Disability in Schools: Supporting Teachers and Children with Health Care Plans, and Credentialled Workers

Transcription

1 Disability in Schools: Supporting Teachers and Children with Health Care Plans, and Credentialled Workers Nigel Stewart Cheryl Boles, Jenny Bury, Nigel Stewart Canberra, Australian Capital Territory, 4-7 March 2001

2 Disability in schools: supporting teachers and children with health care plans, and credentialled workers Cheryl Boles, Jenny Bury, Nigel Stewart, Northern Regional Paediatric Unit, Port Augusta Hospital, SA INTRODUCTION The Northern Regional Paediatric Unit School Based Health Care Service grew out of the need of one child in 1998, who was refused school entry to the local school. Staff at the school refused to accept responsibility and had not been trained for delivering health care that has traditionally been seen as nursing work. A project was in place in Adelaide for children at school with a disability, but not available to any child in rural and remote South Australia. Since responding to that need of one child, the Northern Regional Paediatric Unit and it s partners embarked on the development of a whole new regional service that supports children in schools who have complex or special health needs and provide support, education and training to professional teachers and school support officers. It was also a pilot project possibly only to last six months. OUR REGION Port Augusta is situated some 300 kms north of Adelaide, population approx The region covers people alike. In 1994, Dr Nigel Stewart had a vision to develop a uniquely rural paediatric service equivalent to paediatric services provided for city children. Currently the unit has three paediatricians and one registrar, registered nurses and five administrative support staff. The unit covers a huge area north of Port Augusta, to the boundaries of northern South Australia and the Iron Triangle area, three times the size of Britain. The unit offer paediatric services to the region and is an invaluable resource of education, and advice to nursing staff and other health professionals in this region. The Northern Regional Paediatric Unit also provides facilities to a group of visiting specialists and colleagues from the Women s and Children Hospital, Adelaide with whom we have a partnership agreement. We liaise with individual groups such as Special Needs, Allied Health, and Palliative Care, Flinders and Far North Health Service and the Child Development Units across the region. 1

3 Port Augusta has a strong Aboriginal community consisting of traditional, urban and a transitional population where culturally appropriate service and considerations are a necessity. The unit has partnership clinics with Pika Wiya Health Service in Port Augusta and Port Lincoln, Whyalla, Coober Pedy, Ceduna and Yalata Aboriginal Health to provide clinics, education and support services for health workers and Aboriginal clients. AIMS The original aims of the Country School Based Health Care program were to ensure consistent and safe health care support in educational settings in Port Augusta. Families would be reassured that when their children attended school their health care needs would be met. DEVELOPING THE PROJECT AND REGIONAL PLAN The development of the project consisted of a series of meetings with key players, operating as the The Project Management Committee. This involved representatives from both the health and the education areas, and it should be noted that up until now, these two parties had not traditionally worked in formal partnership together. Teachers had a strong commitment to accept these children at school and a desire to provide a professional standard of care. This attitude from school staff certainly made the project easier to get off the ground than it would have been if we had needed to convince school staff to accept a relationship of collaboration and commitment which was critical to the development of an interagency project such as this. The project management committee This group consisted of paediatricians, managers of Child and Youth Health, speech pathologists and Disability Health Support Service representatives, they developed the terms of reference as detailed below. Terms of reference To develop, document, implement and monitor provision of the Country Based Health Care in educational settings in the preschool and school communities served by the Port Augusta Hospital Paediatric unit to advise recommendations regarding sustainable delivery of Country Based Health Care in educational settings, to brief relevant government services purchasing representatives on the implications of the project outcomes. 2

4 Other membership included The education reference group This group was Department of Education based and included representatives from various areas mainly the metropolitan region. This group included school principles, Disability Support Services, Early Childhood Services, speech pathologist and project officers. Terms of reference To identify education-related issues and provide advice regarding their resolution through the pilot study, Country Based Health Care Support in educational settings. To inform the Department of Education, Training and Employment of the potential development, sustainability and transferability of the piloted model. The groups met on a further three consecutive times, either in Adelaide or Port Augusta during a six-month trail period. The group s proposal was to model the project on the already established service that was operating successfully in Adelaide using the Disability Health Care Support Service model. Policies and procedures were adopted and approved after the unit purchased the Disability Health Care Support Service manual at the cost of $350. Other proposals included: the credentialling would be provided locally by the Northern Regional Paediatric Unit, Port Augusta; and quality assurance and accountability will be through the hospital employing the credentialling nurse. The project would be professionally appropriate, could be replicated for any other child identified with special health needs and is sustainable long term. Can apply to any setting for that child, eg at school, respite, out of hours care. REFERRALS As the Northern Regional Paediatric Unit already had one referral and the possibility of many more in the region, it was decided that the referrals would be accepted from the following services: Northern Regional Paediatric Unit paediatricians; school departments; child and youth health services; families; general practitioners; and special needs network. 3

5 The children involved in the service need to be seen as a client of the Northern Regional Paediatric Unit so that they come under our umbrella of care, support, training and responsibility of our unit. This was not at all difficult, as parents of the children were more than enthusiastic of this proposed service operating within there own regions. HEALTH CARE PLANS The child and family meet with the paediatrician and the child s needs are discussed. Once a referral had been received, the registered nurse makes an appointment with the child s family and other care providers. At the initial meeting the program is explained to family and all other workers involved, and a detailed health care assessment is made using Department of Education s standard health care plans. In consultation with all involved with the identified child, a health care plan is written in such a way that any lay person with no knowledge of medical terms can understand it. The health care plan identifies all current health care needs of that child and explains the necessary actions required by workers to meet that need. The health care plan is signed by the parents, registered nurse and paediatrician and clearly details the commitment and responsibility to that child s health care needs. It supports the workers in their practice, which has traditionally always been the role of the registered nurse. The plan is reviewed every twelve months or earlier if that child s needs change. Health professionals who want to add to or change the health care plan, need to do so through the Paediatric Unit registered nurse. From the health care plan it becomes very clear what training requirements the school workers need. TRAINING SCHOOL WORKERS TO DELIVER COMPLEX HEALTH CARE The Northern Regional Paediatric Unit has developed a procedure for every identified health care need that we currently deal with. The procedures have been written in conjunction with the Disability Health Care Support Service manual and the registered nurse of the unit, and are endorsed by the paediatricians. Before being eligible for any training from the registered nurse, all school workers must undergo the minimum mandatory training set out by the unit. 4

6 This ensures that the worker understands what will be involved when caring for this child and also gives the workers some time to seriously think about their own commitment to this training long term. It should be noted that some workers after they have started some of the training modules, choose to abandon the long-term commitment. The unit also acknowledges recognition of prior learning, eg workers may have been a registered or enrolled nurse at some time, and or still have current registration but not work in an acute care setting. The minimum mandatory training consists of: senior first aid/casualty care course; chocking and gagging; personal care/and or disability; universal precautions; and police check on background. The minimum training is not delivered by the paediatric unit (with the exception of universal precautions package), but by other recognised training facilities such a Red Cross, St Johns or TAFE. Workers are to provide documented evidence of their training, which is kept on file and database. All workers are then responsible to maintain their current First Aid status and notify the registered nurse if it becomes invalid. The training provided is client specific and does not give the worker general skills that they can apply to any other child. For example if the worker is trained to deliver gastrostomy feeding to one child, the worker still requires an equal amount of training for another child that they may care for. The training consists of a minimum or small amount of theory and a demonstration of actual skill, with an accompanying explanation of the procedure. Workers are then required to demonstrate the skill in a supervised situation, and to achieve competency three times on three separate occasions until they obtain permission from the registered nurse to practice unsupervised in the school environment. Reassessment To maintain their status as a recognised trained school support worker, they need to be reassessed every six months. This involves the registered nurse observing the skill, which the worker has achieved. The worker must actually be practising the skill to maintain a status of competency for that skill with that particular child. 5

