- Email: [email protected]
The role of the community children's nurse: the perspective of a practitioner and an educator
Current Paediatrics (2002) 12, 425^ 430
c 2002 Elsevier Science Ltd doi:10.1006/cupe.2002.0321, available online at http://www.idealibrary.com on
The role of the community children’s nurse: the perspective of a practitioner and an educator Julie Hughes* and Jo Horsburghw *Lecturer, Department of Health and Social Care, University of Reading, Bulmershe Campus, Woodlands Avenue, Earley, RG161HY Reading, UK and w Community Children’s Nurse, Hounslow and Spelthorne Community and Mental Health NHS Trust, UK
KEYWORDS Community Children’s Nursing, skills and knowledge, empowerment and partnership education
Summary This article will illustrate the development of Community Children’s Nursing services in the United Kingdom and the role of the Community Children’s Nurse (CCN) as perceived by a practitioner and a community children’s nurse educator. The increasing survival rate of children with once fatalillnesses has proved a challenge to paediatrics as children survive with increasingly complex and often technology-dependent health needs. Nursing and medical colleagues alike are aware that the acute hospital environment is often not an appropriate setting for these children to receive care and there has been increasing pressure from the paediatric ¢eld to attain government recognition and resources to develop children’s homecare services. CCNs provide care to a range of children and families including those with complex and acute nursing need.Their role is complex and unique and this paper will highlightthe practice and the educational preparation that is required to ful¢l such a multi-faceted role.
c 2002 Elsevier Science Ltd
PRACTICE POINTS K
K
K
K
Community Children’s Nurses work in collaboration with health, social, education and voluntary sector colleagues to deliver a service to children and families with health needs in the community setting CCNs have a unique and complex role in children’s health care The underpinning philosophy for CCN practice is one of partnership and empowerment for children and families CCNs undertake educational programmes to develop the knowledge and skills demanded of their role
Over the last decade there have been signi¢cant developments in the delivery of nursing care to children in the community setting. As recognized by the document ‘Child health in the community: A guide to good practice’,1 this aspect of nursing has experienced growth and innovation during a time of societal shift in the emphasis of health-care delivery from the acute services to the Correspondence to: JH.Tel.: +44 -1189-318853; Fax: +44-1189-316808; E-mail: [email protected].
primary care setting. This paper will endeavour to address the role of the Community Children’s Nurse (CCN) in the context of the historical development of CCN services, and to discuss the challenges of the educational preparation for this complex, multi-faceted role.
THE DEVELOPMENTOF COMMUNITYCHILDREN’S NURSING SERVICES A CCN service ¢rst appeared in the United Kingdom NHS in Rotherham in 1949 in response to concerns regarding hospital acquired infection and associated infant mortality.2 This was followed in the 1950s by service developments in Birmingham and Paddington. Existing services at this time were based predominantly on meeting the needs of children with acute illness but in 1969 there was an innovative service development in Southampton to meet the needs of children following day surgery.More recent service developments have been in£uenced by the increasing survival rates of children with complex health problems3 and thus the CCN role has had to incorporate care needs of children with acute illness, post-surgery and chronic illness.
426 Despite the recommendations of the Platt Report4 that children should, wherever possible, be nursed in their own home, expansion of services was slow. The Court report5 reiterated the government support to provide sick children with the opportunity to be nursed in the home environment but still by 1980 there were only eight teams in the UK. However during the 1980s, there was more signi¢cant growth culminating in the emergence in1987 of the Royal College of Nursing Community Children’s Nursing Forum as the major focus of CCN policy and practice development in the UK. The Forum has provided a voice for the CCN in the wider ¢eld of policy development and has been in£uential in the continued expansion of CCN services. This voice was evident in the recommendations of the House of Commons Select Committee report in 19976 stating the following: K
K
K
All children requiring nursing should have access to a community children’s nursing service, sta¡ed by quali¢ed children’s nurses supplemented by those in training, in whatever setting in the community they are being nursed. This service should be available 24 h a day, 7 days a week. Every GP should have a named CCN.
As we enter a new millennium there are over 250 CCN teams in the UK representing greater equity of access for children and families.7 As services continue to develop there is emphasis on exploring in greater depth the role of the CCN. Because of the lack of a national strategy, CCN services have been established on an ad-hoc basis generally in response to local need. They may be based on a generalist or a specialist service model and they could be funded by a variety of sources including acute Trusts, Primary Care Trusts and charities. It is clear from the literature that services vary in their organization and management and in many cases the criteria for referral of children and families to the service may di¡er.The disparity of service delivery in no way detracts from the commonality of the underlying philosophy of the CCN to deliver safe, e¡ective health care in partnership with children and their families, and in collaboration with other health, social and voluntary sector colleagues, in the community setting. This shared philosophy has shaped the role of the CCN and the complexity of this role will now be analysed.
