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An evaluation of the utilisation of the Child and Family Health needs Assessment Framework to the public health
nurses’ role in Child Protection and Welfare.
For partial fulfilment of the
Post Graduate Diploma in Child protection and Welfare
Author: Frances McCready
Tutor: Siobhán Young
Date Submitted: 26/05/15
Word Count: 6683
Abstract
The purpose of this project was to evaluate the current use of the Child and Family Health
Needs Assessment Framework by Public Health Nurses (PHNs) in the assessment of
vulnerable children and families. This is a small scale qualitative study, based on the analysis
of responses from eight public health nurses, working in North -West Dublin. Each of these
PHNS had a caseload that included vulnerable children and their families. The study was a
qualitative one, using semi- structured interviews. The study took into account the fact that
the tool was at an early stage of implementation and that it had been piloted in another
area.
The relevant literature on the use of frameworks in child protection and welfare was
reviewed and key questions were formulated based on previous research. The perspectives
of the interviewees were recorded, collated and analysed.
The main findings of the study included the frequency and application of the Child and
Family Health Needs Assessment Framework to practice. Secondly, the study highlighted the
need for increased supervision and more training, including follow-up training, at local level.
The issue of gaps in service and multi-disciplinary communication were also explored. The
benefits and limitations of the framework as an assessment tool emerged in the course of
the specific research and was reflected in the literature. Recommendations were made in
relation to the findings especially in relation to further training and the importance of
supervision and leadership.
Acknowledgements
I would like to thank the following people:
• The Health Service Executive for facilitating study leave
• The Director of Public Health Nursing for North West Dublin, Marianne Healy for her
guidance and support
• The public health nurses who volunteered to participate in the study
• My supervisor Siobhán Young
• The NMPDU who provided funding
• My public health nursing colleagues for the additional burden my study leave placed
on them
• My family and friends for their support and encouragement
Table of Contents
Chapter 1: Introduction .............................................................................................................. 3
1.1 The role of the public health nurse and child protection ................................................ 3
1.2 Introduction to “The Child and Family Health Need Assessment Framework” ............... 4
1.3 Background for the study ................................................................................................. 6
1.4 Rationale for the study ..................................................................................................... 6
1.5 Aims and objectives.......................................................................................................... 7
1.6 Summary .......................................................................................................................... 7
Chapter 2: Literature Review ..................................................................................................... 8
2.1 Introduction ...................................................................................................................... 8
2.2 The concept of risk and vulnerable families .................................................................... 9
2.3 Early identification and intervention in an evidence-based, knowledge-based approach .............................................................................................................................................. 10
2.4 Multi-disciplinary enhancement ................................................................................... 11
2.5 Decision-making ............................................................................................................. 11
2.6 Role of managers in implementation of the assessment framework ............................ 12
2.7 Conclusion ...................................................................................................................... 13
Chapter 3: Methodology .......................................................................................................... 14
3.1 Study Design ................................................................................................................... 14
3.2 Study participants and sampling technique ................................................................... 14
3.3 Ethical Considerations .................................................................................................... 15
3.4 Data Collection ............................................................................................................... 15
3.5 Data Analysis .................................................................................................................. 16
3.6 Limitations ...................................................................................................................... 16
2
3.7 Conclusion ...................................................................................................................... 17
Chapter 4: Findings and Discussion .......................................................................................... 18
4.1 Introduction .................................................................................................................... 18
4.2 Frequency and application of CFHNAF to PHN practice ................................................ 18
4.3 How it applies to practice? ............................................................................................. 19
4.4 The user-friendly aspect of the Tool .............................................................................. 20
4.5 Some limitations ............................................................................................................. 21
4.6 Multi -Disciplinary Communication facilitated by the CFHNAF ..................................... 21
4.7 Supervision and management........................................................................................ 22
4.8 The Tool’s ability to identify gaps in service provision .................................................. 23
Chapter 5: Recommendations and Conclusion ....................................................................... 24
References ................................................................................................................................ 26
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Chapter 1: Introduction
The focus of this research project is to assess public health nurses (PHNs) experiences of
applying the Child and Family Health Needs Assessment Framework (CFHNAF) to their
practice, one year post its implementation in North West Dublin.