7 Trouble shooting To achieve the standard of competence, it is important that the workers demonstrate an understanding of the limitations of their level of practice. Workers are given no scope to troubleshoot any problems. If the procedure does not go exactly as expected to the Health Care plan specifications then the worker is required to abandon the procedure and immediately notify the parent, registered nurse and or the paediatrician. These limitations are a critical part of the training process and all parties involved need to recognise and understand their own boundaries. Any trouble shooting clearly belongs to the registered nurse or paediatrician. Problems are often a sign that the care plan needs revising. TERMINOLOGY What is a credentialled procedure? The Northern Regional Paediatric Unit recognises in the Health Care Plan that not all health care needs of that child are credentialled procedures. These may include: general care of the child; continence management; physiotherapy; and safety. Credentialled procedures include: medication management administration of oral, buccal, per rectum, intramuscularly, gastrostomy, inhaled, eye/ear medication; gastrostomy feeding: via a tube or PEG button; naso-gastric feeding; intermittent catheterisation; anaphylaxis and seizure management; and also variety of others that at present we are not involved with. The Northern Regional Paediatric Unit has developed procedures only for the skills that are required for our existing clients. If a client is referred with a need that we do not have a corresponding procedure then one is developed at that time. Credentialling or delegated care? Credentialling is defined as a skill that is taught from one person (usually the registered nurse) to another (eg school support service officer) to a certain skill level. 6

8 It should not be dictated by the agency concerned, client, or carer but by the registered nurse. Registered nurses involved in the credentialling model are in a position to support clients by proactively negotiating a level of care, and influencing medical management decisions relevant to specific environments. Delegation of care? Means the same as credentialling but is a new age word description of the same skills. It sounds less hostile to a school support worker and family but also sounds less professional. FUNDING OF THIS PROJECT This appears to be an ongoing issue with the unit. Although the original project was for a six-month period and was funded through the paediatric unit, it should be noted that some two years down the track, sustainable funding of this project is still in most of our minds. The Northern Regional Paediatric Unit recognises that without the availability of this service in the region that children with special health needs would not be able to attend school. Parents would have to come in during school hours and attend to the needs of that child. The unit recognises that there is a definite need for these workers to be trained, as local statistics show in our area an increasing number of children in our community with high health care needs. Currently the Child and Youth Health services pay trained workers by the hour for their services. These workers are called Access Assistants. The Northern Regional Paediatric Unit fund the wages of the registered nurse, administration costs, travel, accommodation and transport. A proposal for Child and Youth Health to fund a 0.5 position in Port Augusta is under evaluation. Child and Youth Health through the Access Assistant program also employ a Port Augusta administrative person that has extensive experience with children with disabilities to supervise the program, offer information and support for all the Access Assistants throughout the region. NURSE S BOARD Issues around credentialling have been constantly addressed by the Nurse s Board. Many believe that to credential unlicensed workers would erode the role of current and future nurses. In South Australia the Nurse s Board are aware of organisations that are involved in credentialling, but at this stage remain unmoved as to either it will change the role of the registered nurse or strengthen it. 7

9 In South Australia, credentialling as a model of health care management has been developed and embraced by the nurses in the disability sector since EVALUATION OF THE PROJECT The evaluation of the School Based Health Care project consists of the endless referrals we seem to receive from Child and Youth Health, schools, families and private disability agencies. The registered nurse annually requests written feedback from the school and family units to determine if this service is meeting the needs of the child and that of the workers. There is a huge interest displayed by private support agencies locally that are now requesting their workers who offer respite to children be credentialled in some skills. Unfortunately requests by these agencies are denied as funding and resources are limited in rural areas, and our unit can only offer client specific care to children under the care of the Northern Regional Paediatric Unit. Many of these agencies also wish to change the process as part of cost cutting and individualising the program. VALID DATA COLLECTION Child: 1 4 years Hypoxic ischaemic encephalopathy Special Needs Nutrition via naso-gastric feeding, medication via nasogastric 2 care workers Child: 2 5 years Hypoxic ischaemic encephalopathy, cerebral palsy Special Needs and attends local kindergarten Nutrition via gastrostomy 3 care workers Special Needs Mealtime management plan Chocking and gagging Mobility 8

