Introduction

Good nursing practice is based on evidence, and undertaking a community health needs assessment is a means to providing the evidence to guide community nursing practice. A community health needs assessment is simply a process that examines the health status and social needs of a population. It may be conducted at a whole-of-community level, a subcommunity level or even a sub-system level. Nursing practice frequently involves gathering data and assessing individuals or families to determine appropriate nursing interventions. This concept is transferable to an identified community, when the community itself is viewed as being the client.

A community health needs assessment can be undertaken for a number of reasons, which primarily relate to developing an understanding of that specific community. Most often this is done to improve the quality of life for those living in that community. The findings from a community health needs assessment contribute to developing informed, relevant and appropriate strategies for health promotion activities and interventions (Kazda et al., 2009). This may be through prioritising resource allocation, service redevelopment, workforce development needs, or to inform program planning or facilitate community development. The intention of a community health needs assessment is to promote, support and create a healthy community.

A community health needs assessment should be viewed as a tool that focuses thinking on what the client – in this case the community – requires, rather than focusing on what services are being provided. It provides direction to ensure that nurses (and other health professionals, organisations and governments) are not simply doing what is considered a good idea or what is easy or comfortable to do, but rather are doing what is necessary based on careful analysis of the available data.

A community health needs assessment has a slightly different focus to that of a health needs assessment, which tends to focus on needs related to specific physical and mental health conditions, rather than considering social factors such as housing, employment and education that influence well-being and health more broadly. Adopting a primary health care perspective requires that a community health needs assessment should reflect the social view of health. It is therefore essential that the process undertaken in determining need incorporates social justice, equity and meaningful community participation.

Introduction

A general practice nurse (GPN) provides nursing care in a primary care (general practice) setting (Halcomb, Patterson & Davidson, 2006). There are over 11 000 nurses working within general practice in Australia, with around 63.3 per cent of general practices employing at least one GPN (Australian Medicare Local Alliance, 2012). New Zealand workforce data from 2014–15 reveals that some 6.6 per cent of all nurses work in general practice, accounting for some 3317 nurses (Nursing Council of New Zealand, 2015). This places general practice as one of the five largest practice areas within the New Zealand nursing workforce (Nursing Council of New Zealand, 2015). In countries such as New Zealand and the UK, practice nursing has been well established for many years. However, in Australia it is a relatively new phenomenon. The number of nurses working in Australian general practice has exponentially expanded in recent decades (Australian Medicare Local Alliance, 2012). This has come about in response to positive government policy and financial incentives to enhance the provision of nursing services in primary care to address the growing burden of chronic and complex disease associated with population aging (Halcomb et al., 2008; Harris & Lloyd, 2012).

The general practice setting

Australian general practices are predominantly run as small businesses comprising selfemployed medical practitioners who are funded through fee-for-service payments (Merrick et al., 2012). Many practices are owned by general practitioner (GP) ‘principals’ who have the joint role of employer and clinician. The Australian health system is complex, as the federal government sets a scheduled fee for services under the Medicare payment scheme and then reimburses up to 85 per cent of the scheduled fee for the GP service (Merrick et al., 2012). Individual practices then decide whether the client will be charged an additional ‘gap’ fee. The nature of general practice operating as a business creates a significantly different environment to government-funded acute care services. While in the small business setting there is an emphasis on recouping costs for equipment and staff time, in the acute sector these resources are funded more broadly. It is vital, therefore, that GPNs understand the nature of the general practice business model and the impact that this has on service delivery.

Introduction

The provision of health care to those who have been incarcerated in correctional environments provides an essential service for a vulnerable and at-risk group in the community (Condon, Gill & Harris, 2007). The reality for many people housed in correctional environments is far from the somewhat glamorous stereotypes portrayed in the media and popular culture. Often, the lives of people in prison have been impaired by chronic health problems, illiteracy, poverty, unemployment, homelessness and high-risk behaviours, such as unsafe sex, drug use and alcoholism (Australian Institute of Health and Welfare [AIHW], 2014; 2015; Bennett et al., 2010; Butler et al., 2008; Davidson, 2015; Hickey et al., 2014). The correctional population is extremely varied and complex, composed of male and female adults and adolescents, who are both the victims and perpetrators of crime (Norman & Parrish, 1999; Parahoo, 2010). For many, incarceration provides an opportunity for mental and physical health issues to be assessed and appropriate health care initiated (AIHW, 2014; Butler et al., 2008; Dinkel & Schmidt, 2014; Mills, 2014).

