The role of nursing staff in public health

'Prevent' case studies

In Northern Ireland, height and weight measurement is carried out during school health appraisals which are undertaken with all Year 1 and Year 8 pupils as a requirement of the regional Healthy Child, Healthy Future universal child health promotion programme (DHSSPS, 2010).

School nurses are, therefore, uniquely placed to address childhood obesity given their skill in clinical overview and the scope for individually tailored family based interventions.

What initiative or project are you involved in?

The Healthy Weight Pathway for School Nursing was developed in the Northern Health and Social Care Trust (NHSCT) as a service improvement initiative targeting childhood obesity and overweight. It is a school nurse-led care pathway which represents the route through the school nursing service which is offered following identification of overweight and obesity at school health appraisals in Year 8. 

What prompted the work?

Levels of clinical obesity in Year 8 pupils in NHSCT had almost doubled from 7.5% to 14% in three years (2012/13-2015/16).  It was unclear whether consistent procedures were in place for informing families of the outcome of growth measurement following school health appraisal in Northern Ireland. There was a need to improve how that information was communicated and contextualised, how misperception of weight and related issues was addressed, and how practitioners could be supported to improve family support for healthier lifestyle behaviours. School nurses wanted to formalise a guided conversation and pathway to ensure consistency and quality of practice.

How did you initiate the work? 

The pathway makes provision for feedback with parents/carers and guided discussion by telephone for those assessed as ‘very overweight’ (clinically obese) and ‘overweight’ within the BMI centile range (RCPCH, 2013). Practice based learning sessions were provided to support teams to introduce the pathway and increase knowledge, skills and confidence.

School nurses complete telephone contact to inform parents of the outcome of their child’s school health appraisal and initiate discussion to increase knowledge and skills. Families are supported to make lifestyle changes to maintain healthy weight and improve BMI over time. Parents indicate how they would like to proceed with the information provided, whether self-care, or a school nurse-led health plan, with review at 3-6 months. Motivational tools, resources and local activities are provided or signposted. This is in line with 2013 NICE guidelines on lifestyle weight management services for overweight and obesity among children and young people (NICE, 2013). 

Measures of success

• Universal access to school-nurse led intervention for all young people identified as overweight and obese following school health appraisal in Year 8 
• Number of telephone contacts and number accepted/declined discussion
• % agreed self-care at home with school nurse support as required
• % agreed school nurse-led health plan with follow-up/review
• % self-reported healthier eating and meal patterns , new or increased physical activity, decreased weight/waist size and/or reduction in BMI centile range following clinical assessment

Outcomes

In 2016/17, school nursing teams completed 893 telephone contacts with families. 99% of parents accepted the telephone discussion and received feedback on the outcome of their child’s health appraisal. One third of families agreed to ‘self-care’ using information and advice provided and a third of families agreed a school nurse-led health plan with structured follow-up/review at 3-6 months. Nearly half of follow-up/reviews were achieved at 3-6 months.79% of parents reported healthier eating and meal patterns and exclusion/reduction of sugary drinks. 67% of parents reported that their child had taken up a new form of physical activity, or increased activity levels. 46.5 % of parents either self-reported that their child had decreased weight/waist size, and/or the school nurse recorded maintenance/reduction in BMI centile range at clinic follow-up.

What difference has the project or initiative made?

The Healthy Weight Pathway is an effective universal model for school nursing that supports families to make lifestyle changes, to maintain healthy weight and improve BMI over time. This is in line with 2013 NICE guidance on lifestyle weight management services for overweight and obesity among children and young people (NICE, 2013).

The Healthy Weight Pathway is integrated and quality assured into school nursing service provision.  Use of the pathway’s guided conversation has been pivotal in increasing the acceptability, awareness and engagement with families. School Nurses said that ‘There were no angry, defensive, or abusive phone calls this year’; ‘staff felt better able to guide discussion’; and ‘there was less hostility, better engagement’. 

The majority of parents had a positive attitude to the information and advice provided about their child’s weight status. This is notable given that there is a widely held perception that parents may have a hostile reaction to raising the sensitive issue of weight. Year on year, we demonstrate lifestyle behaviour change and re-engage parents with the role of the school nurse. 

What are the long-term objectives?

This information will be used to inform concurrent health profiling work in individual schools and localities. It is also be used in the planning and development of a model of school nursing in the NHSCT Public Health Nursing Service. School localities where childhood obesity and overweight exceeds the regional average have been identified for additional support and intervention. We will continue to explore the extent to which the guided discussion, and school nurse support, changed lifestyle behaviours at home and in school. As well as contributing to regional obesity targets set out in Northern Ireland’s Obesity Strategy (DHSSPS, 2012), we record an annual profile of overweight and obesity in Y8 young people.  This contributes to the work of the strategic planning group, the Northern Obesity Partnership. 

References 

1. Department of Health, Social Services and Public Safety (2010) Healthy Child, Healthy Future:  A Framework for the Universal Child Health Promotion Programme in Northern Ireland

2. NICE (2013) Weight management: lifestyle services for overweight or obese children and young people

3. Department of Health, Social Services and Public Safety (2012) A Fitter Future for All: A Framework for Preventing and Addressing Overweight and Obesity in Northern Ireland 2012-2022

What: A two year pilot within North Warwickshire to improve School Readiness within the county.

Who: Hayley Norman, Project Lead, School Readiness, Warwickshire School Health and Wellbeing Service

What is the initiative and or project you are involved in?