THE CCN ROLE:THE PRACTITIONER PERSPECTIVE The role of the CCN has been described as being diverse, £exible and responsive whilst maintaining its philosophy regarding service delivery.8 CCNs have a unique role, encompassing key skills and knowledge that
CURRENT PAEDIATRICS
enable children and families to be cared for at home. To analyse the complexity of the role, key areas will be discussed that will give an overview of the role of the CCN. These key areas are: K K K
Caseload pro¢le. Partnership and empowerment. Family care.
Caseload pro¢le The exact pattern of referral to a CCN will vary in accordance with the organizational model of CCN service delivery. However in analysing the CCN role, it is essential to o¡er examples of the children that CCNs are likely to be involved with and the professionals that might refer to the service (Table 1).
Partnership and empowerment It is important that the CCN has the ability to enable families to care for their child without causing undue stress, through working in partnership and empowering them with knowledge regarding the care of their child. This aspect of the CCN role has been explored to be markedly di¡erent from that of the hospital-based nurse. To enable the family to manage the care of their child, it is essential that little or no disruption is created to the daily living of the family. Hence, the CCN will share her skills with the families and empower the family to make decisions about the child independently but with support. Empowerment is a term that CCNs use consistently in their work. Allowing families to make decisions with support is something that is developed with the experience and expertise of the CCN.9 However, it is important to emphasize that CCNs have to exercise professional judgement and their focus is the child’s safety and rights, as the child’s best interests are paramount and underpin the philosophy of care.
Table 1 Caseload pro¢le Types of referrals Examples Asthma, eczema and constipation Cystic ¢brosis Oncology-related illness Gastric problems Tracheostomy care Chronic lung disease Neuromuscular disorders Post-surgery IVAntibiotic administration
Who might refer? General practitioner Community/acute pediatrician Health visitor District nurse A & E department Other professions allied [speech therapy/dietitian]
THE ROLE OF THE COMMUNITYCHILDREN’S NURSE
427
Partnership is fundamental to the role of the CCN. It can lead, ultimately, to the family being independent with all care, to the point where the CCN can withdraw the service. A key skill that is paramount for partnership is teaching.Teaching and education are integral and are carried out in a variety of ways. Much of the CCN teaching will be carried out in the home, whereby telling and showing parents how to carry out technical tasks or use equipment is essential to the care of the child.8 To assist CCNs in their teaching skills it has been identi¢ed that other elements in their practice enhanced e¡ective learning for the family.8 These elements were that CCNs and families had formed developmental partnerships rather than implementation partnerships, they were exploring, clarifying and making sense of the circumstances.This partnership and trust helps build on the families’ self-con¢dence and allows them to explore and become partners securely. Furthermore, partnership can aid co-ordinated interprofessional support, which is important to the families. CCNs view liaison and partnership with other professionals as an essential part of their role and are quite often perceived as the keyworker, who is able to manage the caseload for the family.10 Liaison can take the form of many elements,‘including o⁄cial liaison, case conferences and unceremonious e¡orts, communication and goodwill’.8 The inter-professional support can be with professionals from health, social, education and voluntary sectors, which encourage good working practices. Achieving this partnership gives rise to CCNs having a combination of skills that incorporate: self-management, knowledge of the service and the community at large and willingness to seek information and go on to share that information.
sharing. It has been recognized that due to the length of time of a care episode, interaction between the nurse and family and the insight into the families’ needs and circumstances provides a deep relationship individualized to the families’ needs. Within this relationship negotiation and listening to the needs of the family are essential skills. Negotiation and listening empowers the family and builds trust with the CCN, allowing the family to explore in a trusting environment. Support is a highly regarded skill, whether physical or psychosocial, which is often the key reason for the CCN’s involvement with the family. This can be clearly seen with children who have complex health needs, where the families are independent but at times require support from professionals. Adaptation to illness can produce feelings for the family that are too much to bear and the support needs will £uctuate in accordance with the wellness of the child and external in£uencing factors of other family members.CCNs have an integral part to play in times of crisis, including bereavement, and o¡er much support and counselling to the family at a time of much despair. Although CCNs would acknowledge they were not experts in this area, the comfort brought to the family is overwhelming, due to the strong and established relationship. Support could be provided in di¡erent ways and simply listening to the concerns of the child and family actively ensures any action needed is negotiated and appropriate to meet their needs.Other qualities that are involved are ‘being watchful and mindful, and knowing the boundaries of one’s own skills’.8 It is important to families that they are able to share the burden of care and have acknowledgement from the CCN who is able to understand the complex problems from the families’ perspectives.9 The relationship between the CCN and family is unique and very satisfying and can draw the CCN into a closer involvement with the family. However, this may have consequences for the CCN. Three areas of potential di⁄culty have been recognized:8
Family nursing CCNs care for children with a variety of complex healthcare needs that require an awareness of the current needs of both the child and family. Research clearly indicates the impact the care can have on a family. The cost of caring is summarized as follows: 10 K K K K K
Adverse e¡ects on the siblings. Social isolation. Lack of privacy. Financial loss. Parental stress.
