Improving Primary Care Services for Children with Acute Minor Illnesses – The Role of the Children’s Advanced Practitioner Dianne L Cook

Background SELF SERVICE PRESENTATION

An important element therefore was to scope, explore and reflect upon whether children being seen by key stakeholders in Manchester Primary Care were adequately preventing unnecessary referrals to secondary care.

Or with the intervention and support of a children’s advanced practitioner, provision and quality of care for children and young people could be improved by knowledge utilisation and transfer.

Around 3.5 million children per year attend emergency departments in the UK (Royal College of Paediatrics and Child Health 2007), equating to around 28% of the child population each year.

About 90% of these children attending an emergency department will be seen with acute minor illnesses and discharged without involvement of any in-patient team.

Children with acute minor childhood illness at home constitute a significant proportion of the workload of G.P’s.

The 0-4 year age group consults more often than any other group except the elderly (Royal College of Paediatrics & Child Health 2007). Acute childhood illness constitutes a high proportion of these consultations.

CoughsColds RashesUpper Respiratory Infection Lower Respiratory InfectionVomiting Childhood Infectious disease (mumps, measles, chickenpox) Gastroenteritis Otitis MediaFever AsthmaEczema ConstipationTonsillitis Urinary Tract InfectionsConjunctivitis Soft tissue injuriesMuscle strains

Providing services for children and young people need to be safe, high quality and effective. We need to offer a new kind of community based care and more health care provided at home (as recommended in professor Darzi’s ‘Framework of Action’).

Children’s Community Nurses are in an ideal position and should be encouraged to be at the forefront of change.

Why the Advanced Practitioner Role? If the child is stable, the environment is suitable and the parent/carer is confident and supported, then most acute or chronic conditions can be cared for outside of a hospital setting

Why the Advanced Practitioner Role? What they need is: THE RIGHT PERSON to deliver THE RIGHT SKILLS to THE RIGHT CHILD in THE RIGHT PLACE at THE RIGHT TIME

What is an Advanced Nurse Practitioner? RCN 2008 ‘ A registered nurse who has undertaken a specific course of study of at least first degree (Honours) level and who:

Makes professional autonomous decisions, for which they are accountable Receives patients with undifferentiated and undiagnosed problems and makes an assessment of their health care needs, based on highly developed nursing knowledge and skills, including skills not usually exercised by nurses, such as physical examination

Screens patients for disease risk factors and early signs of illness Makes differential diagnosis using decision-making and problem- solving skills Develops with the patient an ongoing nursing care plan for health, with an emphasis on preventative measures

Orders necessary investigations, and provides treatment and care both individually, as part of a team, and through referral to other agencies Has a supportive role in helping people to manage and live with illness Provides counselling and health education

Has the authority to admit or discharge patients from their caseload, and refer patients to other health care providers as appropriate Works collaboratively with other health care professionals and disciplines Provides a leadership and consultancy function as required

The Advanced Role – Differences (Will vary between disciplines) Work with a High Degree of Professional Autonomy Leadership/Consultancy Developing or Changing Practice Being involved in Broader Health Issues Research

The Advanced Role – Differences (Will vary between disciplines) Process Specific – Getting There Offers a complementary source of care to that offered by medical practitioners and other health care professionals Grounded in Practice & Reflection for the purpose of further Development

Research Design & Tool A qualitative approach through an action research framework A 14 Item questionnaire was sent to North Manchester Practice Nurses Out of the 32 questionnaires that were sent out, 21 were returned (66%). 2 excluded therefore, 19 analysed

Q1: Participants were asked how many children they see weekly with acute minor illnesses. (n=19) 47 % (9) Practice nurses stated they saw 0 children with an acute illness. 37 % (7) Practice nurses stated they saw between 1-5 children with an acute illness. 16 % (3) Practice nurses see between children.

Q 2:Participants were asked if within the last two years whether they had had any paediatric teaching/training regards clinical knowledge and skills of acute minor illnesses (n=19) Of those nurses who stated they see children weekly 53 % (n=10) only 20% (n=2) stated they had had paediatric teaching training re: clinical knowledge and skills of acute minor illnesses. 80 % (n=8) stated they had not

Q 2:Cont And of those 8 who had NOT had any training, a further question was asked as to how long ago it was that they had: 75% (n=6) declined to state how long ago. 12.5% (n=1) stated more than 8 years ago. 12.5% (n=1) stated 15 years ago.

Q 3: Participants were asked if they do not have the relevant skills or knowledge relating to an acute minor illness were they aware of where to gain advice or support from (n=19). All the nurses (n=19) stated they were aware of where to gain advice from and specified several categories

Q4: Participants (n=10) were asked how many children weekly that they see do they refer onwards for a second consultation and assessment and to whom. 30% (n=3) practice nurses stated they send 100% onwards for a second consultation and assessment. 20% (n=2) Practice nurses sent 50% 20% (n=2) Practice nurse sent 30% 30% (n=3) didn’t comment.