1.1 The role of the public health nurse and child protection
The author of this research is a PHN in North West Dublin, an area of mixed population
demographics. There are many areas of vulnerability as well as affluent areas. As a public
health nurse I have universal access to all families in their homes which Hanafin (1998)
recognises as a unique opportunity for early detection of vulnerable situations that may put
children at risk. The PHN in Ireland has a statutory role to promote and support the health of
all mothers and babies under the 1970 Health Care Act and circular 41/2000. PHN have a
mandate to provide a curative, preventative role in a designated population area. PHN are
governed by the Nursing Board, “An Bord Altranais,” which guides nurse practice. Under the
1991 Child Care Act section 2, subsection 2 the Health Board is directed to “take such steps
as are considered requisite to identify children who are not receiving adequate care and
attention… “Children First: National Guidance for the Protection and Welfare of Children
(DOHC, 2011) identifies the roles and responsibilities of professionals and others working
with children and families in their role of child protection and welfare. The Child Protection
and Welfare Handbook (HSE 2011), whilst not a policy document, provides guidance to
persons working with children in child protection and welfare. Similarly the CFHNAF provides
guidance to the PHN in the assessment, early identification and interventions for children at
risk and their families (O’ Dwyer 2012). The over-arching principle that has guided this
project is that the welfare of children is of paramount importance and that effective and
comprehensive assessment is one means to that end.
The PHN provides a new birth visit to every home in the first visit, following notification from
the maternity Hospital of the birth and details on the mother and baby’s condition and
history. Following this visit the PHN uses her discretion to determine if more visits are
required at this time. It is common for at least one follow-up visit maybe to monitor feeding,
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weight check or parental issue that may need extra support or observation. Otherwise the
core health screening and surveillance programme is provided at 3- 4 months, 7- 9 months,
18- 24 months and 3-3.5 years.
In the context of the PHN’s role in child protection and welfare, Hanafin (1998) identifies
three roles for the PHN: a primary role of prevention of child abuse, a secondary role in early
identification and intervention for vulnerable children and families and a limited tertiary role
when the child is under social work care. The application of the CFHNAF focuses the PHN’s
assessment in identifying and interpreting the child and family health needs. It also allows
the PHN to assess parenting capacity, family and environmental factors, risk and protective
factors that impact on a child’s health and development. The purpose of an assessment
framework (Buckley et al 2006) is to guide practitioners to remain child centred during
assessments. It is a standardised method of gathering necessary information to inform
effective levels of child protection and welfare interventions at primary, secondary and
tertiary levels.
Likewise O’ Dwyer (2012), identifies the primary and secondary preventative roles of PHNs
as members of the multi-disciplinary primary care teams (PCT).A primary care team is based
in a designated geographical area. Professionals work together to deliver local health and
social services to a defined population. In the role of child protection the PHN recognises
that some families with children require additional public health nurse services such as first
time mothers, teen parents, mothers with depression and parents and children with
disabilities. These supports vary from temporary support needs to ongoing support or
intensive multi-disciplinary support to safeguard and protect their children.
1.2 Introduction to “The Child and Family Health Need Assessment Framework”
There is increasing recognition that risk and protective factors are key concepts in assessing
the health and social needs of children and families (O’ Dwyer 2012). The CFHNAF
incorporates these factors into the assessment process.
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This framework was developed in Ireland by the HSE Dublin Mid-Leinster public health
nursing service of counties Laois, Offaly, Longford and Westmeath. The framework is
informed by the “Framework for the Assessment of children in need and their families”
(Department of Health U.K., 2000), The National Children’s strategy Our Children: Their Lives
(Government of Ireland 2000), Quality and Fairness : A Health System for You (DOHC, 2001),
Best Health for Children Revisited (HSE 2005) and Guide to Getting it Right for Every Child
(Scottish Government, 2008).
The framework includes three domains, organised around the inter-relationship of the
child’s developmental needs, parenting capacity, family and environmental factors. The
framework also identifies risk and protective factors, all of which influence a child’s
development and wellbeing. There are four levels also known as thresholds of needs, based
on the Hardiker Model (1991) of assessment, graded as follows:
Level 1: Normal needs as provided in the universal service needs provided to
all children.
Level 2: Enhanced needs due to risk factors requiring early intervention.
Levels 3 and 4: Complex needs and /or acute needs that warrant social work
intervention due to significant risk factors.
There are child and family health needs questions located in the PHN core developmental
check record that is part of the assessment base of the CFHNAF. These questions relate to
any change in circumstances from the last contact, any issues with parenting, housing and
environment or family and community supports. This process may warrant a referral to
Tusla, Child and Family Agency for a child protection or welfare concern or it may warrant
support at a local level. A care-plan is formulated with parental consent and parents and
family are encouraged to participate once it is established that the child is not at immediate
risk (O’ Dwyer, 2012).
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1.3 Background for the study
PHNS, within their statutory role, work with children and families on a daily basis (O’ Dwyer
2012). Since 1993, there have been 29 child abuse inquiries in Ireland (Buckley and O’ Nolan
2013). Two of these ensuing reports, in particular, have criticised the role of the PHN, The
Monageer Report (Brosnan et., al, 2009) and The Roscommon Child Care Inquiry (HSE,
2010).These reports highlighted failures in the PHN’s role, including their ability to identify
children at risk, poor communication with other agencies and inadequate record -keeping
(O’ Dwyer, 2012). The CFHNAF was developed as a result of these findings in order to
address these criticisms of the PHN role in child protection and welfare. The framework tool
was introduced into Dublin North West PHN practice in January 2013. This is the first study
conducted on the PHN’s experience of utilising the tool in their practice of child protection
and welfare since the pilot study, conducted six months post implementation, of the
CFHNAF in the Midland area of Ireland, by its author Patricia O’ Dwyer in October 2012.