School readiness remains an area of concern across the country and has been highlighted recently by Amanda Spielman (Chief Inspector, OFSTED) at the Pre-school Learning Alliance Annual Conference. All the evidence indicates that if a child is not ready for school they are immediately disadvantage and the impact on their social and emotional development and their learning can be significant. Warwickshire School Health and Wellbeing Service (WSHWBS) has been commissioned via Public Health Warwickshire to undertake a 2 year pilot, utilising a new component of The Lancaster Model, within North Warwickshire to improve School Readiness within the county. The pilot commenced April 2017 and the outcomes will be fully understood by March 2019 following evaluation.

What prompted you to do this work? 

The Warwickshire Smart Start Strategy 2016-2020 focuses on children 0-5 years and aims to ensure that Warwickshire children have the best possible start in life. A major consideration within this strategy is to improve school readiness in Warwickshire. Warwickshire Public Health data from 2016 indicates that 71% of children do achieve a Good level of Development (GLD - is used to measure school readiness) in Warwickshire, however in boroughs of North Warwickshire, children achieved lower levels with approximately 1 in 3 children not reaching a GLD at the end of reception year and this is raised to nearly half within the male cohort.

The final mandated contact that children and families have with Health Visiting is 2¼. Consequently any health issues or concerns that emerge following this may not be addressed until children reach school age and their health is reviewed at school entry. The pilot aims to close the gap for children between the last Health Visiting contact and them starting school, facilitating their access to services and shaping public health interventions.

How did you initiate the work?

WSHWBS currently uses a health needs assessment tool (The Lancaster Model) to collect school entry data (Healthy Child Programme) and produce a public health plan which facilitates partnership working with schools. The health needs assessment is in the form of an online questionnaire and is offered universally to all parents who access the questionnaire through a secure portal. The school age questionnaire was developed by Kath Lancaster, to meet the needs of the pre-school child with regard to school readiness from an individual child and public health perspective.

During the first year of the pilot WSHWBS worked with 22 Early Years settings including Childrens Centres. Our aim was to work collaboratively with them, using their established communication processes, to offer their parents the opportunity to complete the online health needs assessment questionnaire. In order to facilitate the rollout of the questionnaire, we held focus groups with the Early Years professionals to understand the barriers and challenges that could present. The Early Years settings were keen to be involved with the pilot and assisted us by distributing to parents an explanatory letter, which included the link for parents to access and complete the health needs assessment online, and were pivotal in its promotion.  

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?

The Early Years settings raised concerns that the pilot would increase their workload and add pressure to an already stretched workforce. We met with all the settings individually and listened to their concerns and adopted an approach that was not prescriptive but allowed for flexibility of delivery depending on the individual settings circumstances. 

Has the initiative or project made a difference to patients/service users and or staff?

WSHWBS reviewed the completed questionnaires and contacted parents where a concern had been indicated.  So far only anecdotal evidence is available, however parents are reporting that the response from WSHWBS was timely and that they have received the extra help required. 

A number of children were identified as requiring extra support regarding behaviour, toileting and eating issues and these were referred back to the Health Visiting Service. We identified a number of children who were not attending dentists or having eye tests and these parents were given information regarding the importance of engaging with these services for their child and how to access them. Early indicators are that a number of parents have accessed these services and further analysis of this data will be undertaken following parents completing the school entry questionnaire.

The data gathered from the individual questionnaires was anonymised, collated via The Lancaster Model, and shared by WSHWBS with the Early Years settings. Facilitated and supported by WSHWBS, the Early Years settings reviewed the data and 3 public health initiatives have been devised to reflect the findings within specific geographical locations. Each initiative considers different aspects of school readiness and are fully supported by Warwickshire Public Health. The initiatives, which all impact on elements of school readiness, include:

Bottle swop – Health Needs Assessment Data indicated concerns in the areas of speech and language, accessing dental services and diet. Early Years professionals were concerned regarding the number of children using bottles within the age range of 1-4 years. WSHWBS approached public health to request funding to buy 1000 freeflow beakers/cups for the children within the locality, with the aim of supporting parents to swop from using feeding bottles to age appropriate drinking cups. The bottle swop will enable a face to face contact between a key professional and parent and support a discussion regarding the circumstances that the bottle is used and the advantages to health for changing from a bottle. Public Health messages will be given to parents which are linked to school readiness and parents will receive continued support in order to sustain the change. 

Adult Mental Health – Health Needs Assessment data indicated that within the cohort that completed the questionnaire approximately 1:5 adults reported a history of anxiety or depression. Using the data collected and collated by WSHWBS a comparison was made with the School Entry data which showed that this figure increased to approximately 1:3 adults within the school entry cohort during the same academic year. This was shared with Early Years professionals and following discussions it was noted that generally adult mental health is not addressed within the Early Years settings and the training that is received is limited. Early Years settings had informed us during the focus groups that they find it difficult to identify and access robust training and therefore within this area, the decision was made to focus on upskilling the early years workforce by providing an Adult Mental Health workshops. The training will include promoting positive adult mental health, recognising signs of deteriorating adult mental health, starting difficult conversations and signposting to relevant services. Stakeholders representing commissioning, adult and child mental health agencies, voluntary and third sector organisations have been approached and training workshops are now planned for the autumn.  

School Readiness – After reviewing the data the settings decided to focus on the skills that children require to be school ready, particularly physical skills and language skills. A decision was made to initially survey the local reception teachers from their feeder schools to determine the priority skills they would like to see improved with regard to school readiness. Using this information and knowledge from within the settings the plan is to develop a series of activities that, can be supported at home, to ensure that the children acquire the necessary competencies. 