Stemming from the international frameworks developed by the World Health Organization (WHO, 2007), in Australia and New Zealand incarcerated individuals are expected to receive health care equivalent to that available in their community without discrimination (AIHW, 2014; Bennett et al., 2010). Therefore, correctional nursing provides an essential service in undertaking the assessment, planning and implementation of health care for incarcerated individuals (International Council of Nurses, 1998). Successful health interventions implemented during incarceration can mean that individuals return to the community with a more positive attitude to personal health and improved health status compared to when they entered custody (Dinkel & Schmidt, 2014; Mills, 2014).

Given the unique clinical environment and patient needs, correctional nurses are required to be equipped to have specific skills sets, knowledge and personal attributes, which vary from traditional nursing. In addition to the specific clinical skills, nurses are also required to possess both practical and theoretical knowledge of the workings of the criminal justice system, the function of the courts and health legislation (Bowring-Lossock, 2006).

Correctional health systems

Traditionally, health care staff working in correctional environments were employed as part of the correctional services workforce, and as a result worked in a hierarchical system similar to that of correctional officers (Smith, 2010).

Introduction

The World Health Organization (WHO) (2014) has reported that chronic conditions, or non-communicable diseases, currently cause a greater number of deaths than all other causes of death combined. Additionally, it estimates that deaths related to chronic conditions will rise from some 38 million deaths in 2012 to 52 million deaths by 2030 (WHO, 2014). The majority of these deaths (82%) are due to the four major chronic diseases: cardiovascular disease (CVD), chronic respiratory disease, diabetes and cancer (WHO, 2014). However, other chronic conditions, including injuries that result in persistent disability and mental health disorders, also contribute to increased morbidity and mortality. The significant increase in preventable chronic conditions and the management of these are major health care concerns of the industralised world.

Regardless of the specific diagnosis, many chronic conditions have been shown to be amenable to a number of broad approaches to care (Flinders University, 2009). Interventions focus on early identification of risk; modification of lifestyle risk factor behaviours such as smoking, nutrition and physical activity; optimising evidence-based care and facilitating self-management (Flinders University, 2009). Addressing these factors contributes to reducing the burden of the development and progression of chronic conditions. While this may appear simple, the issues surrounding lifestyle risk are complex and, therefore, intervention strategies need to be multifaceted.

Primary health care nurses, as part of the multidisciplinary health team, have been demonstrated to have a significant role in both health promotion and chronic disease management (Halcomb et al., 2007). However, to achieve these gains nurses need to be equipped with the skills and knowledge to intervene effectively. This chapter will present some of the key considerations and strategies that nurses need to understand to assist in both reducing lifestyle risk factors and managing chronic conditions.

What is a chronic condition?

A chronic condition is any disability or disease which an individual experiences over an extended period of time, usually for longer than six months (Department of Health and Ageing, 2009; Flinders University, 2009). The term ‘chronic condition’ is used rather than ‘chronic disease’ as it is inclusive of the broader range of diseases, injuries and disabilities which have ongoing health effects upon individuals (Flinders University, 2009). Such conditions may occur at any point across the lifespan; however, they are more prevalent with advancing age (Australian Health Ministers Conference, 2005).

Introduction

The relationship between primary health care, health literacy and health education with empowering individuals and communities to improve and maintain optimum health is explored in this chapter. These concepts were introduced in the previous chapter, with a more detailed examination presented here. Within the primary health care (PHC) philosophy, principles of accessibility, affordability, sustainability, social justice and equity, self-determination, community participation and intersectoral collaboration drive health care service delivery and health care reform. Health care reform aims to meet the health care needs of people and communities through developing a sustainable health care system to reduce health disparity and improve health outcomes for all Australians and New Zealanders. A key component of this is developing the health literacy of consumers, health care providers and health care systems. Optimum health literacy is achieved through addressing the social determinants of health, to ensure these are working for people rather than against them. Health care professionals and systems need to work in ways which empower individuals and communities to achieve better health outcomes. Empowerment is a fundamental component of social justice, which seeks to redistribute power so those who are disadvantaged can have more control of the factors that influence their lives (Ife, 2013).

PHC in the Australian context

Australia is both a member and supporter of the global PHC movement, and has been involved in the World Health Assembly conferences. A definition of PHC in the Australian context was developed by the Australian Primary Health Care Research Institute (APHCRI):

This definition captures the key principles that advocate PHC as people-centred health care.

Health care reform

Historically, PHC in Australia has consisted of an unrelated set of services rather than an integrated service system (Department of Health and Ageing, 2010).

Introduction

One of the common questions asked by students and even staff involved in nursing education has been: ‘Why do we need a separate topic/chapter/course on Indigenous health?’ While this should be self-evident considering where the greatest health challenges of our time lie, it is not always clear. Indigenous peoples in countries such as Australia and Āotearoa New Zealand, although diverse in languages, cultures and histories, often share a common experience of profound relevance to health professionals today – an experience of being colonised that had detrimental and ongoing impact on health and well-being. However, in spite of these common experiences, there is also a resilience and capacity among Indigenous peoples that provides the community/primary health care nurse with an opportunity to affect real change towards better health outcomes.

