of choice for in Chapter 4. Some of the concepts are rather complicated, hospital sleep clinics and leading sleep experts’ (p73). Leading but application to scenarios helped. Chapter 5 considers the child psychologists and psychotherapists such as Margot use of intuition is considered and is very interesting. Sunderland, Sue Gerhart and Penelope Leach would contest Chapter 6 is about child-centred care and ensuring their this. I was concerned about some of the information on diet, voice is heard in assessment. Useful guidance is given to weaning and allergy management. The book recommends the overcome the barriers to engaging with children. use of goat’s or sheep’s milk for babies with allergies, which is Further opportunities for practice development in analysis not recommended for infants under one year. are provided in Chapter 7, where the concepts of previous This book contains much excellent information, but is let chapters are brought together to apply to practice examples. down by the lack of evidence to support statements and its Although there is a summary at the end of each chapter, overreliance on controlled crying as the main method for the book ends rather abruptly. However, there is a compre- sleep training. Other gentler sleep coaching programmes such hensive bibliography and both a subject and author index. as pick-up, put-down and the kissing game are not Overall, this book provides practical guidance for profes- mentioned, nor is the management of breath-holding attacks sionals in roles associated with the welfare of children. that are sometimes seen as a response to controlled crying.
Reviewed by: Judith Moore Reviewed by: Maggie Fisher Unite/CPHVA Health Visitor Forum member Unite/CPHVA Health Visitor Forum chair
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Skill mix in health visiting and community Record-keeping and nursing teams: principles into practice documentation: principles by Maggie Fisher into practice At a time when spending in the NHS is by Rita Newland under scrutiny, it is important that all An easy-to-use publication decisions are based on the best filled with practical information evidence and knowledge of what works. to help practitioners to Skill mix is a very under-researched establish and maintain area in the community, but Maggie effective and efficient record- Fisher has successfully brought keeping and documentation together the available research and practice. A must for students placed it within a professional and and qualified staff. policy context. £15 Unite/CPHVA members £17.50 Unite/CPHVA members £17.50 non-members £27.50 non-members Getting it right: supporting the Tackling child obesity with HENRY: health of refugees and people a handbook for community seeking asylum and health practitioners by Cath Maffia and Steve Conway by Candida Hunt and Mary Rudolf How and why people come to the UK An approach to help practitioners in search of sanctuary, what happens engage successfully with parents to them when they arrive, and the and carers, and encourage them to likely health impacts of their unique give their babies and toddlers an and varied experiences. optimal start to life. £10 Unite/CPHVA members £10 Unite/CPHVA members £12 non-members £12 non-members
The principles of health visiting: Discovering the future of school nursing: opening the door to public health the evidence base practice in the 21st century by Diane DeBell and Alice Tomkins by Sarah Cowley and Marion Frost £10 Unite/CPHVA members £10 Unite/CPHVA members £12 non-members £15 non-members
Protecting babies’ heads: a teaching Clinical effectiveness: a practical guide for toolbox for preventing shaking and the community nurse head injuries in babies by Cheryll Adams by Lisa Coles £8.50 Unite/CPHVA members £8 Unite/CPHVA members £10.50 non-members £10 non-members
Community development: Positive parenting: a public health priority new challenges, new opportunities by Christine Bidmead and Karen Whittaker by Catherine J Mackereth £4 Unite/CPHVA members £10 Unite/CPHVA members £10 non-members £15 non-members
Towards personal, social The vital link: preventing and health education family homelessness (Key Stage 1 and 2) by Jane Cook, Marie Vickers, Sue Walters £8 each and Sarah Gordon £4 Unite/CPHVA members £10 non-members
Community nursery nurse (CNN) handbook New Unite/CPHVA handbook with information Calling all CNN members! on subjects including leadership, record- If you are a CNN member, contact Ros Godson for your free keeping and lone working copy of the CNN handbook. Email your name, Unite/CPHVA FREE to CNN members of Unite/CPHVA membership number, job title, hours per week and primary care £10 otherwise trust/employer name to: [email protected] RECRUITMENT
