essentials of care Paediatric Family-centred Paediatric Family Centred Care Outcomes Paediatric Family Centred Care Domains

Transcription

1 essentials of care Family-centred care is a central principle of paediatric nursing and requires a process of collaboration between health professionals and the child, young person and family, which results in shared decisionmaking about what the child s or young person s care will be and who will provide this. For family-centred care to be a reality nurses need to collaborate and communicate with, and support children, young people and their families effectively. Families need to be able to reach agreement with nurses about what this participation will involve and to negotiate new roles for themselves in sharing care of their sick child or young person. The Essentials of Care - Paediatric Family Centred Care Framework provides an approach to the planning, implementation and evaluation of care that is grounded in effective partnerships between nurses and children, young people and families. The term child refers to any individual from birth through infancy (including neonates), and childhood, recognising the particular needs for specific ages. The term young person refers to adolescence, recognising the particular needs of adolescence, especially the transition to adulthood. The family refers to the child or young person s significant carer(s), as defined by the individual and/or their parent(s)/carer(s)/legal guardian(s). Paediatric Family Centred Care Domains There are nine broad domains of nursing care, on which the Essentials of Care -Paediatric Family Centred Care program focuses. The domains embody the major elements of care that affect the management of the child, young person and family throughout their hospital stay. All of the domains are interrelated. For example, Communication and Documentation is an important component of all aspects of care. The interrelated domains are cross referenced with each other throughout the care outcomes. Many elements of care have been categorised into domains as depicted in Diagram 1: Essentials of Care - Paediatric Family Centred Care Domains, page? of this manual. The elements listed under each domain are a guide to the components of each domain, though these lists are not designed to be exhaustive. The Care Domains identified are: 1. Personal Care 2. Documentation and Communication 3. Promoting Self Management 4. Medications, Intravenous and Blood Products 5. Privacy and Dignity 6. Clinical Interventions and Management 7. Clinical Assessment and Monitoring 8. Preventing Risk and Promoting safety 9. Learning Culture and Development of Practice Paediatric Family Centred Care Outcomes Care outcomes have been developed to set internal benchmarks for acceptable standards of practice within specific care domains. The care outcomes in this resource have been mapped to paediatric practice by consulting with paediatric nurses across New South Wales, using the original resource document created by staff from Prince of Wales Hospital. While these will be similar in the majority of organisations there is space left for individual organisations to include reference to their own policy and procedure manuals. Reference is also included in the resource to relevant Department of Health Policy documents. The National Health Service (NHS) Essence of Care Document1 was used by Prince of Wales Hospital as a foundation to build and develop the care framework, care outcomes and benchmark indices. The Benchmarks are broad indices, which can be rated in terms of attainment, ranging from optimal or highest attainable through to not attained. It is expected that nurses will strive to achieve optimal attainment, however care can often fall somewhere in between. Some indices are mandated by various governing bodies, such as those relating to medication administration, where the highest attainable standard is required. 1

2 TLC: Teamwork-Learning-Change and Essentials of Care - Paediatric Family Centred Care Program 2 In Paediatrics, some paediatric areas are using an integrated learning and development model TLC: Teamwork- Learning-Change to embed the philosophy of family centred care within clinical units and to implement the Essentials of Care (EOC) program. If you would like to use the TLC model, please refer to page 29 of this document. Diagram 1: Essentials of Care - Paediatric Family Centred Care Domains Personal care Hygiene Elimination Nutrition/hydration Oral care Body image Eye care Skin integrity Learning culture and development of practice Skill development and competence Orientation and induction Clinical teaching Preceptorship and mentoring Reflective practice Mandatory education Succession planning Knowledge generation and utilisation Evolving practice Preventing risk and promoting safety Patient identification and consent Child protection Infection control Care environment Pressure damage prevention Falls minimisation Aggression Mental health Escorting the child and young person Pre- & post-operative intervention care radiation and cytotoxic safety Sensory deficit/overload management Deep venous thrombosis prevention Documentation and Communication Admission Clinical handover Care planning Reporting care Multidisciplinary team communication Negotiating care with children, young people and families Provision of care Discharge planning Promoting self management Child, young person and family education Mobility Discharge planning Referral Transition planning Essentials of Care - Paediatric Family-centred Care Clinical assessment and monitoring Clinical handover Systematic assessment & observations including physiological assessment Recognition and responding to the deteriorating child or young person Identification and responding to adverse events (clinical incidents) Vital signs Fluid balance assessment Assessment and prevention of pain Medications/IV products (including blood products) Administration Charting Documentation Transport/delivery Storage Privacy and dignity End of life care Respectful care Confidentiality Use of restraints Clinical interventions and management Planning, implementation and evaluation of interventions Consent IV access management Wound care management Respiratory care Enteral Feeding Tube insertion and management