It is too early in the pilot to determine what changes have been made and sustained within the 3 initiatives as the plan is to launch all 3 initiatives within the academic year 2018-19. 

The pilot identified the need for a countywide school readiness policy and this was fed back to Warwickshire Public Health. A broad working party has been established, with representatives from health, education and local authority, to co-produce a policy which will be available to all interested parties including parents. The aim will be to ensure a consistent approach to the expectations of children regarding school readiness.  

What are the long-term aims for the work?

Year 1 of the pilot was successful and will be extended and replicated to cover a larger part of the county during the second year. 96 settings have been invited to be included within Year 2 with the potential of reaching 2300 children. The anticipated outcomes are that there will be improved contact with services from families with children between the age of 3 and 5 years and that there will be more cohesive working between Health and Early Years professionals. Intelligence that is gathered from the health needs assessment questionnaire will be useful to inform any redesigning of services in a way that is evidenced and targeted to local needs.

Engaging with and working closely with the Early Years settings has proven to be pivotal to accessing parents of pre-school children due to the unique relationships that they build with parents. The settings also appreciated the extra support that they received from health and that there was a forum for them to discuss their issues regarding children’s health and development and their challenges accessing services.

Parental completion rate of the questionnaire overall was 39%. Parents have been surveyed to gain their views of the questionnaire and to understand their motivation for completion or non-completion. Recommendations have been made from this for year 2 of the pilot in an attempt to improve completion rates. This includes altering some processes and offering extra support to parents within the settings to complete the questionnaire. 

All outcomes of the pilot are shared with Warwickshire Public Health and are being measured by Coventry University. Following analysis of the pilot, Warwickshire Public Health will make any decisions regarding taking the initiative forward. 

Star Babies is an enhanced universal home visiting service for all first-time parents, offering monthly visits from the antenatal period until the baby is 12 months of age. The focus is on promoting infant mental health and supporting the transition to parenthood.

What prompted the work?

Star Babies was developed in response to evidence on the impact of early childhood experience and parenting relationships on later outcomes. Local parents indicated the need for more contact with their health visiting team and a greater focus on nurturing and emotional support, especially with a first baby. 

How did you initiate the work?

Star Babies began as a pilot service in 2013. By increasing the number of home visits available to first time mothers and fathers, the health visiting service has more opportunity to provide quality support and information about activities that promote sensitive, responsive parenting and the quality of secure attachment relationships. Key information and knowledge about aspects of child development, health and wellbeing and parenting support, paced within an enhanced framework of visits up to twelve months. 

Measures of success

• universal access and uptake for first time mothers and fathers
• effective delivery of skill mix service
• service user experience.

Outcomes

• increased support during transition to parenthood
• increased parental understanding of baby brain development and early experience on social and emotional development.
• increased awareness of healthy child development in context of public health issues. 
• increased inclusion of fathers.
• increased parenting confidence and skills.

Teams consist of health visitors, public health staff nurses and child health assistants. They receive Star Babies training, with follow-up practice based learning and mentoring. Star Babies is aligned to public health priorities, such as infant mental health, childhood obesity, physical activity, childhood injury prevention and school readiness. Public health issues include lifestyle behaviours, managing childhood illness, childhood injury prevention, breastfeeding and infant feeding, physical activity in non-walkers, safer sleep, and healthy emotional and social development.

What difference has the project or initiative made?

Nearly 4000 first time families received Star Babies between 2013- 2017. All parents are asked to complete an evaluation and results remain strongly positive. For example, 94% of respondents either strongly agreed or, agreed that Star Babies had increased their knowledge, confidence and skills as a new parent. One respondent commented: “I feel that there is a lot of pressure on new parents to follow ‘text book’ routines. Star Babies is so important for new parents to reassure them of their baby’s individual needs.”  

What are the long-term objectives?

Professional research commissioned to evaluate Star Babies and contribute to the evidence base. Star Babies contributes to the NHSCT Infant Mental Health Strategy and Action Plan (NHSCT, 2017).

What: Weigh To Go - A weight management programme for 12-18 year olds

Who: Julie Gordon – Health Improvement Lead and Coordinator, Youth Health Services

Youth Health Service Nurse - Kate Dods

Business Support Assistant (Ryan Hughes during Pilot phase)

Background

Qualified in 1984 with a BSc in Nursing from Dundee, quickly moving into Primary Care and Community Nursing, gaining a Diploma in District Nursing (Glasgow) in 1989, followed by a post in Practice Nursing for an inner city GP practice. Thereafter, she gained her family planning qualification (1991) and worked in the area of sexual health with a particular interest in young people, ultimately securing the position of Lead Nurse for young people at the Sandyford Initiative, Glasgow. In 2000, following an arts based consultation with local young people, in her role of Clinical Youth Co-Ordinator, Julie set up the first holistic service for young people aged 12-19 years of age, in the Maryhill area of Glasgow. The aim of which was to respond to complex issues using a “one stop shop” approach.

Julie Gordon has presented at the Approaches Conference (Glasgow 1995); Association for Young People’s Health (London 2008) and the World Health Organisation (Edinburgh 2009). Julie Gordon has also been a guest Lecturer at Glasgow Caledonian University for a period of five years.

