SEPT 2012
www.commprac.com | www.unitetheunion.org/cphva Volume 85 Number 1 Completing the circle Returning tohealthvisitingpractice and Young People’s Health The report oftheChildren Supporting motherswith COMMUNITY perinatal depression AND HEARD BOTH SEEN Outcomes Forum BUILDING
Community CONTENTS Practitioner
Unite/CPHVA Existing Unite/CPHVA members with queries relating to their membership should contact: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for further details. To join Unite/CPHVA, please see: www.unitetheunion.org Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN Tel: 020 3371 2006 Community Practitioner journal 44 Unite/CPHVA members receive the journal free each month and have free access to all content from 2004 onwards 20 Professional and Features via the online archive. 3 Editorial 36 Courage and research Building community by Non-members of Unite/CPHVA and Embedding an supporting mothers: institutions may subscribe to the journal commitment: a mantra to receive it every month and access the for the new school year electronic health record new approaches to online journal archive. By Ros Godson within a health visiting perinatal care Non-member subscription rates: service By Katherine Evans Individual (UK) £125 4 News round-up Mandy Lowery, Individual (rest of world) £145 The latest in policy Janice Dobbs, 38 FNP in the USA Institution (UK) £145 and practice Aileen Monkhouse By Kate Jones Institution (rest of world) £195 Institution online access: 25 Returning to health Focus on National Up to five users £195 10 Association 41 Six to 10 users £390 LAR of the Year Award; visiting practice: Eczema Week: 11 to 20 users £780 Healthy Communities completing the circle recognising and 21 to 50 users £1560 2012 Stephen Abbott, managing childhood Subscription enquiries may be made to: Sandra Anto-Awuakye, eczema Community Practitioner subscriptions, 12 Antenna Rosamund Bryar, By Julie Van Onselen Ten Alps Subscriber Services ‘A Future That Works’; Seema G Trivedi and Margaret Cox Abacus e-Media Limited Bournehall House, Bournehall Road It takes courage; Bushey WD23 3YG New NICE guidelines 30 Breastfeeding 44 Employment Tel: 020 8950 9117 on autism; Research knowledge and Independent Pay [email protected] evidence; Bookbug education needs of early Review Body? Maybe www.cphvabookshop.com childhood centre staff next year … The journal is published on behalf of 14 News feature Kathleen Mary Manhire, By James Lazou Unite/CPHVA by: Both seen and heard Glenn Horrocks, Ten Alps Creative By Chloe Harries Angeline Tangiora One New Oxford Street 48 Diary & London WC1A 1NU Noticeboard Tel: 020 7878 2300 18 150 years Nick Stimpson – Managing Director For editorial contacts, please see the panel over the page. Advertising queries: COVER STORY: Claire Barber Tel: 020 7878 2319 COMPLETING THE CIRCLE: [email protected] Returning to health Sponsorship/supplement queries: Sunil Singh Tel: 020 7878 2327 visiting practice [email protected] Production: Ten Alps Creative – Design and production Williams Press – Printing Community © 2012 Community Practitioners’ and Health Visitors’ Association Practitioner ISSN 1462-2815 The journal of the Community Practitioners’ and The views expressed do not COVER IMAGE: THINKSTOCK Health Visitors’ Association (Unite/CPHVA) necessarily represent those of the editor nor of Unite/CPHVA. Paid advertisements in the journal do not imply endorsement of the products or services advertised.
September 2012 Volume 85 Number 9 Community Practitioner | 1 GROUP BOOKING DISCOUNT available now – call 020 7324 4330 for details
ctice Pra rsing h Nu Public Healt Y A R N SA N IV ER
Keynote speakers: Rt Hon Andy Burnham MP Len McCluskey Shadow Secretary of State for Health General Secretary, Unite the Union Professor Viv Bennett Dame Elizabeth Fradd Department of Health’s Director of Nursing and the Chair, Health Visitors’ Taskforce; Government’s Principal Advisor on Public Health Nursing Independent Health Service Advisor
This annual professional conference will: our PREP o y re • Bring you up to date with policy developments that will affect practice in the coming year t qu te ir u e m ib r e t n n • Highlight the best innovations and working practices from around the UK t o
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• Review the new employment destinations of nurses after the closure of PCTs o P u E r
R P • Look at the safeguarding of children and the rules and practices needed • Help understand the impact of information technology on the work of nurses across the community • Look at the risks social networking media creates for children and professionals • Learn from different experiences in Scotland, Wales, Northern Ireland and internationally • Understand the implications for school nursing of the new academies in England • Hear the latest information on employment trends and professional structures • Look at the evolving regulations and standards environment and the implications for health visitors, school nurses, community nursery nurses and associated colleagues • Examine how public health nursing is focusing back on its local government and community roots • Contribute to your CPD requirements Register today at: www.neilstewartassociates.com/cphva Or call: 020 7324 4334 EDITORIAL Community Practitioner
Editorial Advisory Board Courage and commitment: Gaynor Kershaw (Chair) – Health Visitor, Heywood, Middleton and Rochdale PCT Obi Amadi – Unite/CPHVA Lead a mantra for the new school year Professional Officer Maggie Breen – Macmillan Clinical The beginning of the academic year is Nurse Specialist – Children and Young People, The Royal Marsden Hospital NHS always quite a rush, sorting out where Foundation Trust the children have gone, mandatory Toity Deave – Senior Research Fellow, training days, immunisation schedules Centre for Child and Adolescent Health, to organise and all the safeguarding University of the West of England, Bristol meetings that were delayed over Barbara Evans – Community Nursery the summer. Nurse, Leicestershire Partnership NHS Trust School nurses in England, however, Gavin Fergie – Unite/CPHVA Professional may notice something else: lots of new Officer for Scotland and Northern Ireland health visitors, many of whom may have Margaret Haughton-James – School Nurse limited professional knowledge of school Team Leader and Practice Nurse, Guy’s and nursing practice. In the current climate St Thomas’ Hospital of service redesign, increased caseload Catherine Mackereth – Public Health Lead, South Tyneside Primary Care Trust sizes and other numerous demands on Brenda Poulton – Emerita Professor practitioner time, a gap in professional of Public Health Nursing, University of understanding and knowledge between Ulster colleagues is beneficial to none of us. Well, here is your chance to influence Editorial Team a brand new cohort, so I suggest you Polly Moffat – Editor embrace your new colleagues and liaise It will take courage to insist that local [email protected] with their line managers to make sure healthcare plans cater for the public Jane Appleton – Professional Editor that their induction includes days out health of school-aged children, and [email protected] with school nurses, and results in an commitment to meet with directors of Chloe Harries – Assistant Editor public health and local politicians. Above [email protected] understanding of the depth and breadth all you will need courage to stand up for Tel: 020 7878 2404 of work that school nurses undertake to the rights of children and young people Naveed Khokhar – Designer improve the health of five to 19 year olds. [email protected] Jane Cummings, the new Chief and be committed to improvement in Nursing Officer for England, has their wellbeing. Unite/CPHVA Honorary Officers outlined five attributes for nurses: care, Lord Victor Adebowale – President compassion, courage, commitment and Elizabeth Anionwu – Vice-President communication. As your professional Alison Higley – Chair organisation, CPHVA fully supports these, and would like to develop them. Ros Godson Unite Health Sector Officers This journal is our best way of Professional Officer for School Health Tel: 020 3371 2006 communicating with you, but courage and commitment are more intriguing. and Public Health Obi Amadi – Lead Professional Officer Unite/CPHVA Rachael Maskell – Head of Health We know that we should be evidence- Gavin Fergie – Professional Officer for based practitioners, but we might Scotland and Northern Ireland struggle to find support for some of Rosalind Godson – Professional Officer our practice. I have a circulation list of school nurses for School Health and Public Health It will take courage to challenge who want to be kept regularly up to date. Dave Munday – Professional Officer our favourite ways of working and If you are an active school nurse, but are Shaun Noble – Communications Officer commitment to change in line with user not receiving regular emails from me, [email protected] involvement, the school nurse vision and please contact me and I will add you to my list: [email protected] Fiona Farmer – National Officer local pathways. Barrie Brown – National Officer James Lazou – Research Officer
September 2012 Volume 85 Number 9 Community Practitioner | 3 NEWS ROUND-UP New NMC Chair appointed amidst ongoing fee rise debate The Health Secretary, Andrew Lansley, has asked the Nursing and Midwifery Council to reconsider the regulator’s decision to raise registration fees for health visitors, nurses and midwives to £120 per year, an increase of 58%
n a letter to Professor Judith Ellis, the Deputy The change in fee is due to be agreed upon IChair of the Nursing and Midwifery Council in September, so that the increases can be (NMC), Andrew Lansley stated: ‘If, following implemented as of January 2013. consultation, the NMC decides to press ahead The fee debate has been continuing alongside with a fee increase, it must be able to assure itself the appointment of the new NMC Chair, and, most importantly, its registrants and the Mark Addison – previously Director of the wider public that such a decision is made on a National Archives – who was elected swiftly sound financial basis’. and unexpectedly by the Privy Council. The He added: ‘I believe it is vital that the NMC appointment has been met with concern by seek independent verification of its case for a Council members. The NMC has so far spent fees rise, taking into account the lessons learned £62 000 on the recruitment of a new Chair, with from the Council for Healthcare Regulatory a shortlist of eight candidates already drawn up. Excellence strategic review about previous All of this has now been abandoned in light of failings in financial management’. the appointment. The NMC’s ruling council expressed its Union response concerns over the decision: ‘The NMC council Unite, the Royal College of Midwives and acknowledge the appointment by the Privy Unison have responded positively to the Mark Addison, new NMC Chair Council of Mark Addison as Chair of the NMC. comments and the possibility of a rethink on the unions representing nurses and midwives we However, as the council of an independent the fee hike issue. welcome the request from the government for regulator, they feel it necessary to express their Unite Lead Professional Officer, Obi Amadi, the NMC to commission an independent audit grave concern regarding the appointment said: ‘An earlier intervention by the Health of its case for a fee rise. selection and lack of an open, transparent and Secretary would have been better – but we are ‘It is also only right that the deadline for equal opportunities process to demonstrate how glad it has happened. We, as registrants, need to submissions to the NMC’s current consultation this person meets the specifications for the chair be completely confident that the NMC financial should be extended so that the results of this laid out in the CHRE report’. plan will take the organisation through the next audit can be taken into account.’ decade in a transparent and competent manner’. Unite researchers, looking into where NMC Need for action A statement from the NMC read: ‘The NMC’s fees would be increased to in line with inflation, A DH spokesperson responded: ‘Strong and Council has sought and received external have found that the total rise would be around effective professional regulation of nurses and assurance that the business case for the fee rise is £10, or £86 per year. Ms Amadi added: ‘Health midwives is crucial to public protection and financially sound, and this advice was taken into visitors, midwives and community nurses have confidence. The NMC needs the best leadership account in the proposals set out in the fee rise been horrified at this proposed increase from to achieve this and it is appropriate that a consultation document. £76 to £120 a year, as they have to pay this fee in swift appointment was made. In light of the ‘We have actively shared and continue to share order to work in the NHS.’ review published by the Council for Healthcare information about the NMC’s financial position Regulatory Excellence the Appointments and the proposed fee rise with the Department CHRE report Commission withdrew its recruitment exercise of Health, the Council for Healthcare Regulatory The fees debate follows the critical Council for a chair. There clearly was a need to act Excellence, and the unions. Council remains for Healthcare Regulatory Excellence (CHRE) quickly to bring certainty to the NMC. concerned that further delays in implementing review into the NMC, which found that the Responding to the furore surrounding his a fee rise will have a negative impact on public regulator was ‘failing at every level.’ The fee hike recruitment, Addison said, ‘Addressing the protection.’ has been met with opposition across the board. findings of the CHRE report will be a challenge. In a joint statement, the RCN, the Royal Ms Amadi said: ‘Unite regards this fee as But the report makes clear that the organisation College of Midwives and Unison said: ‘We are ‘another tax’ on hard-pressed and dedicated is moving in the right direction and that staff pleased that the Secretary of State agrees with community nurses already hit by a two-year pay have the ability to manage these changes and us that it is difficult to justify a fee increase for freeze, a steep increase in pension contributions emerge stronger. That gives a strong platform on registrants, and has intervened in this way. As and facing the prospect of regional pay’. which to build.’
4 | Community Practitioner September 2012 Volume 85 Number 9 NEWS ROUND-UP
All children to receive flu vaccination Health ministers have announced that the flu immunisation will be offered to all school- aged children by 2014. It is currently only administered to children in at-risk groups. Unite/CPHVA Professional Officer, Dave Munday, said: ‘Unite welcomes the decision to introduce the vaccination to this age group, especially as data show that a 30% take-up will reduce deaths by 2 000 and result in 11 000 fewer hospital admissions’. As reported in June this year, the Joint Committee on Vaccination and Immunisation (JCVI) backed the proposal to extend the vaccination programme to all children aged between two and 17 years on the NHS. The JCVI did recognise, however, that there would be significant challenges involved, including a in responsibility regarding new immunisations accepted by children, it will still be necessary lack of school nurses available to administer to the schedule’. to get informed consent from each child, the vaccine, which comes in the form of nasal Unlike the seasonal flu jab, the nasal spray according to their age and understanding, spray Fluenz. (which was first used in the US) contains a live and so considerable nursing resources, either Dave Munday continued: ‘The JCVI is correct strain of flu virus, which causes a very mild flu from school nurses or practice nurses will be that there would need to be a dramatic increase infection. Usually, children aged under nine required to roll out this programme. CPHVA in the number of school nurses alongside are given two doses in the autumn, before the does not support non-medical personnel, the 4 200 more health visitors that have been flu season starts. One of the options being such as healthcare assistants, delivering pledged by the coalition government by 2015. considered is for parents to give the vaccination immunisations of any kind to children’. However, it is important to remember that themselves. Dave Munday added: ‘Unite continues to the school nursing service remains under the Unite/CPHVA Professional Officer for campaign on the need for one full-time school cosh of increased work loads, without the same school nursing, Ros Godson, said: ‘Although nurse in every secondary school and their increase in the number of staff, or any increase the new inhaled vaccine should be better feeder school’. Research will give insight into child abuse fatalities and lead to greater child protection
According to a joint study into serious case 2007 to 2008 to 71 in 2010 to 2011. reviews carried out by the University of Professor Peter Sidebotham from the East Anglia and the University of Warwick, University of Warwick said: ‘While there is approximately 85 children die each year evidence that overall rates of child abuse through abuse or neglect. fatalities have fallen over recent years, we The groundbreaking research analysed must not be complacent. There is much we serious case reviews from 2009 to 2011, can learn from each child’s death. The lessons resulting in the first piece of research of its from this research can help us all strive to kind showing the average number of children protect other children and support families’. who die each year as a result of abuse. The research showed that the number of Lead author of the report, Marian Brandon, deaths occurring at a time a child protection Senior Lecturer at the University of East plan was in place for the child had dropped Anglia, said: ‘This report produces a number to 10% during the period 2009 to 2011, of new insights alongside the more familiar with the reality that not all of these deaths can compared with 16% in 2007 to 2009. messages. We now know for the first time that be prevented’. Of the 85 deaths on average each year of around 85 children die each year as a result of The study also found that the number of children aged under 17, around 50 to 55 were abuse or neglect. babies dying through neglect or abuse had caused by abuse or neglect. Accidents, sudden ‘Every single death is a shocking and fallen, and that the number of serious case unexpected deaths in infancy and suicide distressing waste of life, but we have to live reviews undertaken had fallen from 137 in accounted for 30 to 35 of the deaths.
September 2012 Volume 85 Number 9 Community Practitioner | 5 NEWS ROUND-UP Local health visitors campaign against nappy sack danger
Health visitors from the Sandwell Trust, based in the West Midlands, are promoting a new safety campaign to warn parents about the dangers of nappy sacks, which can be fatal if a baby is left alone with one. So far, 11 babies in the UK have died from suffocation due to nappy sacks that have been stored near to their cots. The thinness of the plastic sacks mean that they can cling to a baby’s face when breathed in. Usually young babies are unable to then pull the bag away from their faces. Sandwell Heath Visitor Matron, Mandy Sagoo, said: ‘In the case of nappy sacks, we can’t expect parents to be aware of the hazards, because there is little in the way of information to forewarn them. By adopting the campaign in our area, we hope to educate parents and other carers not to leave nappy sacks within a Children’s Accident Prevention Ms Sagoo added: ‘Young babies are most baby’s reach’. Co-ordinator and campaign founder, Beth at risk because they naturally grasp things The campaign was sparked by concerns Beynon, said: ‘By rolling it out through public and pull them to their mouths, but then find raised by Cornwall coroner, Dr Emma Carlyon, health teams at a national level, we hope to it difficult to let go. Nappy sacks are small following the death of two babies from take this campaign out to communities to and flimsy, and cling to babies’ faces so they asphyxia through nappy sacks. Both incidents reach parents, grandparents and carers in the can’t breathe. This campaign will help to involved babies under six months who had hope of preventing any more babies from raise parents’ and carers’ awareness of the nappy sacks stored under their mattresses. needlessly dying’. dangers, while we continue to apply pressure The campaign will see information on the The European Committee for Standardisation internationally for a solution.’ subject, in the form of posters and leaflets, is now reviewing whether it can introduce new In addition to the posters and leaflets, there is distributed to GP surgeries, children’s centres, manufacturing guidelines to improve safety. a video message about the campaign which can Family Information Services, and health European member countries will also create a be viewed on YouTube at: visitors and public health teams nationally. joint factsheet to raise public awareness. www.youtube.com/watch?v=0PrfoS_RCDA Breastfeeding falls as cuts to maternity services rise
According to research, England’s Aldred, said: ‘The Department of Health breastfeeding rates are dropping in areas places huge emphasis on the importance where maternity services have had their of breastfeeding and says there is a clear budgets slashed, meaning that mothers who case for investing in services to support live in areas that have experienced cuts are breastfeeding as part of a local child health likely to stop breastfeeding within the first strategy. However, this seems at odds with eight weeks following birth. the reduction in spending and staffing we The research, carried out by health data have found.’ analysts SSentif, shows that overall spending Unite Professional Officer Gavin Fergie on maternity services has decreased by said: ‘Unite share the disappointment and almost 4%, with health visitor and midwife lives and how much their services have frustration of CPHVA members reading rates dropping by 6% year-on-year. The been cut. For example, Westminster PCT this story who have contributed greatly research also reveals that across England, has seen a spending increase of 157.5% to the increase in breastfeeding initiation only 72% of mothers take up breastfeeding, on maternity services, with nine out of 10 and continuation rates. It is an extremely and two-thirds of these stop within the first new mothers starting breastfeeding and short-sighted decision to reduce these six to eight weeks. However, the rates vary only 6.7% stopping in the first six to eight services, and is another example of a lack of greatly depending on where the mother weeks. Managing Director of SSentif, Judy foresight in public health planning.’