Q 4: Participants (n=10) were asked how many children weekly that they see do they refer onwards for a second consultation and assessment and to whom. Of those that refer onwards (n=7): 14% (n=1) Practice nurse stated they refer to the GP or hospital. 58% (n=4) Practice nurses stated they refer to the GP. 14% (n=1) Practice nurse stated they refer to the Health Visitor. 14% (n=1) Practice nurse stated they refer to the Health Visitor or GP.

Q5: Participants were asked whether they had specific evidence-based guidelines and protocols in place for children attending their clinics Of those practice nurses that see children (n=10): 10 % (1) stated they have specific evidence based guidelines and protocols in place for children. 80 % (8) stated they did not. 10 % (1) declined to comment.

Q 5 Cont…: Of those practice nurses that stated they did not see children (n=9): 44 % (4) stated they did. 44 % (4) stated they did not. 12 % (1) declined to comment.

Q6:Participants were asked whether they had specific diagnostic equipment for children and young people (E.g., BP cuff, O2 Sats Probe, Oroscope) Of those who see children (n=10): 60 % (6) Practice nurses stated they had specific diagnostic equipment for children and young people. 40 % (4) Practice nurses stated they did not. Practice Nurses that see Children 60% 40% Specific diagnostic equipment for children No specific equipment

Q7: Participants were asked if they had any individual training and practice development needs in relation to their work with children and young people. Of those who see children (n=10): 50 % (5) Practice nurses stated they did and identified: Key clinical acute minor illness skills and knowledge Children and young people development 50 % (5) Practice nurses stated they did not.

Question 7 cont … None of the practice nurses however, stated that they had any training issues in relation to ‘safeguarding and promoting the welfare of the child’ despite only 50% of them having had a recent update in child protection.

Of those practice nurses who didn’t see children (n=9): 33 % (3) practice nurses stated they did and identified: Sexual health in older children Safeguarding and promoting the welfare of the child Key clinical acute minor illness skills and knowledge 56 % (5) Practice nurses stated they did not. 11 % (1) did not comment.

Q8: Participants (n=10) were asked if they had read any of the following documents DocumentsYes No Getting it right for children and young people (A self- assessment tool for practice nurses) (RCN 2006) 50 % (5) Children’s National Service Framework (DoH 2004) 20 % (2)80 % (8) Every child matters (DfES 2003) 50 % (5)

Q9: Participants (n=19) were asked if they see communicating with children and young people as a specialised skill: 84 % (16) stated Yes 6 % (1) stated No 10% (2) didn’t comment

Q10: Participants (n=10) were asked if they utilised play within their consultation 90 % (9) practice nurses stated they did 10 % (1) stated they did not.

Q11:Participants (n=10) were asked if they were a prescriber, and if so do they prescribe for children with acute minor illnesses. 30 % (3) are prescribers and prescribe for children. 70 % (7) are not prescribers.

Q12: Participants (n=10) were asked whether they had in the last year had/received an update in child protection. If they hadn’t, they were then asked how long ago it was. 50% (5) Practice nurses had received an update. 50% (5) Practice nurses had not. All stated it was between 2-5 years ago when they had.

Q13: Participants were asked (n=19) if they had access to support and supervision from a qualified children’s nurse Of the practice nurses that saw children (n=10): 10 % (1) stated they have access to support and supervision from a qualified children’s nurse practitioner. 90 % (9) stated they did not.

Question 13 cont… Of the practice nurses that did not see children (n=9): 11 % (1) stated they have and named a health visitor. 78 % (7) stated they did not. 11 % (1) did not comment.

Q14: When the practice nurses who saw children (n=10) were asked, ‘would it be useful if an identified children’s advanced practitioner provided regular updates and/or support?’ All 10 (100%) stated Yes and comments made as to how were: ‘increase/update knowledge/skills pertinent to children and young people’ ‘Giving more update knowledge and interpersonal skills to all the team members’

Question 14 cont … ‘To update knowledge and skills. Increase confidence and competence’ ‘Somebody we could refer to for further advice’ ‘I am frightened to make a mistake with children, so always ask the GPs; however, at times they can humiliate me. I dread seeing a child with a minor illness!’

Question 14 cont … Of the practice nurses who do not see children (n=9): 11 % (1) practice nurse stated she wouldn’t find it useful 11 % (1) did not comment 78 % (7) stated Yes with the following comments as to how:

Question 14 cont … ‘In all the areas listed in the question’ ‘Helpful to have a contact for unusual problems’ ‘Most updates/courses are aimed at the adult, not the child’ ‘No updates received at present, all training is useful’ ‘I don’t see children as I’m not good with them!’ ‘It’s not my role!’

Focusing on providing more services outside of the hospital into community settings were the key objectives of the service development improvement.

As boundaries of workload and responsibilities between doctors and nurses are being redefined, nurses in general practice are increasingly managing minor illness Joint working, at best, is thought to cut down on duplication and overlap, prevent gaps in service and help to clarify roles and responsibilities.

The need therefore, to share expertise, pool knowledge and cross traditional boundaries has been portrayed as not a choice but an essential ingredient of delivering high quality health and social care for children in community settings