With the creation of Community Health Care Partnerships in Glasgow, Julie Gordon became the Lead for Youth Health, both clinically in delivery of Youth Health Services (YHS) and also from a Health Improvement perspective in the North West of the City, as a result of various organisational changes, within North West of the City. There are currently three YHS in this area, targeting areas of greatest need, offering the same holistic approach. In her current role, her focus is on addressing the inequalities of health for young people living in the North West Locality of Glasgow City Health and Social Care Partnership. In 2014, with colleagues and following a successful application to the British Heart Foundation to become a Hearty Lives Pilot Project, she was tasked with the implementation of the researched model for weight reduction in young people. Initially this targeted 16-18 year olds.

Approach: Prevention

Location: Glasgow City Health & Social Care Partnership (HSCP) – North West Sector

Speciality: Health Improvement

What is the initiative and or project you are involved in?

Weigh To Go was a weight management programme for young people 16-18 years of age in some of Glasgow’s most deprived neighbourhoods. Originally funded by the British Heart Foundation as part of its Hearty Lives initiative, the pilot was managed by Glasgow City HSCP – under the umbrella of the North West Youth Health Service. In light of the obesity epidemic, this pilot project was designed to support young people aged 16-18 years of age, who have a BMI of over 25, to lose weight and consequently reduce their cardiovascular risk. Young people were provided with regular support from Youth Health Service/Outreach nursing staff, and free access to commercial weight management. The longer term aim was to contribute to the evidence base about successful interventions which address the issue of obesity in young people.

What prompted the work

People living in the poorest areas of the country are, on average, more likely to die from cardiovascular disease than people living in the most affluent. Glasgow, as a city, experiences marked inequalities of health with multiple areas of deprivation, consequently, young people from Scottish Index of Multiple Deprivation (SIMD) 1 & 2 were targeted.

The British Heart Foundation funded a number of Hearty Lives initiatives in communities at greatest risk of heart disease and stroke to tackle these health inequalities.

The pilot was prompted by a range of factors:

• official figures for Scotland, between 1995 and 2012, the proportion of people aged 16 to 64 who were overweight or obese increased from 52.4% to 61.9%. Currently the rate of obesity in teenagers is approx 30%.
• young people who are obese are more likely to develop risk factors for cardiovascular disease, such as high cholesterol, high blood pressure and type 2 diabetes 
• lack of evidence on the most effective obesity intervention programmes for young people
• gap in NHS Greater Glasgow and Clyde service provision for young people who are overweight or obese
• the opportunity to secure funding from the British Heart Foundation for projects which aim to reduce the risk of cardiovascular disease for children and young people across the UK
• health inequalities in Glasgow. 

How did you initiate the work?

A business plan was presented to British Heart Foundation based on local surveillance data and a proposed model informed by extensive consultation with young people.

The programme was implemented in 3 of the most deprived areas in the North West Glasgow, with a comprehensive marketing campaign. The publicity and marketing materials were developed and influenced by young people to address the potential challenge of recruiting and retaining young people. 

From a monitoring and evaluation perspective robust data collection tools were created to support reporting to NHS GG&C and the British Heart Foundation.

Young people were screened for inclusion to the programme and a 1:1 assessment tool repeated at various intervals. The young people were supported by Youth Health Service/Outreach nursing staff for up to 24 weeks. Benefits included:

• regular contact with nurses, face-to-face and/or by phone, to check on progress and offer advice and help
• free access to weight management support through a contracted arrangement with Scottish Slimmers / Weight Watchers and ultimately solely Slimming World (using BMA approved programmes) 
• encouragement to engage in physical activity, especially walking.

Measures of success include:

• weight loss; weights recorded by commercial weight management services, on a weekly basis- 5% weight loss being considered as clinically significant
• participation in physical activity; noted through 1:1 assessment
• levels of motivation, confidence and self esteem; measured using approved tools e.g. Rosenberg Self-Esteem Scale (Rosenberg, 1965)
• behavioural change; measured using research-based questions to identify behaviour modification. For example: Fizzy Drink or Take away consumption
• roll out of the programme across Glasgow City HSCP (years 2 and 3).

What difference has the project or initiative made?

From the 75 participants recruited from across Glasgow:

• 78% achieved weight loss, between week 0 and 12
• 55% achieved a 3% target weight loss.

On average, improvements in behaviour change were noted for example increased consumption of fruit and vegetables, and participants reported improved confidence and self esteem.
Individual case studies showed broader benefits for example, a reduction in prescribed medication, and engagement with volunteering opportunities.

What are the long term aims for the work?

The long term aim of the work was to contribute to the evidence base on models, which work in terms of supporting young people to lose weight and impact on cardiovascular risk. The pilot has been adopted by the Glasgow City HSCP following the end of funding from the British Heart Foundation. The age has been expanded to include young people from age 12 years and the service has been rolled out to the other 5 HSCP areas in NHSGG&C.  At a celebration event in October 2017 in the Glasgow Science Centre, young people and families described the benefits to them via a short pre recorded film. Some young people have lost ½ their body weight. Some have gained employment and some describe how much more confidence they have and that they are happier. Other young people have become volunteers and gained youth achievement awards after engaging with the programme.  

The Weigh To Go project was nominated for a number of awards and was successful in winning the British Heart Foundation - Hearty Lives Impact Award in 2015.