Therefore, the CCN’s insight into each family is essential to be able to work and plan for the future. It is also imperative that CCNs are still involved with children who have a chronic condition that is well managed, as their skills and knowledge are vital when the child/family require intervention.11 Communication skills have been a main theme in analysing the role of the CCN, like listening, informing and
K
K
K
Building supportive relationships with certain families may jeopardize other families and increase the workload of the CCN. Creating over-dependency on the service could inhibit the families from taking control. Ensuring that the CCN has clear professional boundaries with each family for personal protection.
Research has highlighted that although these problems could arise, the experience of CCNs in relation to their awareness of family relationships and the support they receive from colleagues are some of the ways that they deal with di⁄cult issues. In analysing the role of the CCN, it is apparent that the relationship between the CCN and their families is of a special nature. Although there are many
428
practicalities to the job, much emphasis has been on the skills of empathy, compassion, partnership and listening. To ensure that families receive this ongoing service, it is imperative that appropriate education is given to CCNs who wish to develop their skills and enhance their scope of practice. Education is the key to going forward and this will now be fully explored.
EDUCATIONAL PREPARATION FOR THE CCN:THE EDUCATIONALIST’S PERSPECTIVE The practitioner perspective highlights the complexity of the CCN role and adds weight to the argument that the role should be recognized as a branch of community specialist nursing practice.12 Prior to the publication of the UKCC standards for the preparation of community specialist practitioners the only available education for CCNs was the Health Visiting or District Nursing course.Whilst this would equip the student with the appropriate skills and knowledge to deliver care in the community setting, such programmes would not address the speci¢c issues that the CCN meets in everyday practice in relation to sick children’s nursing. Thus, the new developments were welcomed by the profession and courses conjointly validated by the ENB and the relevant academic board were developed. Educationalists have been working closely with CCNs to ensure that the curriculum addresses the needs of CCNs locally as well as addressing the wider national context of CCN care delivery.13 It has been argued 14 that the CCN practitioners of today are those best placed to identify the skills and knowledge required by the CCNs of the future and thus the structure of the curriculum planning team must re£ect this. CCN input is also crucial to the practice component of the course as appropriate placements and mentors will need to be identi¢ed to support the development of the CCN student. In the initial stages of development of the programme practice placements proved challenging due to the limited number of CCN services and appropriately quali¢ed mentors. Over the past 5 years the continued development of services and educational preparation for mentors has alleviated the element of challenge of ¢nding the placement,15 but the challenge of providing an educationally sound practice placement and ensuring students and mentors are suitably supported must always be recognized to ensure continuous quality.16 All the specialist practitioner programmes address four broad areas of practice as set out by the UKCC and these four areas will now be explored addressing both the practice and theory elements speci¢c to the CCN role. K K
Clinical practice. Care and programme management.
CURRENT PAEDIATRICS
K K
Clinical practice development. Clinical practice leadership.
Clinical practice This area of the programme aims to develop the CCN’s skills in assessing, planning, delivering and evaluating care for children with health problems. The knowledge required to care for sick children and their families is changing.The pattern of childhood illness is one of decreasing mortality and increasing survival of children with very complex health needs often resulting in technology dependence.3 Thus, the practical skills for the CCN must be developed and course outcomes must include a practitioner who has reached expert status in care planning. Much of the care delivery is in partnership with family carers and CCNs are therefore required to have the skills to teach and support carers in their role.Often this will require a great deal of practical expertise in dealing with complex technology but also requires attitudinal skill in working closely with family members. The ENB commissioned research 8 illustrates six speci¢c skills that the CCN must be equipped with and this area of the course programme will address the following two skills: K K
Formal knowledge and technical skills. Teaching skills
Care and programme management This area of the programme aims to develop the CCN’s skills in promoting and improving health in children, their families and the wider community.The student will develop a critically analytical awareness of the health needs of children and families and will recognize the collaborative nature of care programming. During the course they would be encouraged to seek out social, education and voluntary sector colleagues to discuss issues surrounding care management for sick children in the community. It is likely that much of the theoretical component of this area of the curriculum will be shared learning with other specialist practitioners in addressing community pro¢ling and care management. This will address the following:8 K
Relational, interpersonal and support skills.