1.4 Rationale for the study
In the PHN role of child protection and welfare there has never been a framework to guide
assessments in early identification of needs and appropriate interventions in children and
families with additional needs (O’ Dwyer 2012). The CFHNAF is the first tool to offer a second
level framework to PHNs for this purpose. In the implementing of any new tool to practice, it
is important to realise that the effectiveness of the tool is dependent on local approaches to
implementation (Horwath 2002).
I hope that this study will identify issues and challenges experienced by PHNs in the use of
the CFHNAF. As this study is a small qualitative research project limited to one PHN
geographical area, I am aware that the results cannot be generalised to all the PHNs in
Ireland. The information from this study will be presented to the Director of Nursing in North
West Dublin, to evaluate the findings and address any problem areas that emerge on the
local utilisation of the framework.
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1.5 Aims and objectives
The aim of the study is to evaluate the application of the CFHNAF to PHN practice in relation
to child protection and welfare.
The objectives are:
• To assess the regular application of the tool in PHN practice.
• To evaluate the service benefit of the CFHNAF to the PHN in the assessment of
vulnerable children and families.
• To assess the effectiveness of the tool in multi-disciplinary communication and
decision making
• To assess PHN opinion on the support of managers and their attitudes to the
introduction of supervision.
1.6 Summary
This chapter has introduced the topic and has discussed the policy and agency context and
background. It also includes an introduction to the CFHNAF and outlines the rationale, aim
and objectives of the study. The next step is to conduct the literature review, which will
focus on the use of an assessment framework for professionals in their role of child
protection and welfare. The literature review will be followed by chapters on the
methodology, findings, analysis of the data as well as conclusions and recommendations. I
am hopeful that the findings will inform best practice in the utilisation of the CFHNAF in the
PHN role of child protection and welfare in North West Dublin.
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Chapter 2: Literature Review
2.1 Introduction
This chapter will explore previous knowledge on the utilisation of an assessment framework
to professional practice of child protection and welfare. As the literature is limited on the
public health nurses’ utilisation of a framework, I extended my search to the practice of
social workers in Ireland and abroad, mainly the U.K. I included the health visitors in England
as they are the nurses in the community that provide child health services in the United
Kingdom. This chapter will open with a short discussion on the concept of risk and the
vulnerable family. While this study aims to provide an evaluation of how effectively the
framework is utilised in practice, it is not possible to cover all aspects relating to this subject.
I have identified four key areas of relevance to the utilisation of an assessment framework in
the assessment of children at risk and their families:
• It provides a standardised and structured evidence and knowledge-based
assessment.
• It enables effective early identification and intervention in vulnerable children and
their families.
• It facilitates multi-disciplinary communication and decision–making.
• It examines the support of managers in the implementation of a framework to
practice.
There have been many reforms in the system governing child protection and welfare in the
aftermath of inquiries into child abuse since The Kilkenny Incest Investigation in 1993, which
is credited as the stimulus for placing child protection and welfare in the political forum
(Buckley et al 2006).The establishment of the statutory Tusla, the Child and Family Agency in
January 2014, dedicated to child protection and welfare, is seen as a significant reform. All
referrals for child protection and welfare are assessed through this agency. The statistics in
the Review of Adequacy for HSE and family services (Tusla 2013) report that referrals for
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child protection concerns nationally were 19,044 and child welfare referrals were 21,043,
representing 52.6% of all referrals of welfare concerns. These referrals require additional
support and early interventions (Tusla 2014) to protect the child and support the family to
meet the child’s needs early, thus preventing escalation to a child protection system. This
finding indicates the pressure on services in both child protection and welfare thresholds.
For PHNs this means long waiting lists to access supports for vulnerable children and
families. Since the establishment of Tusla PHNs can no longer access support services
independently and must send all referrals through Tusla.
2.2 The concept of risk and vulnerable families
Risk is a complex and confusing concept that is associated with unwanted outcomes,
according to Munroe (2002).Furthermore, she identifies that a risk assessment tries to
predict the probability of a child being abused, if the child’s circumstances remain
unchanged. Similarly, Parton (2010) discusses that the terms have re-focused from reference
to an assessment of risk of child abuse, to a broader focus of risk of harm to a child’s overall
development. Thus, the assessment would be performed in the context of the child’s family
and community environment.