What: Finding Balance - a collaborative ‘digital interactive theatre’ (DIT) project designed and delivered as a public health/public engagement activity to raise awareness of mental health about ‘low level stress and anxiety’

Who: James Wilson, Principal Teaching Fellow, University of Southampton 

Background 

Finding Balance is a collaborative ‘digital interactive theatre’ (DIT) project designed and delivered as a public health/public engagement activity to raise awareness of mental health about ‘low level stress and anxiety’. It was specifically created to focus on the experience of the Sixth Form College student exploring the life decisions taken prior to their a-level exams. A DIT combines a story written in a 'choose your own adventure' style with multiple paths and then presented as a live theatrical play to the audience. At choice points via a student response system the audience get to make decisions on how the actor proceeds. 

Who was involved?

The collaboration included staff and students from both the University of Southampton & Barton Peveril Sixth Form College. University of Southampton student nurses volunteered to be the actors for the project. The project lead was James Wilson, Principal Teaching Fellow, University of Southampton. The Key partners in the project included: Nicola Carcone, Deputy Principal, Barton Peveril, College, eight student nurses from the University of Southampton and two Barton Peveril College students. 

Personal background

The collaboration was led by James Wilson, Principal Teaching Fellow at the University of Southampton, a National Teaching Fellow with the Higher Education Academy and a registered mental health nurse. James created the digital interactive theatre method in 2014 to provide academics and students the opportunity to reach out to the community and achieve an education that truly values person-centre care and co-production. 

Approach: Promotion and Prevention

Location: University of Southampton Nuffield Theatres (City), Southampton Barton Peveril Sixth Form College, Eastleigh

Speciality: Public Mental Health and Wellbeing Awareness

What prompted the work? 

Public mental health and wellbeing is recognised as one of the “greatest social challenges of our time”. Overall, it is estimated that one in ten children and young people have a diagnosable mental disorder – the equivalent of three pupils in every classroom across the country. Schools and Colleges are a vital part of a wider systems approach in promoting positive wellbeing and preventing mental illness. The specific issue identified and focused on was 'low level stress and anxiety' amongst upper sixth form students particularly around the preparation and performance of A-Level exams. The project is a response to the national reporting trends on increasing numbers of young people seeking mental health support around the exam season.

How did you initiate your work?

Work to co-create an authentic story included the input the student nurses and Barton college students. Eight student nurses were recruited as volunteers and underwent a rehearsal process. Dates to perform the project were agreed and included: a 'health through arts' festival and Barton Peveril College. Local media outlets were contacted to extend the mental health awareness messages (e.g. BBC Radio Solent). An evaluation of the project was designed and individual reflective accounts and peer reviews provided the evidence of effectiveness.

What difference has your work made?

College students evaluations via the pre & post questions showed they had a heightened ability to recognize stress in themselves and in others. Student nurse reflections highlighted the beneficial personal development opportunities. Public comments included 'every sixth former should see this play'. Peer review (Healthwatch) stated Finding balance has an important role in influencing change. 

What are the long term objectives?

The Finding Balance DIT is an innovative production combining theatre and technology. 

Sustainability and scalability is being explored which will include link work with University outreach teams, public health organisations, student unions and sixth form colleges.

Health literacy is about people having enough knowledge, understanding, skills and confidence to use health information, to be active partners in their care, and to navigate health and social care systems. 

More information can be found at NHS Education for Scotland's The Health Literacy Place.

What: A programme of health literacy and ‘teach back’ to promote better understanding and self-management by patients

Who: Kate Burton – Public Health Practitioner

Approach: Promotion
Location: Edinburgh Community Health Partnership
Speciality: Long-term health conditions

What initiative or project are you involved in?

A programme of health literacy and ‘teach back’ to promote better understanding and self-management by patients.

What prompted the work?

The NHS Healthcare Quality Strategy in Scotland made a commitment to ‘improve resources to support better health literacy’.

Teach back is a technique that improves communication, patient safety, self-management and health literacy.

‘Teach back’ is a method used by healthcare providers, to confirm they have explained healthcare information in a manner understood by their patients.

Actions to achieve this ambition are system wide and will include ‘improving communication and effective collaboration between patients and staff’.

What difference has the project or initiative made?

Teach back has proved to be a simple but effective way to check, not only a patient’s understanding of their condition, but also to assimilate better the explanation and advice given to them at each interaction with nurses.

What: Case study about supporting a young person with anxiety

Who: Ashley Witnall, School Staff Nurse, Warwickshire School Health and Wellbeing Service

What is the initiative and or project you are involved in?

As a school staff nurse one of my roles involves me supporting children and young people on an individual basis. This case study outlines some work I undertook with a young person who was referred to me.

What prompted you to do this work? 

The young person was referred into Warwickshire School Health and Wellbeing service by the school’s Welfare Lead. They considered that the young person had issues around social anxiety and felt that support by a Public Health nurse would assist the individual.

How did you initiate the work?

I invited the young person to meet with me in school to discuss the issue of anxiety. In preparation I gathered together a list of useful websites, a list of SMART phone apps, and the ChatHealth texting teen line number.

When I met with the young person, they reported that they had a problem with social anxiety, and they were able to describe physical and emotional symptoms of anxiety such as; being unable to concentrate, pounding heart, breathing fast, sweaty palms and churning stomach. These symptoms resulted in the young person reporting that they were unable to speak in class to peers or to the teacher. The young person felt that their grades were suffering as they were struggling to concentrate in class.

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?

I provided the young person with anxiety support over three sessions. During the first session we explored the young person’s symptoms and possible triggers and I directed them to some self-help emotional health websites and mobile phone applications. During the second session we discussed strategies that could be tried to relieve anxiety such as breathing techniques and relaxation and I also discussed the importance of exercise on mental wellbeing. At the final session we explored whether the suggested strategies and self-help resources had been helpful. The young person felt that the support I had provided had been valuable and useful.

However I got the impression that there remained an underlying concern which the young person hadn’t yet revealed to me. Through gentle use of probing questioning the young person acknowledged that they did have a concern which we hadn’t yet discussed. Through gentle use of open ended questioning and active listening I found that the young person gradually chose to share their innermost concern with me. Over a period of time the young person revealed that they were transgender and considered herself as male, rather than female.

This disclosure enabled me to assist the young person in a more specific way. 

• I completed a child and adolescent mental health (CAMHS) referral with the young person’s consent
• We discussed the anxiety the young person was feeling about being transgender
• We discussed and jointly researched support options/groups specific to LGBT (Mermaids UK and Proud Youth Warwickshire)
• We discussed how they could inform their parents and we role played how they could go about this
  
  

Has the initiative or project made a difference to patients/service users and or staff?

The care provided by me as part of the Warwickshire School Health and Wellbeing Service, ensured that the emotional health and wellbeing issues presented by the young person were appropriately addressed and supported. Without this intervention by there is a likelihood that the young person would have continued to struggle with anxiety, affecting school and social life and may not have sought support as a transgender young person.

This would have had a further negative impact on the young person’s educational attainment and emotional health and wellbeing. As a consequence this could have spiralled into emotional harm as there is evidence that transgender young people are more likely to suffer depression, self-harm and go on to commit suicide. The interventions I provided have enabled the young person to take control of his emotional and mental wellbeing and access the support of appropriate services.

The young person now presents as a happier and more confident person and has even found the courage to tell their mother. Through deciding to change hair style they have begun the transition to becoming male. With encouragement from me, the young person has taken the step of approaching the GP for hormone blocker medication. The young person has had his assessment with CAMHS in June 2018 and is excited about what the future holds for him.

What are the long-term aims for the work?

School Health and Well-being have now completed the work with the young person. Through the support we have provided this young person is now accessing the most appropriate specialist support.

As a service we are aware of the importance of supporting children, young people and families around transgender issues. At our annual service Away Day we received update training from Proud Youth Warwickshire. This has enabled the all practitioners to become more knowledgeable about LGBT+ issues and now have a greater understanding on how to support a young person who discloses that they are a member of the LGBT+ community.

Professional learning:

As a relatively new School Staff Nurse I felt privileged to have been able to support this young person. The School Nursing team responded promptly to the referral from the school and therefore we were able to swiftly respond to this important health concern. As School Health works across professional agencies I was able to meet with the young person in an environment which was convenient and familiar to them. This enabled me to quickly build rapport and trust. I am proud that the School Health is able to provide such a professional service to support children and young people.

What: A health education programme that encourages local patients and staff to take responsibility for their health and well-being

Who: Anne Thomas – Staff Nurse

Background: Anne is a band 6 Staff Nurse, with a BSc in Health Studies and qualifications in Health Education and counselling. 

Location: Betsi Cadwaladr University Health Board, Outpatient Department, Dolgellau Hospital, NHS Wales

Specialty: Community nursing and health promotion

What initiative or project are you involved in?

A health promotion hub that encourages local patients, staff and the community to make healthy lifestyle choices, and signposts to other available forms of help and support.

Working in a small hospital at the heart of a rural community, the outpatient team at Dolgellau Hospital provides an effective, patient-centred health education programme.
Since 2012, the team have developed several initiatives, including:

Healthy Hearts: a programme of 6 individual sessions to support chronically ill patients who are at risk of cardiovascular disease or who would benefit from making positive lifestyle changes. An expansion of the Healthy Hearts programme to include rheumatoid patients; a study of these patients resulted in a research study of the effectiveness of the Healthy Hearts programme.

Working for a Healthy Heart: an initiative developed for Dolgellau Hospital staff to provide support for lifestyle changes. This includes initiatives such as the walking and hydration challenge to improve ealth in an enjoyable way.

Prostate Symptom support Sessions: Men are able to drop in or be referred for education and tests for prostate symptoms. Providing services locally has been the key to successful health promotion.

Testicular Awareness: Visits to colleges and schools to give presentations to raise awareness of testicular cancer.

Sun Awareness and Skin Cancer Recognition: Health education is taken to where it is needed most. Staff visit farmers markets and target other outdoor workers such as postmen, giving health education literature and sun screen samples. 

Farmers mental health support: (See video above)

Carers Health and Well-being: Carers Outreach Service is available for carers within the department.

Macmillan Health and Well-being: Drop in sessions to provide support for patients and carers following treatment.

What prompted the work?

Self care is a key theme in the Welsh Government’s Delivering Local Health care plan (2013). The focus is on providing support for people to adopt and maintain healthy lifestyles, as well as empowering them to manage and minimise the impact of long-term conditions on their day-to-day life.

Self care is part of a continuum of care, starting with the responsibility individuals have in making daily choices about their lifestyle, right through to major trauma where responsibility for care is entirely in the hands of the health care professionals, until the start of recovery when self care can begin again. The outpatient team at Dolgellau Hospital support people to self care at all points along the continuum.

The Rural Health Plan (Welsh Government 2013) and own research identified barriers to accessing health education in rural areas. The development of the Out Patient Department as a Health Promotion Hub aims to encourage the rural community to see it as a resource for good health as well as ill health.

What difference has the project or initiative made?

The change in focus to preventative health care has had a positive impact on patients, staff and community at no extra cost to the NHS.