Clinical practice development This area of the programme addresses the skills required by the CCN for continuous personal and professional development. There has been much evidence to suggest that experiential learning is an e¡ective strategy when managed appropriately. For the purpose of the course students are encouraged to keep a re£ective diary and
THE ROLE OF THE COMMUNITYCHILDREN’S NURSE
429
they are required to complete assignments directly re£ecting on a critical incident from their practice. Re£ective practice requires a high level of cognitive thought and it is essential that if students are required to re£ect there is support from a mentor who is an appropriate role model. By utilizing a model of re£ective practice (Fig. 1) the student will describe the incident and then analyse and evaluate their feelings about it, thereby learning through the experience. Developing these skills of re£ective practice is essential to promote practice development and both mentors and students will be supported by tutors in utilizing skills of re£ection in their daily practice.The skill development here is:
relative infancy of the role accounts for this and the more opportunity we have as a profession to publish and present conference papers the more likely we are to raise awareness. Developing leadership skills in CCNs of the future is therefore essential to the continuous development of the service. CCNs need not only to have the skills to empower families, but also to be empowered as professionals to enable them to promote their service to commissioners and ultimately improve the quality and equity of care for children and families. The two skills remaining from those advocated by the ENB research will be addressed in this area of the curriculum:
K
Thinking skills. K K
Clinical practice leadership The specialist practitioner programme is designed to produce leaders in the ¢eld of community nursing. This area of the curriculum therefore has a focus on leadership issues both for the individual and in relation to team membership. Throughout the programme students will develop the skills to manage a caseload of children with a variety of health needs and will demonstrate appropriate caseload management aØ propos prioritizing care. Continuous quality of care will also be addressed linking the relevance of auditing to the CCN role for the purpose of demonstrating both the quality and quantity issues for CCNs. From personal experience as a CCN team leader I am very aware that CCNs feel that they are constantly required to justify their role to colleagues from both the acute and primary care sectors. The
Description What happened?
Action Plan
Feelings
If it arose again what
What were you thinking
would you do?
And feeling?
Conclusion
Evaluation
What else could you have done?
What was good and bad about the experience ?
Analysis What sense can you make of the situation ?
Figure 1 Gibbs re£ective cycle.
Skills for managing their own work. Co-ordinating knowledge and skills.
This paper gives a broad overview of the role of the CCN as perceived by the practitioner and the educationalist and highlights the complexity of the role. It is clear that both practitioners and educationalists must work together in adjusting and improving the educational preparation to accommodate the needs of students, colleagues and ultimately children and families.
REFERENCES 1. Great Britain Department of Health. Child Health in the Community: A Guide to Good Practice. London: The Stationery Office, 1996. 2. Whiting M. Building a nationwide community paediatric nursing service. Nurs Standard 1985; 419: 5. 3. Kirk S. Families experiences of caring at home for a technology dependant child: a review of the literature. Child Care: Health Dev 1998; 24: 101–114 4. Ministry of Health. The Welfare of Children in Hospital. London: HMSO, 1959. 5. Department of Health and Social Security. Fit for the Future: The Report on the Committee of Child Health Services. London: HMSO, 1976. 6. House of Commons. Services for Children and Young People in the Community 3rd Report of the Health Select Committee. London: The Stationery Office, 1997. 7. Royal College of Nursing. Directory of Community Children’s Nursing Services, 15th edn. London: RCN, 2001. 8. English National Board. Researching Professional Education: Preparation for the Developing Role of the Community Children’s Nurses. ENB: London, 1999. 9. Department of Health. Evaluation of the Pilot Project Programme for Children with Life Threatening Illnesses. London: HMSO, 1998. 10. Murphy G. The technology-dependent child at home. Part 1: in whose best interest? Paediatr Nursing 2001; 13. 11. Carter, B. Ways of working: CCNs and chronic illness. J Child Health Care 2000; 4: 66–72. 12. United Kingdom Central Council. The Future of Professional PracticeFthe Councils Standards for Education and Practice Following Registration. London: UKCC, 1994.
430
13. Livsey, P. Setting the agenda for education. (Chapter 9) Muir J, Sidey A, eds. Textbook of Community Children’s Nursing. In: London: Baillie`re Tindall, 2000. 14. Moyse K, Dryden S. A degree in Community Children’s Nursing. Nursing Times 1999; 95: 49–50. 15. Canham J, Bennett J. Mentorship in Community Nursing. London, Edinburgh: Blackwell Science Oxford, 2002. 16. Proud C. Community children’s nursing (Chapter 13). Canham J, Bennett J, eds. Mentorship in Community Nursing. In: London, Edinburgh: Blackwell Science Oxford, 2002. 17. Gibbs G. Learning by doing: a Guide to Teaching and Learning Methods. Oxford: Further Education Unit, 1998.