3 Paediatric Family-Centred Care Domains and Care Outcomes essentials of care Domain 1: Personal Care Purpose 1. To provide safe, comfortable and appropriate personal care ensuring that the child s or young person s dignity and well-being are maintained during the provision of this care. 2. To maintain an optimum level within all facets of personal care 3. To provide personal care that is appropriate for the age and developmental level of the child or young person and is inclusive of the child, young person and family in the planning and the provision of care. Includes but not limited to: Personal hygiene Urinary elimination Faecal elimination Nutrition, including enteral, parenteral and oral Hydration, including oral, parenteral and enteral Oral care Body image Eye care Skin integrity Cross References Documentation and Communication Promoting Self Management Privacy and dignity Clinical Interventions & Management Clinical Assessment & Monitoring Preventing risk and Promoting safety Learning Culture and Development of Practice Care Outcomes Personal care will: 1. Include an individualised assessment, action plan and outcome for patients to achieve all facets incorporated within the personal care domain. This is done with the child, young person and family. 2. Meet all necessary requirements as outlined by the professional code of conduct2 and ethical standards3 in the provision of personal care. 3. Be documented in the child s or young person s medical record. 4. Be provided in negotiation with the child, young person and family and carried out in a coordinated and timely manner. 5. Be provided in accordance with hospital policy where applicable and be based on up to date evidence. 6. Be provided so that it respects and is flexible to the child s, young person s and family s culture and religion. 7. Include education of the child, young person and family about the purpose and provision of personal care. 8. Incorporate the use of allied health. Related policies and guidelines Please refer to your local and Area policies and guidelines 3

4 Benchmark for Personal Care Care Outcomes Optimal / Highest Attainable Not Attained 4 1. Include an individualised assessment, action plan and outcome for patients to achieve all facets incorporated within the personal care domain. This is done in consultation with the child, young person and family. Prior to the provision of personal care an individual patient assessment is conducted with the child, young person and family to determine care An individualised care plan is developed with the child, young person and family based on the assessment findings, which incorporates all aspects of personal care The outcomes from the care plan are continuously evaluated There is no evidence that the child s or young person s personal care requirements have been assessed There is no evidence that an individualised care plan has been developed or that the child, young person and family have been involved in its development There is no evidence of continuous evaluation of the child s or young person s personal care needs 2. Meet all necessary requirements as outlined by the professional code of conduct and ethical standards in the provision of personal care. 3. Episodes of personal care are documented in the patient s medical records. The Professional code of conduct is maintained at all times during the provision of patient care The Professional code of conduct is maintained at all times during the provision of patient care Nursing staff act in an ethical manner during episodes of personal care for the child or young person All documentation is legible and contains correct child or young person identification and date and time The time recorded is an accurate reflection of the time that personal care was delivered All aspects of the provision of personal care are documented in the child s or young person s medical records Personal care is carried out in a manner that is not in line with the Professional code of conduct The Professional code of conduct is maintained at all times during the provision of patient care Nursing staff act in a manner which is not in line with ethical standards Documentation is unreadable and lacking the child s or young person s identification information, date or time The time recorded does not accurately reflect the time that the personal care was delivered Episodes of personal care are not documented in the child s or young person s medical records 4. The provision of personal care is negotiated with the child, young person and family and carried out in a coordinated and timely manner. The time of personal care delivery is negotiated with the child, young person and family Explicit or expressed consent is obtained from the child, young person and family prior to the provision of care There is no negotiation between the nurse and the child, young person and family as to the timing of the provision of personal care There is no consent obtained from the child, young person and family prior to the provision of care Preparation for and completion of personal care needs is coordinated and performed in a timely manner There is no preparation and the intervention is conducted in a haphazard manner taking an inordinate amount of time to compete the intervention

5 essentials of care Benchmark for Personal Care Care Outcomes Optimal / Highest Attainable Not Attained 5. The provision of personal care is delivered in accordance with hospital policy where applicable. Nursing staff are familiar with which aspects of personal care are governed by hospital policy and follow that policy accordingly. This policy is evidence based and up to date Nursing staff are unaware of which aspects of personal care are covered by hospital policy, or do not follow the policy. There is no evidence for care or the evidence for care is out of date 5 Nursing staff access the clinical practice guidelines / procedures manual to obtain the relevant information or refer to other clinicians when required Nursing staff do not access the clinical practice guidelines / procedures manual or refer to other clinicians appropriately 6. The provision of personal care is delivered so that it respects and is flexible to the child s, young person s and family s culture and religion. 7. Includes education of the child, young person and family about the purpose and provision of person care. 8. The provision of personal care incorporates the use of Allied Health as required. Nursing staff are proactive in anticipating the needs and preferences of the child, young person and family Attempts are made to make the environment conducive to individual religious and cultural sensitivities Information and education is provided to the child, young person and family on all aspects of personal care Allied health therapists are utilised as required for role play/medical play/ distraction (if available at local site) Nursing staff do not anticipate the needs and preferences of the child, young person and family No attempts are made to make the environment conducive to individual religious and cultural sensitivities No information or education is provided to the child, young person and family Allied health therapists are available and not utilised

6 6 Domain 2: Documentation and Communication Purpose Effective communication is required to ensure continuity in care and prevent system breakdown in patient care. 4 Documentation provides an accurate detailed account of the patient s care, problems and outcomes throughout their hospital journey.5 Includes but is not limited to: Admission Assessment & Observation Diagnosis Care planning / action plan Treatment interventions and management Provision of Care Multidisciplinary team communication Child, young person and family education Discharge planning, transition of care & follow up care Interagency communication Professional advice Clinical Incident Identification & Management Child Protection and Mandatory Reporting End of life care Cross References Personal Care Promoting Self Management Medications and IV Products Privacy and Dignity Clinical Intervention & Management Clinical Assessment & Monitoring Preventing Risk and Promoting Safety Learning Culture and Development of Practice Care Outcomes Communication will: 1. Be effective and include all members of the health care team, child, young person and family, with a comprehensive plan, which is regularly updated and evaluated. 2. Maintain patient confidentiality. 3. Be accessible, accurate and up to date and meet the needs of individuals consistently. Documentation will: 4. Be clear, concise, contemporaneous, progressive and accurate. 5. Include assessment, action and outcome and complications. 6. Meet all necessary medico-legal requirements for documentation. Related policies and guidelines NSW Health PD Medical records PD Medical records in Hospitals and Community Care Centres PD Discharge Planning: Responsive Standards Please refer to your local and Area policies and guidelines

7 essentials of care Benchmark for Documentation and Communication Care Outcomes Optimal / Highest Attainable Not Attained 1. Communication is effective and inclusive, with a comprehensive plan which is regularly updated and evaluated. 2. Patient confidentiality is maintained during communication. 3. Documentation is clear, concise, contemporaneous, progressive and accurate. 4. Documentation includes assessment actions and outcomes. 5. Documentation meets all necessary medicolegal requirements. Communication between health professionals, and with the child, young person and family is recorded The child s, young person s and family s communication needs are assessed, problems identified and addressed i.e. the use of interpreters for the culturally and linguistically diverse (CALD), hearing impaired etc The child, young person and family understand the information given Care planning is accessible, evaluated and current Continuity of care is achieved through effective and accurate handover between health care workers Information and care planning relating to patients is shared with health care professionals, child, young person and family in a professional manner while maintaining patients rights to confidentiality Documentation is factual and to the point, enabling an independent clinician to fully understand the care events that have occurred Documentation accurately reflects the care that has been provided Provision of care is documented at the time it occurs in a sequential manner Incorporates observation, assessment, diagnosis, management and treatment, and response to clinical interventions reflecting child or young person outcomes Observation and assessment information is recorded in the appropriate chart / record at the time of collection All documentation is legible and contains correct child or young person identification and date and time The time recorded is an accurate reflection of the time observations were collected or the child or young person care intervention being documented took place Only accepted abbreviations are used Communication is not recorded or documented The child s, young person s and family s communication needs are not assessed and interpreters are not used when required There is no understanding of the information given Care planning is not easily distinguishable, accessible or current Handover between healthcare workers is ineffective and does not accurately reflect the child s, young person s and family s needs Information sharing and care planning is unprofessional and breaches patient confidentiality Documentation is not factual or the care that has taken place is not easily recognisable to the reader The information recorded is not an accurate representation of the care provided Written documentation occurs at the end of a shift Documentation of assessment and interventions is incomplete and does not reflect child or young person outcomes Observation and assessment information is incomplete, documented incorrectly / in an inappropriate place or delayed Documentation is unreadable and lacking child or young person identification information, date or time The time recorded does not accurately reflect the time the child or young person care interventions or observations occurred Documentation contains abbreviations that are non-standard or not accepted for use 7

8 8 Domain 3: Promoting Self Management Purpose Promoting self management will optimise the child s or young person s physical function and independence. The child, young person and family remain informed about their health issues and exercise informed choice about their health goals and ongoing care needs. Self management behaviour is a key concept in health promotion and refers to decisions and actions that an individual can take to cope with a health problem or to improve his or her health 6. Self management is defined as activities that individuals, families, and communities undertake with the intention of enhancing health, preventing disease, limiting illness, and restoring health. These activities are derived from knowledge and skills from the pool of both professional and lay experience. They are usually complementary to professional health care services and undertaken by lay people on their own behalf, either separately or in participative collaboration with professionals 7. In the Paediatric context the philosophy underpinning this is enabling children and young people to be empowered to make decisions about their management with the goal of working towards self-management within the family unit through to transitioning as an independent person. The guidance towards achieving this outcome will be dependant on the child s or young person s physical capability, their cognitive capacity and their psychological readiness to understand the nature of their condition and the processes involved in this. Where the child or young person is unable to be totally responsible for self-management the responsibility will be with the family. Children and young people with a chronic / complex illness, disability, developmental delay, behavioural or emotional condition and their families have a long term responsibility for self-management of their health and illness. Health care workers (HCW) need to form effective partnerships with children, young people and their families to promote effective selfmanagement practices, to maintain and promote health and prevent complications. Includes but is not limited to: Individual assessment, to maintain, optimise or return the child or young person to a maximum level of self care and independence incorporating: Care planning / action planning Child, young person and family education Mobility Discharge planning Referral & Access to follow up care Planning for and transition to adult services Community based support groups/peer support groups Cross References Personal Care Documentation and Communication Medications and IV Products Privacy and Dignity Preventing Risk and Promoting Safety Care Outcomes 1. Each child or young person has an individualised continuous assessment and appropriate interventions related to self-care, mobility, discharge needs and education. 2. Self-management and mobilisation activities occur safely and in the most appropriate environment without incident to the child, young person, family or staff. 3. Children, young people and families are willing and informed participants in self management activities. 4. Transition of young people with a chronic illness to adult services will be a well planned coordinated process done in consultation with the young person and family. 5. The child or young person and family are discharged safely on the predicted date with all necessary resources and follow up. Related policies and guidelines NSW Health: PD Discharge Planning: Responsive Standards Transition Care Please refer to your local and Area policies and guidelines.

9 essentials of care Benchmark for Promoting Self-management Care Outcomes Optimal / Highest Attainable Not Attained 1. Each child, young person and family has an Individualised continuous assessment and appropriate interventions related to self-care, mobility, discharge needs and education. Health care staff work in partnership with the child, young person and family to identify self-management needs, set goals and identify strategies to meet those goals Mobility aides, other resources and equipment are provided as required All children and young people have a documented assessment for selfmanagement needs including mobility and education Risk assessment tools are utilised, i.e. Falls, skin integrity etc Health care workers identify and remove contributing factors to unsafe mobilisation Health care workers are educated regarding manual handling and falls minimisation The child, young persons and family are adequately supervised during self-management activities Health care workers are provided with adequate education and support to provide supervision, teaching and promote independence The child, young person and family are provided with appropriate education to maintain and promote health and prevent complications The child, young person and family will be treated with dignity and given necessary information so they can at all times make informed decisions The child, young person and family are not involved in identifying selfmanagement needs and goal setting Mobility aides, resources and equipment are not available or provided when required The child s or young person s selfmanagement needs are not assessed 9 2. Self-management activities occur safely and in the most appropriate environment. 3. The child, young person and family are willing and informed participants in self-management activities. Falls and other risks are not assessed The child or young person is mobilised without appropriate equipment or environment Health care workers needs are not identified or addressed The child, young person and family are not adequately supervised during self-management activities Health care worker needs not identified or addressed The child, young person and family are not provided with pertinent education to maintain and promote health or to prevent complications The child, young person and family are not treated with dignity or are not given necessary information so that they unable to make informed decisions The child s, young person s and family s concerns not identified, listened to or addressed Young people with chronic illness are not identified for transition planning and therefore planning is not commenced or there is no consultation with the young person and family. Transition planning is not completed by age 18yrs There is no access to available resources for young people and their families The child s, young person s and family s concerns are listened to respected and acted upon Young people with chronic illness will be identified and transition planning commenced at an appropriate age and completed by age 18yrs in partnership with the young person and family 4. Transition of young people with a chronic illness to adult services will be a well planned, coordinated process done in consultation with the young person and family. Young people and their families have access to available resources to assist with the transition planning process

10 Care Outcomes Optimal / Highest Attainable Not Attained The child, young person and family are discharged on predicted date with the necessary resources and follow-up. Health care workers and the child, young person and family collaborate to meet identified self- management goals including completion of a Discharge Planning Risk Assessment Self-management assessment, discharge planning and referrals commence at admission and are re-evaluated when ever the child s or young person s condition changes Resources (i.e. community services and equipment) are available at the time the child or young person are ready for discharge The cost of equipment required to optimise wellness and provide a safe environment is discussed with the family unit A home assessment and / or community follow up is arranged and provided in an appropriate time frame for the child, young person and family The child, young person and family are discharged safely and in a timely manner with appropriate resources in place Health care workers and the child, young person and family do not collaborate and identified goals are not met. A Discharge Planning Risk Assessment is not conducted Self-management and discharge planning are not identified at admission and referrals are inappropriate or not made as required Resources have not been identified, arranged or are not available Cost of equipment is not discussed with the family unit Community follow-up or assessment is not arranged or provided at the time required by the child, young person and family The child, young person and family are discharged without appropriate resources or services in place

11 essentials of care Domain 4: Medications, IV Products & Blood Components Purpose Medication refers to a drug that is used to treat an illness or disease according to established medical guidelines. This domain refers to the prescribing, transportation, storage, handling and administration of medications via any route. Blood and blood components are prescribed, handled, transported, stored and administered using similar principles to the administration of medications. Includes but is not limited to: Medications via any route Intravenous fluids / TPN Blood and Blood Components Cross References Personal Care Documentation and Communication Promoting Self Management Privacy and Dignity Clinical Interventions & Management Clinical Assessment & Monitoring Preventing Risk and Promoting Safety Learning Culture and Development of Practice Care Outcomes Medications and Blood components will be: 1. Prescribed, stored, handled and administered in a manner that is safe, legal and appropriate according to NSW legislation 8 and other appropriate governing bodies (Australian Red Cross Blood Service ARCBS)9 and local policies. 2. Administered in accordance with hospital policy and the child s or young person s safety are paramount during any medication administration procedure. 3. Adverse events and errors are identified, managed and reported appropriately. 4. Prescribed following local and national guidelines and be appropriate for the child s or young person s clinical condition. Related policies and guidelines NSW Health PD Medication Handling in Public Hospitals Guideline Fresh Blood and Blood Components Management Please refer to your local and Area policies and guidelines 11

12 Benchmark for Medications, IV Products and Blood Components Care Outcomes Optimal / Highest Attainable Not Attained Prescribed, stored, handled and administered in a manner that is safe, legal and appropriate according to NSW Health Department, other appropriate governing bodies (i.e. ARCBS) and local policies. 2. Medications and blood components are administered in accordance with hospital standards and the child s or young person s safety is paramount during any medication administration procedure. Medications and blood components are administered according to hospital clinical standards based on evidence of best practice and national guidelines Medications are prescribed according to national guidelines in a legal and legible manner Appropriate action is taken to address prescriptions that do not meet national prescribing standards Medications and blood components are stored, handled and transported according to clinical and legislative requirements The child or young person is identified via patient arm band according to hospital patient identification standard The child, young person and family are given information about the medication and course of treatment. This includes Consumer Medicines Information leaflets (CMI) being available Medications are administered to the correct patient, in the correct form and dose of the correct drug at the correct time via the correct route for the correct reasons Medications and blood components are checked with a staff member accredited in medication administration according to hospital standards and legislative requirements Medications are safely administered taking into consideration the age and developmental level of the child or young person i.e. syrup for infants, the use of distraction techniques, negotiate parental assistance, therapeutic holding etc. Nurses engage in discussion with the child, young person and family about medication administration and their possible level of involvement Medication and blood component administration is not performed according to national guidelines or hospital clinical standards Medication orders are not legible, are incomplete or not in accordance with national guidelines Action is not taken in response to identification of prescription that don t meet required standards Medications and blood components are stored and transported inappropriately or not in compliance with to local and legislative requirements The child or young person is not identified correctly using full name, unique identifier and date of birth No information about the medication and course of treatment is given. Consumer Medicines Information leaflets (CMI) are not available The five rights of medication administration are not followed Medications or blood components are not checked with a staff member accredited in medication administration. Hospital policy or legislative requirements are breached Medications are unsafely administered without taking into consideration the age and developmental level of the child or young person. Unnecessary force is used or restraint of the child or young person against best practice guidance occurs There is no discussion with the child, young person and family about medication administration. The child, young person and family are not involved in medication administration There is no regard for the prior experience of medication administration at home Medication is administered at the same/ similar time and in a similar manner to how the medication is administered at home wherever possible