What are the long-term objectives?

• To reduce inequalities in health in rural areas with a particular focus on men’s health.
• To make health education more accessible to the community by taking ‘Out Patients Out’. Including young people; learning disability groups; patients with chronic illness at home. 
• To take the model of Health Promotion Hubs to other rural community hospitals.

Patient Testimonials

'The help, advice and support was beneficial in pointing out to me things I already knew but was not implementing in my lifestyle.’ (68 year-old female)

‘This approach for me is helpful as sometimes I think more about work than my own well-being.’ (55 year-old male)

‘The programme has helped me to address my health and weight issues without being made to feel guilty.’ (45 year-old female)
 
'I have found that students are more willing to discuss their health since you have been coming to the construction department.' (College Tutor)

'I wouldn’t have bothered to come (for a flow rate test) if I had to travel.' (64 year-old male)

'I like it that I can drop in for advice without an appointment.' (56 year-old male)

Awards

• BCUHB 2012 Achievement Awards: Evidence into Practice: Healthy Hearts Programme
• BCUHB 2013 Achievement Awards: Evidence into Practice: Healthy Hearts Programme/Rheumatology department collaboration
• Shortlisted for 2014 Nursing Times Awards: ‘Working for a Healthy Heart: Promoting Rural Workplace Health and Wellbeing’
• Nursing and Midwifery Awards 2014
• BCUHB 2014 Achievement Awards Winner: Contribution to Improving the Health and Wellbeing of Staff in the Workplace
• BCUHB 2015 Achievement Awards: ‘Working in Partnership’
• RCN Nurse of the Year Award 2015, runner-up in ‘Improving Individual and Population Health’
• BCUHB Achievement Awards 2016 Winner
• RCN Health Care assistant of the Year Award 2016
• RCN Wales Health Care Support Worker of the Year Award 2017
• RCN Nurse of the Year Community Nursing Award 2017 for ’Addressing Inequalities in Men’s Health in a Rural Community’

We know increasing numbers of working age people and families, particularly people with long term health conditions, including mental health problems and lone parents, are experiencing financial pressures and debt, due austerity and changes to welfare provision.

Significant life events such as pregnancy, onset of illness / disease, traumatic life changing injury, bereavement or becoming a carer can also result in financial pressures. 

Whilst nurses are not trained money advisers, there are four simple steps they can follow to support those with money worries get the help they need when they need it:

1. Consider money worries as an underlying cause of both mental and physical health conditions
2. Ask patients simple questions about money worries, such as ‘Have you got any money worries that might be affecting how you are feeling?’
3. Refer patients to an appropriate money / welfare adviser, preferably one who is integrated into their health & social care team
4. Engage with the adviser, providing access to medical records, with the patient’s consent, or producing medical reports if required.

What: An independent travel clinic and consultancy business

Who: James Moore – Director and Clinical Nurse Specialist

Background: The Exeter Travel Clinic began in 2008 when clinic director James Moore, decided to combine his love of travel and healthcare. With a background in Emergency Nursing and qualifications in Travel Medicine and Tropical Nursing, James felt that there was a place for a specialist travel clinic where individuals can get advice from well trained staff who also have experience of working and travelling abroad.

James’s links with travel and expedition medicine are wide and varied. From being a past Honorary Secretary for the British Global and Travel Health Association, to a current member of the Medical Cell at the Royal Geographical Society. He is one of the authors and Editors of the Oxford Handbook of Expedition and Wilderness Medicine and co-director of the UK’s first post-graduate diploma in Wilderness and Expedition Medicine, at the Royal College of Physicians and Surgeons of Glasgow.

Approach: Protection
Location: Exeter
Speciality: Travel health and expedition medicine

What initiative or project are you involved in?

The clinic provides a dedicated travel medicine service, offering a range of interventions; from off-site services, to travel groups with specific needs, through to on-site appointments for individuals. The clinic acts as a resource for local GP surgeries and practice nurses, whilst at the same time providing travel medicine study days across the UK. In addition to the vaccination services, the clinic also provides travel health consultancy advice for a range of business, companies, schools and colleges across the country. Working with a local GP, the clinic has also developed and launched a special expedition and travel medicine study module for medical students at a local medical school.

What prompted the work?

With more people travelling abroad there was a requirement to give access to advice, vaccinations and medication for the prevention of malaria.

How did you initiate the work?

Initially I studied travel medicine and tropical nursing whilst working as an Emergency Nurse Practitioner. At the same I got involved in a number of expeditions, providing leadership and medical skills across the globe, from the Jungles of Papua New Guinea through to the mountains of Nepal. Lots of study, combined with plenty of experience in the field naturally lead to a business plan and the rest, so they say, is history.

What difference has the project or initiative made?

I think the clinic has made a huge difference to the level and quality of travel health advice available here in the Southwest. Not just from the clinic itself, but through the help, support and training we are able to provide Practice Nurses across the region.

Travel medicine is a fascinating subject and, when taught properly and practiced well, can be a very motivating and positive addition to a nurses CV.

What are the long-term objectives?

To continue to develop the services we offer whilst maintaining the high quality of patient care we currently provide.

I would also like to develop the training we provide via the clinic, in a range of areas such as expedition first aid (something we currently provide through a partner company – Phoenix Medical Training), and an academic module in travel medicine for those undertaking practice nurse study.

However, the priority is offering the best possible service through the development, motivation and training of a great team of nurses.

Public Health England (PHE) protects and improves the nation’s health and well-being, and reduces health inequalities. PHE is an executive agency of the Department of Health. One of the most important functions of PHE is to protect the public from infectious disease outbreaks.

What is an outbreak?

An outbreak is the occurrence of more cases of disease than would be expected within a specific place or group of people over a given period of time. The purpose of outbreak management is to protect public health by identifying the source and implementing control measures to prevent further spread or recurrence of the infection.

Who manages outbreaks?

PHE provides the surveillance, epidemiology and expertise in outbreak management (the management responsibility usually lies with the provider service organisation – however PHE may lead an outbreak that crosses boundaries, Directors of Public Health are responsible for the health of their population).This really would depend on the outbreak (any infectious disease should be reported to the “Proper Officer” who can be found via the PHE Centre Health Protection Team) Code of Practice 2010 updated July 2015.

Registered providers, excluding personal care providers, should ensure that advice is received from suitably informed practitioners and that, if advised, registered providers should inform their local health protection team of any outbreaks or serious incidents relating to infection in a timely manner.

Health Protection Regulations (2010) require attending doctors (registered medical practitioners) to notify the Proper Officer of the local authority of cases of specified infectious disease or of other infectious disease or contamination, which present, or could present, significant harm to human health, to allow prompt investigation and response.

The regulations also require diagnostic laboratories testing human samples to notify Public Health England of the identification of specified causative agents of infectious disease. 

Local health protection teams (HPTs) lead Public Health England’s response to all health related incidents:

• providing specialist public health advice and operational support to NHS, local authorities and other agencies
• monitoring and investigating infectious disease outbreaks. 

HPTs are located within regional PHE Centres across England. Teams are made up of small groups of consultants, health protection nurses and practitioners, and surveillance staff.

The role of centres is to:

• provide local health protection services, expertise, response and advice to the local NHS, local authorities and other partners.

Centres can have one or more local health protection team, depending on their size and geography. These teams can assist with specific health protection enquiries, such as reporting notifiable diseases and causative organisms. 

How are outbreaks detected?

The most common way that outbreaks are detected is through notifications from a health provider or citizen. Local HPTs provide an acute response service and calls are answered through the acute response desk.

The role of health protection nurses and practitioners is to receive notifications about potential incidents or outbreaks and then interpret, prioritise and act on them.When reports of an outbreak are received, the following information is gathered:

• the person reporting the outbreak & geographical area and environment involved
• characteristics of the suspected outbreak
• persons directly affected by the outbreak
• population at risk of exposure.

These details are entered into HP zone; the web based surveillance and case management tool used by HPTs throughout England. This decision support software enables the team to:

• view a summary of all current activity
• run queries
• extract timely and comprehensive information on incidents and outbreaks.

There are two different types of surveillance systems that may be used to identify an outbreak:

• event-based surveillance is based on the direct reporting, typically by clinical staff, of outbreaks or exceptional events. It is most commonly used to detect locally confined, acute onset outbreaks, for example food poisoning and emerging disease problems, for example drug resistance to bacteria
• case-based surveillance is based on the analysis, typically using statistical tools, of collated reports of individual cases. It is best suited to detecting geographically dispersed outbreaks with lower rates of transmission, for example tuberculosis and hepatitis B.

The PHE have published operational guidance for the management of outbreaks of communicable disease.

What: A student project which involved the development of a Patients and Health Care Professionals Communication Booklet 

Who: Student nurses from the University of East London, including: Luul Abdirisak Ali, Nilia Moreno e Silva and Maura David Lourenco.

Senior Lecturer in Public Health and Nursing: Anna Caffrey

What is the initiative and or project you are involved in?

We have designed the Patients and Health Care Professionals Communication Booklet to facilitate communication between patients with Limited English Proficiency (LEP) and health care professionals. The booklet aims to empower patients during their stay in the hospital, giving them the independence to express their basic needs without requiring an interpreter. The booklet contains common sentences that patients and health care professionals frequently use, in the 6 most common languages spoken in Newham – English, Bengali, Gujarati, Polish, Punjabi and Urdu (Aston-Mansfield’s Community Involvement Unit, 2017).

What prompted you to do this work?

During our first placement in a hospital setting, we identified many patients with LEP who could not express what they needed, because hospitals do not provide adequate translation services (Robinson, 2013). This is an example of structural racism, which widens health inequalities and must be addressed to reduce discrimination and improve services (Equality and Diversity act 2010). For example, we saw that a cup of tea or pad change was not offered to LEP patients. LEP patients deserve to feel seen and listened to like any other patient.

How did you initiate the work?

For all three of us, English is our second language, so we thought about ourselves, our families and patients’ experiences. We also spoke with healthcare professionals about how they interact with patients with LEP. After reflecting on the above we made a plan to fill the most critical communication gaps we encountered.

What have the challenges to implementing the service/intervention been?

At the moment, there is no organisation involved as this was a university assignment, but we would like to see it implemented in the future with even more languages and professional graphics.

Outcomes

To measure the success of the booklet before and after, we would interview patients and caregivers (Sakes and Allsop, 2019) to understand if the toolkit was easy to use. We are keen to comparing their satisfaction levels to LEP patients without access to the booklet, and receive feedback on how to improve services for LEP patients.

What are the long-term aims for the work?

Long term we would like to see health inequalities for LEP patients dramatically reduced and for these patients and their families to feel empowered. It would be exciting to see this low cost low tech solution rolled out nationwide.

You can read the case study in full here.