CURRENT PAEDIATRICS
FURTHER READING Fradd E. Setting up a paediatric community nursing service. Senior Nurse 1990; 10: 34 ^36. Marland J. Back where they belong: caring for sick children at home. Child Health1994; 2(1): 40 ^ 42. Muir J, Sidey A. Textbook of Community Children’s Nursing. London: BaillieØreTindall, 2000. RCN. Promoting E¡ective Team-Working for Children and their Families. London: RCN, 2000. Winter A. Construction and application of paediatric community nursing services. J Child Health Care 1997; 1: 24 ^29.
c 2002 Elsevier Science Ltd doi:10.1006/cupe.2002.0321, available online at http://www.idealibrary.com on
The role of the community children’s nurse: the perspective of a practitioner and an educator Julie Hughes* and Jo Horsburghw *Lecturer, Department of Health and Social Care, University of Reading, Bulmershe Campus, Woodlands Avenue, Earley, RG161HY Reading, UK and w Community Children’s Nurse, Hounslow and Spelthorne Community and Mental Health NHS Trust, UK
KEYWORDS Community Children’s Nursing, skills and knowledge, empowerment and partnership education
Summary This article will illustrate the development of Community Children’s Nursing services in the United Kingdom and the role of the Community Children’s Nurse (CCN) as perceived by a practitioner and a community children’s nurse educator. The increasing survival rate of children with once fatalillnesses has proved a challenge to paediatrics as children survive with increasingly complex and often technology-dependent health needs. Nursing and medical colleagues alike are aware that the acute hospital environment is often not an appropriate setting for these children to receive care and there has been increasing pressure from the paediatric ¢eld to attain government recognition and resources to develop children’s homecare services. CCNs provide care to a range of children and families including those with complex and acute nursing need.Their role is complex and unique and this paper will highlightthe practice and the educational preparation that is required to ful¢l such a multi-faceted role.
c 2002 Elsevier Science Ltd
PRACTICE POINTS K
K
K
K
Community Children’s Nurses work in collaboration with health, social, education and voluntary sector colleagues to deliver a service to children and families with health needs in the community setting CCNs have a unique and complex role in children’s health care The underpinning philosophy for CCN practice is one of partnership and empowerment for children and families CCNs undertake educational programmes to develop the knowledge and skills demanded of their role
Over the last decade there have been signi¢cant developments in the delivery of nursing care to children in the community setting. As recognized by the document ‘Child health in the community: A guide to good practice’,1 this aspect of nursing has experienced growth and innovation during a time of societal shift in the emphasis of health-care delivery from the acute services to the Correspondence to: JH.Tel.: +44 -1189-318853; Fax: +44-1189-316808; E-mail: [email protected].
primary care setting. This paper will endeavour to address the role of the Community Children’s Nurse (CCN) in the context of the historical development of CCN services, and to discuss the challenges of the educational preparation for this complex, multi-faceted role.
THE DEVELOPMENTOF COMMUNITYCHILDREN’S NURSING SERVICES A CCN service ¢rst appeared in the United Kingdom NHS in Rotherham in 1949 in response to concerns regarding hospital acquired infection and associated infant mortality.2 This was followed in the 1950s by service developments in Birmingham and Paddington. Existing services at this time were based predominantly on meeting the needs of children with acute illness but in 1969 there was an innovative service development in Southampton to meet the needs of children following day surgery.More recent service developments have been in£uenced by the increasing survival rates of children with complex health problems3 and thus the CCN role has had to incorporate care needs of children with acute illness, post-surgery and chronic illness.
426 Despite the recommendations of the Platt Report4 that children should, wherever possible, be nursed in their own home, expansion of services was slow. The Court report5 reiterated the government support to provide sick children with the opportunity to be nursed in the home environment but still by 1980 there were only eight teams in the UK. However during the 1980s, there was more signi¢cant growth culminating in the emergence in1987 of the Royal College of Nursing Community Children’s Nursing Forum as the major focus of CCN policy and practice development in the UK. The Forum has provided a voice for the CCN in the wider ¢eld of policy development and has been in£uential in the continued expansion of CCN services. This voice was evident in the recommendations of the House of Commons Select Committee report in 19976 stating the following: K
K
K
All children requiring nursing should have access to a community children’s nursing service, sta¡ed by quali¢ed children’s nurses supplemented by those in training, in whatever setting in the community they are being nursed. This service should be available 24 h a day, 7 days a week. Every GP should have a named CCN.
As we enter a new millennium there are over 250 CCN teams in the UK representing greater equity of access for children and families.7 As services continue to develop there is emphasis on exploring in greater depth the role of the CCN. Because of the lack of a national strategy, CCN services have been established on an ad-hoc basis generally in response to local need. They may be based on a generalist or a specialist service model and they could be funded by a variety of sources including acute Trusts, Primary Care Trusts and charities. It is clear from the literature that services vary in their organization and management and in many cases the criteria for referral of children and families to the service may di¡er.The disparity of service delivery in no way detracts from the commonality of the underlying philosophy of the CCN to deliver safe, e¡ective health care in partnership with children and their families, and in collaboration with other health, social and voluntary sector colleagues, in the community setting. This shared philosophy has shaped the role of the CCN and the complexity of this role will now be analysed.
