case study of child health nursing

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Children's nursing case studies

Read first-hand stories from staff who work in a range of different children’s health specialties and nursing. Find out about the different routes to working in this area, with advice for anyone who is thinking of making the move into children’s nursing.

Search:  Children and young people

Who is this resource for?

This resource is aimed at nurses across all settings and levels of practice, including students of health, social work and care professions.

What will this resource give me?

• Case study: Adele Watkins, Mental Health Clinical Nurse Specialist for Women and Children at Noah Ark’s Children’s Hospital for Wales, Cardiff.
• Case study: Angela Wright, Clinical Nurse Specialist for children with Intestinal Failure at Barts Health, The Royal London Hospital.
• Case study: Christine Desmon, Advanced Nurse Practitioner – Paediatric Endocrinology at the Royal Berkshire Hospital, Reading.
• Case study: Claire Gillan, Clinical Educator and Liaison Nurse at Ulster Hospital, South Eastern Trust.
• Case study: Coral Rees, Advanced Paediatric Nurse Practitioner at Children’s Hospital for Wales, Cardiff.
• Case study: Erica Thomas, Advanced Nurse Practitioner Paediatric Surgery at the Children’s Hospital for Wales, Cardiff.
• Case study: Gillian Priday, Sister, Children’s nursing, Teenage Ward at The Christie NHS Foundation Trust.
• Case study: Grace Edge, Head of Children’s Nursing at Northern Health and Social Care Trust.
• Case study: Helen Morris, Matron, Lead Nurse Southwest Paediatric Oncology, at Bristol Royal Hospital for Children.
• Case study: Jackie O’Connell, Matron Children’s Community Nursing Team at North Middlesex Hospital.
• Case study: Lucinda Armstrong, Sister at University Hospitals Bristol NHS Foundation Trust.
• Case study: Martyn Wood, Paediatric Disability Clinical Specialist at University Hospitals Bristol NHS Foundation Trust.
• Case study: Pauline Nelson, Primary Mental Health Practitioner at Southern Health and Social Care Trust.
• Case study: Sarah Kvedaras, Paediatric Neurosurgical Clinical Nurse Specialist at Noah Ark’s Children’s Hospital for Wales.
• Case study: Tendai Nzirawa, Quality Improvement Manager at NHS England and NHS Improvement.

Resource last reviewed

13 Oct 2022

Resource lead

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Children's nursing case studies

Read first-hand stories from staff who work in a range of different children’s health specialties and nursing..

Find out about the different routes to working in this area, with advice for anyone who is thinking of making the move into children’s nursing.

Adele Watkins - Children's Hospital for Wales, Cardiff

Name: Adele Watkins

Job title: Mental Health Clinical Nurse Specialist for Women and Children

Speciality: Acute child health

Organisation: Children's Hospital for Wales, Cardiff

What is your current role?

I am the mental health clinical nurse specialist based within the Children's Hospital for Wales. I am employed by acute child health as a dual-qualified children’s and mental health nurse, which I feel has made a difference in improving the care of those children and young people admitted in mental health crisis. I firmly believe the quote that "there is no physical health without mental health" (World Health Organization) and this drives my motivation each day.

I had been seeking opportunities to provide more specialist mental health nursing in the hospital for some years ago and, when given the opportunity to explore this need further I found the demand and complexity of cases seen within acute child health were growing. With this in mind I achieved the role of Mental Health CNS in 2017 and since then have continued to strive to improve services for these vulnerable group of C&YP.

While my aim is to improve services for patients the need to end Stigma towards mental health is vital in achieving this. My ongoing support and education for staff has improved attitudes and understanding of staff caring for this group of C&YP on acute paediatrics wards. As I educate them, I also stress the need for supporting their own mental health, as we cannot provide the complex care for the C&YP without meeting the our own needs.

What was your route to this role?

My route into this role was my ongoing drive to bridge the gap between physical and mental health services for children admitted into acute child health in-crisis. I became a duel qualified children and mental health nurse to help achieve this.

What prompted you to do this role?

My ongoing passion to improve this service for these vulnerable group of children and young people.

What education/courses/modules have you undertaken to equip you for the role?

I am a qualified RSCN 2001 Project 2000 Registered Mental Health nurse 2005. Ongoing development courses to aid this role e.g. ASIST, brief suicide intervention training, mental health first aid, violence and aggression.

How do you see yourself developing your skills?

I continue to develop my skills and knowledge to improve patient care by bench marking the service with others. Attendance at both local and national conferences to update knowledge and practice. Attendance at study days and courses applicable to my development.

What is your long-term career plan?

• My long term career plan is to develop this role into a band 7 post
• Develop a team of training professionals within the acute child health setting who have to skills and knowledge to care for these C&YP
• In developing the role, I would also like to see a unit separate from acute medical wards to meet the specific age appropriate needs of the C&YP

What advice would you give someone thinking about moving to work in your area of practice?

It would be an excellent and often challenging opportunity to improve the care of this vulnerable group of young people.

What do you most enjoy about this area of care?

Being able to make even the smallest difference to the care that the young person receives in crisis, so that they move forward with a positive attitude toward seeking further help.

Angela Wright - Barts Health, The Royal London Hospital

Name: Angela Wright

Job title: CNS for children with Intestinal Failure

Speciality: Paediatric Gastroenterology

Organisation: Barts Health, The Royal London Hospital

I am currently the lead Clinical Nurse Specialist (CNS) for Children with Intestinal Failure requiring Home Parenteral Nutrition (HPN).

I started my career as a junior staff nurse on a general paediatric ward with specialist gastroenterology. This was were my love and interest in paediatric gastroenterology began. I did however leave this ward to join a general medical paediatric ward in a hospital that had an A&E department in order to gain some more acute experience. I built on this experience and returned to the world of gastro on a surgical gastroenterology ward as a junior sister, during my time on this ward I acted up as a senior sister to cover a maternity leave post.

Following this experience I decided that clinical management rather that ward management was more suited to me and I took my first CNS role as a the Inflammatory Bowel Disease CNS. This was an amazing opportunity, I was part of a truly Multi Disciplinary Team setting up a service that included a young adult/transition component - it was a very exciting time. I held this role for 8 years, following my own Maternity leave I needed a part time role and therefore transferred to the role of CNS for children with Intestinal Failure.

My career history had allowed me to experience both ward management and the management of a clinical case load. I have always enjoyed working within the gastroenterology speciality and saw an opening in an emerging speciality that has allowed me to develop my skills as an advanced nurse practitioner and promote the needs and welfare of children and families with complex long term conditions.

I am an original Project 2000 qualified nurse; following this I obtained multiple degree level modules of interest. I was lucky enough to obtain funding for national and international conferences - allowing for my interest to really grow in the world of paediatric gastroenterology. During my early years as a CNS, I embarked on the Advanced Nursing MSC programme and obtained a Post Grad Diploma Cert.

I continue to attend conferences and speciality courses to ensure that my knowledge is up to date outside of my work base. I have joined advisory groups and belong to a NHS e-stakeholder group for HPN Home Care Commissioning.

I would like to develop my role as a non-medical prescriber.

To continue promoting and advocating for the care needs of children and young adults with complex hidden health care needs. Supporting the family unit is crucial when they are undertaking such complex nursing care tasks within the home - I hope to work with national groups to enhance and continue this.

Find a speciality that really interests you, take your time and learn from others, gaining crucial experience along the way. Although as a CNS you look after a specialist care cohort, it is essential that you have a good understanding of general paediatrics to underpin your practice.

Playing an integral part in helping children, young people and their families throughout the discharge process, teaching complex nursing skills to both parents/carers and young people and supporting children through education and into the world of transition and preparing for adult services.

Christine Desmond - Royal Berkshire Hospital, Reading

Name: Christine Desmond

Job title: Advanced Nurse Practitioner - Paediatric Endocrinology

Speciality: Paediatric Endocrinology

Organisation: Royal Berkshire Hospital, Reading

I am currently an Advanced Nurse Practitioner for paediatric endocrinology services at the Royal Berkshire Hospital.

I began my general nursing career at the Westminster hospital in 1991 consolidating my training on the paediatric ward at the Chelsea and Westminster hospital which I really enjoyed. In 1996, I began work at the Middlesex hospital where I completed a Diploma in Children's Nursing and Bsc in Professional Nursing. It was here that I first began working with patients with endocrine disorders. I was immediately drawn to the management of this complex group of patients and the variety of specialist care and dynamic testing they required. 

It was whilst working at the Middlesex hospital in 1996, where I managed the Adolescent Daycare Unit organising various endocrine tests on a daily basis that my interest in endocrinology began. I loved the structure and fast pace of the dynamic function tests and was intrigued by the physiology and the diagnostic reasoning process used to identify a treatment plan for endocrine patients. I successfully began my career working with children and young people (CYP) with endocrine disorders as a clinical nurse specialist at St Georges Hospital, London. Throughout my nursing career, I continued working as a clinical nurse specialist in this area at Cork University Hospital, Ireland and now currently at the Royal Berkshire Hospital, Reading.

• Registered General Nurse
• Diploma in Children's Nursing
• Bsc Professional Nursing
• Endocrine Module
• Non-Medical Prescribing Certificate
• History taking and Assessment 
• Diagnostic Reasoning
• Applied Research.

I am currently completing the final dissertation module of the Msc Advanced Clinical Practice. This qualification continues to support the advancement and development of my skills in the assessment and management of this complex group of patients. I am also an active member of the CYP specialist forum which has allowed me an opportunity to be involved in updating national guidelines and policies.

I want to continue to support and be an advocate for CYP with endocrine disorders. On completion of my Msc, my plan is to set up a nurse led new patient clinic. I currently manage follow up patients both face to face and virtually but would like to advance this further by assessing new patients referred to the clinic.

It's really important to find a specialty that interests and challenges you, for me this was endocrinology. I have been very lucky to have gained a lot of clinical experience and knowledge throughout my career working alongside some very supportive and inspiring healthcare professionals which I feel was crucial to my success as a specialist nurse.

There is always something new to learn within this specialty which I love. The challenges and learning opportunities the role offers, the remarkable children and young people I continue to meet along the way means I still enjoy my job even after 30 years of nursing.

Claire Gillan - Ulster Hospital, South Eastern Trust

Name: Claire Gillan

Job title: Clinical Educator & Liaison Nurse

Speciality: Children’s nursing

Organisation: Ulster Hospital, South Eastern Trust

There are 2 parts to my role:

1. Clinical Educator, which involves providing education to staff nurse and healthcare assistants in the Children's Unit, being involved in the induction of new staff, and promoting development in existing staff.

2. Liaison. Facilitating and supporting the delivery of age appropriate care to children and young people in adult wards in the hospital, with particular emphasis on fluid management, administration of medicine, consent and safeguarding.

I was Deputy Sister in Craig Ward for 3 years before taking this role. During this time I obtained BLS Instructor qualification and RQF Level 3 in Assessing Vocational Achievement. Before that I was a band 5 on Craig ward for 2 years and RBHSC ED for 7 years.

I really enjoyed mentoring and teaching students, healthcare assistants and new staff and wanted to develop this side of my career further.

I have recently completed the Effective Teaching in Practice Course and hope to start a PGCE soon. I am in the process of completing the RQF Internal Verifier Award. Learning from others has also been a great source of education!

This is a new role within the Children's Unit and Cohort Wards, so I am learning constantly. I am developing skills in teaching, negotiating and time management.

I would like to stay in the area of Clinical Education. It is very rewarding to watch someone you have taught progress to greater things and fulfill their potential.

Go for it! Follow the dream. I came into nursing as a mature student. It is never too late!

I enjoy making a difference to staff. By encouraging, supporting and providing education, they are empowered to progress.

Coral Rees - Children's Hospital for Wales, Cardiff

Name: Coral Rees

Job title: Advanced Paediatric Nurse Practitoner

Speciality: General Paediatrics

Advanced Paediatric Nurse Practitioner - lead for General Paediatrics.

I qualified with a diploma in children's nursing in 2000 at the University of Salford in Manchester. I worked within a variety of areas including critical care in different NHS trust in both England and Wales before securing a trainee ANP role in the children's hospital for Wales in 2005.

During my first few years of being qualified it became very apparent that acute medical nursing was what i enjoyed and I began to develop an interest in the extended roles that nurses where beginning to develop. An aspiration to be a advanced nurse practitioner was beginning to develop.

Bsc in Clinical Practice, Msc in Advanced Practice, PgCert Education for Health Professionals, APLS instructor -generic instructor course.

My skills have developed as the role has developed over the years. My skills are now best used training the ANPs of the future as we have led the way with this role with the General Paediatric field in Wales. I am still very fortunate to be clinical within my role and spend around 70% of my time with direct contact with children and their families.

Consultant nurse role. 

Get as much experience as you can in different areas of acute care and include either critical care or emergency department experience as it will equip you will the skills you need to manage an acutely ill child.

No day is ever the same when i am clinical! I can be on ward round seeing a child who has been admitted with pneumonia then have a crash call to an acutely unwell child in ED. I also enjoy training the new ANPs of the future as it is very rewarding to see them develop.

Erica Thomas - Children's Hospital for Wales, Cardiff

Name: Erica Thomas

Job title: ANP Paediatric Surgery

Speciality: Paediatric Surgery

Organisation: Noah's Ark Children's Hospital for Wales

Currently I am employed as an Advanced Nurse Practitioner for Paediatric Surgery in a tertiary hospital in South Wales. For those interested in expanding their clinical skills to accommodate non- medical prescribing and radiology requisition in combination with clinical assessment and diagnostic skills this is the role for you.

Working alongside a team of surgeons caring for neonates, children and young people up to the age of 16 years. The role has evolved in line with changes in the legislation that govern the Advanced Practitioner role.

This role evolved through my love of clinical contact with patients and particularly those with congenital bowel problem that have had contact with the surgical team from birth. The Welsh Assembly sponsored the MSc Advanced Practice which is a requirement for the role in Wales.

The role involves teaching of medical and nursing staff both at the bedside and in the classroom.

Having been a ward sister on a paediatric surgical unit in London for 13 years, I had attended an ANP conference in the USA through my work with the RCN surgical nurses forum. I had become aware of the potential of such a career opportunity and applied when I saw the job being advertised.

• BSc Nursing Practice
• MSc Advanced Practice
• Non-medical prescribing
• Basic surgical Skills course
• Non-medical radiology requester

Each day is a new learning experience and no two days are the same. By evaluating outcomes I can identify where my weakness can be built upon.

To complete my 40 years within the NHS!

If you like patient contact, don't want to sit behind a desk and want to make a difference by developing yourself and those around you - go for it.

Patient contact.

Gillian Priday - The Christie NHS Foundation Trust

Name: Gillian Priday

Job title: Sister, Children’s nursing, Teenage Ward

Speciality: Teenage Haematology & Oncology

Organisation: The Christie NHS Foundation Trust

I work as a Sister on the Teenage Haematology and Oncology ward at the Christie hospital in Manchester.  I love my job as I get to support junior staff and help develop their skills, I love working with and alongside teenagers and their families and trying to be a light in a dark situation.

After qualifying I worked in Paediatric Intensive Care after two years I worked on paediatric and young adult ward haematology, oncology and bone marrow transplant ward.  From here I got my Sister's post at the Christie Hospital on the Teenage & Young Adult Haematology and Oncology Ward.

I have always had an interest in haematology and oncology as a student nurse I had my final year management placement on a teenage cancer ward which I loved.

I have completed my MSc in Teenage Oncology, I am passionate about research and turning evidence into action. From this research I have won first place in the country for the Royal College of Nursing research award.

I am on the CYP Specialist Care Forum Steering Committee, we provide a voice for our members and advocating for children and young people with specialist nursing care needs.  I have learnt a lot in this role and had the opportunity to present at conferences, update national guidelines and policies.

I would like to be a Teenage Cancer Nurse Specialist and support the teenagers and their families both in and out of hospital and help them to live their life to the full. 

Attend conferences/RCN Congress to find more information about it and it also is a great opportunity to meet other Nurses who work in the area and talk to them about what it is like to work in the area. 

I love that I get to be there for the teenagers and their families from the moment they’re diagnosed, all the way through their cancer journey. It’s about using my experience and knowledge to help navigate people through that journey. I love my job because I know I can make a difference.  

Grace Edge - Northern Health and Social Care Trust

Name: Grace Edge

Job title: Head of Children's Nursing

Speciality: Acute and community paediatrics and neonataology

Organisation: Northern Health and Social Care Trust

I am currently the Head of Children's Nursing within the NHSCT.

I commenced my nursing career in 1988 by undertaking a 4 year combined RGN/RSCN qualification in what was then the Royal Group of Hospitals. Once I qualified in 1992 I worked within acute paediatrics as a Grade D staff nurse in RBHSC for 1 year before moving to England to take up a Grade E staff nurse post within orthopedics, plastic surgery and spinal injuries. Whilst working in England I was successfully appointed to a Grade F ward sister in 1994 and then promoted to a Grade G ward manager in 1996. I moved back to Northern Ireland in 2001 and worked as a Grade E staff nurse in paediatric orthopedics.

In 2003 I was then appointed as a Grade G Senior Nurse Practitioner within community children's nursing in Homefirst Community Trust. In 2007 under the review of public administration I was appointed as a Band 8a Paediatric Lead Nurse for the NHSCT. I acted up into a Band 8B Head of Children's Nursing within the NHSCT for a 6 month period in 2015 before being permanently promoted to my current role in September 2016.

From a young age I was always interested in working with children. When I was still studying a school/college I undertook a number of volunteer roles within local community that related to children (Girl Guiding, hospital volunteer, church summer schemes). I have always sought to develop and seek alternative positions within paediatric nursing to enrich my nursing experiences and further my career.

• Combined training re Registered General Nurse and Registered Sick Children's Nurse
• ENB qualifications in teaching and assessing in practice, orthopaedic nursing and research & development 
• Diploma in Nursing (Staffordshire University)
• BSc (Hons) Community and Public Health Nursing 
• Post Graduate Diploma Health and Social Care management 
• RCN Leadership programme 

Every day is a learning day! I am currently enrolled on the HSC Leadership Centre Aspire programme. This is a programme for Senior Managers across the Health and Social Care System that helps to builds on existing leadership skills. It challenges participants to think about their personal resilience for change and what it takes to make confident decisions and engage effectively within and across organisational boundaries.

I also currently sit on the WellChild advisory panel as the Northern Ireland representative. 

To continue to develop and promote acute and community paediatric nursing and neonatology both regionally and nationally.

As long as you are passionate about working with children and their families then a career in children's nursing is for you. Whilst Children's Nursing can be challenging and varied it is a hugely rewarding career pathway. There are a number of career opportunities available within paediatrics and neonatology e.g. advanced practice, service development, clinical education, governance, management of chronic long term conditions and complex health.

No two days are the same!

Helen Morris - Bristol Royal Hospital for Children

Name: Helen Morris

Job title: Matron, Lead Nurse Southwest Paediatric Oncology

Specialty: Children’s nursing

Organisation: Bristol Royal Hospital for Children

Introduction

I led on the development of an Oncology/Haematology Telephone Triage Tool Kit for Children and Young People as a guideline for the provision of triage assessment and advice for staff answering telephone advice line calls from families who were at home with their children who were undergoing cancer treatment. Having researched a suitable tool, there was none that was available for paediatric oncology patients so decided to create one that could be used nationally.

I recognised in my centre that there was little formal assessed training or guidance for nursing staff taking calls from families at home when undergoing cancer treatment and that documentation and communication about advice given was not always clear. When I raised this at a national meeting, other centres felt the same and so we decided to set up a development group to address this gap. We decided to adapt a validated tool that had been used in the adult setting developed by United Kingdom Oncology Nursing Society (UKONS).

How did you initiate the work? 

A development group was set up consisting of paediatric oncology nurses, UKONS adult nurses and representatives from the RCN. There is little published evidence regarding CYP oncology/haematology triage, though there was anecdotal evidence regarding the provision of 24-hour telephone advice line support for parents and carers in CYP Principal Treatment Centres (PTC) and CYP Paediatric Oncology Shared Care units(POSCU). The development group found following a national audit that the advice and support provided was reliant on the experience and knowledge of the nurse or doctor answering the call and that although there were local models of good practice they had not generally been validated.

There were no tested assessment or decision-making tools in use at the time. Furthermore documentation and record keeping differed from trust to trust. Despite this we wanted to develop a national tool that every centre would use and that families would recognise where ever they were in the country.

This Tool Kit would provide:

• Guidance and support to the practitioner at all stages of the triage and assessment process
• A simple but reliable assessment process
• Safe and understandable advice for the practitioner and the caller
• High quality communication and record keeping
• Competency-based training
• An audit tool

The first phase was to agree nationally the criteria that would be used and this was a challenge initially where different centres used slightly different guidance even based on national criteria. This required working corroboratively and ensuring the medical colleagues were also in board. We also had to think about how we could ensure that the toolkit would work in the many varied environments that paediatric oncology is given.

We then had to think about how we would finance the development of the toolkit and how it would be accessed by everyone. I decided to approach 2 charities and work with them as this toolkit would be very much about improving care and support for families, areas that I was aware both of these charities were very passionate about. CLIC Sargent  agreed to help fund the development, printing and ongoing reviewing and auditing of the toolkit and Children Cancer Leukaemia Group (CCLG) agreed to host the toolkit and associated documentation on their open website so that it was easily accessible.

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

The first phase of implementation was to pilot the tool and the RCN very kindly agreed to support this. The tool was subject to a pilot in 5 PTCs and 2 POSCUs, which resulted in a very positive evaluation from both staff and families. Following some minor alterations we then further developed the education and competencies around the tool and submitted the toolkit to the RCN to be assessed from a governance perspective as nurses needed to be clear they would be supported in its use. Having not undertaken this before, I did underestimate the time that this would take but the toolkit was passed in time for a national launch day supported by the RCN, CCLG and CLIC Sargent.

This day was crucial to get right to ensure that we met our aim of rolling this tool out across all 4 nations of the United Kingdom. We had attendance from nearly all PTC leads and all agreed to roll this tool out to their centres and review its future use in the POSCUs, which was incredible at the time. I believe that we have achieved this due to staff recognising a gap in their knowledge, the big impact that staff could see it would have for patient care, the support of the charities involved and the excellent national networks that we have in paediatric oncology.

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

The pilot feedback was extremely positive with staff saying that they felt much more supported, especially the more junior staff, an improvement in documentation of advice given and positive feedback from families. Most PTCs have now rolled the tool out to their POSCUs as well and I was also approached by a team in Australia who wanted to use it. The tool was also commended in a coroners case that occurred. I presented the toolkit at an international paediatric oncology conference where it won best nursing poster. It is used on a daily basis around the country supporting staff and improving patient care.

What are the long-term aims for the work? 

I believe that we have met our aims of:

a) Improving patient safety and care by ensuring that they receive a robust, reliable assessment every time they or their carers contact a helpline for advice b) Ensuring assessments are of a consistent quality and that advice is determined based on the use of an evidence based assessment tool c) Providing management and advice appropriate to the patient’s level of risk. To ensure that those patients who require urgent assessment in an acute area are identified and that appropriate action is taken, but also to identify and reassure those patients who are at lower risk and may be safely managed by the primary care team or a planned clinical review and avoid unnecessary attendance d) Forming the basis of triage training and competency assessment for practitioners e) Helping to maintain accurate records of the assessment and decision-making process in order to monitor quality, safety and activity

The next step is to ensure this continues so CLIC Sargent  and I are currently in the process of setting up a formal audit and review of the toolkit following 2 years of its use to back up the anecdotal feedback that we have. We will then publish this work. 

Jackie O'Connell - North Middlesex Hospital

Name: Jackie O'Connell

Job title: Matron Children's Community Nursing Team

Speciality: Children’s nursing

Organisation: North Middlesex Hospital 

What is your current role? 

I am Matron for the Children's Community Nursing team and my team consists of specialist nurses and generic nurses.

I started my adult nurse training in 1984 and worked in various areas which included Gynae A/E ITU. I worked in a holiday centre  in Jersey as the resident nurse.

I always wanted to be a children's nurse and loved my placement during my nurse training. I applied for a job on the children's ward at Whittington in 1990 and worked there for eight years and was fortunate enough to undertake and pass my children's nurse training..

I have a degree and I have also completed a pa ediatric cancer course.

I can support and develop my team. I can deliver a high standard of nursing care to my patients. I have managerial skills and have learnt over the years how to communicate with staff effectively.

To continue to grow and develop my team.

Community nursing is so rewarding. It is a privilege to go into a patients home and deliver nursing care.  

Making your own clinical decisions and acting as an independent practitioner.

Looking after children in their own homes. Children are able to relax and care can be delivered at the child's pace.  Growing a team of generic and specialist nurses has been so rewarding.

Lucinda Armstrong - University Hospitals Bristol NHS Foundation Trust

Name: Lucinda Armstrong

Job title: Sister

Specialty: Children’s nursing

Organisation: University Hospitals Bristol NHS Foundation Trust

Wheeze is a very common childhood presentation to Emergency Departments (ED) with a predictable clinical course. In our institution most are admitted to an observation unit to wean the frequency of inhaled medicines, a key step before discharge. Although nurses are allocated to this unit, medics and Emergency Nurse Practitioners (ENP) concurrently deliver care here and in the ED, which may create delays as children who are fit for discharge await their review.

Criteria Led Discharge (CLD) is a protocolised discharge process that empowers nurses to discharge pre-identified patients, and is identified as a method to support ED flow and reduces levels of crowding.

After implementing CLD for wheezy children we undertook serial evaluations to measure efficiency and safety using pre-defined time-related outcomes and safety measures. There was a significant reduction in the time to discharge, by over two hours per child, equivalent to a saving of 130 bed days per year; safety measures were stable pre and post-implementation.

Benefits have been sustained and amplified over three years, and expanded to include similar conditions; this has subsequently spread throughout our hospital and to other institutions.

Childhood hospital admissions are rising annually, especially for breathing problems, with wheeze the most common diagnosis. Most admissions are short; in our institution these children are admitted to our observation unit.

On average, every bed in this unit is used for 2.5 patients per day, reflecting high efficiency. However when fully occupied, suitable patients are admitted to inpatient beds, and flow from the ED is impeded. Targeting efficiency improvement here speeds discharge, improves ED patient flow, and reduces inpatient admission, contributing to financial benefits and improved patient/family experience. Learning from (a) this unit can be translated rapidly to other departments in our institution and similar units nationally, and (b) from wheeze to other appropriate conditions.

Observation unit nurses autonomously wean medication and deliver family education, including inhaler technique and recognition of severe breathing problems. We therefore implemented CLD for wheezy children in this unit, with a planned evaluation to measure efficiency (time to discharge compared to existing practice) and safety (unplanned return rate, reflecting quality of education and safety of discharge decision).

Prior to implementation, the CLD concept was supported by Senior ED Consultant, Nursing, and Management teams via our governance group. Input was sought from all nurses and medics during development of assessment proformas, checklists, communication and training materials, to encourage buy in. Families were not involved in CLD development, but are offered the opportunity to opt-out prior to discharge. Work is planned with families to explore whether any improvements can further enhance their experience.

When implementing CLD hospital-wide we engaged with general paediatric medics and nurses, management, and the hospital innovation team. CLD is covered in hospital induction and included in competency documents for all new doctors and nurses, with support and leadership from senior personnel. We anticipate this will safely improve efficiency hospital-wide, especially during seasonal illness outbreaks such as bronchiolitis, which place huge demands on resources nationally.

We share resources and experiences with paediatric departments and EDs who are keen to implement CLD; when doing so we strive to optimise successful implementation by discussing their infrastructure and common challenges.

Unsurprisingly many of the current issues and obstacles are identical; CLD appears to provide a deliverable solution to at least some of these.

Nursing staff feel empowered and more valued in taking ownership for patients on CLD pathways. The medical team value the use of CLD and the efficiencies it has delivered, identifying that it is patient friendly, family friendly and promotes wider team engagement.

CLD for wheeze was implemented in May 2016; serial evaluations demonstrate excellent adoption by staff.

2018 saw a 100% annual increase in use, with 32% of all patients discharged by CLD. We successfully expanded CLD to other conditions; comparing 2018 to 2017, the number of additional patients discharged by CLD equalled increases in admissions; despite an 18% annual increase in admission there was zero additional workload for medics.

For wheeze, evaluations consistently demonstrate CLD is efficient and safe. Compared to previously, time to discharge decreased by over 2 hours on average, from 140 to 15 minutes. This results in approximately 130 bed days saved per year. Generating this highly efficient turnaround improves ED flow and reduces inpatient admissions.

Safety measures included completion of an education checklist, a written wheeze plan, protocolised primary care communication, proportion removed from CLD pathways, and unplanned reattendance rates.

Completion of checklist, wheeze plan, and primary care communication are 100%; removal from CLD pathways occurs appropriately in 10% due to needing oxygen.

Unplanned reattendance rates remained stable before and after CLD at 1%.

Dissemination has enabled spread in three main domains: (i) our observation unit, (ii) our hospital inpatient wards, and (iii) other similar institutions. Our dissemination strategy included peer-reviewed journal publication (Archives of Disease in Childhood Education & Practice, widely accessed by relevant healthcare staff), presentation at local, regional and national conferences, and social media.

In each forum we shared the results, implementation strategy, and assessment proforma, to enable easy uptake. We are engaging with our Academic Health Science Network to spread this more formally.

In our observation unit we expanded CLD to other conditions including procedural sedation recovery, bronchiolitis, head injury, accidental ingestion and gastroenteritis. In our hospital we worked with the General Paediatricians to support hospital-wide CLD implementation for wheeze and other conditions. This was implemented in late 2018, and is currently undergoing its first round of evaluation; the early signal is optimistic, with increasing numbers of children discharged safely on CLD through the first two months.

We have also trained and supported other paediatric teams, both regionally and nationally, resulting in CLD implementation for wheeze in their observation and paediatric assessment units. Whilst none of these have yet been formally evaluated, initial feedback is uniformly positive.

Martyn Wood - University Hospitals Bristol NHS Foundation Trust

Name: Martyn Wood

Job title: Paediatric Disability Clinical Specialist

Specialty: Children’s nursing

I have set up a pre-admission screening system for children with disabilities to try to meet their needs coming in to hospital for elective admissions. This involves searching the electronic patient record for children with alerts for Learning Disability, Hearing Impairment, Visual Impairment & the Bristol Children's Hospital Passport and contacting the child's parent/carers approximately one week before admission to identify their specific needs based on the hospital environment, communication preferences, play and distraction, and the anaesthetic and recovery process.

This is backed up with video resources that can be accessed from home and offers of play support and desensitisation techniques (e.g. sending an anaesthetic mask home for children to play with, wash, decorate and then bring back in for use).

All patient information letters about admission to Bristol Royal Hospital for Children have the contact details of the Paediatric Disability Team on the reverse. Most phone calls that were made were 1-2 days before admission and in discussion with a range of parent/carers it was apparent that human factors meant that parent/carers typically read the front of the letter on receipt (the date and time of admission) and the reverse closer to the date...leaving little time to make changes.

The Equality Act (2010) states that service providers "take 'reasonable steps‘ and to make ‘simple modifications’ legally known as ‘reasonable adjustments’ to anticipate the needs of disabled people, not just to react as these arise.” It therefore seemed logical to make a proactive effort to contact families of children with identified disabilities in advance to anticipate needs with time to make reasonable adjustments.

Children where a disability has not been identified to the hospital and therefore no alert has been created can still access the Paediatric Disability Team the way they would but would be offered the use of an electronic alert for future admissions.

University Hospitals Bristol uses the Medway electronic medical record system and this has been utilised to add alerts to patient records for a number of clinical and social reasons, including learning, physical and sensory disabilities. Admission lists were already available and the Medway team created 10 day admissions lists for me for four wards with potentially complicated admissions. Information is shared with the ward, play and theatre teams in time to implement the requested reasonable adjustments.

The main challenge to implementing this change has been time. the Paediatric Disability Team is 25 hours per week Band 7 (myself) and 15 hours per week Band 4 support worker. The number and complexity of patients identified can vary each week and only I am doing this work. This means that it has to sit alongside my other responsibilities and other parent/carers contacting directly.

There has been positive feedback from parent/carers, children and young people and from the whole multi-professional team saying that the pre-admission disability assessment makes the care of children with disabilities and complex needs easier with better patient and family experience. Reasonable adjustments have included the use of play for preparation and distraction, information sent out in a child-friendly format, allocation of side rooms, sourcing special beds and supporting parents and carers.

So far data has been collected for three consecutive quarters showing that a total of 181 patient attendances have been pre-assessed by the Paediatric Disability Team. The majority of these are attending the day case unit as this is the preferred location for children with disabilities to support a quick return to the home environment and avoid a complicated discharge following a longer stay. The largest specialty group is orthopedic surgery.

At present the work is continuing as part of my role along side my existing responsibilities. There is work being developed to create more materials for children such as boxes to carry favourite items from the ward to recovery. Ultimately this work could be developed to either a stand-alone role or devolved to each ward area to take responsibilty for their own complex patients.

Pauline Nelson - Southern Health and Social Care Trust

Name: Pauline Nelson

Job title: Primary Mental Health Practitioner

Speciality: Specialist Child & Adolescent Mental Health Nurse

Organisation: Southern Health and Social Care Trust

I currently work in Step 2 Child and Adolescent Mental Health Service where my role is early intervention and prevention. I undertake assessment of individuals and families and provide appropriate therapeutic approach and interventions. The preventative aspect is carried out through a community development approach focused on awareness of emotional and mental health through parent psycho education in community groups like parent & toddler groups and for children & young people through programmes such as Active for Life and school sessions.

I also provide training programmes to Step 1 professionals for example, Health Visitors, Community Paediatric Nurses, School Nurses and teachers. Also included is provision of consultations to Step 1 professionals such as Paediatricians, Nurses, Social workers .

I think that my route began with my interest in people and I completed my Degree in Psychology . I researched many careers and each was eliminated, not fitting with the person that I was until I was impressed by the compassion and enthusiasm when I asked nurses about their career Having completed general and mental health nursing I worked in Southern Trust NI and Riverside Trust, London.

At this time, AIDS was a new illness so I sought further understanding so that I could be better at providing care and completed EMB specialist AIDS Nursing and provided care in GI Surgery. Throughout this I reflected on how many illnesses were preventable & researched prevention in nursing and was drawn to Health Visiting & completed this diploma. 

In the course of working with a wide range of families in the community and with an age range from birth to end of life I became more acutely attuned to the need to develop emotional and mental health I felt that people were frequently aware of the importance of the latter but I was struggling to support their efforts to make changes in their attitudes or interactions to develop emotional literacy in the family. I sought help and found it in a foundation course in family therapy which changed my way of having conversations with families and supported them to consider how they can promote emotional and mental health from birth.

I found myself spending increasing time on this aspect of health in the new born and child as the need was uncovered. The need was such that it was necessary to establish a specific clinic which we called 'The Behaviour Support Clinic' and came to be provided by a number of Health visitors and was additional to our role. We had to acknowledge that we had insufficient time within working hours to provide this service. I counted the number of hours in direct clinic provision and suggested making a business plan to request extra Health Visiting hours in order to provide the service, outlining the need, the aims and the outcomes.

We were initially declined but in the course of a year a new report was launched outlining the need for this type of service. The report was 'Together We Stand' 1995. My excitement was uncontainable and the business plan was re submitted with supportive references from this report. The outcome was positive. We had requested an additional 8 hours of Health visiting time but we were granted 37.5 hours (1 WTE) in the first instance with potential to be increased and this was the birth of Step 2 CAMHS SHSCT.

The post was advertised and one of my health visiting colleagues and I were successful in obtaining it as a shared post as we were both already part time balancing work and family. I completed the Specialist Practice in Child And Adolescent Mental Health. In addition I pursued family therapy to the next level and completed the intermediate family therapy qualifying as a systemic practitioner.

I use an eclectic mix of skills in communicating with families and children and young people individually. I use the skills of establishing therapeutic engagement through the language that I use the type of questioning and curiosity that creates therapeutic conversations through neutrality. This supports the capacity for change, paving the way for incorporating additional interventions such as solution focused therapy, psychological therapies, cognitive-behavioural therapy or social learning theories.

I have to be honest in saying that I have never planned my career but I realize that my career developed as a result of continuous reflective practice. 

'The best place to succeed is where you are with what you have' C.M. Schwab.

I would advise all nurses to be true to themselves in following what commands them to pay attention and to respond to need in service users and seek to address that need through the use of their skills and if necessary seek information and education to give the best to those who come to us. Be inspired to reach wider horizons of thought and action. I would say that if they wish to work to make a difference to the emotional and mental health of children, young people and their families then this is one care service in which to do that. I would add that therapist neutrality is essential.

'The things that constitute real success is not in learning as much as you can but in performing as well as you can something that you consider worthwhile, whether it is healing the sick, giving hope to the hopeless or adding beauty to the world' - W. Raspberry.

To return to my inspiration for nursing - I love working with people! What I find most enjoyable is that every individual is unique and so also the family. I become part of that system for a period in supporting the challenge of change, peeling back the layers of struggles experienced. I like the element of surprise when they come to realize that they are the experts of their own selves or family and together we can discover how they can make things different and have emotional and mental health through healthy interaction and relationships.

Also the sense of achievement in an individual child/young person in developing skills to manage emotional and mental health challenges. The greatest job satisfaction that I feel is that I have made a difference in the lives of families.

Sarah Kvedaras - Noah's Ark Children's Hospital for Wales

Name: Sarah Kvedaras

Job title: Paediatric Neurosurgical Clinical Nurse Specialist

Organisation: Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board

I am currently the clinical nurse specialist for paediatric neurosurgery for inpatients in Cardiff. All children referred from south, mid and west Wales are all transferred into Cardiff as the tertiary centre for paediatric neurosurgery in Wales. 

Since qualifying from Cardiff University in 2013, I undertook a role as a staff nurse in a DGH in England. I then returned back to Cardiff and Vale UHB in 2014. I undertook a rotation around the Children's hospital within medicine, surgery and paediatric critical care. I began the role part-time for 8 months before going full-time. 

Working on the paediatric surgical ward I cared for many children with neurosurgical conditions including head injuries, bleeds and tumours. My experience in critical care also gave me a much deeper insight into the care of a child facing a significant head trauma. My colleague then encouraged me to apply for the role part-time as I had an interest in paediatric neurosurgery and wished to advance my clinical role from a ward staff nurse.

There is no set welsh education course to take on this role and a lot of support and teaching has been undertaken by the neurosurgical registrar team and my consultants, such as the administration of intrathecal antibiotics . I attended a 'Fundamentals of Paediatric Neuroscience Nursing Course' offered by GOSH in 2018. I have also completed venapuncture training within my local hospital.  I have also been completing my nursing masters course part-time over the last four years which I hope to complete this Autumn. This is an MSc in Advanced Practice offered by Cardiff University where I have completed modules in research, leadership and education alongside a paediatric specific module. I have completed this masters in my own time to further my education and development as a nurse. 

I hope to further develop my clinical skills within neurosurgery to undertake reservoir/shunt taps. I also hope to undertake a cannulation course in the next year. I would also like to become a nurse prescriber in the future if I had such an opportunity.

I would really like to further my skills to become an advanced nurse practitioner. Once my masters is completed I can then top this up with an 18 months clinical course. However, this would be a new job role within Wales and is not yet within the scope of practice for the paediatric neurosurgical service. 

I would advise others to undertake any and every opportunity to advance their knowledge and clinical skills. Whether that may be rotating to a new area or undertaking a study day. Further learning can offer so much insight across your scope of practice for the care of children you give. I would also advise not to be afraid of doing something new or working in an area you don't have too much prior knowledge of, you will always learn and be supported within a new role. 

I really enjoy the autonomy this role brings as a children's nurse. As a clinical nurse specialist I can offer support and advice for my client group when parents contact me. I always have the backing of my colleagues and can contact members of my registrar/consultant team for advice. As part of my role I also educate the children's nurses within the hospital which I really enjoy. To support the learning of others is a privilege to offer education about neurosurgical management.  

Tendai Nzirawa - NHS England and NHS Improvement

Name: Tendai Nzirawa

Job title: Quality Improvement Manager 

Organisation: NHS England and NHS Improvement - East of England. Maternity Clinical Network

What is the initiative or project you are involved in?

Paediatric Pan London Oxygen Group (PPLOG) Discharge Bundle has been shared through study days and workshops in order to make the transition from hospital to home of every child on oxygen therapy seamless.

Since July 2018, a total of three study days that include workshops have been run in London (Whittington, St Thomas and Mile End Hospitals). The study days have been well attended. On record about 160 health professionals so far and about 100 health professionals participating either by group/one to one workshops within their clinical area facilitated by a PPLOG member. Prior to the study days, a survey was conducted in 2017/2018 and highlighted that there were various practices in each area on how parents and staff are taught about home oxygen. Furthermore, the results found some areas had guidelines that were either out of date or not evidence based.

What prompted you to do this work?

The Paediatric Pan London Oxygen Group (PPLOG) was founded in 2016 with the aim to bring knowledge and experience of Respiratory Nurses, Community Children's Nurses and Community Neonatal Nurses together, and set standard guidelines that will ensure the management of children on oxygen therapy is safe and uniform within the London region.

The PPLOG members include: Emilie Maughan (Co-Chair), Rebecca Smith (Co-Chair), Abigail Beddow (Secretary), Tendai Nzirawa (Treasurer), Caroline Lock (Air Liquide), Alison Camden, Sook Lin Yap, Nichola Starkowitz, Ceara Turner, Samantha Ahern, Tamsyn Hernandez and Billie Coverly.

The PPLOG discharge bundle contains seven separate documents to aid the safe and timely discharge of a child requiring home oxygen across Greater London. The BTS guidelines for home oxygen in children have been used however the limitation is that there were published 10 years ago therefore slightly out of date based on the current practices. 

How did you initiate the work?

PPLOG came together after a Respiratory Clinical Nurse Advisor set a forum to share concerns and find solutions to make the baby's or child's journey from hospital to home as safe as possible however using evidence based practice.

The barriers were trying to find a location to run the quarterly meetings and setting a meeting date that was convenient for every member. However, this was overcome by routinizing the venues and ensuring as long 70% of members attended the meeting would be held. PPLOG has been run for the past three years with no grants from any organisation, only occasional sponsorship during study days. PPLOG has been peer reviewed and endorsed by WellChild the national charity for sick children, London Neonatal Operational Delivery Network, London Clinical Oxygen Network and Respiratory Futures. 

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

The challenges of implementing PPLOG have been lack of support from some organisations to implement change that would be beneficial for the staff and families. However, through the support of NHS London, London Clinical Oxygen Network, Contract Management Board and Clinical Commissioners Groups, there has been a lot of collaborative working and changes.

There has been written feedback from post-study days surveys that indicates that staff found the PPLOG discharge bundle and the study days usefully to implement positive change within their organisation. The plan would be to conduct a larger feedback survey prior to the PPLOG discharge bundle review in 2020. 

Achievements:

• Finalist (Respiratory Nursing) Nursing Times Awards 2018 
• Finalist (Primary Care Innovation) Health Care Transformation Award 2018 NHS England
• Various poster presentations.

Each study has been attended by 50-55 health professionals involved in the discharge process of children requiring home oxygen daily and includes medical, nursing and educational representation from community, tertiary hospital, neonatal intensive care and commissioned oxygen provider settings. There is now a demand for PPLOG to be shared outside London. There are three study days set for November 2019.

Follow up conclusions and next steps: - What are the long-term aims for the work?

The aims and objectives of PPLOG would be:

• To review the PPLOG discharge bundle in 2020 and make changes based on survey and peer feedback
• To establish standard guidelines for home oxygen weaning within tertiary and community settings
• To streamline the discharge process for children on home oxygen therapy
• To continue facilitating educational programmes for hospital staff preparing to discharge a child on home oxygen therapy
• To support the families with evidence-based information on how to care for their child on home oxygen therapy
• To set a platform and create a Pan London Oxygen protocol for education and management of all children on oxygen therapy within tertiary and community settings
• The PPLOG to audit every setting using the guidelines/pathways annually through staff, parents and children satisfaction feedback
• Guidelines and pathways to be reviewed every three years or earlier if advised of new evidence-based practices.

Please let us know if you have any photographs or slides which will help show the work

See: Paediatric Pan London Oxygen Group (PPLOG) Discharge Bundle

Page last updated - 10/07/2023

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© 2024 Royal College of Nursing

• Open access
• Published: 16 April 2020

Innovations in maternal and child health: case studies from Uganda

• Phyllis Awor 1 ,
• Maxencia Nabiryo 1 &
• Lenore Manderson 2 , 3 , 4  

Infectious Diseases of Poverty volume  9 , Article number:  36 ( 2020 ) Cite this article

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Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Every day, about 300 neonates and infants and 20 mothers die from preventable causes in Uganda [ 1 ]. Most of these deaths occur during delivery and within the first month of life. These deaths are mainly caused by complications to the mother and child in labour and during delivery, and in association with infectious diseases of poverty including malaria, pneumonia, sepsis and HIV/AIDS [ 2 ]. These statistics have remained almost the same over the past 10 years, while the Ugandan government (like others in low income countries) is grappling with low human resources for health, lack of medicines, equipment and diagnostics, weak governance, and limited funding for health [ 3 ].

In Uganda, maternal mortality is mainly attributed to the “three delays”: delay in making the decision to seek care; delay in reaching a health facility in time; and delay in receiving adequate treatment [ 4 ]. The first delay is attributed to the failure of the mother, her family, or the community to recognize a life-threatening condition; in this context, lack of awareness of pregnancy-related health risks is a major reason for the low uptake of maternal health services [ 5 ]. The second delay is associated with delays in reaching a health centre, due to road conditions, lack of or cost of transportation, or location of the facility: over 40% of rural women in Uganda report distance-related barriers to accessing healthcare [ 6 ]. The third delay occurs at the facility where, upon arrival, women receive inadequate care or ineffective treatment because most health facilities in Uganda, especially in rural areas, persistently lack the necessary medicines and equipment to care for mothers during pregnancy and at the time of and after delivery [ 7 ]. The ‘three delays’ model reveals the complexity of maternal health challenges. To tackle these issues, there is need for multi-disciplinary and inclusive approaches that engage various stakeholders, including community members, in solving these problems [ 8 ].

Communities often identify and introduce pragmatic and lasting solutions to challenging health problems. Little is known of these solutions beyond their immediate surroundings, but if some of these were scaled-up, they could contribute to better health outcomes for larger populations. In this article, we focus on community-based solutions for maternal health in Uganda.

Study design

The three case studies described in this article were identified through a six-week crowdsourcing call, in May and June 2017, which invited individuals and community organizations to share their community-based solutions to improve maternal and child health in Uganda. The call was launched through newspaper advertisements in the five main local languages in Uganda and through multiple seminars at Makerere University and with the Ministry of Health technical working groups on maternal and child health, e-health and monitoring and evaluation and operational research. The call was further disseminated through different online platforms, print media, and radio advertisements.

Twenty nine nominations were received from diverse implementers across the country. The submitted nominations were within the following categories: improving access to delivery care, for example, by providing maternal waiting homes; phone apps for pregnancy information and for sexual and gender-based violence reporting; improving neonatal care; ultra sound scanning devices; and creating better social and economic opportunities for disadvantaged women and children. Twenty one nominations were eligible and these were reviewed by an external independent panel of judges that included experts from academia, non-governmental organizations and the Ministry of Health. Five top solutions were selected for further case study research.

Data collection

To better understand the successful social innovations in health, we investigated for novel processes, products, policies, market mechanisms, and practices addressing the health challenges. A descriptive and explorative case study research approach was utilized to understand the selected projects better and to explore the role of social innovation in improving the lives of women and children in Uganda. Further, exploration of cross-case themes that have transferable properties within and between different contexts was undertaken.

Data collection followed the case study methodology as proposed by Yin and Eisenhardt [ 9 ] [ 10 ] This approach allows for an in-depth systematic exploration of a phenomenon via the collection and analysis of multiple forms of data. Yin proposed the use of six sources of evidence as a way to achieve construct validity in case study research. These include documentation, archival records, interviews, direct observations, participant observations, and physical artefacts [ 9 ]. The various forms of data enable an enriched, multi-dimensional layout of the phenomenon of query and supports construct validity.

In this research, data was both qualitative (in depth interviews, observations) and quantitative (evaluation data on the impact of the solution and existing disease and systems indicators on the local health context). Field visits were conducted, and implementers and beneficiaries of the solutions were interviewed. The interviews were recorded and transcribed, and supplementary information was received from the organizations’ records, including reports. This triangulation of multiple forms of qualitative and quantitative data enabled the research team to examine certain aspects in depth, to compare different forms of data around the same aspects, and to constitute or support the coding of a concept using multiple forms of data. Traingulation was also useful for quality control. The collected information was analysed to generate case study reports that reflect the innovative components of each case study and the key health system recommendations for policy makers and implementers.

To support the construction of the social innovation case, data collected through different methods was triangulated as per Table  1 below.

Case studies

Below, we describe three case studies of social innovation in maternal and child health, and provide health system and policy relevant recommendations. Two case studies demonstrate the importance of bringing reproductive health and maternal delivery services closer to recipient populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service. Figure  1 shows the location of the case studies in Uganda.

Map of Uganda showing locations of the case studies

Case 1: mothers’ waiting hostel at Bwindi community hospital

Bwindi Community Hospital (BCH) is a private not-for-profit health facility in South Western Uganda, that has sought to address some of the delays in women’s access to health care by providing a maternity waiting home for pregnant women from remote and hard-to-reach areas for about 1 month prior to expected date of delivery. BCH began as an outreach clinic without fixed facilities — it literally operated under a tree — but it has expanded to a 112-bed hospital which provides health care and health education to the surrounding population.

The hospital serves over 100 000 people, including the Batwa pygmies who lived in the Bwindi forest, and were evicted when the area was made a national park in 1991. The Batwa have been subject to systematic structural violence, with extremely poor health as a result of poverty and displacement. The hospital initially aimed to serve the Batwa, but then expanded to provide health care for other people also in the surrounding sub-counties of Kayonza, Kanyantorogo and Mpungu. The terrain is mountainous and settlements isolated; in consequence, women often walk for approximately 8 h to reach a health care centre [ 11 ].

The waiting hostel was established in 2008 within the BCH to provide pregnant women with a place to stay prior to delivery, so that they did not have to endure long journeys through difficult terrain when they were in labour. By its location within the hospital, the waiting hostel ensured that pregnant women would have access to a skilled birth attendant at delivery. It also ensures that women who are HIV infected are enrolled onto the prevention of mother to child transmission (PMTCT) program, to protect their children from infection. Women are required to make a one-time payment of United States Dollars (USD) 1.5 for the duration of their stay in the hostel. BCH leverages funding from other hospital programs and existing structures, such as sexual and reproductive health services and the Community Based Health Insurance Scheme (CBHI). These services have now been in operation for 10 years.

BCH utilizes existing hospital staff to take care of the women in the waiting hostel. A full time nurse checks each day women’s general condition and vital signs (blood pressure, fetal heart rate etc.). In case of emergency, the fully equipped hospital operating theatre is available and a full time obstetrician is on duty. At the hostel, women prepare their own meals and contribute to cleaning. They also receive basic health education, including on how to prepare nutritious meals for their infants and young children. First time mothers are also engaged in peer learning on how to care for a new-born. The nurses and midwives also conduct sexual health sessions on child spacing, the advantage of small families, and family planning methods, so that women make an informed choice about contraceptive use.

The community health worker outreach program

BCH has a community health outreach department with three community health nurses, who work with 502 community health workers in 101 villages to conduct health promotion activities and identify women with high risk pregnancies. Women in the high-risk category as per the WHO definition are especially encouraged to stay at the hostel a few weeks before their expected date of delivery.

Impact on health care delivery

From July 2006 to 2012, on average 106 deliveries occurred monthly and an estimated 30% of the mothers utilized the hostel. In 2014, there was a 10.5% increase in women’s utilization of the mothers’ waiting hostel by women from distant sub-counties; and a fourfold increase in the utilization of delivery services at BCH. By 2017, the hospital was delivering an average of 150 babies monthly, and approximately 45–60% of the women utilized the waiting hostel. Thus increasing numbers of women marginalized by location have been accessing the hostel, the antenatal care it provides, and the PMTCT program. In total, following the launch of the health insurance scheme March 2010, there has been a consistent increase in outpatient attendance, inpatient admissions, and deliveries at BCH. Further, about 150 children receive immunization services weekly and all new-born babies received. Bacille Calmette-Guerinand polio vaccines on the maternity ward.

The idea of a maternity waiting hostel is not new in African or other settings. Global guidance on waiting homes in hard-to-reach areas exit, and many countries have related policies [ 12 ]. However, in Uganda, there are no publicly run maternity waiting homes. Over 30% of women in rural areas deliver at home, because of continuing barriers to seeking, reaching and receiving quality maternal health care [ 13 ]. Distance to a health facility, limited transport services and the direct and indirect costs of travel all influence women’s delivery location, with women living the farthest away from facilities most likely to deliver at home [ 13 , 14 , 15 ]. Maternity waiting homes like this one in BCH can contribute to increased access to skilled birth attendants, timely interventions, and better delivery outcomes.

Case 2: imaging the world, Africa

Due to low income and lack of advanced medical imaging technology, rural women living in remote and under-served areas are unable to access diagnostic imaging, and so have difficulty in receiving timely diagnosis of pregnancy complications. This increases the risk of severe morbidity and mortality among pregnant women. Imaging the World Africa (ITWA) is a Ugandan-registered NGO which focuses on incorporating low-cost ultrasound services into remote health care facilities which routinely do not provide this service, which lack the standard infrastructure required of imaging systems, and where there is a shortage of radiologists. ITWA integrates technology, training and community participation to bring medical proficiency and high-quality imaging services to the population [ 16 ].

The imaging the world model

The ultrasound program was originally introduced in 2010 to identify high-risk pregnancies in one health facility in eastern Uganda, and expanded to six other districts and 11 facilities by 2016. The model incorporates point of care ultrasound imaging devices, task shifting, training and innovative real-time external radiological expert reviews, using telemedicine services. It combines these services with community awareness and pragmatic funding models that promote self-sufficiency. ITWA provides the program by training nurses and midwives at remote health centres to perform basic ultrasound scans. ITWA developed software to compress and transmit full ultrasound images via the internet to an offsite team of participating radiologists, both in Uganda and abroad, for real-time interpretation, enabling them to review the images, provide a diagnosis, and relay the results back to the transmitting centre.

Task-shifting training program

ITWA equips nurses and midwives with the skills and knowledge to conduct obstetric ultrasound scans. They developed a 6 to 8 week certified training program for non-specialist health workers located in rural areas, delivered at the Ernest Cook Ultrasound Research and Education Institute (ECUREI), a private for-profit sonography training centre located in Kampala. Selected midwives or nurses with an expressed interest in sonography undertake practical and theoretical training on how to conduct abdominal sweeps and transmit the images for interpretation. Once health professionals have successfully completed the training course, they are awarded a certificate of completion and ITWA then provides the health facilities in which they are based with ultrasound machines to perform scans.

E-health/telemedicine ultrasound radiology service

ITWA developed software (utilizing Digital Imaging and Communications in Medicine) that compresses and transmits full ultrasound images via the internet. During ultrasonography, the probe is passed across the abdomen of the pregnant woman in a series of six prescribed sweeps using a low-frequency transducer, so acquiring a series of static images. These images are de-identified and stored locally on a computer before being compressed and transmitted digitally via an internet connection. They can then be immediately viewed by participating radiologists, the majority of whom are local Ugandan radiologists who volunteer to interpret the scans. An abbreviated report of the findings is sent via SMS to the nurse/midwife’s cell phone, and a full report is sent by email, usually within an hour. In order for this to happen, there must be a laptop, a cell-phone, internet connection, and an ultrasound machine at the point-of-care.

ITWA has rolled out ultrasound services in 11 rural health facilities in Uganda and has trained 150 health workers to perform obstetric ultrasound. Since 2010, 200 000 ultrasound scans have been conducted, with each scan generating data to aid decision making. ITWA maintain that obstetric ultrasound results have helped change the management in 23% of pregnancies with complications. The others did not require imaging for decision making.

The availability of ultrasound scans has allowed pregnant women to receive timely care at the appropriate level of health facility, thereby reducing unnecessary delays and complications of delivery. This has led to an increase in the number of women seeking antenatal care, increased male involvement in ANC services and attendance, because of their interest in seeing an image of the unborn child, and improved birth planning.

Ultrasound sonography has been extended to include echocardiography through a cardiac ultrasound pilot program, with radiologists in the US usually viewing and supporting the interpretation of these images. The pilot program identified 58 pregnant women with heart disease, who were monitored and treated at the clinic close to home. Seven women were monitored for specialized delivery, and one had her first baby after multiple late pregnancy fetal deaths [ 16 ]. The US-based radiologists also provide support in interpreting other complex images, such as those taken to determine breast cancer.

Case 3: action for women and awakening in rural environment (AWARE-Uganda)

AWARE-Uganda is a non-governmental organization operating in three districts of Karamoja region in northeast Uganda: Kaabong, Kotido and Abim districts. Karamoja is the least developed region in the country, with low levels of employment, high levels of illiteracy, food insecurity, poverty and poor health care services, intimate partner violence, and a history of armed conflict, abduction and war-related gender-based violence [ 17 ]. The consequences of these challenges, coupled with unfavourable attitudes towards women’s education and community beliefs in the value of early marriage for wealth, have caused great suffering to women and girls in the area [ 18 , 19 ].

The AWARE holistic approach to women’s health and empowerment

AWARE Uganda was established in 1989 by a group of local women in Kaabong district with the aim of advancing the social, cultural and economic status of women in the region [ 20 ]. AWARE utilizes a holistic approach to address development issues through women’s empowerment and engagement to improve their own and others’ livelihoods in their community. AWARE provides supportive conditions for women to engage in small business enterprises and agricultural practices, and to increase their roles in leadership and decision making. Women are also sensitized about their rights.

With the establishment of a maternity waiting house, the organization has also improved access to maternal and child health care services, bringing pregnant women closer to Kaabong hospital. As a result, maternal and perinatal morbidity has been reduced.

AWARE-Uganda has engaged and empowered over 5000 women in its activities, including the delivery of an integrated package of services to address the health, economic and social needs of women. Most activities at AWARE are offered by local volunteers, often previous beneficiaries, contributing to the sustainability of the program. Working with men to address negative gender dynamics and to change beliefs around the value of women has been critical, illustrating how empowering and engaging with vulnerable groups and their communities is an effective approach to creating social change.

Impact on women’s health

AWARE has conducted community sensitization and capacity building on gender-based violence and intimate partner violence to police officers, health workers, elders, district leaders, and in schools, where child rights clubs have been established in Kaabong district. Community members, including children, are also sensitized on all forms of discrimination against women and human rights, case handling, and reporting procedures. Over 50 girls have been rescued from various forms of violence including gender-based violence and forced marriages, and have received counselling from AWARE staff who also link them to treatment at Kaabong hospital.

In 2016, AWARE Uganda conducted 28 training workshops for ten women’s groups on the use of modern farming methods, including the use of ox ploughs, crop spacing, and making and using composite manure to improve soil quality and crop yields. These skills were shared with over 370 households. AWARE purchased 25 ploughs and 25 ox chains, and 550 hoes, pangas and axes to assist women in agriculture. About 200 women from four communities were involved in chilli and honey production, improving their livelihood and those of their families.

AWARE also runs a mother’s waiting home in the semi-arid Karamoja region. The 20-bed maternal waiting home at the AWARE centre was established in 2010 and is the only one of its kind in the area. Since this date to time of writing (2019), over 500 women have received services at this facility per annum, including antenatal case, clinical monitoring when the pregnant women is resident at the home, and skilled delivery care; many more receive health education information. About 1000 people have utilized family planning services provided at AWARE.

With support from partners, AWARE distributed 12 040 home health care kits, including condoms, to community members in Kaabong district. AWARE registered and trained 32 Village Health Teams (VHTs) to operate in five sub-counties, with VHTs following up on those who need care at household or community level.

Leveraging community social capital as a resource for this organization was pivotal. The founders did not wait for funding opportunities to start organizing women, but rather, drew on women’s ideas, energy and time. Women asked for land from the district government and were granted this. They then bought and planted 150 fruit tree seedlings, and this marked the start of their activities.

Utilizing volunteers and beneficiaries was key to sustaining AWARE’s efforts, and it has operated for 30 years in these rural areas. Women have become empowered to support other women in similar situations. AWARE believes in working with partners to strengthen and advance work, and in this context, the police and Kaabong Main Hospital work together to support the organization in addressing gender-based violence, receiving and attending to referrals from the organization. One major challenge that AWARE had was to overcome negative attitudes towards women, and to change men’s mind set, AWARE started involving men in activities while working to empower women. AWARE has therefore shown that it is possible to overcome discriminatory cultural perceptions and practices through committed long-term involvement.

These three cases provide innovative and pragmatic solutions to the three delays in access to health care, which are known to significantly contribute to maternal mortality in Uganda. When pregnant women in remote and hard to reach locations access and utilize maternal waiting homes prior to the onset of labour and delivery, this immediately removes the problem of recognition of danger signs in pregnancy, as well as that of delayed health care decision making and lack of access to a skilled birth attendant. In addition, taking ultrasound imaging closer to pregnant women, also directly contributes to reductions in all the three delays. This is through early recognition of high risk pregnancies like multiple pregnancies and placenta previa and decision making related to birth planning and delivery.

Key health system lessons

Based on these case studies, three key health system lessons emerge:

The first is that while maternity waiting homes for high-risk pregnant women in remote areas are recommended in national and global health policies, they are almost non-existent in Uganda and other low income settings. Maternity waiting homes can contribute to increasing institutional deliveries, reducing obstetric delays and improving maternal and perinatal health outcomes in remote areas. In hard to reach areas, maternity waiting homes may contribute to reducing the high maternal deaths. As shown above, the waiting home can also provide opportunities for health education for mothers to improve the wellbeing of their new born children and families. For stronger effect, CHW outreach programs can contribute to identifying and getting women into hospital in remote and inaccessible areas.

The second health system lesson relates to the important role of shifting some acceptable health care roles from higher qualified to less qualified health workers (task shifting). The majority of community-based innovations identified within the SIHI involved some task-shifting activities. As we have illustrated for ITWA, task shifting can create an effective way to deliver ultrasound services to low resource settings. Trained midwives can conduct the ultrasound scan, reducing the cost of hiring a sonographer in low resource and remote settings. In addition, the integration of telemedicine for the interpretation of ultrasound scans is feasible and provides an opportunity to improve the quality of care to patients.

Thirdly, in order to contribute to effective social change for women experiencing discrimination and violence, full community and multi-sectoral action is necessary, including men’s participation in women’s empowerment and increased decision making. The bottom up approach utilised by AWARE is important for effective change. AWARE works to ensure that all community members (men and women) have skills to improve their livelihoods and to support gender equality. Past program beneficiaries, for example, women and girls who experienced GBV, can become active providers of services to new beneficiaries, sensitizing them about gender-based violence and contributing to sustainability.

Principles of social innovation

All these cases also demonstrate the principles of social innovation [ 21 , 22 ]. These are: strong community participation; multi-stakeholder engagement; addressing gaps in health and wellbeing (needs-based); and contribution to transformation in the health and lives of beneficiaries. Additional characteristics of the three case studies are that they are complementary to public health care provision and they focus on improving access to health care (affordability of services, bringing services closer to the people, and utilization of task-shifting mechanisms).

Affordability is a key component of these social innovation solutions, as services must be provided at an affordable price, so that communities can access them consistently, and sustainably. Two of the solutions request a user fee of about USD 1.5, while AWARE provides free services, sustained by the grants it receives.

Finally, availability of health services and geographical access are key components, which are addressed in these case studies through the utilization of lay community health workers to provide health services and through task shifting and training midwives for obstetric imaging service provision.

The ability of communities to identify and implement practical solutions to health care challenges in low income settings needs to be recognised and embraced. The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Stronger emphasis should be put on identification, capacity building and research, in order to support the scale up of these community-based health solutions.

Availability of data and materials

Original case studies are available online at https://socialinnovationinhealth.org/uganda/

Abbreviations

Antenatal care

Action for Women and Awakening in Rural Environment

Bacille Calmette-Guerín

Bwindi Community Hospital

Community Based Health Insurance Scheme

Chief executive officer

Community health worker

Ernest Cook Ultrasound Research and Education Institute

Gender Based Violence

Imaging the World Africa

Mothers’ Waiting Hostel

Non-governmental organization

Social Innovation in Health Initiative

Special Programme for Research and Training in Tropical Diseases

United States dollar

Village health team

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Acknowledgements

We acknowledge the individuals who supported the data collection and case study writing: Juliet Nabirye, Christine Nalwadda and Lindi van Niekerk. We also acknowledge input from participants from the case studies who provided input toward their individual case studies that are available online. They are: Grace Luomo, Birungi Mutahunga, Renny Ssembatya and Matovu Alphonse.

The Social Innovation in Health Initiative (SIHI) Uganda received funding from the Special Programme for Research and Training in Tropical Diseases (TDR) to conduct this research.

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PA contributed to the development of the research protocol. PA and MN engaged in data collection and writing of the first drafts of the case studies. LM reviewed the drafted case studies and the manuscript and provided professional expertise that improved the writings. PA wrote the first draft of the manuscript. All authors provided input and endorsed the final version. All authors read and approved the final manuscript.

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Awor, P., Nabiryo, M. & Manderson, L. Innovations in maternal and child health: case studies from Uganda. Infect Dis Poverty 9 , 36 (2020). https://doi.org/10.1186/s40249-020-00651-0

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• MATERNAL-CHILD NURSING TEST SUCCESS: AN UNFOLDING CASE STUDY REVIEW; Half Title Page; Authors' Page; Title Page; Copyright; Dedication; Contents; Preface; Acknowledgments; Half Title Page;
• Chapter 1: NCLEX-RN®: Preparation Tips and How We Really Feel; A Guide FOR Students BY Students; What We Like to Call Our "Introduction"; Study Skills and Habits; Preparing for NCLEX-RN®; YOUR PLAN: Two to Three Months Before the Exam; Four to Six Weeks Before the Exam; One Week Before the Exam; Anchors and Lifesavers; Leading Up to Test Day; Test Day; References;
• Chapter 2: Newborn Nursing Care.
• Case Study 1 Jasmine and RiverAnswers;
• Chapter 3: Postpartum Care; Case Study 2 Jolene; Case Study 3 Paula; Answers;
• Chapter 4: Infertility, Preconception, Conception, and Preterm Labor; Case Study 4 Isabella and Christopher; Answers; Reference;
• Chapter 5: Hyperemesis Gravidarum (HG); Case Study 5 Tamiko; Answers;
• Chapter 6: Sexually Transmitted Infections; Case Study 6 Sonia; Answers;
• Chapter 7: Labor and Delivery; Case Study 7 Karen; Answers;
• Chapter 8: First Trimester Bleeding and Previa; Case 8 Chelsea; Answers;
• Chapter 9: Ectopic Pregnancy; Case Study 9 Bonita; Answers.
• Chapter 10: Hydatidiform Mole (Gestational Trophoblastic Disease or GTD)Case Study 10 Lauren; Answers;
• Chapter 11: Incompetent Cervix, Abruption, and DIC; Case Study 1 Lillian; Answers;
• Chapter 12: Gestational Hypertension and HELLP; Case 12 La-Neisha; Answers; Reference;
• Chapter 13: Gestational Diabetes (GD); Case Study 13 Margaret; Answers;
• Chapter 14: ABO Incompatibility; Case Study 14 Regina; Answers;
• Chapter 15: Rupture of the Membranes (ROM); Case 15 Savannah; Answers;
• Chapter 16: Preterm Labor (PTL); Case 16 Bonnie; Answers;
• Chapter 17: Cardiac Disease; Case Study 17 Maggie; Answers.
• Chapter 18: AsthmaCase Study 18 Rachel; Answers;
• Chapter 19: Sickle Cell Anemia; Case Study 19 Maria; Answers;
• Chapter 20: Human Immunodeficiency Virus (HIV); Case Study 20 Kendall; Answers;
• Chapter 21: Preterm Infant Care; Case Study 21 Preterm Multiples; Answers; References;
• Chapter 22: Retinopathy of Prematurity and Bronchopulmonary Dysplasia (BPD); Case Study 22 Robert; Answers;
• Chapter 23: Anemia and Polycythemia; Case Study 23 Twin-to-Twin Transfusion Syndrome (TTTS); Answers;
• Chapter 24: Transient Tachypnea of the Newborn (TTN); Case Study 24 Aaron; Answers.
• Chapter 25: Meconium Aspiration Syndrome (MAS)Case Study 25 Benjamin; Answers;
• Chapter 26: Periventricular-Interventicular Hemorrhage; Case Study 26 Jason; Answers;
• Chapter 27: Neonatal Abstinence Syndrome (NAS); Case Study 27 Michael; Answers;
• Chapter 28: Inborn Errors of Metabolism; Case Study 28 Frances; Answers; References; Index.

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Nursing Case Study for Maternal Newborn

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Luisa, 25 years old, is a 37-week pregnant patient who presents to triage with abdominal and back pain. She says she thinks she is in labor because her contractions are regular and about 10 minutes apart. Her electronic health record indicates she is G3 P1 A1 and she is followed by a local obstetrics and gynecology office. She states she thinks she may be in labor but “has not seen any fluid.”

What does G3P1A1 mean in regard to this patient?

• Gravida 3 (number of pregnancies), P 1 (number of live or stillbirths) A 1 (number of abortions [induced] or fetal demises before 20 weeks’ gestation). So, Luisa could have 3 pregnancies and no live children (due to stillbirth) or 1 live child. She may have had an abortion or a miscarriage. Note: if A is 0 it may be omitted.

What does the triage nurse understand labor to be in a pregnant woman?

• Labor is defined as regular and painful uterine contractions that cause progressive dilation and effacement of the cervix. Normal labor results in descent and eventual expulsion of the fetus. Interpreting labor progress depends on the stage and phase:
• First stage: The time from onset of labor (i.e., when contractions started to occur regularly every three to five minutes for more than an hour) to complete cervical dilation (noted when first identified on physical examination)
• Phases: The first stage consists of a latent phase and an active phase. The latent phase is characterized by gradual cervical change, and the active phase is characterized by more rapid cervical change.
• Second stage: The time from complete cervical dilation to fetal expulsion.
• Third stage: The time between fetal expulsion and placental expulsion.
• Lack of fluid indicates that the rupture of the membranes (amniotic sac) has not occurred yet

Vital signs are as follows: BP 150/94 mmHg SpO2 98% on room air HR 91 bpm and regular Pain 2/10 at rest, 8/10 when she reports a contraction RR 12 bpm at rest, 24 bpm when she reports what she thinks is a contraction Temp 36.8°C

Which vital sign is most concerning to the nurse? What should they do regarding this vital sign?

• This blood pressure may indicate pre-eclampsia (“Preeclampsia refers to the new onset of hypertension and proteinuria or the new onset of hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation or postpartum in a previously normotensive woman”).
• (Hypertension denotes a rise in systolic blood pressure of 30 mmHg or more and a rise in diastolic blood pressure of 15 mmHg or more from baseline)
• The end-organ dysfunction is evaluated by looking at certain criteria: proteinuria, platelet count, serum creatinine, liver transaminases, pulmonary edema, new-onset and persistent headache unresponsive to analgesics, visual symptoms.”

The nurse decides to take the patient’s blood pressure manually which gives a reading of 130/82. Therefore, the patient is admitted to the labor and delivery unit.

SBAR report is given and Luisa’s admission for labor is started. She is placed in a convertible birthing bed with a fetal monitor attached to her abdomen.

What is the monitor called? What is it for?

•  “Tocodynamometry provides contraction frequency and approximate duration of labor contractions” and measures both fetal heart rate and maternal contractions. It is placed externally to watch both mother and baby as labor progresses.” There are also internal devices that can be placed on the fetus within the mother to monitor fetal heart rate.

Luisa progresses through an uneventful labor with her significant other at the bedside. She does not want any pain control and eventually delivers her newborn son, to be named after his father, Santiago.

At the time of birth, how would staff evaluate Santiago?

• “Staff asks three questions. The answers are used to determine whether the newborn is admitted to the normal nursery (neonatal level of care 1) or requires a higher level of care (neonatal level of care 2, 3, or 4)
• Is the newborn’s GA ≥35 weeks?
• Does the newborn have good muscle tone?
• Is the newborn breathing or crying?”

They determine Santiago is healthy enough to be placed on his mother’s chest to promote bonding and encourage breastfeeding. The staff takes him from his mother after a few minutes and she asks why.

What are staff doing when they remove Santiago at 5 minutes old?

• Checking an Apgar score (“Apgar score — The Apgar scores at one and five minutes of age provide an accepted, universally used method to assess the status of the newborn infant immediately after birth. Although data from a population-based study reported that lower Apgar scores of 7, 8, and 9 versus 10 were associated with higher neonatal mortality and morbidity, the Apgar score should not be used to predict individual neonatal outcomes as it is not an accurate prognostic tool The following signs are given values of 0, 1, or 2, and added to compute the Apgar score. Scores may be determined using the Apgar score calculator.
• Respiratory effort
• Muscle tone
• Reflex irritability
• Approximately 90 percent of neonates have Apgar scores of 7 to 10 and generally require no further intervention. These neonates usually have all of the following characteristics and can be admitted to the level 1 newborn nursery for routine care:
• Gestational age (GA) ≥35 weeks
• Spontaneous breathing or crying
• Good muscle tone
• Also, they record length, weight, head and chest circumference.

Santiago weighs 3550 grams and is 50.6 cm long. Luisa and Santiago, Sr. ask what that is in pounds and inches so they can tell family and post on social media.

How does the staff respond to this?

• A size chart may be available for staff to convert from metric to English measure and electronic health records may convert these values. But it is key that nursing staff knows how to convert mathematically.
• 50.6 cm/2.54cm per in = 19.9 inches (long)
• 3550 gm x .0022 gm/lb = 7.8 lbs or 7 lbs 12.8 oz. Alternatively, the nurse can convert gm to kg (3550 gm = 3.55 kg) then 3.55 kg x 2.2 lb/kg = 7.8 lbs (the 10th place is multiplied by 16 oz to convert to ounces i.e., 0.8 x 16 = 12.8)

Luisa and Santiago (referred to as a “mother-baby couplet”) are moved from the labor & delivery unit to the postpartum care unit as per protocol. The staff takes the newborn to the nursery for an evaluation. Luisa wants to know what they are looking for and if her son is healthy.

How should the nurse respond?

• Staff frequently (per protocol) assess a postpartum mother for possible complications. A good acronym for this assessment is BUBBLE which is essentially a focused head-to-toe (working from top to bottom) assessment.
• B – breasts (tenderness, size, shape, etc.) U – uterus (is it firm, boggy? This is done by feeling the fundus and massaging if necessary. This is to help assess for a serious postpartum complication – maternal hemorrhage) B – bladder (is mom voiding? Is there distension or difficulty urinating? This is also a good time to discuss self-peri-care) B – bowel (is mom constipated? She may need a stool softener to ease discomfort) L – lochia (quality, quantity of postpartum bleeding). You could also add an “L” for legs to check for swelling, Homan’s sign, etc. E – episiotomy (if this was done, it should be assessed for bleeding or hematoma. Use the REEDA acronym to remember what to look for {Redness, edema, ecchymosis, discharge, approximation)

While the infant is being evaluated in the nursery, postpartum staff come in and assess Luisa. She wants to know why they keep feeling her abdomen and asking her about bleeding. She says, “I thought everything went OK. Why are you always checking on me?”

What is the best answer for Luisa?

• “By pressing on your abdomen, we are assessing your fundus to ensure that the uterine muscle is properly contracting, which prevents bleeding. Similarly, we are evaluating how much you are bleeding to verify that there are no complications after delivering your baby.”

The mother-baby couplet is set to be discharged home after a few days. It turns out that Luisa has no living children as her first pregnancy ended in stillbirth and her second was a miscarriage. She holds Santiago and is tearful as staff prepares to educate her for going home. She says, “I am so afraid I will hurt him or not do stuff right. Why do I keep crying? This is overwhelming.”

Should the nurse address this? What may help the transition from a postpartum unit to home?

• Explain that hormonal changes (for mother) are to be expected at this time but reassure her that discharge criteria have been met. Maybe explain, “In the United States, because of concerns that early discharge could adversely affect maternal and infant health outcomes, both state and federal governments passed postpartum discharge laws in the late 1990s (Newborns’ and Mothers’ Health Protection Act [NMHPA]) to prevent extremely short hospital stays. In general, these laws require insurance plans to cover postpartum stays of up to 48 hours for infants born by vaginal deliveries (96 for c-sections). The impact of legislation ensuring insurance coverage for a minimum of 48 hours has increased the LOHS of newborn infants and their mothers and appears to have decreased neonatal readmission rates and emergency department visits.” Also, providing resources for education and follow-up will help ease anxiety. Always be prepared with whatever resources the facility and/or OB/GYN practice provides. There may be support numbers or websites available and those should be provided to the mother as appropriate.

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View the full transcript, nursing case studies.

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
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GI/GU Nursing Case Studies

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Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

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Mental health nursing case studies.

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Other nursing case studies.

Using Systems Thinking for Translating Evidence into Practice: A Case Study of Embedding Shared Decision Making within a Federally Qualified Health Center Network

The following is a mixed-methods case study that examines how Access Community Health Network (ACCESS), a large federally qualified health center located in the Chicago metropolitan area, used a systems approach to incorporate Shared Decision Making into its practice model. Using both qualitative and quantitative methods including a survey of ACCESS staff and providers, as well as interviews with a range of providers and leadership, the study sought to answer the question: How successfully has ACCESS, as a complex primary care system, made Shared Decision Making an integral part of its Patient Centered Medical Home practice model?

With a high degree of consistency across both the survey and interview data, the study concludes that ACCESS has successfully shifted its culture towards Shared Decision Making and, over the course of the past several years, made it a part of its PCMH practice model. At the same time, there are still areas for improvement and ways that ACCESS can further embed SDM within its practice model. Opportunities exist to use this study as a foundation for further exploring the impact of SDM on patients and health outcomes (not a part of this study). Further, the results can be used by other complex health systems as a model for how to successfully integrate and translate best practice or innovation into care models.

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Systematic and rigorous inquiry allows us to discover the fundamental mechanisms and causes of disease and disparities. At our Office of Research ( research@BSPH), we translate that knowledge to develop, evaluate, and disseminate treatment and prevention strategies and inform public health practice. Research along this entire spectrum represents a fundamental mission of the Johns Hopkins Bloomberg School of Public Health.

From laboratories at Baltimore’s Wolfe Street building, to Bangladesh maternity wards in densely   packed neighborhoods, to field studies in rural Botswana, Bloomberg School faculty lead research that directly addresses the most critical public health issues worldwide. Research spans from molecules to societies and relies on methodologies as diverse as bench science and epidemiology. That research is translated into impact, from discovering ways to eliminate malaria, increase healthy behavior, reduce the toll of chronic disease, improve the health of mothers and infants, or change the biology of aging.

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Report: Georgia drops 300,000 children from Medicaid

Georgia dropped more than 300,000 children from the Medicaid and PeachCare for Kids health insurance program, with one of the worst child disenrollment rates in the nation, according to a new study from Georgetown University. The study authors fear the majority of them are now uninsured and might decide they cannot afford health care as a result.

Georgia and all states are re-evaluating all Medicaid case files in a yearlong national culling process , after case rolls swelled during the pandemic. The process is scheduled to finish soon.

Georgia’s number of children kicked off Medicaid was bigger by December than the entire population of Augusta or Columbus. Georgia disenrolled far more children than California, a state that started with more than double the child Medicaid enrollment of Georgia, the report found.

Pediatricians in Georgia have seen the experience in person as families show up to find out they’re not covered, and turn around and leave without care. “It’s so hard,” said Dr. Anu Sheth, a Lawrenceville pediatrician and board member of the Georgia Chapter of the American Academy of Pediatrics. “It’s heartbreaking for the kids.”

There is no way to track exactly where those children wound up. Despite Georgia officials’ suggestion that many might have gone on to better insurance, the researchers say disheartening signs indicate that the vast majority may have simply lost insurance and perhaps gone without care, the study’s authors said.

“It’s very likely that a substantial share of children losing Medicaid, especially those disenrolled for (missing paperwork) reasons, likely ended up uninsured,” said Edwin Park, one of the study’s authors, addressing the Georgia data. Missing paperwork is the most common reason behind Georgia’s disenrollments.

Medicaid is the government health insurance program for poor children and some poor adults, such as some who are elderly or disabled. Some may meet eligibility requirements by working at least 80 hours a month or attending school.

During the pandemic, everybody who got on Medicaid stayed on, and didn’t have to do the annual paperwork to show they still qualified. In Georgia the rolls swelled to one-quarter of the state’s population, 2.8 million people. But now that federal pandemic emergencies have ended, the federal government is requiring every state to go back through all their case files over the course of a year to evaluate each one and make sure they still qualify. The process is called redetermination, or unwinding.