6 | Community Practitioner September 2012 Volume 85 Number 9 NEWS ROUND-UP ADVERTISEMENT
Scotland launches consultation on Children and Young People Bill Scotland’s Minister for Children and Young People, Aileen Campbell, has launched a consultation on the upcoming Children and Young People Bill at a nursery in Edinburgh, claiming that it is ‘the best and most flexible package of family support in the UK’. The proposed law will help parents to structure their childcare to best suit their family’s needs. The proposals include: l Increasing the amount of flexible, early learning and childcare to a minimum of 600 hours annually for three and four-year-olds and looked-after two-year-olds l Embedding the Getting it right for every child approach in a single system of planning and delivery across children’s services l Public bodies required to design, plan and deliver policies and services that focus on improving children and young people’s wellbeing l Improving Scotland’s care system so that it offers effective, efficient support for children and families, centred on short and long-term needs.
Ms Campbell said: ‘This legislation will boost our ongoing efforts to strengthen the rights of the child, making Scotland a nation where the rights of children and young people are not only recognised but rooted deeply in our society and across our public services.’ The consultation will run for 12 weeks and the deadline for submissions is 25 September 2012. Any members who have opinions regarding the consultation that they would like to share can contact Gavin Fergie at: [email protected]
‘Don’t smoke in car’, urges Wales Health Minister Wales’s Health and Social Services Minister, Lesley Griffiths, has been encouraging smokers to register for a ‘Fresh Start’ pack, in a bid to reduce the number of parents smoking in cars. The Fresh Start campaign was launched by Dr Tony Jewell, Wales’s Chief Medical Officer, earlier this year. The packs include helpful tips and advice on how smokers can protect themselves and their family from harm through second-hand smoke. It is hoped that the packs will discourage parents who are smokers from lighting up while driving, especially when children are in the car. Ms Griffiths said: ‘Almost all of the cigarette smoke is invisible and doesn’t have a smell, so parents who smoke in their cars can be exposing their children to harm, without realising it. ‘It can even linger in the atmosphere for up to two hours after a cigarette is extinguished, and can be absorbed into the seat lining and carpets of family cars.’ Each Fresh Start pack contains a toy, a Fresh Start manual, a journey planner with stickers, a smoke-free car cling, a Health and Wealth dial, a money box and a ‘What’s in a cigarette?’ leaflet. Packs will be available from community pharmacies and can also be ordered from the Fresh Start website: www.freshstartwales.co.uk
September 2012 Volume 85 Number 9 Community Practitioner | 7 NEWS ROUND-UP
Newsinbrief Outbreak continues as increased Government proposes free childcare for children with SEN From September 2013, two year olds with cases of whooping cough reported special educational needs (SEN) will be able to benefit from free childcare, according to The Health Protection Agency (HPA) has a proposed Department for Education (DfE) announced that the number of confirmed consultation. cases of whooping cough (pertussis) reported Children’s Minister, Sarah Teather, said: ‘Babies so far this year has reached 2 466. In 2011, born this year will receive the benefit of high- 1 118 cases were reported for the whole year. quality early education in two years’ time. It’s vital that we get this right for their sake. This This includes an increase in the number of government is doing all it can to ensure that infants aged under three months who have children in the poorest families are able to contracted the disease, from 72 in 2011 (Jan achieve what they want to’. to Jun) to the current 186 reported cases. As of next September, 20% of two-year-olds The increase has been reported across all will be entitled to 15 hours of free childcare. In England, 10 areas will be trialling the initiative regions in England and Wales, with clusters from this September. in school and healthcare settings. Increased cough vaccination to pregnant women’. rates have also been recorded in Northern Whooping cough, a cyclical disease that can Family Parenting Institute and Daycare Trust Ireland and Scotland. Figures show that cases affect people of all ages, is most dangerous a ‘natural fit’ in Northern Ireland had risen to 27 this year in the very young. The vaccine is given to all The Daycare Trust and the Family and Parenting Institute have announced their from a 2011 total of 13; and in Scotland there babies in the UK after two, three and four planned merger. The organisations stated that have so far been 150 reported cases, compared months, with a booster jab administered before combining their resources and experience will to 22 for the period January to March 2011. the child starts primary school. The vaccine be beneficial to the public. A spokesperson Head of Immunisation at the HPA, Dr Mary does wear off eventually, meaning that adults for both groups said: ‘Charities in all sectors Ramsay, said: ‘The HPA is very concerned can also contract the disease. are considering how best to serve their beneficiaries in economically challenging about the ongoing increase in cases and we Dr Ramsay said: ‘Anyone showing signs and times. For us, coming together means we are working closely with the Department of symptoms, which include severe coughing fits can better promote the needs of families and Health’s Joint Committee of Vaccination and accompanied by the characteristic “whoop” children, campaign for a family-friendly UK and Immunisation (JCVI) to consider the most sound in young children, but as a prolonged improve childcare at a time when families need effective ways to tackle the ongoing outbreak. cough in older children and adults, should a strong voice more than ever.’ The JCVI is reviewing a large number of visit their GP.’ Qualified Teacher Status staff employed at options including the introduction as a booster NHS Direct and NHS 24 are also available to three-quarters of centres dose in teenagers and offering a whooping anyone concerned about whooping cough. Seventy-seven per cent of children’s centres now have at least one staff member with Qualified Teacher Status, according to a new report commissioned by the Department for HPV jab denied on religious grounds Children, School and Families, which surveyed 500 children’s centres last year. It has been found that some schools in England The survey, carried out by NatCen Social have opted out of the HPV vaccination Research and Oxford University, looked in programme on religious grounds. A number particular at centres that opened in the first two phases of the Sure Start programme in the most of schools have decided that, as their pupils are disadvantaged areas in England.The report is assumed to follow strict religious principles not the first of six, which will look at how families to have sex outside of marriage, they do not use children’s centres; analyse services; assess need the HPV vaccine. impact and conduct a cost-benefit analysis. The HPV jab is given to girls aged between Drug-related deaths in Scotland increased 12 and 13 years, and protects against strains in 2011 16 and 18 of the virus, which cause around According to statistics published by the Registrar 70% of cervical cancer cases. An investigation The Deputy Chairman of the British Medical General, Scotland had 584 drug-related carried out by GP magazine found that 15 of Association’s GP committee, Dr Richard deaths in 2011, representing 1% of all deaths 83 PCT areas that responded to a Freedom Vautrey, said: ‘It is a concern that so many areas recorded. A total of 584 drug-related deaths were registered in Scotland in 2011 – more than of Information request had schools that were are reporting that schools have refused to allow in any previous year and an increase of 99 (20%) opting out of the immunisation programme. their children to receive the HPV vaccine on compared with 2010. This was 252 (76%) more Reasons given by schools for denying the jab the premises’. than in 2001. The statisics reveal there have been included: ‘Not in keeping with the school ethos’; Each year there are around 1 000 deaths due to increases in six of the past 10 years. ‘The school does not want parents/students to cervical cancer. Comparing the annual average for 2007 to 2011 with that for 1997 to 2001, the feel pressured by peers or the school setting’; This comes at a time when the government percentage increase in the number of drug- and ‘Pupils follow strict Christian principals, have announced a switch from the current related deaths was greater for women (117%) marry within their community and do not vaccine Cervarix, made by GlaxoSmithKline to than for men (85%). practice sex outside of marriage’. Sanofi/MSD’s Gardasil.
8 | Community Practitioner September 2012 Volume 85 Number 9 ADVERTISEMENT Effective teething relief from the makers of CALPOL® McNeil Healthcare (UK) Ltd., the makers of CALPOL®, understand that when a child is feeling poorly, parents want to do all they can to get them back to normal. Teething can be of great concern for parents as it can disrupt a child’s sleeping and feeding patterns. In fact, research shows that a third of parents (30% out of 107) seek the advice of a healthcare professional about teething1, so it is important that parents get the help and support they need. The makers of CALPOL® have spent over 45 years researching the particular needs of children and developing medicines especially for them. CALGEL® Teething Gel (lidocaine hydrochloride and cetylpyridinium chloride) has been developed to effectively and quickly relieve teething pain in children from 3 months.
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Myth Fact Teething begins Every child is different. The complete set of 20 primary teeth is usually by six months present by the age of two-and-a-half years and in most babies, these teeth of age start to emerge through the gums when they are around six months old, but the timing of teething varies and some children may not develop any Provides dual-acting teething teeth until they are more than a year old.2 relief which: Teething can The symptoms of teething tend to be mild. Symptoms include drooling, 1. Rapidly relieves pain cause severe irritability, facial rash, poor appetite, disturbed sleep and mild temperature 2. Contains a mild antiseptic systemic symptoms elevation (less than 38°C).3 There has been a perception among healthcare like diarrhoea professionals that teething can cause severe systemic symptoms, such as to prevent infection 4 diarrhoea, but there is no research to prove that these symptoms are linked. Soothes sore gums to help It’s best just to use There are several ways you can advise parents to help make teething with feeding and sleep natural remedies to easier for their baby. It can be helpful for the child to have something hard treat teething pain to chew on and teething rings that can be cooled in the fridge can be Is sugar free particularly soothing. Teething gels containing local anaesthetics, such as Has a mild flavour CALGEL® Teething Gel, are proven to help provide pain relief from sore gums.2
CALPOL® is the UK’s best-selling children’s pain and fever relief medicine5, trusted by parents and healthcare professionals for over 45 years. CALPOL® is a trusted expert in children’s medicine – with more mums trusting, using and recommending CALPOL® than any other brand.1 For more information on the CALPOL® range, or to download the CALPOL® teething chart, please visit: www.calpol.co.uk or you can contact the McNeil Healthcare (UK) Ltd. Care Line on 01344 864042.
Calpol Infant and Sugar-free Infant Suspension Product Information: contraceptives. Patients with rare hereditary problems of fructose Calgel Teething Gel Product Information: Presentation: Suspension containing 120mg Paracetamol per 5ml intolerance should not take this medicine. Due to the presence of Presentation: Topical gel containing Lidocaine hydrochloride 0.33% Uses: Treatment of mild to moderate pain and as an antipyretic. Can sucrose and sorbital in the Infant Suspension, patients with glucose- w/w and Cetylpyridinium chloride 0.1% w/w. Uses: Relief of teething be used in many conditions including headache, toothache, earache, galactose malabsorption or sucrose-isomaltase insufficiency should not pain. Dosage: Children over 3 months: rub 1/3rd inch (7.5mm) of teething, sore throat, colds and influenza, aches and pains and post take this medicine. Maltitol may have a mild laxative effect (Sugar- gel onto affected area of gum up to 6 times a day. Do not reapply immunisation fever. Dosage for Children over 3 months Do not give Free only). Parahydroxybenzoates and carmoisine may cause allergic within 20 minutes. Contraindications: Hypersensitivity to ingredients. more than 4 doses in 24 hours and leave at least 4 hours between reactions. Fertility, pregnancy and lactation: Consult doctor before use. Precautions: Do not exceed stated dose. Avoid in patients with rare doses. Children 4 to 6 years: 10ml. Children 2 years to 4 years: 7.5 Side effects: Very rarely hypersensitivity and anaphylactic reactions fructose intolerance. Pregnancy and lactation: Not applicable. Side ml. Children 6 to 24 months: 5 ml. Children 3 to 6 months: 2.5 ml. including skin rash. Blood dyscrasias, chronic hepatic necrosis and effects: Rarely hypersensitivity reactions or allergic reactions. RRP (ex- Dosage for Infants 2-3 months: Post –vaccination fever at 2 months: papillary necrosis have been reported. RRP (ex-VAT): 100ml bottle: VAT): 10g: £2.17. Legal category: GSL. PL holder: McNeil Products 2.5ml, and a second dose, if necessary, after 4-6 hours. The same £2.60; 200ml bottle: £4.36; 12 x 5ml sachets: £2.87 ; 20 x 5ml sachets Ltd, Foundation Park, Maidenhead, Berkshire, SL6 3UG. PL number: two doses can be given for the treatment of mild to moderate pain (sugar free only): £4.62. Legal category: 200ml bottle: P; 100ml bottle: 15513/0015. Date of preparation: May 2008 and as an antipyretic in infants weighing over 4kg and not born GSL; Sachets: GSL. PL holder: McNeil Products Ltd, Maidenhead, before 37 weeks. Contraindications: Hypersensitivity to paracetamol Berkshire, SL6 3UG. PL numbers: Calpol Infant suspension: 100ml bottle: or other ingredients. Precautions: Caution in severe hepatic or 15513/0122; 200ml bottle : 15513/0004; Sachets: 15513/0154. Calpol renal impairment. Interactions with domperidone, metoclopramide, Sugar-free Infant Suspension: 100ml bottle: 15513/0123; 200ml bottle: colestyramine, anticoagulants, alcohol, anticonvulsants and oral 15513/0006; Sachets:15513/0155. Date of preparation: March 2012.
References 1. Data on File. Millward Brown Equity Tracking 2012 2. Netdoctor, Teething http://www.netdoctor.co.uk/health_advice/facts/teething.htm Last accessed 3 May 2012 3. NHS Choices, Symptoms of teething http://www.nhs.uk/Conditions/Teething/Pages/Symptoms.aspx Last accessed 3 May 2012 4. Clinical Knowledge Summaries (CKS), Teething http://www.cks.nhs.uk/teething/evidence/supporting_evidence/teething_ symptoms Last accessed 3 May 2012 5. Source: IRI Volume sales 13 w/e 31 March 2012. UK/CA/12-0413c
15110 Calpol Advertorial A4 V4.indd 1 02/08/2012 17:19 ASSOCIATION
Funding for ‘A Future That Works’: CPHVA members and reps to attend mass demonstration Annual Conference undreds of thousands of people s part of the 150th anniversary marched for the alternative on 26 year celebrations, Unite/CPHVA H A March 2011. We are now back to march is supporting the funding for CPHVA for a future that works – on Saturday 20 members to attend the anniversary October 2012. Unite will be marching in conference at the Brighton Centre, London and Glasgow against the cuts and Kings Road, Brighton BN1 2GR. This against the coalition. Let’s make sure our funding will be for the full ticket price presence is huge. and gala dinner. Workers’ wages are failing to stretch to the The funding will be allocated on a end of the month with the money running regional/country basis, ensuring that out after just 21 days. Unite says stand up there is equitable representation across for a better future and join the march for a all membership groups. There will also future that works on 20 October 2012. be specific tickets identified for Unite/ The London march will begin forming CPHVA accredited representatives. up on Embankment, and marchers are The deadline for applications is Friday suggested to head towards Blackfriars, to 14 September 2012. Members will be join the rear of the march, as the number notified of the outcome by Friday 28 expected mean it will be hard to join further September 2012. toward Westminster. The march will then You can apply via this link: pass Parliament and Trafalgar Square and Visit: www.unitetheunion.org/news__events/ http://unitetheunion.org/cphva Piccadilly Circus. events/_a_future_that_works__-_mass_t. It is important to ensure that all fields Campaign materials, including a poster, aspx are completed and correct as this leaflet and more details about the march information will be used to assess your route and transport, are available to For more details about the march taking place application and notify you of the result. download on the Unite/CPHVA website. in Glasgow see: www.stuc.org.uk/20-oct LAR of the Year Healthy Communities 2012: Award 2012 Fully funded delegate places for Branches invited to nominate local accredited representatives Unite members
nite/CPHVA is calling for ealthy Communities 2012, the second obesity, smoking, air quality and lack of Unominations for this year’s LAR of HNational Conference and Exhibition exercise, and exploring the solutions sought the Year Award, due to be presented to explore the Healthy Communities in the creation of truly healthy communities, at the Unite/CPHVA Annual Agenda, ‘Delivering Healthier, Happier and as well as the pivotal role localism has to Professional Conference 2012. Longer Lives’, will be held at the prestigious play in this agenda. Branches are encouraged to Brewery Conference Centre, London, on This event will clarify latest policy nominate suitable candidates for Wednesday 19 September 2012. decisions and will feature experts in the this important annual award using ‘Healthy Communities 2012: Delivering field and those leaders driving progress on the nomination form available online Healthier, Happier and Longer Lives’ is the ground. (www.unitetheunion.org/cphva). the second Annual National Conference All nominations must be returned by examining the priorities ahead for Limited funded places are available for 1 October, by email to: healthcare professionals, while providing public and third sector only. To book your [email protected] or an invaluable insight into the latest policy place email: [email protected] by post to: Barrie Brown, National directives. quoting ref UTU2. Officer, Unite/CPHVA, 128 Theobald’s This year’s conference will focus on the Road, London, WC1X 8TN. causes behind health inequality and the For more information about the conference current threats to public health, such as visit: www.healthy-communities.co.uk
10 | Community Practitioner September 2012 Volume 85 Number 9 Small but mighty Calogen Extra – the only high energy* supplement with added protein and 36% RNI of vitamins and minerals#
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“It takes a lot of courage” Children and young people’s experiences of complaints procedures
needs may find it difficult to engage with than complaining, or only accessing them Ros Godson services but are unable to articulate their when at crisis point. Unite/CPHVA Professional Officer concerns. The report also points out that the UN Recommendations his new report from the Children’s Convention on the Rights of the Child (which l Ensure adherence to NHS statutory Commissioner for England was the UK ratified in 1991) specifically covered responsibilities Tpublished in July, against a background active participation in matters relating to l Provide comprehensive support for children of large-scale reorganisation in the NHS young people’s lives and a right to the highest and young people who wish to make a and significant cutbacks to services for standards of health care. complaint children and young people, particularly in the Complaints systems to the NHS and local l Make the complaints process more ‘young voluntary sector. authorities are explained, and it is easy to person friendly’ Although the government has published the see that young people might soon become l Take the necessary steps to address staff NHS Constitution and endorsed the ‘You’re disillusioned with the arcane processes attitudes and change NHS organisational Welcome’ quality criteria, there are concerns involved without the support and guidance culture about what will happen to complaints some statutory or voluntary organisations l Embed the involvement of children and handling when the new structures are in place. provide. The responsibilities of the new ‘local young people in NHS service at all levels. This new report is a fairly long document Healthwatch’ bodies are also explained. (88 pages), resulting in an in-depth attempt Children report that they are not provided This report doesn’t just replay what we already to analyse the key messages from children, to with information on how to complain about know; there are also practical and structural understand how they use formal and informal services; their complaints are not always suggestions from young people about how the complaints systems and how to make them treated in confidence; and they may be labelled system could be improved, several of which more accessible. as troublemakers. On the other hand some do not cost money but are based on improved There are interviews with young people healthcare staff demonstrate a defensive attitude communication. and advocacy organisations from around to complaints and do not always see them as a There is plenty of food for thought here for the country, whose main concerns relate to learning opportunity to improve services. service commissioners and providers. The not being taken seriously and the complaints Research has shown that dissatisfaction with report in full can be downloaded from: process taking too long. It is highlighted that services often leads to people dropping out of www.childrenscommissioner.gov.uk/content/ children and young people with additional and disengaging with those services, rather publications/content_585
New NICE clinical guidelines to focus on autism in adults n June 2012 the National Institute for such as co-existing conditions or changes communicating with other people, and IHealth and Clinical Excellence (NICE) in circumstances, if left undiagnosed or having problems obtaining or sustaining published new guidance on how to recognise, undetected, autism can cause feelings of employment or education. refer, diagnose and manage autism in adults. isolation, confusion and social and economic While there are estimated to be around There are estimated to be over 500 000 exclusion. This is the first clinical guideline by 332 600 people of working age in the UK people in the UK with an autism spectrum NICE to focus on autism in adults. It aims to with some form of autism, only 6% of condition (ASC), including Asperger help improve the care of adults with autism them have a full-time paid job. The NICE syndrome; the majority are diagnosed in and contribute to achieving the aims of the guideline also highlights employment advice childhood and adolescence. While there first ever autism strategy for adults in England as a particular need as so many adults are many support services and care options launched in 2010. with autism are able and keen to work available, levels of understanding and the The guideline clearly identifies the most and can bring many skills and qualities to availability of services currently vary greatly common, recognisable characteristics that potential employers. across the country. The way that autism could suggest an individual has autism. These The NICE guidance and implementation tools is expressed depends on many factors, include having difficulties with speech and are available from: www.nice.org.uk/CG142
12 | Community Practitioner September 2012 Volume 85 Number 9 ANTENNA
Research evidence New resources New child protection The experience Sexual and Are the arts an website launched of becoming a reproductive effective setting The Scottish government has launched a new grandmother to a health needs of for promoting national website offering premature infant young people health messages? help and support to The aim of this study was Access to services is a central The promotion of health vulnerable children and to explore and describe the concern surrounding the messages is a cognitive strategy families on child protection experience of becoming a promotion of sexual and used to influence the adoption issues. The new site – grandmother to a premature reproductive health and rights of of health-enhancing behaviours, childprotectionscotland. infant. Few studies have young people. Despite efforts to to promote anti-smoking, org – includes information on what the public should approached the grandmother’s provide youth-friendly services, the safe alcohol consumption do if they are concerned own experience of becoming uptake of services by young people and nutrition messages to the for a child’s welfare. It will a grandmother to a premature is very low. What must be taken general population. The aim also feature a range of infant. The grandmothers into account are young people’s of this Australian study was to information and links to surveyed sensed the seriousness pathways to seeking services; and evaluate the effectiveness of downloadable materials of the situation at the same time the specific barriers they face arts sponsorship to promote for children themselves, as they wanted to be happy about before getting to the services, while health messages and gauge including cartoons and the newborn infant. They worried receiving services, and after leaving the effectiveness of the arts as online games providing about their adult child’s as well as the service delivery sites. Attention a communication channel to child safety tips. the premature infant’s health but to the perceptions and needs of promote health to the general put their own needs aside. The young people is essential along population. Findings from this NICE social care grandmothers need guidance and with development of policies, study suggest the arts have merit quality standards open information about what to expect services, and programmes that beyond intrinsic artistic value for consultation concerning the infants health and address those needs – particularly and are a viable means of NICE’s first two social their own role. the youth-friendly approach to promoting health messages to the care quality standards on dementia care and the J Clin Nurs 2012 service delivery. general population. health and wellbeing of doi: 10.1111/j.1365- Int J Gynaecol Obstet 2012 Perspect Public Health 2012 looked-after children and 2702.2012.04204.x. [Epub ahead of print] [Epub ahead of print] young people are now open for consultation. NICE will be developing a range of quality standards Public health nurses in Scotland: and other guidance on social care topics. The Bookbug for the Home consultation is aimed at a range of parties that he Bookbug programme programme is Bookbug for the Lothian. Each include national patient Tencourages parents and Home training for professionals, area has an and carer organisations, children to share books together including public health nurses Assertive healthcare professionals, from birth. It gifts free packs going into the homes of Outreach steering group made commissioners of health of books to every baby, toddler, vulnerable families with children up of local representatives from services and the public. three and five year old in aged 0 to five. The training the NHS Health Board, the Scotland. This is supported by is to give them confidence to Third Sector and the council Baby slings – advice Bookbug Sessions – song and introduce some of the core education, library and early years and information rhyme sessions for birth to four principles of Bookbug – talking, departments. The steering for parents Advice from the Royal – in libraries and community reading, cuddling and singing group determines which local Society for the Prevention sessions across Scotland. Public with young children – into their early years professionals should of Accidents on the safe health nurses in Scotland are regular visits to encourage more be trained. use of baby slings, after responsible for gifting the positive interaction between If you are interested in taking US authorities advised Bookbug Baby and Toddler packs parents and children at home. part in Assertive Outreach and parents to be cautious to families. Bookbug Assertive Outreach would like more information, when using infant slings The charity has just launched is currently taking place in please get in touch with Scottish for babies younger than its Assertive Outreach Argyll and Bute, Dundee, Book Trust’s Early Years Team at: four months. Visit: programme, targeted to East Renfrewshire, Glasgow, Email: bookbug@ www.rospa.com/faqs/ vulnerable families to access Inverclyde, South Lanarkshire, scottishbooktrust.com detail.aspx?faq=588 Bookbug. At the core of the West Dunbartonshire and West Tel: 0131 524 0179.
September 2012 Volume 85 Number 9 Community Practitioner | 13 NEWS FEATURE
Both seen and heard In January of this year Health Secretary, Andrew Lansley, launched an independent forum to look at how to improve care for children and young people. Six months on, the report of the Children and Young People’s Health Outcomes Forum has been published
l Identify the health outcomes that matter the which concluded that the NHS does not seem Chloe Harries most for children and young people be prioritising improving children’s services. Assistant Editor l Consider how well these are supported The forum agreed with this analysis, and has little over six months ago, an by the NHS and Public Health Outcomes included some of the 2010 report’s findings independent group of childcare Framework and make recommendations within their strategy. Aexperts, co-chaired by Professor Ian l Set out the contribution that each part of the Announcing the publication of the report, Lewis, Medical Director of Alder Hey Children’s new health system needs to make in order Christine Lenehan said: ‘This report needs to NHS Foundation Trust and Christine Lenehan that there health outcomes are achieved. form the basis of a wider children and young OBE, Director of the Council for Disabled The report consulted around 2 000 children, people’s health outcomes strategy, which needs Children, formed the Children and Young young people and their families, and those to be owned by all organisations in the health People’s Health Outcomes Forum. working in health systems (Children and system and beyond who have a responsibility They set out to produce a comprehensive Young People’s Health Outcomes Strategy, for improving the health and wellbeing for report on the major issues in public health 2012). The forum identified several key areas this group’. that are relevant to children and young that needed to be focused upon, referencing Visiting Professor at King’s College London, people today. The forum was tasked with Sir Ian Kennedy’s 2010 report, Getting it Right Sarah Cowley, said: ‘The authors need to be three major objectives: for Children and Young People (DH, 2010), congratulated, because it is a very thoughtful,
14 | Community Practitioner September 2012 Volume 85 Number 9 NEWS FEATURE
detailed and helpful examination of the issues. be added to the NHS Outcomes Framework: It is potentially very useful in determining a l The time between first NHS presentation to way forward for identifying suitable outcomes’. diagnosis or start or the commencement of treatment Failures l Developing a new measure for integrated care While the report acknowledges the great l Improving the transition from children’s to strides made in many areas, such as a adult services reduction in teenage pregnancies and youth l A focus on age-appropriate services, with smoking levels, the authors also identify an particular focus on teenagers. ‘enormous and unexplained variation in many aspects of children’s health care’. It states: Delivery of improvements ‘In some areas … more children and young The forum sets out some recommendations people under 14 years of age are dying in this on how the health and care system can help country than in other countries in northern deliver the improvements recommended and western Europe’. within the report: Other areas of failed care include: l All data about children and young people l More than one in five children are obese by should be presented in five-year age bands age three though childhood and the teenage years – this l Twenty-six percent of deaths showed ‘identifiable failures’ in the child’s care will allow relevant international comparisons l More than half of 15 to 16-year-olds had as well as national or local comparisons. This consumed in excess of five alcoholic drinks in should be implemented as soon as possible the previous months l A lack of planning involving young people l The revised NHS Constitution to be l Around eight in 10 adults who smoke, or who and their families. applicable to all children, young people and have smoked, began under the age of 19 their families l Eight in 10 obese children will go on to be Recommendations l The use of the NHS number as the unique obese adults. A key area identified in the report is the issue of identifier, bringing together health, education, addressing inequality. Children from deprived and social care and criminal justice records Professor Cowley noted a limitation of the areas are more likely to face poor health, for children and young people. report: ‘The dominance of the “medical economic, and social outcomes. It is now widely model” – hospital acute care and long- acknowledged that children, young people The forum warns that if the recommendations term conditions, significant disability – is and their families need to have their voices are ignored the NHS will fail to secure ‘the disappointing, since most children do not heard, and to be involved in decisions that benefits that our children and families need’. come under those catetgories’. that are being made about their health and the It concludes: ‘The implementation of these treatment that they receive. recommendations is crucial. This work should Consultation The report’s main recommendations are: be seen as the first phase in the new Children l The forum undertook a survey of 350 young Putting children, young people and families at and Young People’s Health Outcomes Strategy. people, more than 40 of whom were in the heart of what happens This is a real opportunity for improvement and care (and care leavers) and also conducted l Acting early and intervening at the right time the forum, therefore, urges government and an online consultation, attracting more l Integration and partnership all organisations in the wider health system to than 1 000 responses from children, young l Safe and sustainable services accept these recommendations and act now’. people and their parents. The results showed l Workforce education and training that children and young people want to be l Knowledge and evidence Further information involved in decisions being made about their l Leadership, accountability and assurance The forum has produced factsheets to help health; information to be presented in a more l Incentives. child-friendly way; and to be cared for by children, young people and their families to professionals who have had training in working The authors state: ‘In making our be involved in decisions about their care, and with children and young people. recommendations, we have sought to strengthen organisations and individuals to meet the needs The consultation presented concerns from existing indicators, extending a number of them of children and young people. They can be children and their families, including: to reflect that different stages of the life course accessed, along with the full report, at: l A lack of joined-up services for health, social and life cycle require a different emphasis; from www.dh.gov.uk/health/2012/07/cyp-report/ and education services conception through pregnancy to birth, the l Poor and delayed diagnosis of conditions early years, mid-childhood, to teenagers and References l General practice not meeting the needs young adults, and that using a single measure Children and Young People’s Health Outcomes Strategy. (2012) Report of the children and young people’s health children and young people for 0 to 19-year-olds is inappropriate’. outcomes forum. London: DH. l Concerns the transition from children’s to In addition, the forum has recommended Department of Health. (DH) (2010) Getting it Right for adult services is disjointed four new outcome indicators that they want to Children and Young People. London: DH.
September 2012 Volume 85 Number 9 Community Practitioner | 15 22332_Aptamil Abacus DPS Ad_Comm Pract_AW:1 2/2/12 15:30 Page 1
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*Small balls represent LCPs at minimum expert recommendations. Large balls represent LCPs in excess of minimum recommendations. Reference: Koletzko B et al. The rules of long-chain polyunsaturated fatty acids in pregnancy, lactation and infancy: review of current knowledge and consensus recommendations. J Perinat Med 2008;36:5-14. 22332_Aptamil Abacus DPS Ad_Comm Pract_AW:1 2/2/12 15:30 Page 2
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Every month, we provide practical support and share research1 on infant feeding with thousands of healthcare professionals. To find out more you can visit our specialised HCP website or call our dedicated HCP helpline. aptamilprofessional.co.uk 0800 996 1234 Reference: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first 2 years of life. J Nutr 2008;138:1091-5. Available through all major supermarkets, pharmacies and drugstores. Aptamil: Abacus DPS Ad 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 a babies Journal: Community Practitioner health. Infant formula and follow up milks should be used only on the advice of a Size: 297 x 420 mm Bleed: 3 mm Supply as hi-res PDF Job No: 22332
healthcare professional. MAFv2 Health Visiting
of public health
uring the period from 1996 to 2007, the union underwent some major changes that led to the formation of today’s organisation. DIn 1996, the Health Visitors’ Association (HVA) celebrated its 100th year, holding a special conference and reception, as well as publishing 1896-1996: A History in Health, a comprehensive biography of the association. It also voted on a name change, with the result that as of 1 January 1997, the union’s name officially became the Community Practitioners’ and Health Visitors’ Association (CPHVA). In 2001, the overall union organisation shifted when Manufacturing, Science and Finance merged with the Amalgamated Engineering and Electrical Union (AEEU) to form Amicus which, in 2007, merged with the Transport and General Workers Union to form Unite the Union, which today is the largest trade union in Britain and Ireland with around 1.5 million members. As the number of health visitors began to drop, the role of health visiting was heavily scrutinised, with the ruling body changing yet again and the role redefined in a series of investigative reports. The Nursing and Midwifery Order 2001 led to the establishment of the Nursing and Midwifery Council (NMC) in 2002 as the successor of the UK Central Council for Nursing, Midwifery and Health Visitors and the four National Boards. The NMC took over the roles embodied in its predecessor, including setting the standards of education, registering those involved in nursing, midwifery and specialised public health nursing, including health visitors, and ensuring that all members are qualified and competent. A major Department of Health report, Facing the Future: A review of the role of health visitors, was published in 2007 as part of the government’s Modernising Nursing Careers efforts. The report recommended a specific focus on children under the age of five and their families, rather than the ‘birth-to-grave’ approach, and listed the primary role of visitors as Letters page of the Health Visitor, implementing the Child Health Promotion programme and carrying out January 1996, where proposals for a intensive interventions for the most vulnerable children. name change were debated. Options discussed included ‘Community This was not the only report concerning community practitioners at Healthcare Association’, ‘Community the time; others included the 1999 Department of Health report Making Nurses Healthcare Association’ and a Difference: Strengthening the nursing, midwifery and health visiting ‘Community Healthcare Nurses’ contribution to health and health care and the Chief Nursing Officer’s Review of the Nursing, Midwifery and Health Visiting Contribution to Vulnerable Children and Young People, which appeared in 2004.
18 | Community Practitioner September 2012 Volume 85 Number 9 Timeline 1996 The Health Visitors’ Association (HVA) celebrates its centenary with a range of events, including a Centenary Reception and Conference. 1997 On 1 January, the HVA undergoes its latest name change, becoming today’s Community Practitioners’ and Health Visitors’ Association.
Following the name change from the Health Visitors’ Association (HVA) to the Community Practitioners’ and Health 2001 Visitors’ Association (CPHVA), the journal changes from the When the Manufacturing, Science and Finance Health Visitor to Community Practitioner (MSF) union and the Amalgamated Engineering and Electrical Union (AEEU) merge, the CPHVA officially becomes part of Amicus. News story from June 1998, announcing a pledge from then Home Secretary Jack Straw to focus and invest more in the role of health visitor 2002 On 1 April, the Nursing and Midwifery Council, as designed in the Nursing and Midwifery Order 2001, replaces the UK Central Council for Nursing, Midwifery and Health Visitors (UKCC) and the four National Boards. The NMC keeps the register of nurses, midwives and specialty public health nurses, ensuring their standards of education, qualifications and competence.
2007 The merger of Amicus and the Transport and General Workers Union creates Unite the union, which CPHVA is a part of today.
As part of the 2006 Modernising nursing careers report, Facing the Future: A review of the role of health visitors gives recommendations to clarify the future direction of health visiting. It advocates for a targeted focus on children CPHVA becomes the first and families, and believed the primary role nursing union to offer full should be either delivering the Child Health membership to community Promotion Programme or working on intensive nursery nurses programmes for the most vulnerable children.
September 2012 Volume 85 Number 9 Community Practitioner | 19 PROFESSIONAL AND RESEARCH: PEER REVIEWED
Embedding an electronic health record within a health visiting service
Introduction Mandy Lowery MSc BSc PGCE(HE) RHV In 2008 County Durham and Darlington mechanisms are needed to help identify those Hub Manager County Durham Community Health Services (CDDCHS) children and young people who are suffering,
Janice Dobbs BSc RHV RMW introduced an electronic health record or are likely to suffer, harm. Clinical IT Facilitator County Durham across community services, including health The government’s white paper, Equity and visiting, child health and urgent care settings. Excellence: Liberating the NHS (DH, 2010a), set Aileen Monkhouse MSc BSc(Hons) Pgcert(HE) DMS Originally a strategically led IT project, with out to empower professionals and providers, RGN SCPHN(OH) LPE Principal Lecturer, Teesside University clinical input it soon became apparent that giving them more autonomy and, in return, further development to the system had to be making them more accountable for the results initiated to ensure health visitor compliance they achieve at a local level through the Abstract with SystmOne. information revolution. Edwards et al (2011) County Durham and Darlington’s implementation of an electronic health record Audit and investigations were extremely suggest that high-quality care depends upon across community health services provided an time consuming in areas that had paper- good information being accessible when and ideal opportunity for health visitors to take the based child health information systems and where it is needed. The government believes lead in enhancing the system to reflect their the movement of paper records increased the that one way of achieving this is through paper clinical record. Practitioners’ concerns, fears and anxieties in relation to confidentiality risk of data loss. Implementing an integrated the use of electronic health records (EHRs), and professional accountability resulted in the IT system was vital to managing risk and which they define as longitudinal records that project being further developed to include patient safety, improving communication and follow patients’ care for a lifetime (DH, 1998; the employment of three full-time clinical IT information sharing, which aimed to improve Hayrinen et al, 2008; Schloeffel, 2002). facilitators. These were experienced health visitors and ‘IT champions’ with a sound outcomes for children, young people and Concerns regarding security of patient knowledge of information governance with a their families. information are paramount for healthcare specific remit to provide clinical support and The appropriate use of health informatics professionals, organisations and clients. supervision to health visitors in electronic enables information to be collected, managed, Following a number of data losses committed by clinical record keeping. These practitioners were instrumental in developing the system used and shared safely to support the delivery the NHS and other public sector organisations, and proved the key to the project’s success of health care and to promote health (Council such as Her Majesty’s Revenue and Customs and ensuring that the electronic record was for Health Informatics Professions, 2012). The (HMRC), in which personal information on embedded into health visiting practice to needs of the health visiting service were very a disc was lost in the postal system, how we improve the quality of patient care. different to other disciplines within the trust store, move and share information was very Keywords as the health visiting service aimed to use this much on the political agenda. For any system SystmOne, clinical IT facilitator, record keeping, as a full health record, which had implications to be implemented effectively it is essential care plans, electronic health record for clinical record keeping and professional that this is a fundamental component of accountability (Nursing and Midwifery the development. Community Practitioner, 2012; 85(9): 20–23. Council (NMC), 2010). The challenge was to The aim was to reduce duplication, improve No potential competing interests declared address these and considerable investment was communication to benefit clients in areas required if the system was to be fully used and such as A&E attendance, safeguarding and the benefits seen. information sharing around domestic Using a transformational leadership style violence and to stop the endless paper trail (Marshall, 2011), the authors empowered that is a risk to patient safety due to data loss. health visitors to use their knowledge and A lean-thinking process using the Quality, skills to design the system further and make Innovation, Productivity and Prevention it work for them, giving staff ownership and Challenge (QUIPP) (DH, 2010b) to improve resulted in a system designed by practitioners, quality of care and reduce cost was another for practitioners. driver for the project. The Healthy Child Programme (DH, 2009a) Background is an integral part of health visiting and school The findings of the Victoria Climbié inquiry nursing pathways, and it was believed that (Laming, 2003) and the Munro report (Munro, using an electronic record provided a window 2012) highlight the need for improved of opportunity to evidence health visiting communication, information sharing and how practice and enable the commissioning process.
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With the emergence of the Support For All notes to enable staff to evaluate all contacts Box 1. Health visitors’ and document (DCSF, 1998) many health visitors in the same way, as the evaluation sheets managers’ fears felt the guidance it contained was already within the paper record. These notes appear being put into practice. It could be argued in chronological order of contact time, Health visitors’ fears that this is another example of the difficulties within the record alongside other SystmOne l What can and I write and who will see it? health visitors face in demonstrating clinical users, such as urgent care and GP contacts, l Breach of confidentiality effectiveness. Yet, eight years later it felt that improving communication and information l Professional accountability we were still in the same dilemma, unable to sharing contributing to improving outcomes l Accessibility and being not able to demonstrate the efficacy of our daily work, for children. update the system knowledgeable about our clients, communities However, on ‘go live day’, it did not feel to l When to share the information and practice, hanging onto birth books, index practitioners that the system met their needs. l ‘Big Brother’ is watching me cards and paper records yet for the authors, Although the electronic system allowed for l Increase in time for documentation we believed our knowledge is our practice and contemporaneous record keeping, enabling l System not reflective of our paper record that was what we aimed to demonstrate. staff to book visits and evaluate care, it lacked the ‘tools of the trade’. Care plans, significant Managers’ fears Project context events and assessment tools, such as the l No buy-in from staff Although a considerable amount of work Edinburgh Postnatal Depression Score and l Staff continue to use paper records had already been undertaken to streamline the Framework for the Assessment of Children paper records to ensure consistency by nursing in Need (DH, 2000), vital to clinical record l Two systems in operation, staff using both paper record and electronic record managers, CDDCHS began implementing keeping within our universal paper records, l TPP SystmOne across services in 2008 as were not provided within SystmOne as Too much information being recorded l an electronic health record. Funded through anticipated. Lack of clinical support and guidance the NHS National Project for IT (NPfIT) the Despite all the planning and the availability l Clinical risk project board included the director of nursing, of IT staff to support health visitors following clinical leads and representatives from IT, the programme going ‘live’, health visitors’ Framework for the Assessment of Children in data quality, information governance and fears and anxieties (Box 1) were to prove a Need (DH, 2000) and an electronic version of business support. threat to the electronic record being used the organisation’s ‘significant events form’ in The team followed the Prince 2 methodology fully. Concerns around clinical record accordance with the trust’s safeguarding policy. (www.prince2.com), which provided a keeping, information governance, breach of All of these were linked to certain symbols strategic framework to the project within confidentiality and risk to staff members’ or ‘flags’ to alert other users of vulnerable health visiting, school nursing, child health, NMC registration were very pertinent points. families, domestic violence and child protection urgent care and allied health professionals. It was evident that the electronic record concerns. Pilot sites were identified, project initiation needed to be more specific to health visiting documents completed and practitioners practice. As O’Connor et al (2007) highlight, Care plans encouraged to participate in the ‘as is’ and introducing a new record system must also The care plans (Box 2) were developed from the ‘to be’ workshops via process mapping include time management, accountability Healthy Child Programme policy (DH, 2009a) exercises. This would facilitate identification and planning patient care. We had already based on universal, targeted and specialist of appropriate information required for data undertaken a review of the paper records interventions for child, parent/carer and family. collection within the new system. Training was to ensure consistency and it was evident we Each care plan attached to the records has provided to clinical staff and ‘super users’ to needed an electronic system that reflected a goal, objective and is evidence based with support some additional IT functions. Super our paper record and clear guidance, to give the relevant clinical policy including available users were identified as key staff managers staff confidence that the system met the trust’s NICE guidance. believed would be proficient users of record keeping policy (CDDCHS, 2007) and the system. maintained NMC record keeping standards Hazard review process The project board provided advice and (NMC, 2010). The data collated within the templates are direction on unit configuration, IT and attached to read codes carefully selected so connectivity, smart card distribution, training Revitalising the system to embed into the correct information can be retrieved from and IT support and deployed IT staff to floor clinical practice within the clinical record. The use of read codes walk, to support staff in using the system. Developing the electronic health record by the is strictly controlled by the organisation and The project group designed a number of practitioners, for the practitioners, was one staff are not allowed to create, amend or publish features specifically for HV practice, such of the early lessons learned and was the aim templates or care plans without going through as templates with read codes attached to of the next phase of the project. Harnessing a rigorous peer review process. This is due to facilitate data collation. These included breast the enthusiasm of some of the health visitor the fact some of the codes are attached to the feeding data, blood spot, maternal mood and ‘super users’ and involving staff in the system NICE Quality Outcomes Framework (QOF), clinic contact including growth centile charts design gave them the opportunity to lead the which initiate a diagnosis on the clinical record (DH, 2009b). service development. and have many implications for both nursing The system allowed for free text consultation Templates were designed to include the and medical practitioners. Other read codes, if
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excellent leadership and IT skills, knowledge of Box 2. Care plans SystmOne, excellent knowledge of clinical and Core care plans Targeted care plans Specialist care plans information governance and were line managed l Antenatal l Accident and emergency l Child in need within the service. Their remit (Box 3) was to l Primary visit l Behavior management l Safeguarding provide clinical support and supervision to l 4–8 week contact l Immunisation l Vulnerable family staff to maintain safe clinical record keeping. l 6 week–6 months l Infant massage l Common Assessment They promoted and supported the l 6–12 months l Maternal mood l Framework development of a continuous improvement l 1–3 year contact l Breastfeeding l Domestic violence culture, sharing good practice, proactively l l l 3–5 year contact Safety Drug and alcohol identifying and improving the use of SystmOne, ensuring its use was efficient and effective. Box 3. Clinical IT facilitator remit They developed a user forum to give staff the opportunity to develop a user guide, which l To provide support to health visitors and establish support groups, in person and over provided a framework for a clinical policy. The the telephone SystmOne user guidance handbook contained l To enhance quality of data information/entry crib sheets, screen shots, flow charts and l To ensure compliance and maintaining record keeping standards easy directions. l Ensure record keeping is within clinical and information governance framework During the project development, snapshot l Ensure NICE recommendations are reflected within templates and care plans data were collected from staff diaries on a l Ongoing development of system to reflect changes to services and service needs. ie, creating new care plans and read codes to templates quarterly basis and cross-referenced against l Develop SystmOne guidance for clinical practice the same data gathered from SystmOne. The l Contribute to clinical policy development care plans staff attached to the record were used to measure the activity. As staff became more confident with the system there was a used incorrectly, can affect the accuracy of data by clinical staff. Managers were constantly more direct correlation with the snapshot data collection; for example, caesarian section will contacted as staff sought clinical advice on from the diary and that of SystmOne data. be counted twice if on both the mother’s and what to write, where and how. It was believed Eventually, the trust and staff felt confident baby’s records. All peer reviewers are trained IT by the health visiting manager that the solution with the reliability of electronic system, and risk assessors in template design, structure and lay within the health visiting service itself and paper data collection ceased. read code hierarchy. The panel meets monthly that there was a need to employ health visitors In addition to the snapshot audits, the system as part of the process to review and approve without a caseload with the specific remit of provides a clinical reporting function that can templates and care plans before publication providing the clinical support and advice on be used for caseload management instead of within the relevant units across the trust. clinical record keeping and IT use that staff so birth books. This facilitates caseload profiling desperately needed. and can be used by managers to evidence clinical Clinical IT facilitators On the acceptance of a business case and activity. A sample report is demonstrated in Although supervision and support were given, development of job description the trust Figure 1, illustrating the core contacts a health many IT helpdesk queries required specialist employed three full-time clinical IT facilitators, visitor undertook in a year. clinical knowledge that could only be given who were qualified health visitors with The clinical IT facilitator role was seen as a ‘gold standard’ by other directorates. The manager was asked to be actively involved in developing this model further and a business 70 case was submitted to commissioners. However, this successful change resulted in loss of line 60 management of our clinical IT facilitators, 50 as well as a change in job description, title and to some degree the identity and ethos 40 that underpinned their implementation. 30 They became part of the business support function working across the organisation and 20 to some it was considered a loss to the health 10 visiting service.
0 Summary New Primary 4–8 week 6 week– 6 months– 3 year births contacts 6 months 12 months contact Implementing an electronic health record into health visiting practice has provided many challenges and benefits to patients, Figure 1. Health visitor sample report staff and the organisation. Connectivity,
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mobile connections and inter-agency working Key points in areas of safeguarding issues and those l children and families living at a protected Health visitors took in developing an IT system designed for use by practitioners l address have required a more strategic system A system was needed that reflected paper records with care plans, assessment tools and consultation notes, to give staff confidence that the system met professional record improvement. keeping standards However, links with TPP (the company that l The introduction of full-time clinical IT facilitators, health visitors trained to support and produces SystmOne software) and Connecting advise practitioners on electronic record keeping to allay fears and anxieties proved the for Health have helped provide clinical IT key to the project’s success facilitators with creative solutions, which have l Record keeping was used to evidence clinical practice using care plans and templates enabled clinical policy development to support through clinical reporting methods. the development of SystmOne safeguarding l Evidencing the Healthy Child Programme and looked-after children units. The introduction of clinical IT facilitators – qualified health visitors with excellent l The initial advice of dedicated manage- References leadership, IT skills, knowledge of SystmOne, ment time at the outset was not given the Council for Health Informatics Professions. (2012) The UKCHIP vision. Available from: www.ukchip.org clinical and information governance, without consideration it required [Accessed August 2012]. l the pressure of a caseload – were considered The implementation of the clinical IT County Durham Darlington Community Health the key ingredient to the success of the project facilitators is crucial for such a specialist Services (CDDCHS). (2007) Record Keeping Policy. to support staff across the organisation. service and should have been in place at NHS Durham. Information governance, information sharing the outset of the project Department for Children, Schools and Families (DCSF). (1998) Support For All. London: DH. and confidentiality had many implications for l If we had the opportunity again, manage- Department of Health (DH). (1998) Information for health visiting practice. Patient safety and risk ment and leadership of these staff would health: an information strategy for the modern NHS management are of paramount importance stay within the health visiting service. 1998-2005. London: DH. and the success of this project has transformed DH. (2000) Framework for the Assessment of Children how patient information is accessed, collected Conclusion and Families in Need. London: DH. and analysed, so that local people are at Despite all the planning it was evident that DH. (2009a) The Healthy Child Programme: pregnancy the heart of health service provision (DH, this was not just an IT system; practitioner and the first five years of life. London: DH. 2010b). involvement had to be at all levels throughout DH. (2009b) Using the new UK-World Health Organization 0–4 years growth charts. London: DH. Benefits to staff included reassurance, the process to achieve sustainability. Key enhancements to clinical practice and to the success was the implementation of DH. (2009c) Records Management: NHS Code of Practice. London: DH. individual support specifically targeted to the clinical IT facilitators to ensure staff DH. (2010a) Equality and Excellence: Liberating the improve the clinical record. The associated involvement to make the system work for NHS. London: DH. confidence with the use of SystmOne and health visiting. DH. (2010b) The NHS quality, innovation, productivity reduction of anxiety contribute to a positive Staff realised it was not just an IT system, but and prevention challenge: an introduction for clinicians. approach and full use of the system by the also an electronic health record that needed London: DH. service users. In evaluating the process, one to be adapted and developed to maintain Edwards K, Chiweda D, Oyinka A, McKay C, Wiles D. (2011) Assessing the value of electronic records. Nurs staff member said: effective record keeping and professional Times 107(40): 12–14. ‘This system allows me to plan my visits and accountability in accordance with the NMC Hayrinen K, Saranto K, Nyranen P. (2008) Definition, retrieve records and information about clients in Code (NMC, 2011). structure, content, use and impacts of electronic health an instant. I have even given up my birth book’. The system was designed by practitioners, records: a review of the literate. Int J Med Inform 77: 291–304. As a manager, the system provides easy for practitioners, and by embracing the access to clinical records for safeguarding benefits of improved communication and Laming. (2003) The Victoria Climbie Inquiry: Report of an Inquiry by Lord Laming. London: HMSO. issues, handling complaints and managing information sharing, health visitors have Marshall ES. (2011) Transformational Leadership in contacts during staff sickness and absence successfully embedded an electronic health Nursing: From Expert Clinicians to Influential Leader. episodes. record into clinical practice – proof of which New York: Springer. Benefits realisation exercises were also an came when they let go of their birth books. Munro E (2012). Progress report: moving towards integral part of the project development. Next steps are to: a child centred system. London: Department for Education. Improved communication and information l Roll-out to school nursing services and sharing have benefited patient care, and child health information services Nursing and Midwifery Council (NMC). (2010) Record keeping: Guidance for nurses and midwives. manual handling, efficient record retrieval l Apply a four-tier model to clinical care London: NMC. and storage were among some of the benefits plans to evidence levels of need NMC. (2011) Code of Conduct for Members. London: identified, as well making staff confident l Raise the profile of levels of needs against NMC. that they are adhering to the NMC Code of health visiting capacity to commissioners. O’Connor K, Earl T, Hancock P. (2007) Introducing Conduct (NMC, 2011). improved nursing documentation across a trust. Nurs Times 103(6): 32–3. Upon reflection, for other managers Acknowledgement Schloeffel P. (2002) Requirements for an Electronic considering a similar project we would make Many thanks to all the health visitors and Health Record Reference Architecture. Australia: the following recommendations: management involved in this project. International Standards Organisation.
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4757 Pharmacy Guide A4 Ad_AW3.indd 1 09/08/2012 15:11 PROFESSIONAL AND RESEARCH: PEER REVIEWED
Returning to health visiting practice: completing the circle
Introduction 2010, February 2011 and September 2011. Stephen Abbott BA MA(Econ) CQSW Information is provided on the rationale for Research Fellow, School of Health Sciences, City return to practice programmes; the students Information on the students and University London and content of the programme that was the the programme subject of this evaluation. Of the 54 students recruited to the CUL Sandra Anto-Awuakye MSc BSc RN SCPHN(HV) DipHE programme, six dropped out (see Table 1). Lecturer in Public Health and Primary Care, School Rationale for Return to Overall, 43 have completed the programme of Health Sciences, City University London Practice programmes (August 2012) with the progress of five Return to Practice programmes (RTPs) have delayed by life events. Rosamund Bryar PhD MPhil BNurs RN SCPHN(HV) been in place since the 1990s. Relatively The programme comprises 10 theory days NDNCert CertEd(FE) Professor of Community and Primary Care little is known about their extent or success over 10 weeks, combined with a placement. Nursing, School of Health Sciences, City University (Gould, 2005; Amin et al, 2010), but they Each student has a variable amount of London have intuitive appeal. ‘They provide value for placement time, depending on individual money by offering a far more efficient way to learning needs, number of years out of Seema G Trivedi PhD BSc get health visitors into post than any other practice and Nursing and Midwifery Council Education Planning Manager, NHS London route’ (Trivedi, 2011: 2); and ‘an immediate (NMC) requirements (see Table 2). Correspondence to: [email protected] and cost-effective way of addressing shortages’ Consequently, the programme lasts between (Chalmers et al, 2011; Ly, 2011). three and six months, refreshing and updating Abstract In response to health visitor (HV) practice skills and theoretical knowledge. The One strategic health authority, NHS London, shortages (Unite/CPHVA, 2009) and the programme is based on the NMC education initiated a pilot return to health visiting/nursing practice scheme in London in 2010. This paper government’s pledge to increase the number and learning outcomes required for nursing reports on the experiences of the first three of HVs (Department of Health (DH), 2010), and specialist community public health cohorts of returnees on the City University London NHS London (NHSL) launched pilot RTP nursing (SCPHN) (NMC, 2004; DH, 2011a; programme, one of the London programmes, programmes in 2010. The London RTPHV/N 2011b). It was designed for those with both and the adaptations that have been made to the programmes are provided by City University lapsed nursing and SCPHN registration. programme to help provide returnees with the theory base and practice experience to equip London (CUL), Buckinghamshire New However, applications were also received them to work in today’s health visiting. Written University and Greenwich University (from from registrants who had not worked recently evaluation forms were completed by the returnees 2012) (Trivedi et al, 2010). This paper provides as HVs but were still on one or both registers. and information gathered from their application more detail of the CUL programme with The programme provides for such students forms. This information was supplemented for evaluation data from three cohorts: September updating of practice knowledge and skills, and Cohort 1 with some interviews with practice teachers and lecturers and a mid-stage questionnaire to the returnees. Of the 54 students Table 1. Recruitment and completion rates in the three cohorts over half were still on one Cohorts (start date) No of students starting No of students or both Nursing and Midwifery Council registers, course (no dropping out) completing which had not been anticipated at the start of practice hours the programme and led to modifications to the and assignments programme after Cohort 1 with an increase in the to date health visiting specific content. The returnees had 1 (Sept 2010) 18 (3) 15 a wide range of experience to bring back to health 2 (Feb 2011) 22 (1) 18 (as August 2012) visiting reflecting the fact that a large number had been out of health visiting for more than 11 years. 3 (Sept 2011) 14 (2) 10 (as August 2012) The evaluation shows that providing support by Total 54 (6) 43 the university to the practice placement areas; ensuring that the taught element is current and useful to health visiting practice and having a Table 2. Practice hours required by programme (NMC, 2011; DH, 2011a) relevant but not too onerous assessment process Years out of practice Minimum practice hours required Equivalent days in are critical. practice (7.5 hours per day) Key words Education; evaluation; return to practice; 5 – 10 years 150 20 days workforce development 11 – 20 years 300 40 days >20 years 450 60 days Community Practitioner, 2012; 85(9): 25–29.
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Table 3. Registration status of RTPHV students at start of programme typed up immediately afterwards. These data were collected between Cohorts On nursing On neither On both Total September 2010 and December 2011, and (start date) but not register on SCPHN provide evidence from a number of different register perspectives contributing to the validity of the 1 (Sept 2010) 8 9 1 18 conclusions (Creswell, 2007). Although the 2 (Feb 2011) 4 7 11 22 above additional methods of data-gathering 3 (Sept 2011) 2 8 4 14 have not been repeated, they are included as they reflect informal comments by later All 14 24 16 54 cohorts. From these data, a coherent picture for those who need to re-register on one or be counterproductive, so visits to all students emerges of the hopes and experiences of the both registers (see Table 3). were reinstated and are made within the first students and how these affected learning and NHSL provides course fees, a bursary for four to six weeks of practice. These visits teaching. The findings are presented next and students, additional funding for travel and allow lecturers, students and PTs/EPs to discuss considered in relation to available literature childcare may be claimed, and NHS trusts progress, and identify as early as possible any in the discussion. receive a payment for each RTPHV student. concerns. PTs/EPs are invited to a half-day Cohort 1 was taught with students on a induction, held with the RTPHV students Findings concurrent RTP nursing programme, to from Cohort 3 onwards, and a midway study Student sample facilitate dual re-registration. However, RTPHV afternoon. They have an open invitation to Tables 4–6 give a profile of the students. Not students reported that nursing skill sessions RTPHV programme sessions and student all numbers sum to 54 because of missing were less relevant to their health visiting role, presentations on the last day. data (failure to answer particular questions, and the programmes have run separately Each cohort has had a diverse student or absence when questionnaires were since. The RTPHV programme still covers core population. Some have worked at strategic distributed). All percentages are calculated topics needed for re-registration as a nurse, level across health or social services, some out of 54. Table 4 shows that nearly two-thirds such as record keeping and accountability, but outside health care, or out of the working were over 50, bringing considerable expertise contains more content reflecting the principles environment, caring for family members from other fields. Table 5 shows the length of of health visiting (Cowley and Frost, 2006). or children. previous health visiting practice of students.
Programme content and assessments Evaluation of the RTPHV programme Students’ learning priorities The academic programme includes sessions Methods and samples On the first day of academic teaching students on public health policy, the early intervention This paper considers the RTPHV students’ were asked to complete a questionnaire, which agenda, infant and maternal nutrition, working experience in detail drawing on a range of asked: ‘Please identify up to 10 priorities for with vulnerable families and safeguarding evaluation material, including: your personal learning during the Return issues (DH, 2011b). Speakers with specialist l Replies by students in three cohorts to a to Practice (Health Visiting) programme’. expertise contribute, for example, from the questionnaire on the first day of academic Box 1 illustrates responses using emergent Tavistock Centre for Couple Relationships teaching, asking about their expectations of categories. The third cohort was given the (Rhodes, 2012). the course list of categories, to facilitate comparisons Students have to be signed off in practice l Replies by students in three cohorts to a and complete academic assignments at Level questionnaire about what they had learned, Table 4. Age of students 6 with the award of 30 credits. Given the completed on the last day of academic Age range Number different registration status of the students, and teaching (percentage) of following comments from Cohort 1, different l NHSL data (background information about students academic options for course completion are students). 36 – 50 15 (27.8) offered. 51 – 55 12 (22.2) Additional data were gathered during and 56 – 60 14 (25.9) Practice placements shortly after the first programme: 61 – 70 7 (13.0) Students are supported in practice by practice l Students’ midway impressions of ‘the story teachers (PTs) or, for those on both registers, so far’ from an event at NHSL where they Table 5. Length of previous health an experienced practitioner (EP) supported by were invited to write comments on sticky visiting practice a sign-off PT. All students in Cohort 1 received notes placed on a number of posters at least one placement visit from the university l Brief (face-to-face or telephone) interviews Length of practice Number link lecturer. For Cohort 2, commissioners or email exchanges with nine academic in years (percentage) of students suggested that visits be made only to those teachers 0 – 5 15 (27.8) students off both NMC registers. However, l Brief telephone interviews with three 6 – 10 16 (29.6) given the range of practice, academic and practice teachers. 11+ 13 (24.1) pastoral issues experienced this was found to Notes were made during the interviews and
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Table 6. Time elapsed since health Box 1. Learning priorities for personal learning visiting practice Numbers and percentages in brackets are of students mentioning each learning priority Time elapsed in Number years (percentage) of Cohorts 1 and 2 (n=26; 17 Cohort 1, 9 Cohort 2): students Underpinning knowledge/background 0 – 5 2 (3.7) Legislation, policies, guidelines (15, 57.7%) 6 – 10 15 (27.8) Multidisciplinary/multi-agency working (10, 38.5%) 11 – 15 12 (22.2) Structure of NHS (8, 30.8%) Practice skills and knowledge 16+ 15 (27.8) Updating and amplifying knowledge in general (19, 73.1%) Safeguarding children (15, 57.7%) Childcare (including feeding) and child development (12, 46.2%) between future cohorts (see Box 1). Parenting (8, 30.8%) Given how long many had been out of Immunisations (5, 19.2%) practice, it is not surprising that many Processes and procedures specified among their priorities updating Data – collecting, recording, reporting (9, 34.6%) Corporate caseloads (5, 19.2%) of knowledge of legislation, policies and Learning guidance, and practice skills and knowledge. Placements (6, 23.1%) A significant minority were also very Academic writing / assignments (5, 19.2%) concerned about the academic demands of Accessing information (4, 15.4%) the programme. Cohort 3 (n=12): Working with families (10, 83.3%) Students’ experiences Identifying those at risk (8, 66.7%) Were these aspirations met? In the second Health promotion (8, 66.7%) questionnaire students were asked whether Child safeguarding (8, 66.7%) they had learned a lot, a little or not much Data collection and analysis (7, 58.3%) Health protection (6, 50.0%) about each of the topics listed in Table 7. ‘A Screening individuals and populations (5, 41.7%) lot’ was scored 2, ‘a little’ 1, and ‘not much’ Working with groups/communities (5, 41.7%) 0. Adjustments for no reply have been made. Project planning and implementation (5, 41.7%) Table 7 shows the academic component Community development (5, 41.7%) was reasonably successful in helping students achieve their learning priorities. as predominantly negative (this was most not familiar with modern electronic-based The categories were drawn from Cohort noticeable in Cohort 1). The quotations study techniques and the demands of the 1’s replies to questionnaire 1. The lowest below indicate that a didactic ‘talk and chalk’ academic workload. scores relate to aspects of health visiting best style of teaching (which predominated for learned on placement; however, many had Cohort 1) is probably not appropriate for Teachers’ views not completed their placements when the these experienced adult learners. After academic teaching to the first cohort questionnaire was completed. Box 5 shows a minority of students were was complete, nine academics gave their By averaging each student’s scores for all topics, a score is constructed for the course Table 7. What was learned as a whole. Whereas seven of the first cohort Topic Mean Mean Mean (46.7% of the 15) gave average scores of 1.5 score, score, score, or more, four (26.7%) gave less than 1. The cohort 1 cohort 2 cohort 3 (n=15) (n=20) (n=8) equivalent figures for the second cohort are 8/20 (40%) and 5 (25%), and for the Updating knowledge about childcare and child development 1.6 1.9 1.3 third, 5/8 (62.5%) and none. This suggests Updating knowledge about parents’ needs and parenting 1.6 1.7 2.0 lecturers have used student feedback, their Updating knowledge about safeguarding children 1.5 1.4 1.6 own experience with the programme and Putting learning into practice on placement 1.4 1.4 1.9 national guidance (DH, 2011a) to design a programme more fit for purpose, as perceived Understanding the NHS 1.4 1.3 1.1 by students. Students were invited to make Understanding multidisciplinary and inter-agency working 1.3 1.2 1.4 any other comments summarised in Boxes 2 Health promotion 1.2 1.5 1.4 to 5. Many students felt positive about their Study skills 1.1 1.0 1.4 placements although there were some mixed experiences (see Box 2). Writing to an academic standard 1.1 1.1 1.4 Box 3 illustrates the strong awareness of Learning how to collect, record, report data 1.1 1.1 1.4 changes in health visiting practice; these were Learning how to manage corporate caseloads 0.5 0.8 1.1 viewed as challenging, and, by a minority,
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Box 2. Placement experiences PT1 also reported supporting her student with academic work. All three emphasised l My practice area was supportive and all the health staff I came into contact with were that they thought the quantity of academic helpful, enthusiastic, eager to help and guide me in my clinical practice. I was given work was too large and likened it to that access to a wide range of experience, and I enjoyed the overall placement very much expected of students undergoing the one-year (questionnaire) health visiting programme, even though l Very mixed. There is a lot of support and genuine concern but workers are very stretched this programme was much shorter. PT3 and … it has been difficult to plan and structure my learning experiences (questionnaire) believed the academic load was particularly inappropriate for her student, who had been Box 3. The reality of practice out of practice for only seven years. All three regarded the placements as very successful l How can team caseloads deliver on trusting relationship? Can you identify need/risk if and enjoyable. you don’t see families regularly in own home? Is practice safe with very high caseloads? Huge practice concern about lack of home visiting to families. No comparison with 20 Discussion years ago (sticky note) These evaluation data are limited in a number l Sometimes I think it requires one to be superwoman HV and can give a rather negative of ways. Tools for gathering data were feel to the role – always suspicion instead of emphasising the caring role (questionnaire) deliberately kept brief because the academic l A lot of the lectures didn’t bear much relation to what is happening in practice timetable was crowded, so that rich data (questionnaire) could not be gathered. Conversations with academics and PTs were also deliberately kept impressions to SA. ‘Course expectations and required work were short due to their work pressures. Academics agreed with comments in felt to be demanding and time consuming’. Nevertheless, it is clear that RTPHV is not Box 3, noting the students’ experience and (AT7) an easy option, partly because of the academic maturity: This partly reflected the reality of the requirements and partly because of ‘culture ‘A range of backgrounds and experiences; programme, and some lack of confidence shocks’ as students adapt to contemporary high calibre; a lot of rich relevant experience. among students in undertaking academic health visiting practice. The realities of They were highly motivated, wanting to make work after a long break: RTPHV were highlighted by Miller (2011), a a difference, and to improve health visiting ‘They were visibly twitched about assignments, student from the first cohort. After 12 years practice. They brought insights from other they felt them a burden, they felt unnerved. out of practice she explains that some things perspectives. They were a delight to teach, they There was fear of the unknown: “can we cope?’” never change: ‘Clients were anxious about wanted to get the most out of it.’ (AT4) (AT5) the same topics: breastfeeding, sleep and ‘Strong, self-assured and focused on their One teacher confirmed evidence in Box child development’ (Miller, 2011: 19). Yet, the individual and group needs … they knew what 5 that some students were under-equipped culture and pace of modern health visiting they wanted, and were focused on achieving for the use of IT in an academic setting. In and other services have changed drastically, their learning requirements.’ (AT7) general, they enjoyed teaching the groups, with children’s centres, skill mix teams and There was agreement that group work was and appreciated their willingness to engage changing patterns of working with families. the best way to promote learning: and debate. The realities of these challenges require ‘It was good to get them talking, sharing their sensitivity and support from academics broad and rich experience.’ (AT5) Practice teachers and PTs. While a group work approach allowed Three PTs were interviewed by telephone Some of our findings reflect those of an students to share experiences and learn from (PT1-PT3). Their students had been out of evaluation of another RTPHV scheme (Amin each other, it also legitimised the need to health visiting for 25, 12 and seven years et al, 2010), which noted anxieties about ventilate feelings about some conflicts they respectively. The PT supporting the first academic assignments, and the importance of experienced: between theory and practice, needed to provide plenty of input: peer support. between what they remembered from the past ‘Discussing basic detail of what health visiting Diversity of students is an important and their current placement experiences. is about; discussion, reflection, debate about area highlighted in a study of an RTP AT8 drew a clear contrast between practice.’ (PT1) programme for nurses (Barriball et al, 2007). their previous and current practice. She characterised the former as consisting of: Box 4. The student group ‘Making relationships with families; frequent home visits; groups (breastfeeding, post-natal, l We are a challenging group to teach and support. Lots of different experience, different weaning, etc.)’ needs (sticky note) and the latter as: l Lots of experience in the group – would like the opportunity to share this more ‘Skill mix, whereby the lower grades do all (sticky note) l the enjoyable work and all HVs do is the first Group work would mean we could learn more from each other (sticky note) l assessment and safeguarding’. Would prefer more group work, more student-led sessions, more participation by students; and less lecturing and discussion (sticky note) Academics were also aware that:
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Previous experience and expectations varied Box 5. Learning needs considerably, as did students’ responses to placements and changes in health visiting. l For people who have been away from nursing and university for some time, there is a It seems that such diversity is best handled need to include IT skills and presentation skills during the course or before the course by trusting students to use their differences starts (sticky note) l to inform debate and exploration. Although Assignments – anxieties about libraries, databases, and use of IT could be solved by a students hoped to acquire plenty of specific longer induction on these topics alone (sticky note) l A lot of studying over a short period (questionnaire) information, they wished to do so interactively rather than passively; their preference was for andragogic learning, with learners taking Key points responsibility for learning rather than leaving l Return to health visiting practice programmes are successful in supporting people back it with the teacher (Knowles, 1970). into practice Three areas requiring change were identified: l Content of programmes needs to be flexible, evidence-based and focused on current support for students on placement; getting the practice priorities teaching ‘mix’ right; and making the academic l Students need opportunities to explore and debate changes in practice requirements more manageable. l Returnees to health visiting bring a wealth of additional experience to inform their First, the initial plan to visit all students on future practice placement was modified for Cohort 2 but restored for subsequent cohorts to support the programme and seminars are offered Nursing Management 15: 333–431. students and PTs. to support assignments. Changes have also Chalmers L, Hamer S, Holt J, Ramsbottom R, Trickett R. Second, it is challenging to provide classroom been made in financial support making the (2011) Training and retaining. Comm Pract 84(4): 18. education to meet students’ diverse needs. RTPHV/N a viable option for more people. Cowley S, Frost M. (2006) The principles of health visiting: opening the door to public health practice in the 21st The aim is to foster learning informed by Support, flexibility in completing the century. London: CPHVA. practical experience, strategic understanding programme and encouragement are available Department of Health (DH). (2010) 4200 new health and sound academic knowledge. Changes for all those interested in RTPHV. As many visitors to boost young children’s and families’ health and have been made for each cohort providing a of the RTPHVs have told us, returning to wellbeing (press release 21 Oct 2010). London: DH. range of academic and practice teachers who, health visiting practice feels like ‘completing DH. (2011a) Health Visitor Return to Practice Framework. together, can meet these needs. The most the circle’ of their professional careers by A Guide for Education Providers. London: DH. Available important change was that the RTPHV/N returning to what motivated them in the first from: www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ programme was separated from the Return place. The uptake of this RTPHV programme DH_129697 [Accessed April 2012]. to Nursing programme and the revised is making a significant contribution in DH. (2011b) Educating Health Visitors for a transformed programme led by HVs focused on health bringing returnees back into practice with 43 service. London: DH. Available from: www.dh.gov. visiting (DH, 2011a). HVs returned to health visiting to date. We uk/en/Publicationsandstatistics/Publications/ Third, the NMC (2004) requires SCPHN encourage potential returnees to explore their PublicationsPolicyAndGuidance/DH_129682 [Accessed April 2012]. students to demonstrate their level of local programmes and consider returning Gould D. (2005) Return-to-practice initiatives in nursing competence across 25 SCPHN learning to boost the public health workforce and retention. Nurs Stand 19(46): 41–6. outcomes in theory and practice. Students in promote the health and wellbeing of children the first cohorts (who were off the registers) Knowles M. (1970) The modern practice of adult education: and families. andragogy versus pedagogy. New York: Association Press. were expected to undertake two assignments: a 1 000-word learning reflection, and Ly K (2011) More pathways into health visiting. Comm Acknowledgements Pract 84(4): 14–15. reflections across 25 learning outcomes. This We would like to thank all the RTPHVs who Miller B. (2011) Bringing it back. Comm Pract 84(6): 19. second assignment often felt bewildering and completed the evaluation forms and for their unwieldy. Revisions were made and students Nursing and Midwifery Council (NMC). (2004) determination to return to practice: you are all Standards of Proficiency for Specialist Community Public now complete five ‘mini’ essays (in total 6 000 an inspiration! Thanks are also due to all the Health Nurses. London: NCM. words) on topical practice issues: a community practice teachers, experienced practitioners, NMC. (2011) The Prep handbook. London: NMC. profile; health promotion; safeguarding health visiting managers and educational Rhodes H. (2012) Why we don’t, why we should and how children at risk; identifying unmet need, and leads in trusts in London for all their support we could. A Short Guide to Working with Co-Parents. the Healthy Child Programme. to the RTPHVs. Last but not least thanks to London: Tavistock Centre for Couple Relationships. Available from: www.tccr.ac.uk/research-publications/ Tori Awani, NHSL, who took over from Seema Conclusion practitioner-guides/200-a-short-guide-to-working- Trivedi and held the whole scheme together. with-co-parents [Accessed April 2012]. Students rarely anticipate the ‘culture shock’ experienced from returning to practice nor Trivedi S, Mansfield H, Smith L. (2010) Coming back for References the future. Comm Pract 83(12): 40–1. the ‘blood, sweat and tears’ of sheer hard Amin M, Martin S, Turney N, Gregory S, O’Donnell A. Trivedi S. (2011) NHS London Health Visitors Return to work at a practical level (Miller 2011: 19). To (2010) Evaluation of a return to practice health visiting scheme. Comm Pract 83(3): 25–8. Practice (RtP) pilot project progress report – February 2011. cushion this students from previous cohorts London: NHS London. Barriball KL, Coopamah V, Roberts J, Watts S. (2007) are invited to the next programme to give Evaluation of return to practice: the views of nurse Unite/CPHVA (2009) The crisis in health visiting (facts advice on how to successfully complete returnees form three NHS Hospital Trusts. Journal of and figures). London: CPHVA
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Breastfeeding knowledge and education needs of early childhood centre staff
Introduction to breastfeeding in public places (Roe et al, Kathleen Mary Manhire The World Health Organization (WHO) 1999); the availability of infant formula; lack RN RM MMidwifery IBCLC recommends exclusive breastfeeding until the of support for breastfeeding and poor maternal Senior Lecturer, Eastern Institute of Technology infant is six months of age and continuing attitudes and knowledge about breastfeeding Glenn Horrocks breastfeeding up to two years and beyond with (Cernadas et al, 2003). BN RN adequate and safe complementary foods (WHO, Alongside increasing numbers of women Clinical Nurse 2003). Despite this, only 12% of infants in New returning to paid employment after childbirth Zealand (NZ) are exclusively breastfed during (Callister, 2007) there are greater numbers of Angeline Tangiora BN RN their first six months; and from six months children under one year of age attending early Research Nurse, University of Otago to one year only 30% receive any breastmilk childhood care providers. Between 2004 and (Royal NZ Plunket Society (RNZPS), 2010). 2008 there was a 20% increase in infants under Abstract NZ breastfeeding rates at birth are consistent one year of age attending an out-of-maternal This survey investigated the breastfeeding knowledge, attitudes beliefs and education with other Organisation for Economic home setting (Bartle and Duncan, 2009). At needs of supervisors and staff at 32 early Cooperation and Development (OECD) present in NZ there are no national guidelines childhood centres in New Zealand. This study countries (Ministry of Health (MOH), 2007a). for the protection, promotion and support of explored numbers of mothers who breastfed UK breastfeeding rates are low and, in 2005 less breastfeeding by providers and consumers at at or supplied expressed breastmilk to the centres, and how breastfeeding education than 1% of British mothers were exclusively ECCs, although a draft has been developed by might enhance an increase in breastfeeding breastfeeding at six months, compared with Bartle and Duncan (2009). rates and child nutrition. Statistical analysis the EU average of 28% (Hosking and Walsh, There has been little research exploring support and open-ended questions revealed a positive 2010). for breastfeeding at the place of childcare in NZ attitude towards breastfeeding among staff. All centres recognised a need for breastfeeding Breastfeeding has a protective and nutritional or the UK or USA. In 2003 Farquhar and Galtry education sessions and greater support role well past the first year (MOH, 2007a) and explored, through two case studies, staff and for breastfeeding mothers. With increasing many studies show that the longer an infant is parental aspects of NZ childcare centre support. numbers of children attending early childhood breastfed the greater the benefits (Crenshaw, They concluded that, although there was a centres, understanding the importance of and implementing support for mothers to continue 2005). For infants in childcare environments supportive attitude by staff, there remained to breastfeed is crucial. there is an increased risk of contracting illnesses a need for breastfeeding to be considered the and babies who are breastfed have a reduction norm in terms of administration, staff and Keywords in infectious disease (Duffy et al, 1997; Pettigrew parental expectations. Breastfeeding, early childhood centre, childcare, breastfeeding knowledge, attitude and beliefs, et al, 2003). Furthermore, there was a need for breastfeeding breastfeeding education Early childhood centres (ECCs) include policy, education about breastfeeding and government licensed and regulated facilities improvement in physical childcare facilities to Community Practitioner, 2012; 85(9): 30–33. for children up to six years of age that include better support breastfeeding families (Farquhar No potential competing interests declared kindergarten, childcare, daycare, crèche, and Galtry, 2003). kohanga reo, language nest, playcentre, early In a US study Clark (2006) found large learning centre, nursery school, Montessori and knowledge deficits among childcare centre Rudolf-Steiner preschools. staff, despite their beliefs about their role in It is evident that there needs to be an increase supporting breastfeeding families. Clark has in breastfeeding duration and an enhancement subsequently developed a web-based infant of the breastfeeding experience for mothers feeding education programme (www.infanet. and babies in NZ and globally. There are many cahs.colostate.edu). In the UK there appears reasons cited for the early discontinuation of to be some focused breastfeeding support, but breastfeeding, such as return to paid work whether this is a generalised feature of early (Dennis, 2001; Valdes et al, 2000) and the childcare is not evident (DirectGov, 2012). baby’s attendance at ECCs (Li et al, 2005; Childcare provides a potential setting for Pearce et al, 2010). Embedded within these breastfeeding promotion and support. A factors may lie other barriers, such as negative recent study found informal childcare (care attitudes from family and the public, especially by friends, grandparents and other relatives)
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was associated with a reduced likelihood of Table 1. Child ages and numbers breastfed (RNZPS, 2010) breastfeeding for all groups of mothers. Formal Percentage Number of children Percentage childcare arrangements (nurseries and crèches) breastfed Child age in age group breastfed (exclusive/full) were only associated with a reduced likelihood (n=1081) (exclusive/full) (n) nationally of breastfeeding if used full-time by more No response 5 advantaged families. The researchers suggested that formal childcare settings offer a potential to 0 – 6 months 11 36% (4) 25% (full/exclusive) support breastfeeding through practical means, 6 months – 1 year 114 9% (10) 35% (exclusive full/ policy and promotion (Pearce et al, 2012). 1 – 2 years 242 7% (16) partial The aim of the research was to investigate the 2 – 3 years 285 2.5% (7) support, knowledge, attitudes and beliefs, about 3 – 5 years 424 0.2% (1) breastfeeding offered by ECCs and to identify breastfeeding education needs in NZ. wants and needs; and demographic data. The centres responded, with a mix of managers and The objectives of this study were: managers’ version included questions about staff participating. The respondents’ centres l To ascertain the numbers of mothers who support for breastfeeding staff and numbers of were 77% urban, 16% semi rural and 7% rural, currently breastfeed, breastfeed at or supply infants at centres. Institutional and government with a combined total of 1,454 children aged expressed breast milk (EBM) to the centres committees granted research and ethics between 0 and five years old. One centre did not l To establish breastfeeding knowledge and approval. provide the number of children attending and attitudes of staff four centres gave their total population but did l To establish breastfeeding education and Data analysis not provide a breakdown of age groups. Centres support needs of managers and staff. Scoring: Both the manager and staff ranged in size from 13 to 261 children. questionnaires contained four knowledge Breastfeeding numbers were highest among the Methods questions. The first concerned the advantages 0 to six months age group (Table 1). Although This study was a quantitative design using of breastfeeding with a score of 2 given for each the number (36%) of infants breastfeeding in a descriptive exploratory survey. The advantage selected (maximum score=24). For this study was higher than the number (25%) questionnaire was adapted with permission the remaining three questions, selecting the breastfeeding (exclusive/full) found by the from Clark (2006). Consultation for adaptation correct answer scored 2. A maximum score National Breastfeeding Advisory Committee to the NZ environment included consideration of 30 could be obtained for the knowledge. of NZ (NBAC, 2008), this study does not of ethnic culture, educational and breastfeeding Similarly, there were four attitude questions ascertain if they were exclusively breastfed or cultural perspectives. that could be scored. Three of these had yes/ the specific age of the infants under six months. no answers (yes scored as 2 and no scored as 0) The numbers in total (11) were very small. Sample and one Likert scale question where the score Breastfeeding numbers declined to 9% after this All ECCs in the province that offered childcare ranged from 0 (dislike it a lot) to 2 (like it a lot). six-month period and were much lower than from 0 to six-years-old, in a structured A maximum score of 8 could be obtained for the overall rate in the area at this age (35% full, educational environment, were sent a letter to attitude; the higher the score the more positive partial and exclusive breastfeeding) (RNZPS, explain the research project and an invitation to the individuals attitude towards breastfeeding. 2010). The number of parents supplying participate. This included urban, semi-rural and Statistical analysis: To explore which factors expressed breast milk was also negligible (four rural centres. Excluded from the sample were had an effect on the score obtained, a general children across all centres). kindergartens, play centres and home-based linear model analysis was performed. The care as they did not provide long-term infant model included score as the dependent variable Knowledge, Attitudes and Beliefs day care. Te Kohanga Reo National Trust, and status (manager or staff), experience level Managers’ and staff responses were similar which provides centres with Maori language and (under four years or four or more years), regarding the perceived advantages of cultural immersion, declined to be involved. ethnicity (Maori, NZ, European or other) breastfeeding (Table 2) and knowledge about Sixty-nine centres were visited and given and hours worked (under 30 hours or 30 or breast milk science, environmental and a package containing an ‘information for more hours) as factors. Initially, a full factorial attitudinal beliefs. However, 2% of staff believed participants’ sheet, three questionnaires model was performed but no interactions were that there were no advantages to breastfeeding. (one manager’s version and two staff worker detected. Therefore, these were dropped from More managers than staff believed there were versions) and a stamped, self-addressed return the model and only the main effects were tested. disadvantages to breastfeeding. Common envelope for each questionnaire. Consent was All statistics were carried out using IBM SPSS comments for disadvantages were: ‘It is only a assumed on return of the questionnaires. version 20. mother’s job’ and ‘Dad may feel he can’t bond with baby’. Another comment was: Questionnaires Results ‘Can be difficult to establish, which can lead The questionnaires consisted of 25 (for staff) Demographic data to difficulties of not feeling competent and/or and 29 (for manager/supervisor) closed and Questionnaires were distributed to 69 managers disruptive of mother–infant bonds. Can be painful open-ended questions exploring the three and 138 staff with a response rate of 45% for … inconvenient … difficult to only ingest food/ parameters of the study: attitudes, beliefs and managers (n=31) and 40% for staff (n=55) for drugs that are good for infant; can be demoralising knowledge about breastfeeding; education an overall response rate of 41.5%. Thirty-two for mothers not able to breastfeed’.
