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OFFICE OF THE NURSING

AND MIDWIFERY

SERVICES DIRECTOR.

Report on Current

Public Health

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OFFICE OF THE NURSING AND MIDWIFERY

SERVICES DIRECTOR.

Current Public Health Nursing Services

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Foreword

On behalf of the Office of the Nursing and Midwifery Services, I am pleased to present the Report on the Current Public Health Nursing Services nationally. The changing and dynamic profile of service need in Primary Care as well as the imperative to reconfigure in order to appropriately respond to client need underpins the rationale to complete the review. The work was undertaken in the context of the reconfiguration of services and describes the delivery of nursing care to identified client groups in the community.

The HSE commitment to the reconfiguration of services to support integration and enhanced responsiveness to client needs is articulated in key policy documents. The shift of the focus of care from secondary to primary care is being actively progressed and is supported by the continued development of primary care teams in tandem with the implementation of the transformation programme, with the emphasis on care in the community and integration of services (HSE National Service Plan 2012 & Transformation Programme 2006). In the context of care and reform and the current drive toward an Integrated Health System (HSE 2008) treating and delivering care to patients in more appropriate settings is an integral part of the role of the Public Health Nurse (PHN) and Registered General Nurse (RGN) working within the primary care team.

The Report describes the current delivery of Public Health Nursing Services nationally utilising the findings from the Survey on the Review of Public Health Nursing Services conducted in November 2011 and addition information as required. The Report on Current Public Health Nursing Services aims to identify the strengths and the challenges faced by the Public Health Nursing Services in the context of Primary Care. Thereafter, the Reports of the findings from the Survey are presented per HSE area, in the context of the provision of clinical care and fulfilment of statutory obligations.

I wish to acknowledge the work and commitment of the members of the Expert Advisory Group who supervised this project. Sincere thanks are extended to Ms Patricia O’Dwyer, Project Officer for her innovation and professional commitment to this initiative. The Office of the Nursing and Midwifery Services wishes to acknowledge the committed participation of all the Public Health Nursing Services staff who contributed to the review. Finally, I wish to particularly thank Dr. Joe Clarke who chaired this group.

_____________________________________ Michael Shannon

Nursing & Midwifery Services Director,

Assistant National Director, Clinical Strategy & Programmes Directorate HSE & Adjunct Professor UCD School of Nursing and Midwifery and Health Systems

This report can be cited as follows:

Office of the Nursing and Midwifery Services Director (2012) Report on Current Public Health Nursing Services; Report prepared by Patricia O’Dwyer, Project Officer to the Expert Advisory Group on Public Health Nursing Services

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Table of Contents

Page

Foreword………2

Context………4

Section 1 Clinical Governance………6

Section 2 Demography of the Public Health Nursing Services………9

Section 3 Child and Family Health Service………..14

Section 4 School Health Service………18

Section 5 Older Persons Health Service………20

Section 6 Disability Service (Children Young People and Adults)………..22

Section 7 Palliative Care / End of Life Care Nursing Service (Adults and Children)……….23

Section 8 Chronic Disease Management………...24

Section 9 Health Promotion and Community Development………..26

Section 10 Nurse/ Midwife led Clinic Service………28

Section 11 Education and Training………29

Appendix Expert Advisory Group Members ……….30

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Report on Current Public Health Nursing Services

Context

In September 2011, the Office of the Nursing and Midwifery Services Director in conjunction with the Directors of Public Health Nursing Services set up an Expert Advisory Group (EAG) for the purposes of conducting a comprehensive Review of Public Health Nursing Services1 in the context of primary care. The need to conduct the Review was in response to the current draft document on the Management of Primary Care Teams (Management of Primary Care Teams Draft HSE dated 29/3/2011). The immediate task for the group once convened, and following agreement on the Terms of Reference for the Review, was to establish ‘what is the current state of the Public Health Nursing Services?’ The EAG mindful of the fact that, the Public Health Nursing Services have not been the subject of a formal review for some considerable time, set about the process of gathering as much information as possible about the service within the tight timeframe of, approximately, 4 months. The EAG requested that the Public Health Nursing Services would be reviewed from the perspective of its internal stakeholders, in the first instance, before the review was extended to external stakeholders.

In an effort to answer this question “what is the current state of the Public Health Nursing Services?” Three principal methods of data collection were used to gather the information required to answer the question posed.

1.

A national Review of current PHN services was carried out.

A booklet style survey was developed following consultation with members of the EAG. The content of the survey was informed by national HSE policy. The draft survey was amended in light of feedback from the EAG. A postal survey was considered to be the most appropriate means of data collection to ensure the best possible response. In November 2011, the Review survey was sent to all 31 Directors of Public Health Nursing Services (DPHN) to be completed in consultation with her staff. In the absence of the DPHN the survey was to be completed by the Acting Director of Public Health Nursing Services in consultation with staff. Where the post of the Director of Public Health Nursing Services is vacant the survey was completed by an Assistant Director of Public Health Nursing in consultation with staff. The Review survey received a very good response with 26 surveys returned- 84% of the total valid sample (n=31).

2.

A questionnaire to gather the views of the Directors and Assistant Directors of Public Health Nursing on their respective roles.

A booklet style questionnaire was also developed following consultation with members of the EAG to gather the views ofDirectors and Assistant Directors of Public Health Nursing on their respective roles. The draft questionnaire was amended in light of feedback from the EAG. Again, a postal survey was considered to be the most appropriate means of data collection to ensure the best possible response. The questionnaire for the DPHN yielded a good response with 22 questionnaires returned - 71% of the total sample (n=31). The number of Assistant Directors of Public Health Nursing questionnaires returned was 88 this represents a 49% yield based on the 179 ADPHNs in post in October 2011.2

1

For the purposes of the review, the term Public Health Nursing Services is to include nursing services provided both by Public Health Nurses and by all registered nurses working in the community.

2

Two ADPHN questionnaires were completed by a group of ADPHNs rather than individually. The group questionnaires were each counted as 1 questionnaire.

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3.

Regional consultation meetings

Regional consultation meetings was the 3rd methodology employed to gather the views of all grades of nursing staff working in the Public Health Nursing Services. The 8 consultation meetings and 1 teleconference were planned and facilitated with the input from the EAG communications subgroup. In total there was 50 hours of consultation, over a 3 week time period, attended by in excess of 300 Public Health Nursing Services staff. The consultation meetings were structured around set topics. The nursing literature on Primary Care in this jurisdiction and internationally was instructive in compiling the consultation topics. This entire process enabled the reviewer (project officer) to study the Public Health Nursing Services from different viewpoints. This Report is a product of these three methodologies. It focuses, in particular, on the emerging findings from the Review survey and is supplemented where relevant with qualitative data from the consultation meetings.

The Report is organised into the following sections and, for the most part, follows the lay out in the Review survey.

Section 1 Clinical Governance

Section 2 Demography of the Public Health Nursing Services. Section 3 Child and Family Health Service.

Section 4 School Health Service Section 5 Older Persons Health Service

Section 6 Disability Service (Children Young People and Adults ) Section 7 Chronic Disease Management

Section 8 Palliative Care / End of Life Care (Adult and Children) Section 9 Health Promotion and Community Development. Section 10 Nurse/ Midwife led Clinic Service.

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Section 1: Clinical Governance

“The introductory section of this Report on Current Public Health Nursing Services is Clinical Governance. It

became clear, as the findings emerged, that most of the data revolved around a common denominator; Clinical Governance. Thus, Clinical Governance self-selected itself as the opening section around which all the other sections in the report orbit”

Health care service providers are responsible and accountable for delivering safe, high quality and cost- effective care that achieves the best health outcomes for the people to whom they provide the service.3 To that end, the Health Service Executive (HSE) has embraced the concept of clinical governance. Clinical governance means corporate accountability for clinical performance built on a model of CEO/ GM working in partnership with Clinical Directors, Directors of Nursing and allied health professional leads. Clinical governance is about people receiving the right care, at the right time by the right person in an open, safe and caring environment.4 Ultimately, clinical governance creates an environment that realises improved clinical outcomes for patients/ clients/ service users. From a Public Health Nursing Services perspective, this environment is created by having and sharing a common understanding of a vision for the service. The Commission on Patient Safety and Quality Assurance agreed that the vision for a health service governance structure should be based around “knowledgeable patients receiving safe and effective care from skilled

practitioners in appropriate environments with assessed outcomes”.

To gain an insight into clinical governance structure development, in the Public Health Nursing Services, the survey covered 4 broad themes drawn from the National Standards for Safer Better Healthcare.5

1. Person- centred care. 2. Safe care.

3. Effective care. 4. Staff development

1. Person-centred care happens when service users’ needs and preferences are at the centre of service design, planning and delivery

Based on the information in 26 surveys returned,

96% of the 26 respondents reported that their service has a Philosophy of Nursing Care statement. 23% of respondents reported that their service has a patient charter.

All 26 respondents reported that their service users are involved in the development and implementation of their own care plans in partnership with the nurse.

31% reported that their service has self-assessment tools to support client’s self-management of their condition.

3

HSE 2010 Achieving Excellence in Clinical Governance Towards a Culture of Accountability.

4

HSE 2011 Draft .National Clinical Programmes Clinical Governance Checklist 11th October.

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2. Safe care happens when service providers protect the safety, health and welfare of service users. Based on the information in the 26 surveys returned.

All respondents reported having a system to monitor, analyse and respond to patient safety incidents. 84% reported that their service has a guideline on record retention.

81% reported having a guideline on record keeping and report writing. 73% reported carrying out an annual audit of service user records.

31% reported having a guideline on obtaining written informed consent from service users for examination and treatment in health care.

23% of respondents reported that their service has a policy on vacant caseload management.

A further question explored whether there is a governance structure in place for the employment of agency staff providing domiciliary paediatric care in the community?

Of the respondents who have agency staff providing domiciliary paediatric care, 65% expressed concerns about the lack of formal governance structures for the employment, monitoring and supervision of agency staff for this care group.

3. Effective care happens when service users assessed needs are based on best available evidence and information.

Based on the information in the 26 survey returned.

81% reported that their service had a structure in place for developing, auditing, and reviewing clinical policies procedures protocols and guidelines.

81% reported up to date/ current guidelines to support the provision of a range of clinical care interventions for adults.

77% reported up to date/ current guidelines and policies to support the provision of child health screening.

63% reported that they had guidelines on domiciliary visiting.

57% reported having guidelines to prioritise the clients to whom the PHN provides a service. 54% reported that they had guidelines for the discharge of clients from their service.

42% indicated that they had guidelines on inactive file management.

The emerging National Clinical Care Programmes prompted a question about guidelines for the Clinical Care and Management of Chronic Disease in primary care.

Based on the information in the 26 surveys returned.

1 (one) respondent reported having a guideline to support the Clinical Care and Management of Stroke patients.

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4. Staff development: High quality safe care happens when service providers recruit staff, maintain, and support the competencies necessary to provide the care that is required.

Based on the information in the 26 surveys returned.

77% reported that their service has a system of professional development for identifying professional development needs of staff.

73% reported having an orientation package for undergraduate student nurses. 73% reported that clinical supervision is available to staff in their service. 46% reported having a formal mentoring scheme for new staff members. 31% reported having a staff appraisal system in place.

15% reported that their service has a professional practice development person.

The match between the vision/ values/culture of the Public Health Nursing Service in Primary Care (not clearly articulated at this point) and its clinical governance structures should be as closely aligned as possible. The preliminary findings show that there is work to be done within the 4 themes ofperson- centred care, safe care, effective care and staff development.

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DPHNs Geographic Area Population Size 0 50000 100000 150000 200000 250000 300000 P o p u la ti o n s iz e in 5 0, 00 00 b an d s

Section 2: Demography of the Public Health Nursing Service.

Demographic data on the population sets the context for the planning and delivery of the health service. Preliminary data from Census 2011 shows that the country is continuing to experience strong population growth. The total recorded population on census night (April, 10th 2011) is 4,581,269 persons, an increase of 8.1% from 2006.

Over the years, the Irish health services have been restructured and former Health Board areas have been renamed, as regions and more recently as health areas. Throughout the renaming of the health service areas, the geographic boundaries have essentially remained the same. The geographic population catchment areas described in this Report correspond, to the former Local Health Office (LHO) areas. The survey findings presented here represents the geographic areas of the 26 respondents who completed the survey. The 26 respondents account for 84% of the total valid sample (n=31).

A key component of this section of the report is to provide a demographic profile of the environment within which the Directors of the Public Health Nursing Services (DPHN) strategically and operationally plan for the delivery of all services to meet the health needs of their respective populations. These data are important in describing the parameters of the Public Health Nursing Services. The data allows us to be more specific about the range of services and contexts when discussing the Public Health Nursing Services.

In this survey the ratio of DPHN to population size ranges from 53 000 to 275,000 with a mean average of 137,000.

The Public Health Nursing Service has evolved over the years to meet the demands of a changing society. The DPHN respondents indicated that, in addition to their Children and Families, School Health, Older Persons Services they also have operational and strategic responsibility for, the nursing element, on average of 6 additional services. These services range from Palliative Care to the Preschool Services.

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23% have responsibility for Infection Control

30% of DPHNs have responsibility for Palliative Care Services, 50% have responsibility for the Health Care Assistant Service, 53% have responsibility for Preschool Service,

57% have responsibility for Home Care Packages

68% of respondents have responsibility for Traveller Health in the community.

‘Other’ services were given by 53% of the respondents. The most frequently reported other services included the Home Births Service6, Immunisation Service, Early Intervention Team and Continence Advisory Service.

Figure 2 Percentage of DPHNs with responsibility for services in addition to the core care groups

38% 30% 23% 50% 38% 57% 30% 53% 68% 23% 23% 53% 7% Asyl um See ker/ ... Com mun ity In te... Day Care Ser vice Heal th C are Assi. .. Hom e He lp S erv. .. Hom e Ca re P ac... Palli ativ e Ca re S ... Pre Scho ols S ervi ce Trav elle r Hea lth Infe ction Con trol Reha bilit ation ... Other No answ er g iven 0 -1 0 0 p e rc e n t

Services and Staff Resources

The new direction articulated in the Health Strategy involves moving from a care group model7 to an arrangement based on Primary Care, Primary Care Teams (PCTs), and Health and Social Care Networks (HSCN). In effect, this entails moving from a unidiscipline to a multidiscipline team based way of working. Accordingly, appropriate staff are being reconfigured into (a) PCTs or (b) specialist community based multidisciplinary teams in the HSCN.

Core health professionals (GPs. PHNs RGNs, Physiotherapists and Occupational Therapists) make up a primary care team. The survey of the 26 geographic areas (population 3.4 million) found that at November 2011, there were 268 primary care teams in place of which Public Health Nurses and Registered General Nurses are members.

6

Director of Public Health Nursing Services is required to manage the provision of the Home Births Service which is provided by Self Employed Community Midwives.

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Of the 268 primary care teams reported to be in place 77% (209) of them were reported to be functioning8 with clinical team meetings with GPs in attendance. Team meetings that are held without the GP in attendance were reported at the consultation meetings “to be ineffective”.

A question in the survey explored the frequency of clinical team meetings

85 % of those who responded reported that clinical team meetings were held monthly, 11% reported that meetings were held bimonthly

4% at another time interval.

In the context of PCT development the survey found that:

68% of those who responded reported that they had some team building activities prior to the establishment of a PCT.

58% of those who responded reported that they were involved in some joint planning for PCTs 15% reported no joint planning

4% of the respondents reported that a community needs assessment was carried out prior to the first clinical PCT meeting.

Health and Social Care Networks (HSCNs) comprise a number of PCTs and provide specialist community services such as Mental Health, Child Protection and Disability Intervention Teams. Data compiled from 24 geographic areas (data missing for 2 respondents) shows that there are 47 Health and Social Care Networks (HSCN) in place.

Data compiled for 26 geographic areas shows that the number of health centres, from where Public Health Nurses work, in a geographic area, range from 7 to 58.9 The total number of health centres for the 26 areas is 391.From the consultation meetings, it was evident there are health centres from which Public Health Nurses work that are inadequate10. In addition to the health centres, there are other settings from which public health nurses work. For example, the reception centres that house Asylum Seekers and Refugees.

As part of the reform agenda, community intervention teams and similar rapid response type services were introduced to enable patients with certain conditions to go home early with support from community services. The survey findings show that

42% of those who responded reported that they had a nurse led community intervention team.

A community rehabilitation service provides intensive support with the aim of maximizing the individual’s ability to function in daily life.

8

Health care professionals representing relevant core team members co-operating in a team for the betterment of patients.

9

This must be examined from a clinical governance perspective.

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35%reported that they had access to a community rehabilitation team.

The Twilight Nursing Service is an extension of the Public Health Nursing Service. The service is for those who require nursing care in their own homes.

31% of the respondents indicate that they provide twilight out of hours nursing service.

PHN Staff resources

Respondents were asked to give details of the number of Whole Time Equivalent staff in their service for different nursing grades. Respondents were also asked to give details of the number of Whole Time Equivalent staff vacancies in their service for different nursing grades. It proved difficult to analyse these questions properly as the questions were left blank in some surveys that were returned. The staff grades for which there is reasonably complete data from the 26 respondents, as of the 18th November 2011, is therefore reported here.11

Table 1 Public Health Nursing Staff Resources per Nursing Grade

In Post Appointed Post Vacant Missing Data

Director of Public Health Nursing Services

15 7 4

WTE WTE Vacancies Missing Data

Assistant Director of Public Health Nursing

112.61 38.4 1

Public Health Nurses 1163.01 58.14 2

Registered General Nurses 352.93 72.35 2

Registered Midwives (Non PHNs)

41.97 0 0

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There are important variations in the manner in which the Public Health Nursing Service has developed in recent years. The differences go beyond the “no one size fits all” argument. The implications of the differences in the population footprint, the number of health centres, the number of, and gaps in, services, for which the Director is ultimately responsible and accountable must be understood in terms of an equitable service and benchmarked against the principles of Clinical Governance touched upon briefly in the previous section.

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SECTION 3: CHILD and FAMILY HEALTH SERVICE

The Health Act, 1970 is the principal legislation providing for children’s health services in Ireland. Section 66 on the 1970 Act, devolves this statutory obligation to the Public Health Nursing Service (amongst others) who provides the service to children up to the age of 6 years and to pupils attending national school. The Health Act, 1970 itself does not prescribe the timing and the content of the health examinations; these details are guided by best practice 12 and set out in Best Health for Children Revisited 2005.

Over the past decade, the birth rate, in Ireland, has increased by 27% from 57,854 in 2001 to 73,424 in 2010. There has been a natural increase of 220,800 more births than deaths. These statistics have a particular relevance to those concerned with the planning and delivery of the Public Health Nursing service as the primary postnatal visit to a new family is afforded priority by the PHN service and the HSE. Significantly, the percentage of mothers and new babies who are contacted by a PHN within 48 hours of discharge home from the maternity service is one of a national set of child health performance indicators.

The results from the survey demonstrate that the percentage of new-born babies visited by a PHN within 48 hours of hospital discharge in the 2nd quarter 2011 range from 48.8 % to 100% with a mean of 85.41%. The HSE health stat target for this performance indicator (P.I) is 100%.

Figure 3 Percentage of new-born babies visited by PHN within 48 hours of hospital discharge.

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The recommended health examinations/ assessments are in the immediate postnatal period at 48 hours following discharge from the maternity services, at 3 month, 7- 9months, 18- 24 months, 3¼- 3½ years,

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In the context of child health the HSE also gathers specific data on child development and screening .The percentage of children who receive a 7- 9 month child development health check by 10 months of age is also a metric that is a prioritized by the PHN service and the HSE. The results from the survey demonstrate that the percentage of children who received their 7-9 month Development Health check by 10month of age in the 2nd quarter 2011 range from 55% to 100% with a mean of 85.96. The HSE health stat target for this P.I. is 90%.

The findings also show that the vast majority of 7- 9 month developmental checks are carried out at clinics led by Public Health Nurses.

Figure 4 % of children who received a 7-9 month Child Development Health Check by 10 months of age

A number of respondents emphasised that the unmet targets in child developmental assessments illustrated above, was as a result of clinical caseloads taking priority over child health screening. Respondents provided additional data on the numbers of unmet child health assessments at 3 months, 18- 24 months and 3¼- 3½ years. This was confirmed at the regional consultation meetings. The following direct quote from a PHN about child health screening is representative of the statements of other participants “clinical care is taking precedent to the detriment of child health screening”

The respondents were asked as to whether they provide a 7 day (Monday – Sunday) postnatal service. All 26 respondents answered this question. Seven (27%) of the 26 respondents said that they provide a 7 day postnatal service. Some respondents indicated that while this service was provided they could no longer do so or that the service was being reduced. In these instances mother and baby return to the maternity service for the New-Born Blood Spot test. A small number of DPHNs maintain a 7 day service for New Born Blood Spot Screening. 0 20 40 60 80 100 DPHNs Geographical Areas p e rc e n ta g e o f c h il d re n w h o re c e iv e d e v e lo p m e n ta l h e a lt h c h e ck b y 1 0 m o n th s o f a g e

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Respondents were also asked about the professionals /services to whom the PHN service could make direct referrals. The respondents reported being able to make direct referral’s to a wide range of disciplines, Typically, (as far as children under 16 years are concerned), PHNs can refer directly to other professionals within the Primary Care Team and the Health and Social Care Network with the exception of the Child Mental Health Services, to whom only a small number of respondents (19%) indicated that they could refer directly.

Maternal Health

Reponses to the question about the screening tools used by Public Health Nurses to assess maternal health provides an insight into their clinical practice with this client group. Public Health Nurses incorporate one or more of the following tools, as applicable, into their practice in the postnatal care of women in primary care setting.

Edinburgh Post Natal Depression Scale. Wholley Questions

Maternal Health Questionnaire Wound Assessment

Continence Assessment

Reflective questions around Parental Capacity.

Child Welfare and Protection. Safeguarding, promoting and protecting the health and wellbeing of children is recognised in the health service plan, in this jurisdiction, as a priority. Public Health Nurses’ role in safeguarding and protecting children is provided for in the Child Care Act, 1991, Ministerial Circular 27/66, and in Children’s First- National Guidance for the Protection and Welfare of Children 2011.13 Aside from the questions that asked about child development performance indicators, a further question asked respondent’s directly about the service they provide to children deemed to be ‘at risk’ of neglect and abuse. The qualitative data from the open ended ‘comment’ section of the question gave some insight into Public Health Nursing practice with ‘at risk’ vulnerable families.

All respondents reported that, their service, based on an assessment of need, provide an early intervention service for children and families where there is a concern about their welfare.

The most frequently cited other response to the question was making a referral to the appropriate community support resource and working with the multidisciplinary team.

As previously stated the Health Act, 1970 is the principal legislation providing for children’s health services in Ireland. In practice public health nurses are directly involved in the delivery of health services to children and their families at home in the immediate postnatal period, in health centres by means of child welfare

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clinics and at other settings. There are variations in the provision of the core recommended child health screening service nationwide. The data shows that some respondents’ can provide a timely and more complete child health service while others (it appears) are finding it difficult to deliver the recommended core service in a timely way. During the consultation meetings there were several references to the challenges/obstacles in attending to the health of the preschool population. This data and the additional information provided in the surveys would support the assessment that clinical care predominates at the expense of child health.

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Section 4: School Health Service.

The health and wellbeing of school children is at the centre of many Government documents, initiatives and reports. It receives considerable public and press interest most recently with the launch of the first findings from” Growing up in Ireland” longitudinal study. The HSE provides a school health screening programme and a school immunization programme for children attending primary schools in Ireland.14 The school health screening and immunization programmes are conducted by the Public Health Nursing Service and by Area Medical Officers.15

Each respondent gave details of the number of primary and post primary schools in their geographic catchment areas.

The number of primary schools in a geographic area range from 38 to 243 and post primary schools from 9 to 46. 16

The survey findings reveal the diversity in school health practices across the country in the provision of the national school screening and immunization programmes.

Data compiled from 23 geographic areas shows that 5 areas (22%) have a designated team of school public health nurses and 7 areas (28%) have a designated immunisation team.

The survey data reveals that the vast majority of PHNs have responsibility for all population groups in their geographic areas including the population of primary and post primary school aged children. From September 2010 the HPV vaccination programme was rolled out nationally to all girls in 1st and 2nd year post primary school by the Public Health Nursing Service and Area Medical Officers.

The target cohort was 59, 235 girls and the uptake for the first year of the programme was 81.9% of the target population.17

Respondents did indicate that unmet targets in school health screening in the areas of vision, hearing and growth development monitoring were as a result of the immunisation programme taking priority. Many diseases and premature deaths are preventable. Increased morbidity and mortality is associated with lifestyle health determinants such as smoking, alcohol consumption and obesity.

The evidence of the health promotion activities for the primary and post primary school aged populations is covered in Section 9.

14

The schools immunization programme has been extended to include the HPV vaccine

15 The Health Acts, 1947, 1953 1970 and Amendment Act 1994 define the requirements for the school health service 16

The respondents were not asked about the number of children in each school.

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The regional consultations held with School Nurses highlighted that they would like to spend more time on health promotion activities and reduce the time spent on immunisations and administration.

Given that the health and wellbeing of school going children is at the centre of numerous initiatives, schools nurses are an important group, having the opportunity to influence the health of the school population. Yet, there appears to be a lack of direction/ focus for the School health programme overall. Some areas, a minority, have dedicated school health nurses while others do not. There appears to be an imbalance in the activities undertaken by schools nurses, in that immunisations tend to dominate possibly at the expense of health promotion activities.

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Section 5: Older Persons Health Service.

A key statistic from a health perspective is the number of people over 65 years of age which is projected to more than double over the next 30 years with the greatest proportional increase in the 85+ age group.18 Census 2011 preliminary population results show a 20.2% increase in the over 65 age group between 2002 and 2011.

This demographic transition is of direct relevance to the Public Health Nursing Services, as the primary provider of nursing services to the 65 +age group, who are recognised as the most frequent users of health services

In the survey all 26 DPHN respondents indicated that the PHN is the key worker, managing the complex nursing care needs of older persons.

38% of respondents indicated that the PHN was supported in the key worker role by an RGN and by a PHN co-ordinator for older persons (37%) and by an Advanced Nurse Practitioner in one geographic area.

Questions were asked on the governance of patient caseloads and the process of admitting and discharging patients. (these results are also mentioned in Section 1)

63% reported that they had guidelines on domiciliary visiting.

57% reported having guidelines to prioritise the clients to whom the PHN provides a service. 54% reported that had guidelines for the discharge of clients from their service.

42% indicated that they had guidelines on inactive file management.

The universal character of the PHN service was raised in the survey

42% of respondents reported having a written policy on eligibility to access their service. This was qualified by some respondents who reported that a National Eligibility Policy was being considered/ developed.

Maintaining older persons in their own homes is prominent in health policy.In this regard a Home Care Package Scheme (HCPS) is provided by the HSE, as part of the public health service, to enable people to be cared for in their own homes. The governance of the HCPS was raised in the survey. Respondents were asked specifically about the primary role of the DPHN, ADPHN, PHN, RGN and the Home Help Co-ordinator in the Scheme.

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The DPHN respondents (57%) reported that they are responsible for the overall management of their service involvement in the scheme.

ADPHNs monitor targets, deals with appeals in relation to the scheme, supervises resource allocation in complex cases

PHNs co-ordinates this service as follows she/ he completes a Common Summary Assessment Record (CSAR) and prioritise clients as necessary, follows up on decision made with the home help co-ordinator, communicates with the family, orders the equipment, and refers to the other allied health professionals as needed..

RGNs completes a Common Summary Assessment Record (CSAR) and undertakes reviews Home Help Co-ordinator among other duties assigns a carer to meet the client’s needs.

Respondents were also asked about the professionals /services which the PHN service can make a direct referral to on behalf of older persons. The respondents reported being able to make direct referral’s to a wide range of disciplines and services. PHNs can directly refer older persons to all other professionals within the Primary Care Team and to some specialists’ services in the Health and Social Care Network. All respondents reported that they can refer directly to the Social Worker for Elder Abuse while 48% indicated that they can refer to the Community Mental Health Nurse.

Clinical nursing care is a constant feature of the Review of Public Health Nursing Services 2011. In the context of the care of older persons and clinical care more generally an understanding of patient acuity/ dependency in a Public Health Nurses’ caseload is required. In other words, some means of making sense of a patient’s nursing needs in an objective a way as possible. There is evidence from a regional consultation meeting that a dependency system that allows patient dependency to be measured (low, medium, high, maximum) has been introduced.19The Population Health Information Tool introduced into the Dublin North Central Public Health Nursing Service also ranks patients according to their level of dependency or their need for nursing care.20 There is evidence that dependency systems support equitable caseload allocation.

19

Pye.V. Director of Public Health Nursing Longford and Westmeath recently published an article on the introduction and use of ‘dependency frameworks’ See . Framework for Success Nursing in the Community Winter 2011

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Section 6: Disability Service (Children Young People and Adult).

The obligation to provide health services to people with disabilities rests with the State.

Children and Young People In 2009, there were 8,043 children less than 18 years registered with having a physical and or a sensory disability. The differences by geographic region show that 9.5% of registered children reside in Dublin North East, 30.1% resided in Dublin Mid Leinster, 30% in the South and the remaining 30.4% resided in the West.21 These statistics are of direct relevance to the PHN service

In this survey the respondents were asked whether the care of children and young people with disabilities is actively coordinated by the Primary Care Team;

16% of respondents reported that the PCT co-ordinated the care 84% of respondents reported that the PCT was not involved.

A further question on nursing care indicated that the domiciliary nursing care requirements for children and young people with disabilities are provided by the PHN service.

There is a legislative provision for an assessment of health and education needs arising out of a disability. Respondents were asked to provide information on who undertakes the health Assessment of Need for children per the Disability Act, 2005. The findings show that the nursing need element, of the assessment, is undertaken by Public Health Nurses and Registered General Nurses.

Adults: Since 2001, people in receipt of disability day services have increased (15%) while the number of full time residents has decreased (1.7%).22 Many of these services are provided by non-profit organisations under arrangements with the HSE. In this survey, the respondents were asked whether the care needs of adults with disabilities was actively co-ordinated by the Primary Care Team;

19% of respondents reported that the PCT co-ordinated the care 81% reported that the PCT was not involved

Of the 81% who indicated that the PCT was not involved, the majority reported that the nursing care needs of adults with disabilities was co- ordinated and provided by the PHN and RGN.

It is not clear from the survey or the consultation meetings how decisions are made about who co-ordinates the health care needs of adult with disabilities. The results suggest that in some areas of the country this is co-ordinated by the PCT and in other areas by the PHN Service. The implications of this, for the Public Health Nursing Service and for service users, is unclear.

21

Department of Children and Youth Affairs 2010The State of the Nation’s Children Ireland

22

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Section 7: Palliative Care / End of Life Care Nursing Service (Adult and Children).

Adults: The projected demographic changes related to life expectancy and aging profiles are an important consideration in the context of health care. The National Cancer Registry has predicted that the number of cancers diagnosed in Ireland is set to double between 1998 and 2020. In relation to cause of death it is important to note that 29% of all deaths in 2010 were related to cancer. The majority of all deaths take place in hospital (48%). Still, a high proportion, 25% take place at home. Community health professionals would be involved in delivering domiciliary care to children and adults at the end of life.

Based on the information in the survey 30% of DPHNs have responsibility for the Palliative Care Home Nursing Services. Respondents, who do not have responsibility for the Palliative Care Service, indicated in the ‘open ended comment section’ the links between both services. The links range from no formal communication between the services to jointly planned monthly meetings.

The respondents were also asked who co-ordinates the nursing care needs of adult palliative care clients. Responses to this question indicate that the PHN assesses and co-ordinates the nursing care needs of all adult palliative care patients in the community. The majority of PHNs are supported in this role by the RGN and the specialist palliative care nurse.

Children and Young People There are approximately 1400 children with life limiting conditions living in Ireland and in the region of approximately 490 childhood deaths each year.23 A key finding of the Children’s Palliative Care Needs Assessment was that the preferred location, of caring for a child with a life-limiting or life threatening condition, is the family home with parents receiving adequate professional support.

Respondents in this survey were asked to identify the practitioner who co-ordinates the care for children with palliative care needs. All the respondents indicated that the PHN co-ordinates the nursing care needs of these children and are supported in this role to some extent by RGNs and specialist palliative care nurses.

The recommended model for children with life limiting conditions is ‘Hospice in the Home’. There is evidence from the consultation meetings of a similar model for children with life limiting conditions and their families in one area of the country.

In the context of Public Health Nursing service and palliative care there appears to be two models of service provision. In one model the Director of Public Health Nursing is responsible for the Palliative Care Nursing Service. In the other model the Director of Public Health Nursing does not have responsibly for the Palliative Care Nursing Service. Within the latter model, there appears to be variations in the degree of contact between both services. The experiences of the consultation participants’ is that there is overlap between the services; in that, for the most part, the Public Health Nurse provides the same care as the Specialist Palliative Care Nurse. There was acknowledgement that the Palliative Care Needs of Children require the support of a Palliative Care Nurse with paediatric experience.

23

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Section 8: Chronic Disease Management.

The principal causes of death in Ireland are related to diseases of the circulatory system (stroke, ischaemic heart disease) and cancer. Many of these diseases and premature deaths are preventable. In 2010, the HSE introduced the Integrated Services Programme and the development of National Clinical Care Programmes. The Integrated Services Programme will facilitate the integration of primary care, secondary care and continuing care for the purpose of providing integrated health and social services for a geographical population. Integrated Services is also the basic building block in the development of National Clinical Care Programmes. The Clinical Care Programmes are designed to standardise service delivery by establishing clinical guidelines in over 20 clinical care areas including Primary Care. The specific services/ diseases selected for the initial clinical care programmes are

With regard to the management of chronic disease in primary care, respondents in the survey were presented with the following list of chronic diseases and several categories of nursing interventions and asked to indicate whether the activities were carried out by a PHN, RGN, a Specialist Nurse or a Home Care Assistant. Across all respondents, the same interventions (administration of drugs, assessment, continence management, general care, specimen collection, respiratory management, support and surveillance, vital signs, wound management palliative care) were carried out by PHNs and RGNs. Table 2 Chronic Disease Interventions

Chronic disease conditions Interventions for each condition

Asthma Administration of drugs, assessment, continence management , general care, specimen collection, respiratory

management, support and surveillance, vital signs, wound management palliative care

Coronary Syndrome As above

COPD As above

Diabetes As above

Epilepsy As above

Rheumatoid Arthritis As above

Stroke As above Stroke Heart Failure Acute Coronary Syndrome Diabetes COPD/ Asthma

Epilepsy Care of the Elderly

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The most frequently occurring intervention undertaken by a clinical nurse specialist was pain control. The most prevalent activity carried out by Home Care Assistants was personal care. In the context of disease management and primary care in general; nursing skill mix and a nursing model for primary care featured prominently at the regional consultation meetings. It is worth mentioning at this time, that relieving pressure from the acute services means early discharge home from hospital for many clients with a diverse range of acute and complex clinical needs The consultation participants’ experience of this phenomenon is that, previously such clients were the subject of pre discharge meetings, these clients are now, in many instances, discharged home with no forward planning. The consultation participants were of the view that ‘in reach’ liaison PHN service is essential to a primary care nursing team: a liaison PHN service, who would work in the referring hospitals including, the maternity and paediatric facilities. In the survey 69% of the respondents reported that their service had a liaison PHN.24

In terms of supporting the developments of Chronic Disease Management in primary care, the survey sought information on the number of nurse prescribers, public health nurses with specialist areas of practice and advanced nurse practitioners

Based on the information in the survey from 26 respondents, there is 1 PHN advanced nurse practitioner (Older Persons).

6 PHN prescribers

4 PHN Cardiac Nurse Specialists

The projected demographic changes and epidemiological trends in chronic disease will result in more people being cared for in a primary care setting. Strengthening the developments in Chronic Disease Management in primary should include advanced nurse practitioners, nurse prescribers and achieving better collaboration between primary and secondary care.

24

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Section 9: Health Promotion and Community Development.

It is important to keep in mind that the health care system serves not only the ill but also has a wider remit in preventative health care. The HSE in their service plan stress a population health approach to health and well-being and in this regard attempt to balance health prevention, promotion, diagnosis, treatment and care (HSE Service Plan, 2011).

An important function of the Public Health Nursing Service lies in profiling, identifying and analysing the health needs of their local communities. Having a comprehensive picture of the health needs of a local community is central to delivering targeted and effective health improvement services. Health promotion initiatives are developed and provided by the PHN services and in partnership with other local community development projects. Thus, the survey sought information on health promotion activities and community development initiatives which the Public Health Nursing Service established or were involved in developing. This question was asked for each of the following population groups/ settings

Preschool Children and Families Primary School

Post Primary Schools Older persons

The respondents reported on providing a range of health promotion activities. Preschool Children and Families

The health promotion activities, most commonly provided, for this population, are breastfeeding support groups, Community Mother’s Programme, and mother and toddler groups. Other activities include postnatal depression groups, infant mental health, baby massage, Triple P (Positive Parenting Programme) discussion groups and family outreach services.

Primary Schools

The health promotion activities, most commonly provided, for this population, revolves around the Healthy Schools Initiatives and education about the Schools immunisation programme for teachers.

Post Primary Schools

The health promotion activities reported on for this population are linked to lifestyle behaviours and suicide prevention. From a community development initiative perspective support is provided for transition year students in the context of Student Career Identification.

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This population group generated the most examples of health promotion activities and community initiatives. The most common health promotion activities centred on, safety, health maintenance and social support. Examples include, Falls Prevention programme, Personal Safety Alarms, Rural Transport Active Retirement Clubs, Diabetes awareness (the Desmond Programme), Cardiovascular Support Groups and Heart Smart

.

All respondents reported that opportunistic health promotion rather than planned health promotion activities dominate public health nursing practice.

Some respondents reported that health promotion initiatives are on hold due to the staff moratorium

The scope to deliver population health initiatives may be large. It appears from the data that PHNs may be hampered in this by their clinical case loads. At the consultation meetings Public Health Nurses stated that they would like to change the balance of their roles in this regard.

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Section 10: Nurse -led/ Midwife- led Clinic Service.

A number of reports have identified the potential of nurse- led and midwife led clinics to support the demographic and epidemiological transitions that are a feature of the Irish health care landscape. The Hanly Report,25the Report of the Commission on Nursing,26 and the Strategic Framework for Role Expansion of Nurses and Midwives: Promoting Quality Patient Care27 recognise the scope for enhancing the roles of nurses and midwives with a view to identifying how these enhancements might be implemented.

The definition of a nurse- led clinic or service is one where the nurse manages the patient caseload which includes assessment, developing implementing and managing a care plan, clinical leadership and decision to admit and discharge.

The survey sought information from the respondents on Public Health Nurse- led; Registered Nurse – led Clinical Nurse Specialist – led and Midwife- led clinics.

The respondents identified the following nurse- led services o Midwife – led antenatal clinics

o Wound management/ tissue viability clinics o Leg ulcer clinics

o Enuresis clinics o Continence service

o Community Intervention teams (Nurse led) o Diabetes clinics

o Well baby clinics

Although many may perceive nurse/ midwife led- services to be a relatively new phenomenon, Public Health Nurses have been providing nurse- led clinics, for more than 30 years.28 The developments of nurse- led and midwife- led clinics will continue as the nurses adapt to the changing health needs of society.

25

Department of Health and Children 2003

26

Government Publications 1998

27

Department of Health 2011.

28

National Council for the Professional Development of Nursing and Midwifery 2005An Evaluation of the Extent and Nature of Nurse –Led/ Midwife- Led services in Ireland.

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Section 11: Education and Training.

Staff Development.

This report also draws attention to the role of the Public Health Nursing Service in staff Development and in the Education and Training of students from 3rs level institutions in Ireland and abroad. To provide high quality safe health care, and to improve it on an on-going basis, requires a skilled and knowledgeable workforce. Staff development has been reported on in Section 1 page 9.

Education and Training.

Respondents were also asked to indicate which modules from a list of 9 modules on Best Health for Children are being provided to PHNs in their areas.

Based on the information from the 24 respondents who answered the question 100% have been provided with new-born blood spot screening module. 91% vision screening module.

87% hearing assessmentmodule. 79% development assessment module. 79% growth monitoring module.

75% health promotion and educationmodule. 50% medical assessmentmodule.

46% child mental and emotional healthmodule. 25% oral and dental healthmodule.

Student clinical placements. With the increased emphasis on Primary Care, there is a demand for nursing and medical students to gain practical clinical experience in this setting. The matter of capacity and resources to meet these extra demands was raised at the consultation meetings Respondents were asked about the numbers of students that their service had facilitated in the academic year 2010-2011.

22 respondents indicated that they facilitated undergraduate student nurses. The numbers of students facilitated by the respondents in the academic year 2010-2011 ranged from 7 – 60.

20 respondents indicated that they facilitated student public health nurses. The numbers of students facilitated by the respondents in the academic year 2010-2011 ranged from 1- 6.

10 respondents indicated that they facilitated trainee GPs. The numbers of trainees facilitated by the respondents in the academic year 2010-2011 ranged from 1- 10

7 respondents indicated that they facilitated medical students. The numbers of medical students facilitated by the respondents in the academic year 2010-2011 ranged from 2- 80.

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Appendix 1 Expert Advisory Group Members

Dr Joe Clarke Chairperson

Marissa Allen Public Health Nurse, HSE South

Anne Boland Director of Public Health Nursing , Mayo

Jennifer Bollard Director of Public Health Nursing Dun Laoghaire

Carmel Buckley Nursing and Midwifery Planning and Development Unit Officer, Cork

Grainne Coogan Meath HSE DNE

Fiona Collins Public Health Nurse Limerick, HSE West

Kathleen Delaney Assistant Director PHN Longford Westmeath

Anna Dineen Registered General Nurse HSE South

Anita Ennis Public Health Nurse, Dublin North Central.

Marianne Healy Director of Public Health Nursing HSE DNE

David Hughes Representative Nursing Alliance (INMO, SIPTU, PNA)

Mary P Keegan Registered General Nurse HSE DML

Catherine Killilea Nursing and Midwifery Planning and Development Unit Director, Cork

Anna Madden Assistant Director PHN, Galway

Fiona Maher Public Health Nurse Kildare West Wicklow HSE DML

Elizabeth O’Connell Assistant Director PHN HSE South

Mary O’Dowd Professional Development Officer, Institute of Community Health Nursing

Patricia O’Dwyer Project Officer

Mary O’Flynn A/ Director of Public Health Nursing, North Cork

Hugh ONeill Administration Support Office of the Nursing and Midwifery Services Director

Virginia Pye Director of Public Health Nursing, Longford/Westmeath

Eileen Quinn Director of Public Health Nursing North , Donegal West HSE

Gwen Regan Registered General Nurse Dublin North HSE DNE

Dr Michael Shannon Office of the Nursing and Midwifery Services Director

Catherine Smyth Assistant Director PHN Louth HSE DNE

Geraldine Tabb Director of Public Health Nursing, Waterford

References

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