Credit: HYOSUB SHIN / AJC

Georgia has made “concerted efforts … to ensure that children retain health care coverage,” a spokeswoman for the state Department of Community Health said in a written statement. And those have increased as the process went on, which may mean that the numbers improved after the study’s data gathering stopped.

In the period of the study, up to December, the research showed some states were doing better than others. Georgia was among the worst, what study author Joan Alker called “the big three.”

The top three states for disenrolling children — Texas, Florida and Georgia — when taken together are responsible for 45% of the nation’s disenrolled children as of December.

Georgia officials responsible for Medicaid — the state Department of Community Health and the state Department of Human Services — point to huge numbers of sign-ups for private plans on the Affordable Care Act marketplace. That could mean, they suggest, that those kids’ families’ incomes rose and the kids moved and got better insurance.

However, the Georgetown researchers said, very few of those new sign-ups were children, a small fraction of the number disenrolled by Georgia. Dependents are expensive on ACA and other private plans, they said.

When it comes to keeping children who should qualify for Medicaid covered by Medicaid, the Georgia DCH and DHS officials say they’ve gone to extra lengths for the unprecedented task. They’ve more than doubled their expected hiring of caseworkers to more than 1,000.

Indeed, Sheth, the doctor, said she’s worked with state officials on the issue, and was impressed by their desire to try to make it work. She sees they have implemented heavy advertising to alert patients they need to check in with the Medicaid office. She’s seen them change some policies to make continued enrollment easier.

One thing that remains a problem, she said: the state’s Gateway computer system for Medicaid.

The Atlanta-Journal-Constitution’s reporting has also found Gateway to be an obstacle for some individual patients, especially those with only cellphones for a computer. Glitches in the Gateway mobile computer interface gave misleading information on patients’ accounts, for example.

AJC reporting also found that enrollees were told to seek help at the Medicaid office, only to find it closed, or that caseworkers work remotely. Enrollees have recounted rarely being able to get through to caseworkers by phone.

The study authors say there are measures that states still can take. But Texas, Georgia and Florida, the report said, are among states that “have prioritized the hasty disenrollment of adults and children, despite projections that many still remain eligible.”

Some examples: Ohio has applied for official federal permission, called a Medicaid waiver, to allow children from babies to six years old to stay on without going through the annual application.

In addition, other states’ computer systems, on average, are finding much more enrollment qualification information automatically in accessible databases than Georgia is.

So far Arizona has been able to re-enroll 75% of its Medicaid beneficiaries with automated database searches, for example, said Joan Alker, executive director of Georgetown’s Center for Children and Families, which released the study. In contrast, Georgia has re-enrolled 35% of its enrollees with automated searches.

“Many of them should be covered by Medicaid and that’s their affordable choice for coverage,” said Alker. “So they’re likely facing a gap in coverage. Which is not good news.”

Georgia officials told the AJC they have expanded the ways that computer systems can make a Georgia enrollee automatically requalified for Medicaid. And Georgia patients will see that, they said.

“The state continues using implemented improvements to minimize the number of procedural terminations and maximize the number of ex parte renewals,” DCH reported.

Medicaid Renewal Tips

• All Medicaid recipients must renew their eligibility status every year in Georgia.
• Medicaid enrollees should log into their online Gateway account to be certain their contact information is current for their mailing address, email address and/or phone number. Enrollees choose the way the state notifies them about any changes in their coverage: mail, email or phone.
• Make sure to check your mail and messages, and keep an eye out for any letters from the state.

The state has established a website with tips for enrollees in many languages: staycovered.ga.gov .

The main phone number is 1-877-GA-DHS-GO (1-877-423-4746).

Those who are denied can request an appeal called a “fair hearing” if they do so in time.

For those who believe they have been denied although they are still eligible, attorneys at Georgia Legal Services , and in the Atlanta area Atlanta Legal Aid , may help.

For more information, click here to see this explainer in the AJC .

About the Author

Ariel Hart is a reporter on health care issues. She works on the AJC’s health team and has reported on subjects including the Voting Rights Act and transportation.

Credit: Jason Getz / [email protected]

Credit: Miguel Martinez

Credit: [email protected]

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Children and young people settings: tools and resources

Updated 21 February 2024

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This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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Exclusion table

This guidance refers to public health exclusions to indicate the time period an individual should not attend a setting to reduce the risk of transmission during the infectious stage. This is different to ‘exclusion’ as used in an educational sense.

*denotes a notifiable disease. Registered medical practitioners in England and Wales have a statutory duty to notify their local authority or UK Health Security Agency ( UKHSA ) health protection team ( HPT ) of suspected cases of certain infectious diseases.

All laboratories in England performing a primary diagnostic role must notify UKHSA when they confirm a notifiable organism.

The NHS website has a useful resource to share with parents.

Download a PDF version of the Exclusion table to print out.

Posters are available for use by all children and young people settings to promote the latest advice and guidance in managing cases of infectious diseases in their settings.

Diarrhoea and vomiting outbreak: action checklist

Download a PDF version of the Diarrhoea and vomiting outbreak action checklist to print out.

Meningitis or septicaemia: action checklist

This checklist is for all children and young people settings.

Single case of suspected meningitis or septicaemia in a child, young person or staff member

The setting should contact the health protection team with details of the individual. The health protection team will contact microbiology and the medical team to obtain further information. The health protection team will then follow up with the setting to discuss any further action required.

If the diagnosis is likely to be meningococcal disease, the HPT will discuss the:

• composition of a letter of reassurance to parents, guardians or students to raise awareness of signs and symptoms
• rationale for antibiotic prophylaxis for close household contacts and why children and young people setting contacts are unlikely to receive prophylaxis

Take care not to breach the confidentiality of the person and their illness.

Two or more children, young people or staff members with suspected meningitis or septicaemia

Further public health action may be required when 2 or more individuals who are linked at the setting have confirmed or probable meningococcal disease within a short period of time (usually 4 weeks).

The HPT will:

• establish an outbreak team
• discuss the need for antibiotics within the setting and to a defined close contact group within the establishment (for example dormitory contacts, classroom contacts, children or young people who share common social activities and/or close friends)
• discuss the composition of a letter of reassurance to parents, carers or students to raise awareness of signs and symptoms
• lead on any media messages or involvement

In the event of 2 or more cases the HPT will liaise with:

• microbiology
• local Director of Public Health and their team within the local authority

If staff or students have a general question about meningitis, or septicaemia or require support, there are 2 charities available (Monday to Friday, 9am to 5pm):

• Meningitis Now : 0808 80 10 388, [email protected]
• Meningitis Research Foundation : 080 8800 3344

Read more guidance on managing meningitis and septicaemia .

Download a PDF version of the Meningitis or septicaemia action checklist to print out.

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NHS England: national infection prevention and control

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Redesigning healthcare: Integrating social care into a safety net health system

Building and maintaining infrastructure will require long-term investment by insurers and other payers

INDIANAPOLIS — Neighborhoods of high need are where investment in social care offers the best opportunities to improve health. Screening for social determinants of health is comparatively easy, but building the infrastructure to meet needs occurring outside the formal healthcare system is quite difficult. Few health systems have achieved more than even partial integration of social care into routine patient care.

In a case study of pioneering social care provided by Eskenazi Health, a safety net health system located in Indianapolis, researchers from Eskenazi Health, Regenstrief Institute and Indiana University School of Medicine highlight the human capital, operational redesign and financial investment needed by a safety net healthcare system to implement the National Academies of Science, Engineering and Medicine’s’ recommendations on integrating social care into medical care.

This insight is relevant to safety net health systems across the U.S. contemplating a greater role in social care for individuals living with high need as well as for their families and neighbors, current and potential employers, insurance companies, voters whose local, state and federal taxes help support safety net hospitals and policymakers who can decide to fund community improvements such as toxic cleanups, school renovations, public health initiatives or other ameliorations.

Individuals with high social need may be the people living next door, around the corner or across town. They may be a high achieving student at a poorly resourced school, a family living in a homeless shelter, a pregnant teen estranged from family or an older adult with dementia and a spouse caregiver who has provided care for years, but can no longer afford food due to medical debt and related expenses.

Food, housing, employment and transportation insecurity, air, water and land pollution, low economic opportunity, as well as neighborhood drug and gun violence are all health related social disparities lying outside the aegis of traditional healthcare. Eskenazi Health relies on “community weavers” to help primary care patients navigate the ecosystem of community-based services . These community weavers are employees, typically residing in one of the neighborhoods in which they work , who identify resources in the neighborhoods surrounding a clinical site, develop relationships with community organizations and help patients navigate access.

“We need to redesign the way we think about healthcare itself. An individual can receive excellent medical care but go home to a neighborhood where there’s low educational attainment, racism, violence, pollution. And that may have a far more negative effect on health than the positive impact from several hours of interaction with the medical care system,” said lead author Christopher Callahan, M.D., Eskenazi Health chief research and development officer and a Regenstrief Institute research scientist. For more than two decades Dr. Callahan has developed, tested and implemented coordinated care models. Dr. Callahan is the founding director of the IU Center for Aging Research at Regenstrief Institute.

“As outlined in the case study we, with philanthropic support, are providing social care to improve health – contributing to the body of evidence that we hope will help payers like Medicaid and Medicare as well as private insurers to say and show with their actions, this is worth our investment,” he added.

Although the cost of a social care infrastructure will vary across different communities, the case study authors indicate that they anticipate that most health systems would need to invest at least $1 million to $3 million per year to build and maintain infrastructure for 5 to 10 years. Additionally, millions of dollars in financial support for day-to-day operations of social services potentially would be required.

“The upfront cost of building an infrastructure to address these social disparities will be high. Failing to address them, however, would ultimately be far costlier,” said case study senior author Lisa Harris, M.D., chief executive officer of Eskenazi Health and a Regenstrief Institute affiliate scientist. “We know that 80 percent of chronic disease can be prevented, better managed and, in some cases, even reversed by lifestyle changes and that low-income populations are most burdened by chronic disease precisely because of inequities in the opportunity of a healthy lifestyle.”

Eskenazi Health, the public hospital division of the Health & Hospital Corporation of Marion County, Indiana, is a safety net health system that includes a federally qualified health centers with multiple primary care locations in neighborhoods of high need.

“ Building the Infrastructure to Integrate Social Care in a Safety Net Health System” is published in American Journal of Public Health.”

Authors and affiliations

Christopher M. Callahan 1 ,  Amy Carter 1 ,  Hannah S. Carty 1 ,  Daniel O. Clark 1 ,  Tedd Grain 1 ,  Seth L. Grant 1 ,  Kimberly McElroy-Jones 1 ,  Deanna Reinoso 1 ,  Lisa E Harris 1 .

1 Christopher M. Callahan, Amy Carter, Hannah S. Carty, Tedd Grain, Seth L. Grant, Kimberly McElroy-Jones, Deanna Reinoso, and Lisa E. Harris are with Eskenazi Health, Indianapolis, IN. Daniel O. Clark is with the Department of Medicine, Indiana University School of Medicine, Indianapolis. Drs. Callahan and Clark are Regenstrief Institute research scientists.

Christopher M. Callahan, M.D.   In addition to his role as a research scientist and the founding director of the Indiana University Center for Aging Research at Regenstrief Institute, Christopher M. Callahan, M.D., is chief research and development officer at Eskenazi Health and a professor of medicine at Indiana University School of Medicine – Indianapolis.

National health IT leader Micky Tripathi to visit Regenstrief Institute

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Regenstrief Institute will host collaborative conference to improve public health data

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INDIANAPOLIS – Clinical trials are constantly being designed and study participants enrolled to determine if medical treatments and therapies

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