THE CCN ROLE:THE PRACTITIONER PERSPECTIVE The role of the CCN has been described as being diverse, £exible and responsive whilst maintaining its philosophy regarding service delivery.8 CCNs have a unique role, encompassing key skills and knowledge that
CURRENT PAEDIATRICS
enable children and families to be cared for at home. To analyse the complexity of the role, key areas will be discussed that will give an overview of the role of the CCN. These key areas are: K K K
Caseload pro¢le. Partnership and empowerment. Family care.
Caseload pro¢le The exact pattern of referral to a CCN will vary in accordance with the organizational model of CCN service delivery. However in analysing the CCN role, it is essential to o¡er examples of the children that CCNs are likely to be involved with and the professionals that might refer to the service (Table 1).
Partnership and empowerment It is important that the CCN has the ability to enable families to care for their child without causing undue stress, through working in partnership and empowering them with knowledge regarding the care of their child. This aspect of the CCN role has been explored to be markedly di¡erent from that of the hospital-based nurse. To enable the family to manage the care of their child, it is essential that little or no disruption is created to the daily living of the family. Hence, the CCN will share her skills with the families and empower the family to make decisions about the child independently but with support. Empowerment is a term that CCNs use consistently in their work. Allowing families to make decisions with support is something that is developed with the experience and expertise of the CCN.9 However, it is important to emphasize that CCNs have to exercise professional judgement and their focus is the child’s safety and rights, as the child’s best interests are paramount and underpin the philosophy of care.
Table 1 Caseload pro¢le Types of referrals Examples Asthma, eczema and constipation Cystic ¢brosis Oncology-related illness Gastric problems Tracheostomy care Chronic lung disease Neuromuscular disorders Post-surgery IVAntibiotic administration
Who might refer? General practitioner Community/acute pediatrician Health visitor District nurse A & E department Other professions allied [speech therapy/dietitian]
THE ROLE OF THE COMMUNITYCHILDREN’S NURSE
427
Partnership is fundamental to the role of the CCN. It can lead, ultimately, to the family being independent with all care, to the point where the CCN can withdraw the service. A key skill that is paramount for partnership is teaching.Teaching and education are integral and are carried out in a variety of ways. Much of the CCN teaching will be carried out in the home, whereby telling and showing parents how to carry out technical tasks or use equipment is essential to the care of the child.8 To assist CCNs in their teaching skills it has been identi¢ed that other elements in their practice enhanced e¡ective learning for the family.8 These elements were that CCNs and families had formed developmental partnerships rather than implementation partnerships, they were exploring, clarifying and making sense of the circumstances.This partnership and trust helps build on the families’ self-con¢dence and allows them to explore and become partners securely. Furthermore, partnership can aid co-ordinated interprofessional support, which is important to the families. CCNs view liaison and partnership with other professionals as an essential part of their role and are quite often perceived as the keyworker, who is able to manage the caseload for the family.10 Liaison can take the form of many elements,‘including o⁄cial liaison, case conferences and unceremonious e¡orts, communication and goodwill’.8 The inter-professional support can be with professionals from health, social, education and voluntary sectors, which encourage good working practices. Achieving this partnership gives rise to CCNs having a combination of skills that incorporate: self-management, knowledge of the service and the community at large and willingness to seek information and go on to share that information.
sharing. It has been recognized that due to the length of time of a care episode, interaction between the nurse and family and the insight into the families’ needs and circumstances provides a deep relationship individualized to the families’ needs. Within this relationship negotiation and listening to the needs of the family are essential skills. Negotiation and listening empowers the family and builds trust with the CCN, allowing the family to explore in a trusting environment. Support is a highly regarded skill, whether physical or psychosocial, which is often the key reason for the CCN’s involvement with the family. This can be clearly seen with children who have complex health needs, where the families are independent but at times require support from professionals. Adaptation to illness can produce feelings for the family that are too much to bear and the support needs will £uctuate in accordance with the wellness of the child and external in£uencing factors of other family members.CCNs have an integral part to play in times of crisis, including bereavement, and o¡er much support and counselling to the family at a time of much despair. Although CCNs would acknowledge they were not experts in this area, the comfort brought to the family is overwhelming, due to the strong and established relationship. Support could be provided in di¡erent ways and simply listening to the concerns of the child and family actively ensures any action needed is negotiated and appropriate to meet their needs.Other qualities that are involved are ‘being watchful and mindful, and knowing the boundaries of one’s own skills’.8 It is important to families that they are able to share the burden of care and have acknowledgement from the CCN who is able to understand the complex problems from the families’ perspectives.9 The relationship between the CCN and family is unique and very satisfying and can draw the CCN into a closer involvement with the family. However, this may have consequences for the CCN. Three areas of potential di⁄culty have been recognized:8
Family nursing CCNs care for children with a variety of complex healthcare needs that require an awareness of the current needs of both the child and family. Research clearly indicates the impact the care can have on a family. The cost of caring is summarized as follows: 10 K K K K K
Adverse e¡ects on the siblings. Social isolation. Lack of privacy. Financial loss. Parental stress.