This chapter introduces Indigenous approaches to health care that have relevance for the Australian and Āotearoa New Zealand contexts. Several of the principles for practice are readily transferrable to other culturally and linguistically diverse populations. The challenges are undeniably major, but the rewards are potentially transformative. Nursing training and education is most often located within mainstream, non-Indigenous settings. Health professionals who want to make a positive difference to the health outcomes of Indigenous clients should be equipped with knowledges and understandings which will facilitate effective engagement. Further, this chapter will examine the historical influences that have impacted on the health and well-being of Indigenous peoples in both Āotearoa New Zealand and Australia, and consider the need for adopting Indigenous approaches to health care practice and engagement such as cultural safety, cultural responsiveness and other cultural frameworks. Finally, it will examine the role of the community nurse in Indigenous primary health care.

A note on terminology before proceeding: ‘In the Australian context, the term “Indigenous” is used to refer to Aboriginal and Torres Strait Islander peoples and, with due respect, these terms are used interchangeably and acknowledge the diversity of languages and cultures that characterise Australian indigeneity’ (Rigby & Jeeawody, 2014, p. 283). In Āotearoa New Zealand, Māori are the first Indigenous peoples who can trace their ancestry and genealogy (whakapapa) right back to those who arrived in the early canoe fleet migrations of the mid-1300s (Ministry for Culture and Heritage, 2005) from the Tahitian and Hawai'iki regions.

Introduction

As a paediatric nurse, you will frequently care for children and young people with chronic conditions. Your initial contact may be during routine assessment, at diagnosis or during subsequent treatment (such as for the management of childhood cancers or type 1 diabetes). You may also be part of a team managing an acute illness in a child or young person with a chronic condition, as might occur during an exacerbation of asthma or a urine infection in a child with spina bifida. Depending on your role, your involvement may extend to a clinic, home, school or community – for example, if you are running a healthy weight program. If you work within one organisation or within one specialty practice for any period of time, you may form long-term relationships with chronically ill children and their families, becoming part of their lives as they grow into young people and adults – or, inevitably for some, until the end of their lives.

It is not usual to associate children and young people with chronic conditions, especially as some definitions relating to adult illness (such as cardiac disease) imply that chronic diseases are those for which action can be taken to prevent their occurrence (ABS, 2015a). However, the most recent available estimates indicate that between 2007 and 2008, 37 per cent of children and young people in Australia had at least one long-term chronic condition. This figure equates to more than 1.5 million future Australian adults (ABS, 2009). Asthma, diabetes and cancer are the most common chronic medical conditions affecting children in Australia, collectively accounting for 20 per cent of the burden of disease among children aged 0–14 years (AIHW, 2012), but the range of chronic conditions affecting children and young people is much broader.

Introduction

Children contract infections regularly during early childhood, and are also at risk of injury; thus they can experience episodes of acute illness. For the most part, these episodes are of short duration and resolve with the care of parents at home, sometimes with support from community health care professionals such as a general practitioner. However, in some instances the illness can reach a level of severity that requires nursing care and medical treatment in a hospital setting. Children aged 0–4 years are the most common age group presenting for care in an emergency department (AIHW, 2015). Infants and children are still developing, so they have physiological and anatomical differences from adults that require specialist skills and knowledge. Hospital environments can be challenging for both the young child and their family. For many families, visiting the emergency department with their sick child may be the first time they have ever had to seek acute care from a hospital. It is important that nurses understand this, and that we ensure the child's care is delivered in a way that is supportive and respectful of the individual child and their family.

In Chapter 6, you were introduced to primary assessment of infants and children and recognition of the sick or deteriorating child. In this chapter, some key nursing considerations and interventions for the acutely unwell child will be discussed. Following this, you will explore some of the illnesses children can acquire that may require hospital care. You will be asked to reflect upon the nursing management of some of these conditions through review of case studies and reflective questions.

Introduction

All people have a right to assume that health professionals are appropriately educated to focus their knowledge and skill on practice that is based on the best available evidence from research, and that this evidence informs the safety and quality of their care. Parents and carers of children and young people extend this assumption to health-care decisions made on behalf of those in their care. The tenet of using the best available evidence for decision-making is so self-evident and fundamental to health care that standards relating to quality, safety, research and evidence-based practice can be found in the professional registration standards of all health disciplines.