Vulnerable families are those identified with risk factors that do not reach the threshold for
social work intervention due to insufficient evidence of actual or potential harm (Mulcahy,
2004).
However, these children and families still require supports to protect the child being at risk
of harm or being harmed (Buckley et., al 2006). The risk factors associated with vulnerability
including poor parental capacity, substance abuse, mental health problems, domestic
violence, poverty, environmental or housing problems all impact on a children’s health and
well-being and their families. The CFHNAF identifies these risk factors and focuses the PHN
to include the impact of these circumstances on the child’s development and welfare.
Similarly, the Framework for the Assessment of Vulnerable Children and their families
(Buckley et al 2006) provides support in assessment of children and families in these
vulnerable situations.
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2.3 Early identification and intervention in an evidence-based, knowledge-based approach
The use of an assessment tool assists in the early identification of children at risk of neglect
and the provision of timely interventions to respond to children’s needs (Powell, 2013, O’
Dwyer, 2012). Furthermore, it is particularly effective in children with additional needs. To
perform an effective assessment (Buckley et., al, 2006), knowledge on normal child
development and application of attachment and resilience theory are essential to the
process. Moreover, professionals should draw on knowledge of how various social cultures
and economic factors can impact on a parent’s ability to meet a child’s needs. Howe et al.
(2000) agrees that attachment theory can help practitioners to make assessments
confidently, if they can understand the mechanism that puts a child on a certain path. He
further suggests that theories help to make judgements on environmental impacts and
organise knowledge.
The CFHNAF incorporates Bronfenbrenner’s ecological model of human development (1994)
which recognises that children’s development is affected by the environment they live in.
The Framework for the Assessment of Vulnerable Children and their Families (Buckley et al,
2006) clearly identifies the environmental risk factors that can impact negatively upon a
child’s health and well-being as outlined earlier. Equally, the quality of early attachment has
consequences for later life in a child’s social and emotional competence (Bowlby, 1998) and
early detection of poor attachment and intervention could prevent long – term effects for
the child’s development. The Scottish framework A Guide to Getting It Right for Every Child
(2012), provides a practice model for practitioners and agencies working with children and
families. The ‘My World’ Triangle approach allows the child to describe their ‘whole world’ in
terms of family and the community which gives professionals an insight into attachment and
environmental impacts that affects a child’s development long-term. Resilience theory is
highlighted in a framework termed ‘a resilience matrix’ to aid professionals in assessment, as
this is considered the most complex theory to assess.
Peckover (2011) conducted a study on the health visitors (HV) role of ” safeguarding
children” and reported that HVS were not comfortable with the use of a tool in assessments
11
of children and families as this process requires their engagement in a complex process to
identify and assess clients with additional needs. Therefore, in a climate of short staff
resources there was concern that HV contact with the child and family would be limited,
thus undermining the principle of the framework assessment. In a study by Selbie (2009) on
the role of health visitors in risk assessment it was found that HVs were not convinced that
the use of an assessment framework assisted in their management of children at risk. Their
reasons were lack of confidence in the tool, that it hinders the establishment of a positive
relationship with the family so it can be a barrier to risk assessment. Powell (2013) in
explaining the use of the common assessment framework discusses the importance of
sharing information through the assessment process so that families are not required to
repeat their story more than once.
2.4 Multi-disciplinary enhancement
Frameworks promote effective information-sharing and co-ordinate plans amongst
professionals, families and other agencies (Powell 2013, Buckley and O’ Nolan 2007). The
framework for Assessment of vulnerable children and their families (Buckley et al 2006),
recognises that the more consistency and agreement there is between professionals
regarding methods of assessment and terminology used, the greater the understanding will
be regarding a family’s needs. Parton (2006) similarly notes that all professionals involved in
child protection and welfare are expected to work in full partnership with other agencies.
Furthermore, the use of a framework provides professionals with guidance to effectively
communicate with children. The guidance document “Supporting parents to improve
outcomes for children” (Tusla 2013) promotes professionals engaging with parents to
effectively collaborate in order to improve interventions to support vulnerable children.
2.5 Decision-making
In Powell’s (2013) evaluation of the Welsh Common Assessment Framework for children and
Young people (Department of Education and Skills 2007), collaboration with families in
decision-making is fundamental to moving away from the practice of professionals having
meetings about families. Instead, there is a more inclusive approach, where families consent
to engage with the process of care-planning. Accordingly, by engaging families and working
12
together from the start, families are more likely to feel empowered to bring about realistic
and sustainable goals. Therefore the process of engaging families in decision-making has
become popular internationally (Morris et al 2010) and family group conferences have been
adapted in England from New Zealand since 1990.There is general agreement in the
literature (Buckley et al 2006, O’ Dwyer 2012, Child and Family Agency 2013) that family
involvement in decision-making is essential, for effective child protection, in families of
children who have additional needs.
According to the new national policy framework Better Outcomes Brighter Futures ( DCYA
2014-2020), listening to children and young people and involving them in decisions about
their lives, is fundamental in order for them to become ”socially active citizens.” This
principle is based on the United Nations Convention on the Rights of the Child, Article 12
(ratified by Ireland in 1992) which states that “children’s views must be taken into
consideration in all matters that concern them, with due regard for their age”.
Decision -making for professionals in child protection and welfare requires a move from
procedure-based practice to an evidence-based professional judgement (Howarth, 2002).
Furthermore, the application of an assessment framework expects the child and family
needs to be assessed in the three domains of child development, parental capacity and
environmental factors. This requires all staff to understand the principles of the framework
(O’ Dwyer, 2012).
2.6 Role of managers in implementation of the assessment framework
Howarth (2002) acknowledges that the introduction of a new guidance that involves a
change in attitude and a conceptual change is challenging. She further identifies that the
effectiveness of the use of an assessment framework is dependent on the local approaches
to implementation. Therefore, Harrison (2009) believes that good quality supervision from
managers is essential for professionals working with children. Moreover, he sees a need for
managers to be familiar with the purpose of the tool and to monitor that it is operating
within the standards of policy development, education of workers and measuring
compliance. Munro (2002) fears that the assessment framework will become another paper
13
exercise starting at page 1 and moving through the task by rote without considering an
engagement with the family or being insensitive to the child’s needs. She further points out
that researchers do not control the work environment or the managers. Supervision is
essential (Buckley et al 2006) to effective practice and managers need to have a good
knowledge of the CFHNAF and be experienced in the role of child protection and welfare to
effectively support staff. Following two days of training on the CFHNAF PHNs attended a
training day on the introduction of supervision into PHN practice. O’ Dwyer (2012) identifies
this as an essential part of the CFHNAF implementation into practice.
2.7 Conclusion
This chapter has explored the research evidence on the use of a framework for professionals
in their role of child and welfare practice. It explored the concept of risk and vulnerable
families, the CFHNAF and its influence on identified areas of practice in the professional role
of child protection and welfare. The next chapter will provide detail of the methodology
employed in this study.
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Chapter 3: Methodology
The literature review in the last chapter discussed previous research conducted on the
theme of this study. This chapter outlines the research process employed to conduct this
study and the rationale for each step of the research process.
3.1 Study Design
As this study required data gathering on the experience of participants in the use of a tool, a
phenomenological approach was adopted in order to gain insight into the “lived experience”
of participants interviewed (Denscombe, 2010). I chose a qualitative research design as the
most appropriate method for this study as it accommodates an in-depth approach,
explaining how the participants felt about an issue and also why they felt that way. A
qualitative research design provides flexibility and Neuman (2011) identifies that the
researcher may not always know how the research will evolve which can contribute to the
overall quality and richness of the information collected (Denscombe, 2010).
The criterion for inclusion in the study was that all public health nurses (PHNs) in North West
Dublin who have used the Child and Family Health Needs Assessment Framework (CFHNAF)
in their practice since its introduction in January 2013 were included in the study. PHNs in
North West Dublin who have not used the CFHNAF since its introduction to practice were
excluded.
3.2 Study participants and sampling technique
A purposive sampling technique was employed which Denzin and Lincoln (2005) describe as
a specified group that are purposely sought and sampled. This was appropriate to this study
to meet the inclusion criteria described above. The participants were chosen with guidance
from the Director of Nursing who identified PHNs in vulnerable areas that met the criteria
for the study. Initially potential participants were contacted by phone to ensure that these
PHNs were using the CFHNAF in their practice. This action immediately ruled out PHNs who
did not meet the criteria, which facilitated time efficiency and identified the exclusion of two
15
potential PHNs contacted who, despite working in known vulnerable areas, had never used
the CFHNAF. I received a positive response from eight PHNs to participate in the study.
These participants were each sent an e-mail to confirm their participation and to thank them
for their co-operation.
3.3 Ethical Considerations
I sought approval for this research project by writing to the Director of Public Health Nursing
detailing the intent of the study (Appendix 1).
Once approval was granted an information sheet (Appendix 2) was circulated to the eight
participants who volunteered to facilitate my study. This sheet detailed the purpose of the
study, predicted duration of interviews and also provided assurances on confidentiality and
anonymity. Confirmation was given that the data recorded would be destroyed once the
study was completed.
A consent form (Appendix 3) was also sent which was signed by the participants at the time
of interview. Assurance was given that the process was voluntary and that participants
should feel free to withdraw at any stage. I formulated 7 open-ended questions to guide the
interviews that were relevant to the research question.
3.4 Data Collection
The method identified to best suit my study for data-collection was semi-structured
interviews (Rubin et al 2005) which allows the interviewer to adapt the order of questions to
suit the particular interview (Turner, 2010) and add or delete probing questions between
subsequent subjects. This gave me an opportunity to clarify answers more clearly in order to
get in-depth data for my analysis. I used open-ended questions taking care to address the
research question. However, I took care not to guide the participant with my own
preconceived ideas as Murray (2003) warns can occur, due to the flexibility of this method.
16
I conducted a pilot interview with an assistant director of public health nursing from a
different area of practice to enhance the reliability of the research questions. This test
interview enabled me to familiarise myself with both the interview process and the use of a
digital dicta phone to record my interviews and create folders for each interviewee to save
the data for transcription. Additional prompt questions were added as a result of this
process.
Appointments for interviews were arranged by email and participants were consulted and
given times and locations of interviews that suited their work-load. All interviews were
conducted in the meeting rooms of the various health centre locations and were pre-booked
to reduce the likelihood of interruption.
3.5 Data Analysis
The interviews were transcribed verbatim on the evening of recording to provide an
accurate account of each one. I allocated the dictaphone folder number on each transcript
as the identifying code of each participant thus ensuring that the transcripts could be easily
matched to the individual PHN’S recorded interview. The interviews were listened to and
transcripts were studied numerous times to identify themes and emerging patterns (O’ Leary
2010) that flowed from the data. The data was then segmented manually and assigned a
code for easy identification of themes and concepts. This process of thematic analysis
(Sanders and Wilkins 2010) enabled me to group similar themes under sub-headings and to
continue this process until I was left with a list of themes that covered the essence of the
data collection.
3.6 Limitations
The size of the sample and the confinement of the study to Dublin North West are key
limitations as they only reflect practice of a small percentage of PHNS, therefore the findings
cannot be generalised. Perhaps the fact that the researcher is a PHN in the same area may
have prevented full disclosure of feelings by participants despite assurances of complete
confidentiality.
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3.7 Conclusion
This chapter has examined the methodology employed and considered relevant to the
author for this particular study. Most of the PHNS that I interviewed appeared comfortable
with the interview process and provided extra information that added to my data collection.
PHNS with 5-10 year experience were notably more confident in their responses as were
PHNS who have used the CFHNAF consistently in their practice of child protection and
welfare.
The next chapter will detail the findings of the research and these will be discussed in the
context of the literature.
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Chapter 4: Findings and Discussion
4.1 Introduction
The aim of this study was to evaluate the utilisation of the Child and Family Health Needs
Assessment Framework to the public health nurse (PHN) practice in child protection.
The objectives were:
• To assess the regular application of the tool in PHN practice.
• To evaluate the service benefit of the CFHNAF to the PHN in the assessment of
vulnerable children and families.
• To assess the effectiveness of the tool in multi-disciplinary communication and
decision making
• To assess PHN opinion on the support of managers and their attitudes to the
introduction of supervision.
In this chapter, I will discuss the findings under main themes that recurred in the data and
which address the research question. The feedback on the use of the CFHNAF were mainly
positive. The attitude to the introduction of supervision is welcomed by the 8 participants of
this study.
4.2 Frequency and application of CFHNAF to PHN practice
The CFHNAF instrument according to O’ Dwyer (2012) is not intended solely for the referral
of a family to social services, where the PHN has a child protection or welfare concern. It is
designed to undertake a formal assessment in circumstances where the PHN identifies a
vulnerable child and family, in need of additional supports to the standard universal
screening and surveillance programme. The interviews in this study relating to this topic
reflect O’ Dwyer’s view.
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Two of the eight PHNS reported that they have only used the framework twice in their
practice to date. One of these respondents replied that she has used the tool on “a couple of
occasions not as often as I should have”. The remainder have used the tool regularly in their
assessments. For example,
“Quite a bit for families identified as very vulnerable or at risk” (PHN 4).
“Working with the Traveller Community lots of vulnerability, caravans not great, so I use it all
time (PHN 5).
4.3 How it applies to practice?
The purpose of the Child and Family Health Needs Assessment Framework is to assess,
identify and interpret the needs of children and their families. It enables assessment of
parenting capacity, family and environmental factors, risk and protective factors that impact
on the health and development of a child ( O’ Dwyer 2012). A number of respondents
considered the tool particularly useful.
“It helps identify vulnerability with three screening questions on the core visit. For example,
history of family with five needs, formulated plan of needs and identified each need and
support required with the help of the tool. Neglect issues recurrent maybe due to motivation
problem or lack of knowledge in their parental capacity. Would not require a referral to
social work initially care plan formulated so gives parent a chance to improve care, review by
two months and decide if any improvement and further action required” (PHN 1).
“Identifies normal development and outcomes first .I am a long time a public health nurse
and this is the first time I have had a tool and structure to do a report using formal language
common to social work “(PHN 4).
“It is a different way of thinking for PHN identifying risk and protective factors on home visits.
The screening questions on child protection and welfare are very useful as some people need
a push to tell you their problems “(PHN 3).
20
“Useful for identification of levels 2-3 thresholds sending standard report form” (PHN5).
However, this PHN pointed out “that it can strain relationships with some Traveller mothers
but the tool is still good and I’ve learned to go on my gut instinct “(PHN 5).
In relation to the frequency and application to practice of the CFHNA the feedback in this
study did not identify any limitations to its use.
4.4 The user-friendly aspect of the Tool
Powell (2013) considers that frameworks help practitioners to develop a common
understanding of vulnerable children and families with additional needs. Buckley et al
(2006) found that some social workers considered the use of a framework comprehensive
and time consuming. However, it is clear from that study that the framework helps to
standardise practice in a range of different settings. Three respondents found that the more
they used the tool the more familiar the process and language involved became.
“Yes it is user-friendly once you get familiar with the language and is great to formulate a
care plan” (PHN 1).
“The more you use it the more familiar you are. Lovely presentation and language efficient”
(PHN 4).
“User Friendly, yes difficult to decide which box to apply” (PHN 6).
Some other advantages were also identified.
“Good prompter. Provides language you need. I use it for every report be it SRF or CFHNA“
(PHN 7).
“You need to be knowledgeable about social work process and theory to know terms”
(PHN 8).
21
4.5 Some limitations
In general, the tool is considered to be user friendly despite language being initially difficult
to understand. However, time was identified as major constraint by four PHNS. Two of these
responded thus:
“Time consuming four page document off putting” (PHN 3).
“If I need to make an urgent referral in a crisis situation the time factor can be an issue as I’m
obliged to fill in the report properly” (PHN 4).
4.6 Multi -Disciplinary Communication facilitated by the CFHNAF
The framework facilities decision making amongst practitioners to consider if the threshold
of intervention has been met. Following analysis of the needs, strengths, and vulnerabilities
identified at assessment practitioners consider the thresholds of these needs and agree on
long and short term goals (Buckley et al 2006). Three of the eight PHNS did not consider the
CNHAF facilitated multi- disciplinary collaboration.
“I never experienced that. Never hear back from social work about referrals” (PHN6).
“It’s a stand-alone document for PHN use only” (PHN 3).
Of the other 5 participants there were mixed views on this theme.
“It does if used properly. In a chaotic environmental situation there is a lot of words. In saying it you have to substantiate it words looks good and social worker understands what you mean” (PHN 5).
“In an ad- hoc way, helps to get your point across for support needed from social work” (PHN 2).
“I work closely with social worker; big highlight of the tool is communication. Following
referral I can email social worker to communicate my need“ (PHN 1).
22
Some respondents were of the opinion that there was limited interaction between the social
worker and PHNs particularly in relation to feedback on SRF referrals. During the interviews
it became clear that PHNs with a Primary Care Team social worker for children had more
inter-action.
4.7 Supervision and management
O ’Dwyer (2012) reports that “PHNs are now receiving professional supervision to support
their caseloads” In Addition a key outcome in Powell’s study (2007) was that the CAF was
not incorporated into routine practice successfully until a CAF lead person was appointed to
promote awareness , training and support to staff.
All respondents were very positive and welcoming in relation to provision of supervision. 4
of the 8 interviewees reported that they had line manager at the time of the interviews.
However, the Director of Nursing was acting in a support capacity and provided good
support to PHNS. Of the reminder one had received positive feedback and good line
management support.
“Good support. Line manager attends all case conferences now” (PHN 1).
“No line manager. Director acting as manager not the same despite being available always
to discuss complex cases and thresholds. PHNS need supervision as I feel we are a vulnerable
group as professionals “(PHN 4).
“Supervision necessary. Good Support from director of Nursing to assist CFHNA and SRF. No
problem with supervision. It’s needed” (PHN 6).
A limitation was identified as regards follow -up on the two day training received.
“the two days training was informative but it needed follow up by managers to make sure
that the forms were being filled. I feel there should have been more rigour and it has now lost
its momentum. (PHN 3).
23
It is clear that leadership, supervision and good line management is essential for successful
implementation.
4.8 The Tool’s ability to identify gaps in service provision
O’Dwyer (2012) reports that the CFHNAF provides reflection on what services and resources
are required to support vulnerable children and their families. PHNS are in a stronger
position to identify service gaps and present an objective and coherent case for service
development.
All of the respondents agree that the tool helps to identify gaps in service but they were
critical of the lack of pathways to address these gaps. In the responses below, there is a
consensus as regards the tool’s ability to identify service gaps but there is a sense of
powerlessness of what to do about.
“Allows identification at level 2. Very frustrating .You see it but you have no way of getting it,
Bernardos appear to be prioritising Tusla assessments ,therefore, pre-crisis cervices are being
directed to threshold 3and 4 thus preventing early intervention”( PHN 4).
“Yes identifying example poor mental health service for teenagers. Where do you go? Tell
line manager goes to Director and stops there. CFHNAF makes you think beyond the
immediate and look at all areas “(PHN 3).
“Yes identify. No way to fill the gap .We can advocate but you know we will be told to set it
up ourselves. Where’s the time to do that? No benefit to PHN identifying the gap. We are at
primary prevention level and that’s where we should be concentrating “(PHN 2).
The first- hand accounts of PHN professionals were most useful in assessing how successful
or otherwise the implementation of CFHNA has been to date. The main conclusions and
recommendations are now outlined.
24
Chapter 5: Recommendations and Conclusion
The eight respondents in the study gave their views openly having being guaranteed
confidentiality. They were very positive as to the benefits that CFHNAF brought to their PHN
practice in child protection and welfare. The two main themes that emerged were the roles
that leadership, supervision and management played, in supporting front line staff in the
implementation phase. The relationship between frequency of use and successful
application of the tool was also evident. The need for consistent support and follow up to
the training provided was highlighted.
There is a need for PHNS to have ongoing education, at a local level, to heighten awareness
of the of ecological, attachment and resilience theories that underpin this framework. This
would give valuable insights into the rationale for the use of the tool in the holistic
assessment of vulnerable children and families.
Allowing for the small sample size and the relatively short time-frame of implementation
from January 2014 to the survey interviews of April, 2015 it is clear that the tool has been
popular with PHNs, and more importantly, has allowed then to identify child protection and
welfare needs within an evidence- based theoretical framework that is based on
international research and best practice.
Ongoing training and supervision is crucial. It is recommended, in agreement with O Dwyer
(2012) that if CFHNAF is not used within six months after training a buddy system needs to
be in place with A PHN with more advanced knowledge and experience. There are
indications in this study that multi-disciplinary communication between PHNS and other
professionals is a limiting factor that needs further development.
In conclusion, it must be remembered that “assessment is not an end in itself but a means to
developing meaningful strategies to improve outcomes for children” (HSE, 2011). The
findings from the report and pilot evaluation on the development and implementation by
Patricia O Dwyer in the Dublin – mid Leinster public health nursing area were very positive.
25
The overall conclusion is that this kind of assessment is needed for PHN practice with at risk
families and it will take time to fully imbed it into PHN practice. This small case study has
pointed out and highlighted both the benefits and limitations, as perceived by eight public
health nurses in North-West Dublin.
26
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Appendices
Appendix A Child and Family Health Needs Assessment Framework Manual
Appendix B Child and Family Health Needs Assessment Questions at Core Developmental
Check
Appendix C Child and Family Health Needs Assessment Record
Appendix D TUSLA Standard Report Form
Appendix 1 Letter to The Director of Nursing
Appendix 2 Interviewee Information Leaflet
Information on Research Project
Roselawn Health Centre,
Castleknock,
Dublin 15
15/03/2015
Dear …………………………..
I am currently undertaking a postgraduate diploma in child protection and welfare at Trinity College
Dublin. In part fulfilment of this course I am undertaking a research project to evaluate the utilisation and
benefits of the Child and Family Child Needs Assessment Framework to the public health nurses’ role in
child protection and welfare in North West Dublin.
I am writing to invite you to participate in an interview of 30-40 minutes duration. In order to accurately
reflect your opinion the interview will be recorded on a digital dictaphone and then transcribed verbatim
for further analysis. These records will be kept confidential and anonymous throughout data collection and
will be destroyed once the study is completed. Participation in this study is completely voluntary and you
may withdraw at any stage.
I appreciate your consideration in assisting me with this study.
Frances McCready phn.
………………………………...
Appendix 3 Interview Consent Form
Consent to participate in study
Roselawn Health Centre
Castleknock,
Dublin 15
15/03/2015
Title: “An evaluation of the utilisation of the Child and Family Health Needs Assessment Framework to
public health nurses in their role in child protection and welfare.
I agree to participate voluntarily in this research study by undertaking a semi-structured interview. The
research purpose has been explained in writing. I understand that anonymity is assured and that I can
withdraw from the study at any stage.
------------------------------------------------
Signed
Appendix 4 Interview Questions
1. Do you use the Child and Family Health Needs Assessment Framework in your everyday practice of
child protection and welfare?
Prompt: If so, what prompts you to use it?
2. Can you tell me how you applied the tool to your practice?
3. Is it user friendly?
Prompt: use of language and the lay-out.
4. Does it enhance multi-disciplinary communication?
5. How do you find the supervision you receive from your line manager?
6. Does the tool enable you to identify gaps in service provision for children at risk and their families?
7. Are there any limitations to the use of this tool?