Therefore, the CCN’s insight into each family is essential to be able to work and plan for the future. It is also imperative that CCNs are still involved with children who have a chronic condition that is well managed, as their skills and knowledge are vital when the child/family require intervention.11 Communication skills have been a main theme in analysing the role of the CCN, like listening, informing and
K
K
K
Building supportive relationships with certain families may jeopardize other families and increase the workload of the CCN. Creating over-dependency on the service could inhibit the families from taking control. Ensuring that the CCN has clear professional boundaries with each family for personal protection.
Research has highlighted that although these problems could arise, the experience of CCNs in relation to their awareness of family relationships and the support they receive from colleagues are some of the ways that they deal with di⁄cult issues. In analysing the role of the CCN, it is apparent that the relationship between the CCN and their families is of a special nature. Although there are many
428
practicalities to the job, much emphasis has been on the skills of empathy, compassion, partnership and listening. To ensure that families receive this ongoing service, it is imperative that appropriate education is given to CCNs who wish to develop their skills and enhance their scope of practice. Education is the key to going forward and this will now be fully explored.
EDUCATIONAL PREPARATION FOR THE CCN:THE EDUCATIONALIST’S PERSPECTIVE The practitioner perspective highlights the complexity of the CCN role and adds weight to the argument that the role should be recognized as a branch of community specialist nursing practice.12 Prior to the publication of the UKCC standards for the preparation of community specialist practitioners the only available education for CCNs was the Health Visiting or District Nursing course.Whilst this would equip the student with the appropriate skills and knowledge to deliver care in the community setting, such programmes would not address the speci¢c issues that the CCN meets in everyday practice in relation to sick children’s nursing. Thus, the new developments were welcomed by the profession and courses conjointly validated by the ENB and the relevant academic board were developed. Educationalists have been working closely with CCNs to ensure that the curriculum addresses the needs of CCNs locally as well as addressing the wider national context of CCN care delivery.13 It has been argued 14 that the CCN practitioners of today are those best placed to identify the skills and knowledge required by the CCNs of the future and thus the structure of the curriculum planning team must re£ect this. CCN input is also crucial to the practice component of the course as appropriate placements and mentors will need to be identi¢ed to support the development of the CCN student. In the initial stages of development of the programme practice placements proved challenging due to the limited number of CCN services and appropriately quali¢ed mentors. Over the past 5 years the continued development of services and educational preparation for mentors has alleviated the element of challenge of ¢nding the placement,15 but the challenge of providing an educationally sound practice placement and ensuring students and mentors are suitably supported must always be recognized to ensure continuous quality.16 All the specialist practitioner programmes address four broad areas of practice as set out by the UKCC and these four areas will now be explored addressing both the practice and theory elements speci¢c to the CCN role. K K
Clinical practice. Care and programme management.
CURRENT PAEDIATRICS
K K
Clinical practice development. Clinical practice leadership.
Clinical practice This area of the programme aims to develop the CCN’s skills in assessing, planning, delivering and evaluating care for children with health problems. The knowledge required to care for sick children and their families is changing.The pattern of childhood illness is one of decreasing mortality and increasing survival of children with very complex health needs often resulting in technology dependence.3 Thus, the practical skills for the CCN must be developed and course outcomes must include a practitioner who has reached expert status in care planning. Much of the care delivery is in partnership with family carers and CCNs are therefore required to have the skills to teach and support carers in their role.Often this will require a great deal of practical expertise in dealing with complex technology but also requires attitudinal skill in working closely with family members. The ENB commissioned research 8 illustrates six speci¢c skills that the CCN must be equipped with and this area of the course programme will address the following two skills: K K
Formal knowledge and technical skills. Teaching skills
Care and programme management This area of the programme aims to develop the CCN’s skills in promoting and improving health in children, their families and the wider community.The student will develop a critically analytical awareness of the health needs of children and families and will recognize the collaborative nature of care programming. During the course they would be encouraged to seek out social, education and voluntary sector colleagues to discuss issues surrounding care management for sick children in the community. It is likely that much of the theoretical component of this area of the curriculum will be shared learning with other specialist practitioners in addressing community pro¢ling and care management. This will address the following:8 K
Relational, interpersonal and support skills.