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Table 2. Childhood centre providers’ perceived advantages of breastfeeding well as support for women to stay longer at (multiple responses were permitted) home after childbirth with Paid Parental Leave (PPL) to 14 weeks (Dickson, 2007). However, Advantages Managers (n=31) Staff (n=55) some women in part-time jobs are ineligible for this (Callister, 2007). In the UK there is No response (1) a statutory maternity leave of 52 weeks with Less risk of illness 74% (23) 78% (43) maternity pay from 39 weeks pregnancy for up It is easier 65% (20) 66% (36) to 39 weeks. Better bonding with mother 87% (27) 82% (45) Few respondents (2%) noted any disadvantages Less risk of diseases in adult life 41% (13) 42% (23) of breastfeeding, which related to potential Better nutritionally 87% (27) 86% (47) Helps make baby smarter 19% (6) 27% (15) attachment issues and breastfeeding problems Baby is easier to care for 45% (14) 33% (18) arising from the separation of mother and baby Less risk of obesity 32% (10) 35% (19) when the mother returns to paid work. These Nappies not as smelly 19% (6) 36% (20) comments might be interpreted as cultural Saves family money 84% (26) 86% (47) beliefs arising from personal experiences or Less rubbish 42% (13) 60% (33) expectations and offer insights for education Not embarrassing 16% (5) 36% (20) about breastfeeding (Farquhar and Galtry, 2003). No advantage 0% 2% (1) Knowledge of the Baby Friendly Hospital and Community Initiative was low for both groups, In response to a question about the WHO and delivered in a face-to-face short course indicating there was a need for education about recommendations for breastfeeding, 58% of format (Table 4). One manager said: this health initiative. managers and 36% of staff could state them ‘None – this is a health issue and should be A supportive breastfeeding environment correctly, and 29% and 36% respectively were addressed by plunket, midwife, nurse or other includes overt displays of breastfeeding via unsure. Staff and managers alike believed that appropriate person. We are teachers – education posters, booklets and other media. Fewer than it was either a child’s or mother’s individual – would primary teachers be approached to input 20% of managers and staff indicated this occurred decision when they stopped breastfeeding. It into a similar topic?’ at their centre. Farquhar and Galtry (2003) was suggested that a natural weaning process found some staff felt that providing breastfeeding happened when the child was between one and Discussion information might make some women feel two years old. Knowledge, Attitude and Beliefs guilty, an attitude which requires discussion and Only 23% of managers and 30% of staff knew Generally positive attitudes and beliefs about education from a health promotion perspective. of the Baby Friendly Hospital and Community breastfeeding and the support of breastfeeding A disturbing finding from the current study Initiative in the region. There was also a lack mothers were expressed by ECC managers and was the low level of awareness of the impact of understanding of the impact of formula staff. There appeared to be a lack of specific formula advertising might have on breastfeeding advertising at the centre, demonstrated by the breastfeeding resources, policies and some duration. A key tenet of breastfeeding support low numbers (16%, n=5) who had no formula knowledge gaps which limit breastfeeding and protection includes an understanding of the advertising at their centre. support. There was an awareness of the need International Code of Marketing Breast Milk Most managers and staff, 87% and 85% for breastfeeding education for ECCs by both Substitutes. Although this Code is designed for respectively, believed that ECCs have a role in managers/supervisors and staff/teachers. health workers, it defines a ‘health worker’ as supporting parents with infant feeding choices Thirty-six percent of infants up to six months someone providing information to pregnant and were happy with mothers’ breastfeeding of age were breastfeeding at the ECCs, although women and mothers, and a healthcare provider at their centre. Ninety-three percent of centres it was not clear what the specific ages of the includes childcare centres and nurseries allowed staff to breastfeed their own children at infants were or what form the breastfeeding was (MOH, 2007b). work, whereas 100% of centres allowed mothers (exclusive, full or partial). In NZ 55% of infants of children to breastfeed at the centre. are fully and exclusively breastfed at three Education needs Status, experience, hours worked per week months and at six months that decreases to 25% There was a request for professional breastfeeding and ethnicity did not have a significant effect on (NZ Breastfeeding Authority (NZBA), 2008). education from ECC staff and managers either knowledge or attitude scores (Table 1). More significant was the sharp reduction in and willingness for both generic and specific There was no correlation between attitude and breastfeeding (exclusive/full/partial) for infants breastfeeding education, with most opting for knowledge scores (r=0.017; P=0.874). from six months to one year to 9% compared a short course at their centre. These results with 35% nationally (RNZPS, 2009). confirm both Clark’s (2006) and Farquhar and Education needs Return to paid work, particularly full-time Galtry’s (2003) findings. Suggested education There was desire for breastfeeding education work earlier than six weeks or three months providers included Well Child nurses (in the UK throughout most ECCs (Table 3). When (Dennis, 2001; Scott and Binns, 1999; Valdes this could be health visitors, community public asked what information and training would et al, 2000) has been described as a barrier to health nurses and community nursery nurses). be helpful, the majority indicated that Plunket breastfeeding duration. In NZ there has been Gildea et al (2009) found that health visitors (well child health service), La Leche League or progress in supporting breastfeeding in the were often the primary and only source of public health nurse support would be beneficial, workplace (Women’s Health Action, 2005) as infant feeding information, which supports the
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Farquhar S, Galtry J. (2003) Developing breastfeeding- Table 3. Education in ECCs friendly childcare to support mothers in paid employment Managers (n=31) Staff (n=55) and studying: Case studies of two centres and draft guidelines for supporting breastfeeding in childcare. Wellington: Yes No Yes No Department of Labour and Ministry of Women’s Affairs. No response 3% (1) 3.5% (2) Gildea A, Sloan S, Stewart M. (2009) Sources of feeding advice in the first year of life: who do parents value? Comm Do you have education sessions 10%(3) 87% (27) 3.5% (2) 93%(51) Pract 82(3): 27–31. Hosking G, Walsh I. (2010) International experience of early intervention for children, young people and their families. Would you encourage your staff to attend breastfeeding 58%(18) 42% (13) Surrey, UK: Wave Trust. education sessions Li R, Darling N, Maurice E, Barker L, Grummer-Straw LM. (2005) Breastfeeding rates in the United States by characteristics of child, mother or family. The 2002 national immunisation survey. Paediatrics 115: 31–7. Table 4. Type of education preferred Ministry of Health (MOH). (2007a) Food and nutrition Managers (n=28) Staff (n=55) guidelines for healthy infants and toddlers. (Aged 0-2). Wellington: MOH. One-day conference/short course 16% (5) 33% (18) MOH. (2007b) Implementing and monitoring the Internet-based course 19% (6) 11% (6) international code of marketing breastmilk substitutes in New Zealand. The Code in New Zealand. Wellington: MOH. 2 – 3 hour centre-based course 11% (11) 60% (33) National Breastfeeding Advisory Committee of NZ (NBAC). Other 19% (6) 15% (8) (2008). National strategic plan of action for breastfeeding. Wellington: NBAC. New Zealand Breastfeeding Authority (NZBA). (2008)Stock concept of health visitors providing education References take of breastfeeding report. Hawke’s Bay District Health to childcare institutions. Board. Wellington: NZBA. Bartle C, Duncan J. (2009) Ten steps for the protection, There are also numerous consumer-focused promotion and support of breastfeeding in early childcare Oddy W. (2001) Breastfeeding protects against illness and centres in New Zealand. (Draft ) Unpublished. infection in infants and children. : A review of the evidence. websites supporting parents preparing their Breastfeeding Review 9(2): 11–17. breastfeeding child for an ECC provider, Callister P. (2007) Parental leave in NZ2005–2006. Evaluation. Wellington: Department of Labour. Pearce A, Li L, Abbas J, Ferguson B, Graham H, Law C, including a NZ guideline for selecting a Millennium Cohort Study Child Health Group. (2012) breastfeeding-friendly ECC (Farquhar, 2005). Cernadas JM, Noceda G, Barrera L, Martinez AM, Garsd Childcare use and inequalities in breastfeeding: findings A. (2003) Maternal and perinatal factors influencing the from the UK Millennium Cohort Study. Arch Dis Child In 2009 Bartle and Duncan developed a guide duration of exclusive breastfeeding during the first 6 months 97(1): 39–42. of life. J Hum Lact 19(2): 136–44. that aims to progress the Baby Friendly model Pettigrew MM, Khodaee M, Kendra Schwartz BG, Bobo JK, by extending the hospital and community Clark A. (2006) Developing and evaluating a website on infant Foxman B. (2003) Duration of breastfeeding, daycare and feeding, specifically breastfeeding, for childcare providers. physician visits among infants of 6 months and younger. initiatives developed by WHO and UNICEF Unpublished master’s thesis, University of Colorado, Ann Epidemiol 13: 431–5. (Bartle and Duncan, 2009). In the UK some Crenshaw J. (2005) Breastfeeding in nonmaternity settings. Roe B, Whittington LA, Beck Fein S, Teisl MF (1999). Is childcare centres do offer breastfeeding support Am J Nurs 105(1): 40–50. there competition between breastfeeding and maternal (Directgov, 2012). Dennis C. (2001) Breastfeeding initiation and duration: employment? Demography 36(2): 157–71. a 1990-2000 literature review. J Obstet Gynaecol Neonatal Royal New Zealand Plunket Society (RNZPS). (2010) Nurs 31(1): 12–30. Breastfeeding outcomes. Wellington: RNZPS. Limitations Dickson M. (2007) It’s about time: towards a parental leave Scott JA, Binns J. (1999) Factors associated with the initiation Limitations of this study include the small sample policy that gives New Zealand families a real choice. Families and duration of breastfeeding: A review of the literature. that was surveyed. Not having Te Kohanga Reo Commission New Zealand. Breastfeeding Review 7(1): 5–16. involvement in the study was disappointing. Directgov (2012). Sure Start Children’s Valdes V, Pugin E, Schooley J, Catalan S, Aravena R (2000). Centres. Available from: www.direct.gov.uk/ Clinical support can make the difference in exclusive enparentspreschooldevelopmentandlearning/ breastfeeding success among working women. Journal of Conclusion nurseriesplaygroupsreceptionclasses/dg_173054 [Accessed Tropical Paediatrics 463(3): 149–53. June 2012]. This project identified a need for increased Women’s Health Action. (2005) Breastfeeding at work. breastfeeding education and support. Duffy LC, Faden H, Wasielewski R, Wolf J, Krystofik D. Wellington: Women’s Health Action. (1997) Exclusive breastfeeding protects against bacterial Knowledgeable staff with an understanding colonisation and day care exposure to otitis media. World Health Organization (WHO). (2003) Global strategy of the different needs of breastfeeding infants Paediatrics 100(4): 7. for infant and young child feeding. Geneva: WHO. compared to formula-fed infants and an environment where breastfeeding is seen as the Key points norm are important. l The ideal environment to support the Providing early children centre (ECC) staff with breastfeeding education will enable them to more effectively support parents with their infant feeding choice and understand the breastfeeding relationship while returning to advantages of breastfeeding paid work needs a three pronged approach: first, l ECC staff should be aware of the World Health Organization recommendations for breastfeeding should be well established through breastfeeding and baby-friendly community initiatives a paid parental leave policy; second, there l To enhance breastfeeding rates, mothers should be encouraged to breastfeed at should be a flexible and supportive workplace the centre environment to encourage breastfeeding; and l By implementing and disseminating infant feeding policies including a breastfeeding finally, ECC staff who are knowledgeable about policy, breastfeeding rates are likely to increase breastfeeding are essential.
September 2012 Volume 85 Number 9 Community Practitioner | 33 BREASTFEEDING IS BEST
Drop for drop, no other formula comes close
Breast milk New SMA Other first infant milks First Infant Milk
References: 1. Aptamil website accessed December 2011 http://www.aptamil.co.uk/products/article/aptamil-fi rst?tr=carousel 2. Bettler J, Kullen MJ. J Pediatr Gastroenterol Nutr 2007; 44 (Suppl 1): e197. PN1-11. 3. Kennedy K et al. Am J Clin Nutr 1999; 70: 920-7. 4. Yao M et al. J Pediatr Gastroenterol Nutr 2010; 50 (Suppl 2): PO-N-444. 5. Yao M et al. Poster presented at 43rd Annual Meeting of ESPGHAN, Istanbul, Turkey, June 9-12, 2010. 6. Lien EL et al. J Pediatr Gastroenterol Nutr 2004; 38: 170-6. 7. Carnielli VP et al. Am J Clin Nutr 1995; 61: 1037-42. 8. Carnielli VP et al. J Pediatr Gastroenterol Nutr 1996; 23: 553-60. 9. Trabulsi J et al. Eur J Clin Nutr 2011; 65: 167-74.
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 breastfed. The decision to discontinue breastfeeding may be diffi cult to reverse and the introduction of partial bottle feeding may reduce breast milk supply. The fi nancial benefi ts of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional.
ZGW0460/02/12
12621 SMA Ad DPS 297x420.indd 1 Drop for drop, no other formula comes close1-9
Breast milk New SMA Other first infant milks First Infant Milk
Breastfeeding is best for babies. Breast milk provides babies with the best New SMA First Infant Milk source of 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 diffi cult to reverse and To find out more, visit smahcp.co.uk the introduction of partial bottle feeding may reduce breast milk supply. The fi nancial benefi ts of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional.
11/04/2012 16:37 Feature
Building community by supporting mothers: new approaches to perinatal care Health visitor Katherine Evans shares her experiences of working directly with some of England’s most vulnerable families tackling perinatal depression
Katherine Evans RGN BSc(Hons) PGDip Health Visitor, Trainee Specialist Practitioner Teacher Homerton University Hospital NHS Foundation Trust
s a qualified nurse of nearly 30 years – the last 11 of which have been spent as Aa health visitor – I am all-too familiar with the damage perinatal depression can cause. Effective multi-agency working is paramount, and while much has been made of partnership working between the various arms of the statutory services, co-operation with community- based organisations outside the sphere of health receives less attention. In my experience, based on my time working with some of the most vulnerable families in the London Borough of Hackney, appropriate and effective collaboration between community-based organisations and primary care services can lead to lasting and positive outcomes for service users.
Identifying perinatal depression Unfortunately, there are few reliable markers for gauging susceptibility to perinatal depression. Although high levels of social deprivation, young parental age and a history of mental illness have been identified as potential indicators, efforts to prevent depression altogether have proved largely unsuccessful. The most successful strategy for combating perinatal depression is early identification, early intervention and continual support throughout the pregnancy and after birth. As health visitors we look to midwives to take the lead on antenatal care but it’s also about
36 | Community Practitioner September 2012 Volume 85 Number 9 Feature
getting to know the mother so that when the Lottery Fund and Monument Trust to extend children’s services. Since then, Family Action baby is born there is a supportive relationship the project to four locations across England, has helped her apply for a grant for her twins, in place. However, the problem is that, for one of which was in Hackney (Lederer, 2009). relocate to a flat with a working lift and even some mothers at risk of mild-to-moderate If a mother is identified as being at risk of helped her to manage her finances. Now when depression, the level of support they receive developing depression and it is thought they she comes into my clinic there is a happy, smiling can be insufficient. Their depression may stem could benefit from additional support, they can woman, completely changed from the woman I from factors practitioners do not have the time be referred to the Perinatal Support Project in referred, and she tells me that this is due to the or capacity to address. Hackney. Saddaf would then arrange a joint support she received from her befriender through visit where they would discuss the intentions Family Action’s Perinatal Support Service. She Isolation of the project, the services on offer and any has now gone back to training to be a nurse. For some depressed mothers, isolation is a huge questions they may have. Based on this visit and any recommendations from the referrer, factor and there are often barriers they must Collaborative working overcome before their condition can improve. Saddaf would pair the mother with one of her We are fortunate in Hackney to have a fantastic Struggling to find the time to do the shopping, 24 volunteer befrienders who would visit her at perinatal mental health team, including a the school run, or even something as simple home at least once a week both during pregnancy specialist health visitor supporting clients with as contending with seven flights of stairs can and up to one year after the birth of the child. a range of mental health issues. Last year, we contribute to a mother’s sense of isolation and, were selected by the DH as an early implementer in turn, her depression. These women are at the Befrienders greatest risk of becoming severely depressed and Befrienders are women who have submitted to site for the Health Visitor Implementation despite our best efforts to identify and support a Criminal Records Bureau check and a two- Plan. As well as workforce expansion, building them, the nature of community health care month training programme, which covers issues community capacity is one of the plan’s core aims means we do not have sufficient time to do so. pertaining to perinatal depression, the mother– and the clearest way health visitors can begin to Initiatives such as the Family Nurse Partnership child relationship and relevant safeguarding deliver this is by working with organisations, like and the Health Visitor Implementation Plan issues. They are personally interviewed by the Family Action, with proven community-based have no doubt helped to increase the level of project co-ordinator and regularly supervised programmes already in place. support vulnerable parents receive (Department throughout the programme, feeding back to The real value of programmes like this is that of Health (DH), 2011). However, there appears them after each visit. Family Action call them they support the work already being carried out to be a gap in provision for these mothers with ‘befrienders’ because their role is to provide the by community healthcare professionals. It’s great mild-to-moderate mental health needs. ongoing emotional and practical support that to know there are projects that can support the these mothers may otherwise be without. This work being done to help women break the cycle Perinatal Support Project can be anything from helping them to do the of depression. Community-based organisations I first heard about Family Action through the shopping, taking the time to have a chat over a add value to the work of health visitors because charity’s work with service users suffering cup of tea or perhaps giving them that extra bit depressed mothers can never receive too much from mental illness, but it wasn’t until I of confidence as a mother. support; and any programme helping them attended a children’s centre multi-agency The programme helps vulnerable mothers to have happier, healthier children should be team (MAT) meeting in Hackney two years access other universal services, such as embraced and supported by healthcare services. ago that I started to work with them. At this children’s centres or play groups, so they can particular meeting, Saddaf Aslam, a Family interact with other mothers, reduce isolation Action Project Co-ordinator, came to talk and build their own support networks. References Department of Health. (DH) Health Visitor Implementation about a pilot scheme they had completed in Last spring I referred a woman named Stella Plan: A Call to Action. London: DH. Southwark, south London. She explained how to the project when she became isolated after Lederer J. Perinatal Support Project Evaluation Report. their Perinatal Support Project had supported the birth of her twin boys. She was forced 2009. 46 socially isolated women identified by to leave her home in west London after the partner agencies as being vulnerable to relationship with her ex-husband broke down Family Action has been a provider of services depression during pregnancy; specifically, and move in with a friend in Hackney. Now a to disadvantaged and socially isolated with the aim of promoting healthy attachment full-time mother to three children under the families since 1869. The charity works with between the mother and baby by supporting age of two and living on the fourth floor with more than 45 000 vulnerable families and the mother. no working lift, Stella became literally unable children a year by providing practical, After an independent evaluation returned to leave the flat and increasingly isolated. emotional and financial support through some very encouraging results, including Saddaf paired Stella with a befriender named more than 100 community-based services dramatic reductions in anxiety, depression and Florence who helped her to get the children out across England. For more information about a universal increase in mother-baby bonding, of the house and do the shopping, and gave her its services, including Perinatal Support they secured extra funding from the Big the confidence she needed to seek out her local Services, visit: www.family-action.org.uk