13 essentials of care Care Outcomes Optimal / Highest Attainable Not Attained 2. Medications and blood components are administered in accordance with hospital standards... (continued) Child, young person or family administration is negotiated and documented in the medical records and reviewed daily in line with local policy Medications are administered according hospital policy Adverse events and errors are detected through clinical monitoring, acted upon and reported accordingly in a timely manner There is no policy addressing child, young person or family administration or there is no negotiation about medication administration Medications are not administered according to hospital policy Adverse events are not detected, managed or reported in an appropriate or timely manner Adverse events and errors are identified, managed and reported appropriately. 4. Prescription of medications and blood components follows local and national guidelines and are appropriate for the child s or young person s clinical condition. Medications and blood components are prescribed according to accepted local and national indications for administration Medications and blood components are prescribed outside of the local and national accepted indications for administration

14 14 Domain 5: Privacy and Dignity Purpose Provide care that benefits children, young people and families in a way that is respectful towards the individual and family and is free from inappropriate and unnecessary intrusion. Maintain an environment and relationships that promote dignity and privacy for children, young people and families. Includes but is not limited to: End of life care, Respectful care, Confidentiality Use of restraints Attitudes, behaviours and beliefs Personal world and personal identity Personal boundaries and spaces Communicating with staff and the child, young person and family Privacy, dignity and modesty Availability of an area for complete privacy Respect for the child, young person and family regardless of their background Mixed gender rooms Cross References Personal care Documentation and Communication Promoting Self Management Clinical Interventions & Management Clinical Assessment & Monitoring Preventing Risk and Promoting Safety Care Outcomes Privacy and dignity will: 1. Promote a feeling amongst children, young people and families that they are the focus of our care. 2. Actively encompass individual values, beliefs and personal relationships. 3. Provide personal space that is identified, communicated, supported and respected by all health care workers (HCW). 4. Ensure communication between staff and children, young people and families is respectful of their individuality. 5. Allow patient information to be shared, with consent, to enable care. 6. Ensure delivery of care that is negotiated with the child, young person and family that protects their privacy, dignity and modesty. 7. Provide a safe environment for children, young people and families to have privacy. Related policies and guidelines NSW Health GL End-of-Life Care and decision making-guidelines PD 2005_554 Privacy Management Plan Please refer to your local and Area policies and guidelines

15 essentials of care Benchmark for Privacy and Dignity Care Outcomes Optimal / Highest Attainable Not attained 1. Promote a feeling amongst the child, young person and family that they are the focus of our care. Appropriate attitudes and behaviour are promoted and assured, including consideration of non verbal behaviour and body language, and inappropriate attitudes and behaviours are challenged The child s, young person s and family s fears and anxieties relating to their hospital admission and physical condition are explored and addressed in a compassionate and empathetic manner The child s, young person s and family s individual needs and choices are ascertained and continuously reviewed Valuing diversity is demonstrated Stereotypical, racial and patronising views are challenged The child s, young person s and family s preferred name is agreed and used Inappropriate attitudes and behaviours are not addressed with individuals 15 The child s, young person s and family s fears and anxieties are not addressed or ignored. The child, young person and family experience negative and offensive attitude and behaviours 2. Actively encompass individual values, beliefs & personal relationships. 3. Provide, communicate and respect personal space. Personal space and boundaries are identified and communicated The child, young person and family are not disturbed or interrupted unnecessarily or without warning eg knocking on door before entering Whenever possible same gender accommodation & facilities are provided for young people. Mixed gender accommodation and facilities are discussed with the young person and family Access to appropriate translation and interpreter services are utilised and clear communication with the child, young person and family is maintained Information is provided in a manner that is understandable and considers individual needs Individual values, beliefs and personal relationships are never explored Diversity is not tolerated Stereotypical, racial and patronising views exist and are not challenged The child, young person and family are addressed by a name decided by staff or are referred to by bed number, diagnosis or procedure Personal space and boundaries are disregarded or invaded Privacy is not maintained and staff enter closed area without warning Young people are placed in mixed gender accommodation and share facilities without any warning or discussion with the young person and family 4. Ensure communication between staff and the child, young person and family is respectful of their individuality. Translation and interpreter services are not utilised, and information is not available in different formats, media or languages Information is not provided in a manner that meets the individuals needs or is delivered at a level inappropriate for the child s, young person s and family s ability to understand

16 Care Outcomes Optimal / Highest Attainable Not attained Allow the child s, young person s and families information to be shared, with their consent, to enable care The child s, young person s and family s private information is not shared inappropriately eg overheard at desks, telephone conversations, on whiteboards Statutory and ethical guidelines are adhered to when dealing with the release of information Privacy is effectively maintained, especially in the presence of others eg using doors, curtains, screens, sheets, towels and appropriate clothing The child or young person have access to their own clothes and/or appropriate clothing is available The child, young person and family can have private conversations The child s, young person s and family s information is shared or enters the public domain without their consent Statutory and ethical guidelines are not adhered to when dealing with the release of information The child or young person is exposed and privacy, dignity and modesty are not considered or maintained at all times The child or young person are not enabled to wear their own or appropriate other clothes There is no opportunity for the child, young person and family to have private conversations The child s or young person s modesty is not considered when moving between care environment 6. Protect the child s or young person s privacy, dignity and modesty. 7. Provide a safe environment for the child, young person and family to have privacy. Modesty is maintained for the child or young person moving between differing care environments eg to X-ray, transfer to wards Quiet or private spaces are available and the child, young person and family are aware of their location Clinical Risk is assessed and minimised in relation to complete privacy Quiet or private spaces are not available or the child, young person and family are unaware of their location or their use is not facilitated The child s, young person s and family s safety is compromised when in private spaces

17 essentials of care Domain 6: Clinical Intervention & Management Purpose Clinical Interventions are essential clinical skills performed during interaction with and the provision of care to children, young people and their families. A clinical intervention may be an invasive or noninvasive task. Includes but not limited to: Patient Identification and Consent (expressed, implied & informed) Preparation and termination of procedures IV access management Wound care management Respiratory care Limb traction Medication administration Enteral feeding tube insertion Lumbar punctures Cross References Personal Care Documentation and Communication Promoting Self Management Medications and IV Products Privacy and dignity Clinical Assessment & Monitoring Preventing Risk and Promoting Safety Learning Culture and Development of Practice Care Outcomes Clinical Interventions will: 1. Have an individualised assessment, action plan, outcome and documentation reflecting this domain. 2. Be performed in a safe and appropriate environment utilising principles of risk minimisation and with minimal trauma to the child, young person, family and clinician. 3. Be performed reflecting hospital policy, procedure guidelines or clinical practice guidelines using evidence of best practice. Related policies and guidelines Please refer to your local and Area policies and guidelines 17

18 Benchmark for Clinical Intervention & Management Care Outcomes Optimal / Highest Attainable Not Attained Will have an individualised assessment, action plan, outcome and documentation reflecting this domain. Prior to clinical intervention an individual child, young person and family assessment is conducted to determine care There is negotiation with the family s regarding parental presence and their level of involvement in the clinical intervention An individualised care plan is developed based on the assessment findings which incorporates all aspects of the clinical intervention The outcomes from the clinical intervention are continuously evaluated There is no evidence that the child, young person and family requirements have been assessed Negotiation with the family about parental presence and/or their level of involvement does not occur There is no evidence that an individualised action plan has been developed 2. Be performed in a safe and appropriate environment utilising principles of risk minimisation and with minimal trauma to the child, young person, family and clinician. Clinical interventions are performed in a safe manner for the child, young person, family and clinician The environment is appropriate and allows the provision of clinical interventions in a safe manner for the child, young person, family or the clinician The potential for pain during a clinical intervention is assessed and prevented or managed effectively Allied health therapists are utilised as required for role play/medical play/ distraction (if available at local site) The child, young person and family will be provided with support prior to, during and following the clinical intervention Health care worker seeks assistance if the intervention is beyond their capabilities Clinical interventions are performed using effective clinical judgement, hospital policies, procedure guidelines, clinical practice guidelines and evidence of best practice There is no evidence of continuous evaluation of the child s or young person s clinical condition, needs or outcomes Clinical interventions are performed in an unsafe manner for the child, young person, family and/or clinician The environment is inappropriate and does not allow the provision of clinical interventions in a safe manner or increases risk of injury or harm to the child, young person, family or the clinician The child or young person experiences pain which is not managed effectively Allied health therapists are available and not utilised No support is given to the child, young person and family prior to, during and following the clinical intervention Health care workers attempt an intervention for which they are not skilled or competent without assistance There is no evidence of effective clinical judgement or use of hospital policy whilst performing clinical interventions 3. Be performed reflecting hospital policy, procedure guidelines, and clinical practice guidelines using evidence of best practice.

19 essentials of care Domain 7: Clinical Assessment & Monitoring Purpose Clinical monitoring involves assessment and the measurement of subjective and objective physiological parameters in order to detect changes in the child s or young person s condition. Appropriate clinical assessment and monitoring is at the heart of clinical decision making, as it ensures early identification of the deteriorating child or young person and facilitates the development of an individualised action plan and appropriate interventions. Includes but not limited to: Clinical Handover Systematic assessment, observation and evaluation of the child s or young person s physiological status, including fluid balance, pain etc. Psychosocial assessment Performing, recording, documenting and interpreting vital signs Assessment and management of invasive devices such as chest drains, Central Venous Catheters (CVC s), enteral feeding tubes, peripheral cannulas etc. Recognition and response to the deteriorating child or young person Recognition and response to clinical incidents (adverse events) Cross References Personal Care Documentation and Communication Medications and IV Products Privacy and Dignity Clinical Interventions & Management Preventing Risk and Promoting Safety Learning Culture and Development of Practice Care Outcomes Appropriate clinical assessment and monitoring will: 1. Include an individualised assessment, action plan and outcome for the child or young person to achieve all facets incorporated within the clinical assessment, monitoring and management domain. 2. Be individualised to the child s or young person s clinical condition. 3. Be performed in a safe manner, paying due regard to the child s or young person s ability to understand and cope with the process. 4. Ensure abnormal physiological findings to be recognised and acted upon within an appropriate time frame according to the child s or young person s clinical condition. Related policies and guidelines NSW Health PD Recognition of a Sick Child In Emergency Departments PD Acute Management of Infants and Children with Acute Abdominal Pain PD Acute Management of Infants and Children with Asthma PD Acute Management of Infants and Children with Bacterial Meningitis PD Acute Management of Infants and Children with Bronchiolitis PD Acute Management of Infants and Children with Croup PD Acute Management of Infants and Children with Fever PD Acute Management of Infants and Children with Gastroenteritis in Hospitals PD Acute Management of Infants and Children with Head Injury PD Acute Management of Infants and Children with Otitis Media PD Acute Management of Infants and Children with Seizures PD Acute Management of Infants and Children with Sore Throat PD Infection Control Policy: Prevention and Management of Multi Resistant Organisms (MRO) Please refer to your local and Area policies and guidelines 19

20 Benchmark for Clinical Assessment & Monitoring Care Outcomes Optimal / Highest Attainable Not Attained 20 1 Include an individualised assessment, action plan and outcome for the child or young person to achieve all facets incorporated within the clinical assessment, monitoring and management domain. 2 Clinical assessment and monitoring is individualised to the child s or young person s clinical condition. Prior to assessment an effective clinical handover occurs between nursing staff that includes accurate and up to date qualitative and quantitative information including the action plan for the child, young person and family Prior to assessment the child s, young person s and family s psychosocial needs are assessed and appropriate action taken At the commencement of the shift, an individual systematic assessment is conducted to determine the level of clinical monitoring and is documented in the child or young person s medical records An individualised care plan is developed with the child, young person and family based on the assessment findings and includes actions in response to deviations from normal The outcomes from the care plan are continuously evaluated Nursing staff give clear explanation to the child or young person, and/or family concerning assessment, monitoring and management Clinical assessment and monitoring occurs at least as frequently as required by hospital clinical standards and evidence of best practice and applied with a view to the needs of the child or young person Clinical monitoring occurs at least as frequently as determined by the child s or young person s clinical assessment and condition The frequency of clinical monitoring is reassessed continually and adjusted if a deterioration or change in the child s or young person s clinical condition is detected Clinical handover does not occur or the information is not accurate and up to date or the action plan for the child, young person and family is not communicated There is no assessment of the child s, young person s and family s psychosocial needs or their needs are not met There is no systematic assessment performed or documented and the level of clinical monitoring is not determined There is no care plan developed based on assessment findings or the child, young person and family are not consulted There is no evidence of continual evaluation of the child s or young person s monitoring needs There is no explanation to the child or young person, and/or family concerning assessment, monitoring and management or the explanation is not understood Clinical assessment and monitoring is not performed as required by hospital clinical procedure guidelines and standards or is based on protocol alone Clinical monitoring is ritualistic rather than based on the child s or young person s clinical assessment and clinical condition Changes in the child s or young person s clinical condition are not considered in decision making in relation to the frequency of clinical monitoring