Clinical practice development This area of the programme addresses the skills required by the CCN for continuous personal and professional development. There has been much evidence to suggest that experiential learning is an e¡ective strategy when managed appropriately. For the purpose of the course students are encouraged to keep a re£ective diary and
THE ROLE OF THE COMMUNITYCHILDREN’S NURSE
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they are required to complete assignments directly re£ecting on a critical incident from their practice. Re£ective practice requires a high level of cognitive thought and it is essential that if students are required to re£ect there is support from a mentor who is an appropriate role model. By utilizing a model of re£ective practice (Fig. 1) the student will describe the incident and then analyse and evaluate their feelings about it, thereby learning through the experience. Developing these skills of re£ective practice is essential to promote practice development and both mentors and students will be supported by tutors in utilizing skills of re£ection in their daily practice.The skill development here is:
relative infancy of the role accounts for this and the more opportunity we have as a profession to publish and present conference papers the more likely we are to raise awareness. Developing leadership skills in CCNs of the future is therefore essential to the continuous development of the service. CCNs need not only to have the skills to empower families, but also to be empowered as professionals to enable them to promote their service to commissioners and ultimately improve the quality and equity of care for children and families. The two skills remaining from those advocated by the ENB research will be addressed in this area of the curriculum:
K
Thinking skills. K K
Clinical practice leadership The specialist practitioner programme is designed to produce leaders in the ¢eld of community nursing. This area of the curriculum therefore has a focus on leadership issues both for the individual and in relation to team membership. Throughout the programme students will develop the skills to manage a caseload of children with a variety of health needs and will demonstrate appropriate caseload management aØ propos prioritizing care. Continuous quality of care will also be addressed linking the relevance of auditing to the CCN role for the purpose of demonstrating both the quality and quantity issues for CCNs. From personal experience as a CCN team leader I am very aware that CCNs feel that they are constantly required to justify their role to colleagues from both the acute and primary care sectors. The
Description What happened?
Action Plan
Feelings
If it arose again what
What were you thinking
would you do?
And feeling?
Conclusion
Evaluation
What else could you have done?
What was good and bad about the experience ?
Analysis What sense can you make of the situation ?
Figure 1 Gibbs re£ective cycle.
Skills for managing their own work. Co-ordinating knowledge and skills.
This paper gives a broad overview of the role of the CCN as perceived by the practitioner and the educationalist and highlights the complexity of the role. It is clear that both practitioners and educationalists must work together in adjusting and improving the educational preparation to accommodate the needs of students, colleagues and ultimately children and families.
REFERENCES 1. Great Britain Department of Health. Child Health in the Community: A Guide to Good Practice. London: The Stationery Office, 1996. 2. Whiting M. Building a nationwide community paediatric nursing service. Nurs Standard 1985; 419: 5. 3. Kirk S. Families experiences of caring at home for a technology dependant child: a review of the literature. Child Care: Health Dev 1998; 24: 101–114 4. Ministry of Health. The Welfare of Children in Hospital. London: HMSO, 1959. 5. Department of Health and Social Security. Fit for the Future: The Report on the Committee of Child Health Services. London: HMSO, 1976. 6. House of Commons. Services for Children and Young People in the Community 3rd Report of the Health Select Committee. London: The Stationery Office, 1997. 7. Royal College of Nursing. Directory of Community Children’s Nursing Services, 15th edn. London: RCN, 2001. 8. English National Board. Researching Professional Education: Preparation for the Developing Role of the Community Children’s Nurses. ENB: London, 1999. 9. Department of Health. Evaluation of the Pilot Project Programme for Children with Life Threatening Illnesses. London: HMSO, 1998. 10. Murphy G. The technology-dependent child at home. Part 1: in whose best interest? Paediatr Nursing 2001; 13. 11. Carter, B. Ways of working: CCNs and chronic illness. J Child Health Care 2000; 4: 66–72. 12. United Kingdom Central Council. The Future of Professional PracticeFthe Councils Standards for Education and Practice Following Registration. London: UKCC, 1994.
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13. Livsey, P. Setting the agenda for education. (Chapter 9) Muir J, Sidey A, eds. Textbook of Community Children’s Nursing. In: London: Baillie`re Tindall, 2000. 14. Moyse K, Dryden S. A degree in Community Children’s Nursing. Nursing Times 1999; 95: 49–50. 15. Canham J, Bennett J. Mentorship in Community Nursing. London, Edinburgh: Blackwell Science Oxford, 2002. 16. Proud C. Community children’s nursing (Chapter 13). Canham J, Bennett J, eds. Mentorship in Community Nursing. In: London, Edinburgh: Blackwell Science Oxford, 2002. 17. Gibbs G. Learning by doing: a Guide to Teaching and Learning Methods. Oxford: Further Education Unit, 1998.
CURRENT PAEDIATRICS
FURTHER READING Fradd E. Setting up a paediatric community nursing service. Senior Nurse 1990; 10: 34 ^36. Marland J. Back where they belong: caring for sick children at home. Child Health1994; 2(1): 40 ^ 42. Muir J, Sidey A. Textbook of Community Children’s Nursing. London: BaillieØreTindall, 2000. RCN. Promoting E¡ective Team-Working for Children and their Families. London: RCN, 2000. Winter A. Construction and application of paediatric community nursing services. J Child Health Care 1997; 1: 24 ^29.