September 2012 Volume 85 Number 9 Community Practitioner | 37 FEATURE
FNP in the USA
As a student health visitor, Kate Jones was required to arrange practice time with an alternative service. Here she describes her experiences with the Nurse-Family Partnership in the US
Arranging a placement a teenage mother was able to verbalise how Kate Jones During the first month of the health visitor strong and independent she felt – and observed Student Health Visitor, Sheffield course I began liaising with a number of wonderful attachments between most of the different professionals involved with the mothers and their children. s a mental health nurse I have always NFP in America; I requested to spend time The time I spent with the FNP not only valued working closely with vulnerable with any willing NFP team to see how the strengthened my desire to adopt the principles Apeople, forming and maintaining American programme has developed since of the model within my own practice, effective therapeutic relationships, and implementation over 30 years ago and witness but also allowed me to dispel some myths enabling them to identify their own strengths first hand the differences in healthcare services surrounding this relatively new service; mainly and abilities to overcome difficult situations. between the USA and the UK. that the role of a family nurse is idealised and The skills I am developing through my health By the halfway point of the health visitor undemanding. Yes, a family nurse should not visitor training, providing holistic care to course I had been directed to a contact based hold a caseload of more than 25 clients, but families and promoting strong attachments to with the NFP of Philadelphia, Pennsylvania, each and every client has significant needs. their children through adopting a public health and was in the process of fine-tuning the The work carried out by the family nurses is in approach, is also fast becoming my passion. details of a proposed week’s placement with depth and strenuous, the level of commitment The model of care offered to mothers them. Six weeks later my flights were booked. and patience required to become a family working with the Family Nurse Partnership I then began to look for a placement with a nurse should not go unrecognised. (FNP) merges these proficiencies; the FNP UK FNP to fully appreciate the differences in I took the information I had gained from works with vulnerable, teenage first-time how the FNP is employed here and observe the FNP across the pond to Philadelphia, a mothers to support them to parent effectively the contrasts between a well established city of six million people in the north east using a strength-based approach. programme (NFP) in comparison to a of the country, where I was welcomed with relatively new programme (FNP). I looked open arms by a fantastic team of nurses. I was FNP model to the FNP based within my practice area very kindly accommodated in the home of To fully embrace alternative practice and glean of Sheffield, and was warmly welcomed to the Philadelphia NFP administrator. Naively, as much information on the FNP as possible I observe their practice before my trip abroad. I had expected health care in America to be looked to where the model of care originated. the example other countries should aspire to I found a wealth of literature on the FNP UK practice week follow; and for those citizens who can afford home visiting programme devised by Professor During my practice week with the Sheffield a good level of insurance I am sure that this David Olds at the University of Colorado in FNP I observed home visits carried out by the is the case. However, for the wider population the USA. The research Professor Olds carried extremely experienced and compassionate who cannot afford health insurance, I was out to evaluate and prove the worth of the family nurses; I was able to shadow a variety of sadly mistaken. programme showed a dramatic improvement visits within the NFP, including antenatal visits; in such things as the number of reported visits to mothers with newborns; and visits FNP vs NFP cases of child abuse and neglect; the number to those nearing the end of their time with The US NFP offers a programme of care to of mothers who smoked during pregnancy; the FNP whose children were approaching first-time, low-income mothers. Unlike the and the number of times a child required two years of age. I was able to fully appreciate FNP nurses, who work with first-time teenage hospitalisation for injuries or ingestions during the level of support these nurses provided to mothers, the US programme does not have the first year of life. their clients – particularly during a visit where an age criteria. When I discussed this with the
38 | Community Practitioner September 2012 Volume 85 Number 9 FEATURE
NFP nurses the nurses were interested in what delivery; or the health and development of manage risk or seek information on unknown was offered to first-time mothers aged 20 and mother and baby afterwards. clients. There was some surprise among above in the UK. the NFP nurses I spoke to (many of whom Looks of disbelief followed as I explained Job security and benefits commenced a family nurse role straight from how every mother has access to the health In the UK, the topics covered during each graduation) that UK FNP nurses are required visiting service, regardless of age, income, home visit are identical; however, due to the to have substantial experience of home visiting geographical area or number of children. fact that the US have used these materials for before working as a family nurse. The NFP nurses spoke about how if a new much longer, and that there are very limited I was astonished at how few benefits the mother in the US is not recruited into a other services available to mothers, agenda nurses are entitled to in the US. Maternity programme of care such as the NFP, they have matching is very common. For the majority of leave is unpaid and, unless a company adopts no involvement with a home visiting service home visits the NFP nurses help their clients the principles of a protective scheme that at all. Many mothers can deliver a baby in with issues such as housing and employment. allows up to 12 weeks per year of unpaid leave hospital and be discharged home with no At a team meeting I attended, the NFP nurses for a nurse, most employers would terminate follow-up; and without any assessment of the discussed devising policies that would help the contract of an employee who became home environment or family situation before them to manage certain situations. This pregnant. stemmed from a number of high-risk incidents that the nurses had been involved with, Conclusions including cross fire from gang shooting. From this experience I take with me wonderful Referrals to the NFP come from many memories, new friendships with a group of sources. Self-referrals are facilitated by nurses amazing clinicians who I will keep in touch THE NFP NURSES FACE VERY leaving business cards and leaflets in public with from Philadelphia and, primarily, a REAL DANGERS EVERY SINGLE places, such as hairdressers and teenage heightened respect for the NHS. DAY OF THEIR WORKING hangouts. In most cases, no information Not only do I feel very privileged to work LIVES, AND HAVE NO OFFICIAL about the mothers or their families is passed for the NHS, but I also feel truly thankful GUIDANCE ON HOW TO on to the NFP before they start home visits. to live in the UK and have access to high- MANAGE RISK Consequently, these nurses face very real quality, universal programmes of care that dangers every single day of their working are delivered by such kind, qualified and lives, and have no official guidance on how to experienced professionals.
September 2012 Volume 85 Number 9 Community Practitioner | 39 Let’s help children cope better with itchy skin
Hi! I’m Qool Vince, but my friends call me
Like you, I do everything I can to help children with sore and itchy skin. From a gentle wash to an intensive ointment, my range of cleansers and moisturisers provides a course of total emollient therapy – morning, noon and night.
I’ve also put together a range of materials, including leafl ets, posters, stickers, colouring books and coloured crayons to help children get involved in their treatment and help parents and carers with compliance. They’re also a fun way to engage with children in your clinic.
PARENTS and CARERS
ter How to use this pos Your child has been prescribed QV emollients. Keeping a record of when your child uses emollients is a great way to reinforce good discipline and get them into a regular skincare routine. This QV day-by-day poster can help you keep a record of eveything you’re doing to look after your ter child’s skin. Encourage them to put a sticker on each time they apply a pos QV cleanser or emollient and fi ll up the chart over the 4 weeks of your This to: child’s treatment plan. Feel the belongs How much should you use? Unlike steroid creams, your child can use difference QV whenever they want. So you should keep some to hand and put it on whenever their ...... skin feels dry or sore. It’s recommended that under-12s apply QV at least twice a day – with morning and evening – during their 4-week treatment plan. The NHS National (InstituteNICE) for Health and Clinical Excellence recommend that children use between 250g and 500g a week – that’s up to 1 tub of QV Cream. Always read the label and use only as prescribed. CHILDREN
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Week 1 Week Week 2 Week How Qool Vince
Week 3 Week stopped his skin
feeling so itchy Week 4 Week
Hi! I’m Qool Vince, but you can call me . Grab a crayon and colour me in. g I’m having a ba colourin th with my favouri book Can you help colour me in? te duck. I’m using some lo tion to soothe my itchy skin. Why not use a crayon to colour me in?
To get your free pack, or for more information, call Crawford Healthcare on 01565 654920 or email [email protected] You can also get lots of useful information and download leafl ets or pictures to colour in at www.qvskincare.co.uk
Distributed in the UK by Crawford Healthcare Ltd www.crawfordhealthcare.com © Crawford Healthcare Ltd 2012
11343 20 QV Ad A4 CP Journal.indd 1 02/08/2012 11:49 Feature
Focus on National Eczema Week 2012: recognising and managing childhood eczema
Margaret Cox National Eczema Week Chief Executive, National Eczema Society Julie Van Onselen For National Eczema Week 2012 (15 to 23 September), the National Eczema Society (NES) is launching a new website (www.eczema.org). Healthcare professionals who Independent Dermatology Nurse, register have immediate access to a wealth of information and will receive regular updates National Eczema Society on new NES publications, the latest research and current thinking. The NES provides people with eczema and healthcare professionals with independent topic eczema is a common and practical advice about treating and managing eczema. childhood skin condition that The NES is also launching a new version of its patient information booklet Childhood Aaffects up to 20% of UK children Atopic Eczema: Frequently asked questions and has 40 free copies to give to healthcare aged three to 11 years (Schofield et al, 2009). professionals. Call 0207 561 8230 or email [email protected] to order. Generally, atopic eczema first presents in the An eczema patient helpline is open Monday to Friday, 8am–8pm on 0800 089 1122 infant or young child; approximately 60% and is the first point of contact for anyone affected by eczema. It provides support and of infants develop atopic eczema in the first guidance on eczema management and treatment. six months of life. Having a baby or child with atopic eczema can cause great concern as it is usually a long-term condition. The against their cots to try and relieve the (NICE, 2007). Parents should be offered tendency to have atopic eczema is inherited; ‘itch’. In children, atopic eczema often information on how to recognise and along with other atopic conditions, such as affects the flexures (with the exception of manage flares. asthma and hay fever. children from African, Afro-Caribbean and There are many potential and different Community practitioners will be involved Asian descent, who have a reverse flexural trigger factors in atopic eczema. Exposure in caring and supporting infants and pattern), such as the backs of knees or to one or more triggers will exacerbate children with atopic eczema and their insides of elbows. Constant scratching will eczema in infants and children. Trigger families. Health visitors have a key role split the skin, causing it to weep, bleed and factors often depend on the individual and to play in recognising the development of become infected. Itching is an unbearable some common ones are: atopic eczema in infants and giving correct symptom of atopic eczema, which can lead l Soap advice on eczema management in the to sleep loss, frustration and stress for the l Overheating early years. whole family. l Skin infection (bacterial and viral) l House dust mites and their droppings Diagnostic criteria Management l Animal dander (fur, hair, saliva) The terms ‘eczema’ and ‘dermatitis’ are Community practitioners can provide l Pollens often used interchangeably. The National advice, education and support for parents l Moulds Institute for Health and Clinical Excellence and carers on atopic eczema, including l Diet (under two years). (NICE) atopic eczema guidelines when and how to use treatment. There is for children under 12 years old are no cure, so eczema management focuses Emollients are an essential treatment for extremely comprehensive and provide an on avoiding triggers, maintaining well atopic eczema because they restore the skin evidence-based, practical approach to the moisturised skin (to promote a healthy skin barrier by providing a surface film of lipids, management of atopic eczema (NICE, barrier) and keeping flares under control. preventing entry of environmental agents/ 2007). The guidance includes diagnostic NICE advocates a stepped approach to triggers and trapping water within the criteria for atopic eczema, which is based management, with the treatment tailored stratum corneum and reducing epidermal on skin signs and symptoms and personal to the severity of the eczema. Emollients water loss (Cork, 1997). An emollient therapy and family history. should form the basis of management package for infants/children includes topical Atopic eczema in infants often starts as and should be used even when eczema is ‘leave-on’ emollient/s (creams or ointments) generalised dry skin, with inflamed and clear. Treatments should be stepped up and emollient wash products. weepy areas on the face. Itch is a major and down when the eczema is flaring, and Leave-on emollients (moisturisers) should feature, babies will often rub their faces prescribed according to the NICE guidance be applied after washing, before bedtime
September 2012 Volume 85 Number 9 Community Practitioner | 41 Feature
and regularly during the day to keep skin second-line treatments are considered. only if used incorrectly or excessively. The well hydrated. They should be smoothed Topical corticosteroids are effective in increased risk is also dependent on the into skin, not rubbed, in a stroking reducing symptoms of inflammation. In the potency of topical corticosteroid, degree downward motion following the direction UK topical corticosteroids are categorised of penetration (body site and occlusion), of hair growth. Children require at least in the UK in four potency groups: mild, extent of area treated and daily volume. 250g per week to be prescribed and should moderate, potent and very potent. be provided with a choice of products. Following the NICE stepped approach, the references Topical treatment should be applied to well most effective preparation should be chosen Cork MJ. (1997) The importance of skin barrier function. Journal of Dermatological Treatment 8: S7. moisturised skin (leaving a gap between for the age of the child, severity of eczema Ersser S, Maguire S, Nicol N et al. (2007) Best applications) (Ersser at al, 2007). and dilution avoided. practice in emollient therapy: a statement for Topical corticosteroids should be first- For example, a mild topical corticosteroid healthcare professionals. Dermatology Nursing 6: line treatment for acute flares. Recognising should be used for treating infants under S2–19. and treating infection (bacterial, fungal one year and facial eczema in children; Schofield JK, Grindlay D, Williams HC. (2009) and viral) is very important, especially if however, as a child gets older a moderate Skin Conditions in the UK: A Health Care Needs Assessment. Nottingham: Centre of Evidence Based the eczema is weepy and inflammation is or potent topical steroid may be required Dermatology, University of Nottingham. not responsive to topical corticosteroids. for short-term treatment on the torso and National Institute for Health and Clinical When atopic eczema is more severe and not limbs. Parents are frequently concerned Excellence (NICE). CG 57 Atopic eczema in children: management of atopic eczema in children from birth up controlled by topical corticosteroids, topical about the potential risks from side-effects to the age of 12 years – Full Guidance. Available from: calcineurin inhibitors (TCIs) and other of topical corticosteroids, which occur www.nice.org.uk/CG57 [Accessed August 2012].
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42 | Community Practitioner September 2012 Volume 85 Number 9 employment
Independent Pay Review Body? Maybe next year …
is still considering how to react to its report the PRB have to make it work. Regional pay James Lazou on market facing pay in the NHS. We should will be no different. Unite Research Officer be under few illusions as to the outcome of this report. Pay cuts George Osborne, Chancellor of the The Department of Health in England his month I had hoped to write Exchequer, has already announced that has made it very clear that it sees scope to about the Pay Review Body (PRB) public sector pay increases will be capped introduce new High Cost Area Supplements Tremit; but just like many things at ‘up to 1%’ for the next two years and the (HCAS) for various areas of the country in the NHS at the moment, nothing is government seems to be intent on driving – primarily, urban centres like Bristol and predictable. through their regional pay policy with or Sheffield. Unite has never been opposed to Try telephoning the Department of Health without reasoned arguments or evidence of properly justified and evidenced HCAS – helpline, for example – I’ve been told twice in its benefits. take London weighting, for example. But recent weeks that they haven’t got a clue how It appears then, that the government the catch with the government’s plans is it the new English NHS is working. ‘Nobody tells will continue to disregard the PRB as is suggesting that to fund these increases, me anything!’ complained the exasperated an independent and objective body that other areas of the NHS will have to face pay adviser on the end of the phone. recommends NHS pay. They want it freezes or even pay cuts. Sources tell us that the PRB will be given to be the other way around, where the This is not acceptable. Supplements should its remit later this year as the government government makes an announcement and be just that – supplementary. They should
44 | Community Practitioner September 2012 Volume 85 Number 9 employment
not be delivered through a policy of beggar- third of their income since the coalition came In these times of ‘more circuses and less thy-neighbour. When we already know that into power. bread’ the NHS, so proudly highlighted in the the pot is only 1%, this doesn’t leave the PRB Olympic opening ceremony, is struggling with much leeway to make recommendations. Battle lines to cope. It looks like they are being used as a Trojan Some trusts are, as usual, taking these attacks It faces the twin evils of £20billion worth of Horse to attack NHS pay and terms … hardly more seriously than others, with the south efficiency savings – described by the health necessary given the widespread assault already west of England leading the way. Nineteen committee as ‘salami slicing’ cuts from NHS going on. trusts have now formed a ‘cartel’ to push services – and the largest reorganisation in Right across the country hard-working through draconian changes to terms and the NHS’s six-decade history. The latter is health professionals are reporting vicious conditions, completely outside of Agenda leading to privatisation at a pace not seen attacks on their terms and conditions. for Change and NHS Staff Council rules. So before, with the likes of Virgin Care and These include massive reductions in on much for partnership working, then. Serco circling like vultures. call payments; removal of recruitment and Unite and other staff-side unions have been All of this is a false economy. Cutting retention premia; major changes to pensions; firm on this issue and battle lines are being services will lead to worse health outcomes, making people pay more, work longer and drawn, but the south-west cartel is driving and reduced access to health care, which get less. forward with its plans. This is an enormous can only lead to less proactive prevention They are also dealing with two previous challenge to the industrial relations system and treatment. At the same time, private years of pay freezes, proposed introduction that has served the NHS so well over the companies will be taking money away from of performance-related pay, down-banding last decade. the front line, by creaming off profits from and deskilling of roles, reductions in sickness While it is clear that there are ringleaders our public health service. The outcome will benefits, proposed cuts to annual leave and ideologues driving this in some of the be higher costs for a worse service. Who is entitlement, extensions of the working day, trusts, there are also others meekly following picking up the bill for all this? Patients, the no pay enhancements on public holidays like behind. Most of these trusts are citing public and hard working NHS staff, the royal wedding and the Queen’s Jubilee, worries about costs and, for that, the blame of course. and attacks on union facility time. Some Unite has to be put squarely back onto the lap of If you are not angry now, then you are not members are reporting pay cuts of up to a the government. paying attention.
September 2012 Volume 85 Number 9 Community Practitioner | 45 CLASSIFIED
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