10 Child: 3 7 years Williams syndrome, Alpha! Antitripsy deficiency Special class at remote region school and child care centre Nutrition via gastrostomy, medication via nebuliser 2 Access Assistants, school trained 4 care workers trained at child care Allergies Chocking and gagging Mealtime management plan Behavioural Child: 4 4 years Hypoxic ischaemic encephalopathy Special school Nutrition via gastrostomy, medication management, gastrostomy 2 Access Assistants Family requested private credentialling for respite Resuscitation orders Seizure management Chocking and gagging Respiratory/asthma action plan Child: 5 4 years Hypoxic ischaemic encephalopathy, cerebral palsy Remote and region child care centre and kindergarten in 2001 Nutrition via gastrostomy, medication management 5 care workers trained at child care 1 care worker will attend child at kindergarten in 2001 Mealtime management plan Seizure management Child: 6 20 years Lafora syndrome Does not attend school, is home managed Oral/buccal Midazolam, per rectum and intra-muscular medication 3 workers trained in respite/home management Seizure management 9

11 Child: 7 16 years Lafora syndrome Private school Oral/buccal Midazolam, per rectum and intra-muscular medication 3 care worked trained at home No Access Assistants trained at present for school 1 other respite worker trained Seizure management Behavioural issues Dietary management Child: 8 4 years Anaphylaxis Remote region child care centre All staff at centre trained annually Epipen training by Department of Education and Training Anaphylaxis emergency management plan Child: 9 8 years Hypoxic ischaemic encephalopathy, cerebral palsy Special school Nutrition via gastrostomy, medication management 2 Access Assistants 1 care worker trained for respite Seizure management Choking and gagging Mealtime management plan Child: years Type I diabetes juvenile onset Remote area school Class teacher trained in diabetes management and all staff educated by diabetic educator 10

12 Child: 11 8 years Type I diabetes juvenile onset, asthma Private school Class teacher trained in diabetes management and all staff educated by diabetic educator Child: 12 6 years Anaphylaxis School All staff at school trained annually Epipen training by Department of Education and Training Anaphylaxis Emergency Plan Child: 13 6 years Anaphylaxis School All staff at school trained annually Epipen training by SA Ambulance Anaphylaxis Emergency Plan Child: years life threatening asthma Remote region secondary school Asthma action plan Asthma first aid plan Exercise induced asthma plan Medication plan Child: 15 3 years Anaphylaxis, asthma Child care centre All workers at centre to be trained (ongoing) Epipen training by Department of Education and Training Asthma management plan 11

13 Child: 16 9 years Undiagnosed developmental delay Private school 1 Access Assistant Chocking and gagging Child: 17 9 years Cerebral palsy, microcephaly Special school (ongoing) No workers trained as yet, child attends school infrequently Seizure management at home Chocking and gagging Mobility Child: years Spastic Quadreplegia, Cerebral Palsy, Raynauds disease, total autonomic nervous dysfunction Special class secondary school Still ongoing at present 2 3 Access Assistants need to be trained Respiratory management VP shunt management Mealtime management Child: 19 3 years Hypoxic ischaemic encephalopathy Nutrition via gastrostomy 3 care workers trained Resuscitation orders (child now deceased) 12

14 Child: years Cerebral palsy Remote primary school School support officers not trained Mobility CONCLUSION This Country Based School Care Program was developed to support children in the Northern and Far Western Health Region and Mid North Region of South Australia with special health care needs in Educational settings and Schools. Previous to the service being developed, there was no other service available to these children and their families. In some instances children were excluded from attending school because staff were unable to meet their health care needs. A school principal is not expected to supervise invasive and complex health care, this is a nursing duty. The Education Department does not employ nurses. There is an identified need in this region for a medical service to write Health Care Plans, train the school workers and supervise and support the workers in their role. The aim of this service is to make available, professional standard care and keep the child and workers safe. The Country Based School Care program is a good example of interagency collaboration and co-operation achieving the development of a service that successfully meets an identified community need. Nineteen Health Care Plans are currently active in this region, which includes not only the Port Augusta region, but Whyalla, Port Pirie, Leigh Creek, Roxby Downs and Coober Pedy. It should be recognised that the School Based Health Care program was awarded a Community Care Quality Service Certificate of Recognition in April AUTHORS Nigel Stewart is a paediatrician and child health specialist who has been based in Port Augusta, South Australia for the last 7½ years. He heads the Northern Regional Paediatric Unit currently employing two paediatricians, a registrar, nursing staff and administrative support providing extensive outreach services. His interest include developmental and behavioural paediatrics and Indigenous children s health. 13