Research and evidence are intimately linked in nursing and health care, but each makes a slightly different contribution. We can broadly distinguish research as a systematic process for deriving new knowledge, and evidence as the knowledge that is produced and used. However, evidence from other sources is also used to inform health and treatment decisions – sometimes because good-quality evidence does not yet exist and sometimes because the evidence that does exist is not directly applicable to the context. The experience of the clinician or carer, the context of the health-care environment and the specific values and priorities of the child, family or community receiving care ultimately shape decisions about the quality of the evidence and how evidence is used. Sometimes these different sources of knowledge are categorised as external evidence (from research) and internal evidence (relating to the child, family, clinician or setting).

Introduction

This chapter examines the health of children and young people growing up in Australia. The aim is to consider children and young people in a more global context and as the future population of Australia. We will look at population characteristics, challenges to healthy growth and development, and emerging health and social trends. We will also define and describe some of the measures (or indicators) of children and young people's health referred to throughout the text.

The future role of the paediatric nurse is not only shaped by emerging physical threats such as childhood obesity, injury and chronic illness, but also by behavioural, developmental and mental threats resulting from the rapid social and environmental change affecting children and young people all over the world. We invite you to consider the idea that the health and welfare of the children and young people of Australia are as much determined by the context of the past and present as they will be by the context of the future.

As you read more widely about the health and wellbeing of children and young people, you will become aware of many different definitions and descriptors for age groups within this population. The Australian Bureau of Statistics (ABS), for example, defines children as those aged under 15 years of age and young people as being 15–24 years of age. In Australia, legal adulthood is established at 18 years of age, and the ABS defines young adults as being in the age range 18–34 years.

Introduction

Children with complex medical needs and their families are important and frequent consumers of paediatric health-care services (Burns et al., 2011); however, their needs are not always met (Noyes et al., 2014). Most children with complex medical care needs are cared for at home, with parents primarily responsible for their day-to-day care, often with the support of ambulatory and outpatient services. Depending on the nature of the child's condition, they may require frequent admission to hospital, psychosocial and socioeconomic support, and resources to maintain health and enable participation in school and other activities of daily living (Burns et al., 2011). The care that parents may be required to provide at home is likely to include procedural care – tasks such as suctioning or medication administration, and physical care such as manual handling, feeding and toileting (Rehm, 2013).

Children and young people who are dependent on medical technology have a higher risk of severe acute illness and are more likely to require admission to an intensive-care unit (Burns et al., 2011; Rehm, 2013). Furthermore, some illnesses may be life-limiting, resulting in premature death in childhood, adolescence or early adulthood. Some children, young people and their families may require palliative care services towards the end of their illness.

It can be difficult to determine when a child can be defined as having complex medical needs (Cohen et al., 2011). What one family finds complex, another family may adapt to more easily. One child with a particular condition may have less severity and more function than another child with the same or a similar condition. Furthermore, the discussion around the care of children with complex medical needs has often used different terms for similar things – care that is ‘medically complex’, or children who are ‘technology dependent’ or ‘medically frail’.

Introduction

This chapter builds on the information in Chapter 1 about the context of paediatric nursing in Australia. It is intended to provide a basis for understanding the ways in which children and young people's rights are upheld in Australia, particularly within the health-care system. This extends to child protection, including nurses’ legal and moral responsibility to report child abuse and neglect.

As a nurse working with children, young people and their parents, you will be challenged to consider many important issues regarding your involvement with them as active participants in their health-care decisions. In your practice, you will explain which treatments or interventions are necessary, and decide whether the child or young person has the capacity to understand the importance and consequences of the choices that you make in collaboration with them and their family. Your assumptions about childhood and the role of parents will underpin the way in which you approach the child or young person and their family. These assumptions need to be evaluated critically and open to scrutiny and review, so you can provide the best possible care within a variety of contexts. This can sometimes be challenging, as there is a disparity of power in the relationships between the child or young person, you and the family, and this needs to be acknowledged and addressed.

The purpose of this chapter is to provide insight into the ways in which human rights, and particularly child rights, inform paediatric nursing policy and practice in Australia. The chapter explains how current Australian legislation attempts to ensure that child rights are protected within the health-care system.

Introduction

In paediatric nursing, families are central to the care of children – in fact, the patient is considered to be both the child and their whole family. In this chapter, you will explore what it means to be a family, learn about the models of paediatric nursing care that emphasise a focus on both the child and their family and discover the frameworks that can be used to assess families in paediatric nursing practice. You will also be invited to consider some of the tensions or challenges experienced by paediatric nurses during care for children and families.

Families in contemporary Australian society

Families in Australia today are diverse in terms of their structure, as well as their membership and functions. Because of this, the concept of ‘family’ is quite challenging to define. It is perhaps useful to think of McCaffery's (1968) reference to pain as being ‘whatever the patient says it is’ and consider families to be defined by their members; even though members of a family may have no blood relationship, they may consider themselves to be a family.

Contemporary Australian families may be: