Health visiting and school nursing practice is informed by several NICE guidelines. An audit was carried to determine the current working knowledge of 5 key NICE guidelines (NG143, CG57, CG84, CG98, CG99).
The audit focused on knowledge of:
1) Key signs and symptoms
2) When further action is needed
3) The correct management and advice to give.
One of the NICE guidelines against which this example was originally submitted (CG47) has now been updated and replaced by NG143. Another (CG57) has been updated. The practice described in the example has been reviewed and is broadly consistent with an audit against the updated guidelines. The updated guidelines should be referred to if undertaking a similar audit.
- Atopic eczema in under 12s: diagnosis and management (CG57)
- Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management (CG84)
- Jaundice in newborn babies under 28 days (CG98)
- Constipation in children and young people: diagnosis and management (CG99)
- Fever in under 5s: assessment and initial management (NG143)
Aims and objectives
The overall aim of the audit was to ensure that health visitors and school nurses within the organisation have a working knowledge of 5 key NICE guidelines relevant to practice.
The objectives were:
- To establish whether health visitors and school nurses are aware of the key signs and symptoms of the condition specified in each guideline.
- To establish whether they can identify when further action is needed.
- To establish whether they are aware of the correct management and advice to give.
Reasons for implementing your project
Gaps had been identified in the knowledge of key issues within the 5 key NICE guidelines following an audit in part of the former organisation. A re-audit had been recommended and additional recommendations were made about the design of the audit tool.
Further evidence of gaps in knowledge about the correct management of prolonged jaundice as described in (CG98) was found in an unpublished audit by a consultant paediatrician.
This baseline audit measured health visitor and school nursing team members' knowledge of key areas within the 5 NICE guidelines across health visitor and school nursing teams. It was considered to be a new audit as it used a new questionnaire as the audit tool, and was carried out across a new organisation.
At the start of the audit there were approximately 270 members of staff within health visiting and school nursing teams. The catchment areas include areas of urban and rural localities and a diverse mix of ethnic background. The area has approximately 228,000 children aged 0-19 years and a birth-rate of approximately 12,000 per year.
How did you implement the project
Prior to the audit the quick reference guide for each of the 5 key guidelines were circulated by email to all staff via the senior nurse and locality managers. The aim of this was to remind staff of their professional responsibilities to read and be familiar with the content. They were sent out over 5 months, one per month, in order to avoid overloading staff with too much information at one time. This was in line with the recommendations from the audit carried out in 2011.
Questionnaires were completed by staff during professional locality meetings from September to November 2012. The audit was listed as an item on the agenda for team meetings as NICE but there was no pre-warning about the audit. Staff were given time to complete the questionnaire at the beginning of the meeting, ensuring a high response rate, and handed them straight back to the manager who sent them to the audit team for analysis. Locality and team meetings are seen as a priority for all health visiting and school nursing staff so a high representative sample should have been achievable. Completed audit forms were returned to the audit office and were inputted and analysed using Excel.
Please refer to the audit report on page 5 for standards and criteria which were set for the audit.
A total of 147 questionnaires were received from qualified staff, 111 from health visiting teams and 36 from school nurse teams. This response rate gives a confidence level of 95% with a margin of error of 7.15%.
Areas of good practice:
The advice and management of feverish illness and of constipation have either green or amber ratings for health visitors. This is positive as these are typical areas of concern encountered in child health clinics, home visits or in telephone calls from parents. Similar positive results were seen in the school nurses responses regarding management of constipation, and with the diagnosis and reason for referral for eczema, again common areas of practice.
Under areas for improvement there are a number of areas rated as red in the results, some of which are more concerning than others. (Please refer to the audit findings on pages 10 and 11).
What impact did the project/changes have on patient/service user outcomes?
When recommended actions have been fully implemented the knowledge base of health visitors will enable the service users to feel confident that advice and management of 5 key conditions is based on current NICE guidance
Key learning points
The questionnaire design made giving multiple answers too easy when single responses were required The original design for the questionnaire had a single box for the participant to write the letter of their answer in, which would have eliminated multiple responses but was not compatible with the intended electronic analysis. As a result inputting of results was very time-consuming.
While inputting the results there was evidence that some teams of staff had completed the questionnaires as a group, sometimes with all giving a wrong answer, which led to inaccuracies when measuring individual knowledge bases. Alternative methods of questionnaire distribution would be equally problematic, with potentially low response rates and the opportunity to complete the form with colleagues or look up the answers if sent electronically or via internal mail.
In retrospect it would be more useful to audit school nurse and health visiting teams separately and audit different areas of knowledge more in keeping with their day to day areas of practice. Some answers were surprising but not clinically significant; for example registered nurses could perhaps be expected to know what NICE stands for but the options given were not too dissimilar from the correct response. Also, the correct response rate for the final question about accessing the guidance was surprisingly low, given that they are freely available on the internet. It is possible that staff thought they may have hard copies of the documents in their offices (as with some other documents) and therefore could not be sure where they were.