DESIGNATED NURSE FOR CHILD PROTECTION One day’s service LOCATION: Wembley Centre for Health and Care HOURS OF DUTY: 37.5 hours per week A lifetime of support GRADE: Band 8B An exciting opportunity has partnerships ensuring that there arisen for a Designated Nurse is a robust policy framework in BRITISH FORCES GERMANY Child Protection within NHS place for local practitioners that Brent due to the retirement of reflect current legislation and HEALTH VISITOR the current post holder. This statutory guidance. statutory post will take a strategic This post is based within Band 6: £25,472 – £34,189 pa professional lead on all aspects the Public Health Directorate of the health service contribution and reports to the Director of Your skills could take you a long way. to Child Protection, to provide Public Health & Regeneration This is a unique opportunity to live and work in Europe, while a comprehensive, coordinated who is the Executive Lead continuing to develop your career in line with established UK and quality service, to a range for Child Protection for NHS standards and best practice initiatives. How? By joining our dynamic of health personnel across NHS Brent. You will work closely Health Service in delivering modern, quality-led integrated healthcare Brent PC. with the Designated Doctor to Service’s personnel and their families domiciled overseas. You will be a dynamic for Child Protection and the We are currently seeking RGNs who are also Registered Specialist advocate and champion of the Strategic Executive team for Community Public Health Nurses (Health Visitors), to join our primary Child Protection agenda, and Child Protection, be a member care health teams within Germany; to work and contribute to their will bring extensive experience of Brent LSCB and sub groups public health agenda. To succeed, you will have relevant post- qualification experience and strong communication, group facilitation working in this field. You will work providing skilled advice on and I.T. skills, combined with the ability to work well within a team. across sectoral and multi-agency health issues. If you believe you possess the above and could quickly adapt to providing a service to a population with diverse health care needs, we want to hear from you. Health For an informal Interested applicants should Who are we? We’re SSAFA Forces Help – a prominent national charity, discussion, please contact apply by going to the NHS dedicated to helping and supporting those who serve in the armed Simon Bowen, Acting jobs website: www.jobs.nhs. forces, those who used to serve, and the families of both. Our work is Director of Public Health & uk – reference no. 721 NHSB varied and our aims are clear. You could help us succeed. Regeneration NHS Brent on 1595C A full driving licence is essential. Closing date for applications is: 0208 795 6747 or Dr Boroda Monday 13th September 2010. Please note that CV applications Closing Date: Designated Doctor for Child will not be accepted. 28th September Protection on 0208 795 6397 For an informal discussion please contact Nia Roberts, Nurse Advisor Public Health and Safeguarding Children on 0049 521 772 79481. For an e-application pack, please email [email protected], quoting reference: HVFG910. Alternatively download the application pack from www.ssafa.org.uk/vacancies.asp SSAFA Forces Help is an Equal Opportunities Employer and is committed to using the Criminal Records Bureau Disclosure Service. Registered Charity Numbers: 210760 (England and Wales) SC038056 (Scotland). Team Leader Established 1885. www.ssafa.org.uk Safeguarding Ref: 708-65SM Salary: Band 8a £38,851 - £46,621 pa pro rata Hours: f/t 37.5 pw - p/t will be considered Are you looking forward to a new challenge? Are you looking Media Number: 043492 for an opportunity to lead and develop a safeguarding team? Media: CPHUA An exciting developmental opportunity has arisen for a suitably qualified and experienced practitioner to provide a professional lead AdTO Size: ADVERTISE PLEASE170 x 88 CALL on the safeguarding of adults and children within Central Essex Date: 13.08.10 Community Services (CECS) and to lead the safeguarding team. Spell Check: 3 You must have significant experience in safeguarding such as domestic Proof: JAMES PRIEST ON3 violence or child protection and be expected to practice your specialty in addition to leading the Safeguarding Team. You will be expected to Artwork Delivery: provide support, give advice, deliver safeguarding supervision and Sent By: 0207 657 1804 develop staff skills on Safeguarding issues in accordance to statutory guidance, LSCB procedures and policies. You will also have sound knowledge and experience of safeguarding ORwww.wjpfloyd.co.uk EMAIL practice/processes, experience of multi-agency working and a willingness to improve current practices. Experience in designing and delivering Safeguarding Training would be an advantage. [email protected] For an informal discussion please contact Vicky Waldon, Director of Operations on 01621 727324 or 07958 579038. To apply for this post or to obtain application information, please visit www.jobs.nhs.uk and search for Job Ref: 708-65SMR. Closing Date: 19 September 2010 Interview Date: 1 October 2010
We are committed to equal opportunities and flexible working practices.
CP Classi September 10.indd 1 19/08/2010 16:30 48 CP Sep 10 Network.qxd:Layout 1 18/8/10 16:25 Page 48
NETWORK
children really NEED author and Developing Positive Eating Diary consultant in neurodevelopmen- Habits for Toddlers: a Noticeboard tal education, Sally Goddard Practical Approach to Sharing Supporting Families Blythe, author and researcher Dr 25 November, London Immunisations at home Where Parents Have Suzanne Zeedyk, researcher This study day will focus on the I am an immunisation nurse Learning Disabilities Professor Koichi Nagayama and need for all those involved in specialist working in Brighton 21 September, Nottingham Sir Richard Bowlby on the legacy caring for toddlers to work and Hove. Following a bench- Seminar to understand barriers of his father John Bowlby. together toward a common goal marking process, we have faced by parents, and practical Organised by the International of establishing healthy eating identified some areas in our initiatives to overcome them. Association of Infant Massage habits and improving their diet. immunisation service that we (IAIM) UK. Bookings can be for Book your place by selecting can look at improving. Families of Women Offenders either one or both days. ‘Study Day 2010’ on our website. One area is the introduction of 28 September, Birmingham IAIM Infant and Toddler Forum specialist health visitors Exploring current policy and T 020 8989 9597 T 020 8971 0022 administering immunisations practice to support families E [email protected] W www.infantandtoddlerforum.org to Traveller children on site. of women in the criminal W www.iaim.org.uk/events Are any health visitors doing justice system. Infant Massage Teacher this already? I would also be Developmental Baby Training Programme interested in contacting any Domestic Abuse Massage Teacher Training On-going, across the UK primary care organisations that and Military Families 16 and 17 October, A five-day comprehensive undertake home immunisation 6 October, Coventry Viveka, West London infant massage programme for of any sort for vulnerable and Research, policy and measures to With Peter Walker, 30 years’ health and family centre hard-to-reach groups. address this little discussed area teaching experience. professionals. This dynamic Rosanna Raven of domestic abuse. Teach mothers these unique course includes simple massage T 01273 275473 techniques, one to one or in techniques and in-depth E [email protected] Each seminar: £165 +VAT. postnatal support groups, knowledge to practise safely T 0115 916 3104 baby massage and movement and professionally, so practi- Healthy weight lead W www.ccclimited.org.uk from birth to standing. tioners feel confident to teach I am a specialist health visitor Certificated course includes parents in a variety of settings. working in West Essex in the Children with Additional theoretical and practical work, Once qualified, teachers can capacity of healthy weight lead. Needs or Disabilities Special DVD and slide presentations, access Touch-Learn CPD stroke I am looking to contact and Interest Group Meeting observation of mother/father reviews and other positive network with other health 8 October, Unite the Union, and baby group. Includes touch workshops. visitors who are undertaking 128 Theobald’s Road, London course notes and Developmental E [email protected] similar work elsewhere. Meeting from 10.30am to 4pm, baby massage DVD. Apply or Marie Lewis with guests for the topic of key arrange in-house teacher Rhythm Kids Workshop T 01277 366495 working. All of those working training in your area. On-going, across the UK E [email protected] with children with special Peter Walker One-day, fun-filled workshop needs are welcome. E [email protected] for baby massage teachers. School nursing questionnaire Lettie Blyth Enhances child’s language, In our PCT, we no longer use a T 020 8444 0040 Soft Postnatal Yoga muscle, cognitive and questionnaire for children on E [email protected] for Mothers, Babies and vestibular development, school entry. However, as the Young Children as well as their social skills. Healthy Child programme Touching the Lives of Babies 23 and 24 October, E [email protected] recommends one, we would and Families Viveka, West London love to hear from school nurses 9 to 10 October, London Two-day teacher training certifi- Baby Yoga Workshop outside the area who are This exciting, dynamic event will cated course with Peter Walker. On-going, across the UK currently using or developing feature high profile international Unique techniques to relieve Two-day workshop for qualified a questionnaire. speakers including Why love mothers’ back pain and regain baby massage teachers. An If you could email me, I would matters author Sue Gerhardt, Dr ‘good shape’. And to show how excellent course to enhance be very grateful. Karl Brisch author of Treating to make full use of a baby’s love teaching skills. Supports Chris Hall Attachment disorders: from theory of movement and encourage bonding and attachment, T 0191 283 1510 to therapy, What babies and children’s flexibility and good parenting skills, physical E [email protected] posture. Includes course notes development and relaxation. and three teacher DVDs. Apply E [email protected] For a paid-for Diary listing, For a free Noticeboard or arrange in-house teacher Tel: 020 7657 1804 or listing, please email: training in your area. Touch-Learn International Ltd email: [email protected] [email protected] Peter Walker T 01889 566222 E [email protected] W www.touchlearn.co.uk
48 COMMUNITY PRACTITIONER September 2010 Volume 83 Number 9
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