The aim of this assignment is to critically examine the complexity of case load management in the area of family violence. The author will focus on an active case that involves domestic violence and child protection. Throughout this assignment the author will discuss the role of the Public Health Nurse (PHN) in the case through the lens of current legislation and policys. A full description of the family involved and the surrounding factors will be presented. Evaluation of the case will be discussed. Finally, a concise evidence-based action plan which could be used to improve care provisions in similar cases. The author will discuss and reflect on the case with her preceptor using the Gibbs reflective practice cycle (1998). For the purpose of this assignment, pseudonyms will be used to maintain confidentiality and anonymity (Nursing and Midwifery Board of Ireland,2014)
Family violence is a broad term which includes several sub titles, such as child abuse, partner abuse or domestic violence and elder abuse. Wallace et al (2016) define family violence as any act or omission by persons who are cohabiting or living together as a family that results in serious injurie to other members of the family. For the purpose of this assignment I have chosen a case that involves domestic violence and the impact of this violence has on the family unit in particular the child involved. Domestic violence is defined as a continuum of behaviours ranging from verbal abuse, physical and sexual abuse to rape and even homicide, with the vast majority of such violence and most severe are chronic incidents are perpetuated by men against women and their children (Department of Health 2010). Domestic violence in Ireland is of growing concerns with the domestic violence statistic report (2014) found that 1 in every 3 women experiences severe psychological violence, 1 in every 4 experienced physical and sexual violence from male partners and 79 percent of women never disclosed severe physical or sexual violence. Research has revealed that domestic violence has a signifying impact on the lives of children and on their current and future wellbeing, (Hester et al 1996).
Child abuse can be categorised in to four different types firstly neglect, secondly emotional abuse, thirdly physical abuse and finally sexual abuse. The Children’s First act 2015 states that the threshold of signifying harm is reached when the child’s needs are neglected to the extent that his or her wellbeing and or development are severely affected. Tusla further defines child neglect as an omission of care, where a child’s health development or welfare is impaired by being deprived of food, clothing, warmth, hygiene, medical care, intellectual stimulation or supervision or safety. In 2017 there was 53,755 referrals to child protection and welfare services increased by 13 presents from the previous year, Tulsa (2017). An interesting study carried out by Farmer and Owen in 2007, named “Child Protection Practice, Private Risks and Public Remedies” found that 3 of every 5 cases where children had suffered physical abuse, neglect or emotional abuse their mothers were also subject to domestic violence living. Research has showed that children do know when domestic violence is happening with the majority of children see or over hear the violence incidents, leaving children often frightened and guilty leading on to physical, emotional, psychological and /or behavioural problems Humphreys et al (2007). This showcases the fact that domestic violence not only effects the individual but the family as a whole unit.
The author will give a details description of the case and the circumstances of the family/ individuals involved. The family choose is an active case which consists of a mother name Kate age 24 years unmarried and her partner Frank age 26years, and their new born baby girl Fay. Kate has two other children to a different partner who are both in foster care of their Grandmother, her ex partner’s mother. Kate has sporadic involvement and contact with the older children. Kate has a history of alcohol and drug misuse in the past. Her extended family consists of her mother Kathleen which she has a poor relationship at present. Kate is in recite of social welfare payments and is unemployed. Due to child protection and parental capacity issues in the past, Kate had been linked with a social worker.
The PHN has first contact with Kate on the birth notification of Fay. Baby Fay was born at 37 weeks by emergency cercaria section due to maternal and fatal compromise, APAGAR was 9 at 1 minuet and 10 at five minutes. Baby’s birth weight was low at 2.80kg. On receipt of the birth notification it was noted that Kates place of residences was the women’s refuge. Kate had been living in the women’s refuge from 33 weeks of pregnancy as she had been physically assaulted by her partner. Incident of domestic violence during pregnancy are of particular concerns and are indicative of highly dangerous perpetrators, Humphreys and Stanley 2006. It is also suggested by Gielen et al 1994 that violence dose not stop with the pregnancy and studies have shown that the postpartum period is the time of greatest risk for moderate to severe violence. Kate had also reported to staff in refuge of been subject to verbal and physical abuse since the beginning of her relationship with her partner of 18 months, which got worse when her partner had been intoxicated. Kates partner Frank has a history of parental alcohol abuse and domestic violence exposure in his childhood. Studies from various countries support the findings that rates of abuse are higher among women whose husbands were abused as children or who saw their mothers being abused, WHO (2002).
The PHN carried out the birth notification at the women’s refuge. Examination of Kate and Baby Fay was carried out, all findings were satisfactory. Blood spot screening was carried out in hospital prior to discharge. Baby was on the 25th centile. Hearing test was passed. The environment was clean and well maintained. Baby was clothed appropriate for time of year, no accidents observed. Baby was on artificially feeding on nutritional formula taking 4 oz. every 3.5 to 4hours. Child safety awareness program, immunisation program and health promotion advise was given to Kate. Kate appeared to be bonding well with her baby. No concerns voiced by mother, advised to contact PHN services if any queries in the coming days and contact details provided. Kate informed PHN that she had good support from her key worker and women refuge staff. A plan was discussed to call again in in 5 days to check baby’s weight, and Kate agreed to engage in services. Advises given regarding follow up baby check with her GP at 2 weeks.
The PHN completed a Child and family needs assessment and informed her line manager of the situations. The purpose of the child and family needs assessment framework is to provide an evidence-based assessment tool and resource to identify families who need early intervention and require additional support. It supports the PHN to assess, interpret and analyse (risk and protective factors) in their work with children and families , O Dwyer (2012). The impact of parenting capacity, family and environmental factors is required to be examined and documented. Findings from the assessment will guide the most appropriate services to be provided, ensuring the optimum health and well being of the child. There are three areas explored firstly child development, secondly parental capacity and finally family and environmental capacity. This assessment framework aids PHNs to identify any issues that require further addressing to ensuring the overall health and welfare of the child and family involved.
Child health care plan was completed and mother health care plan was completed. Problems were identified, Baby Fay low birth weight and interventions and goals set. Mother living in refuge due to domestic violence and parenting capacity , interventions and goals were set ,Kate was advice on local support groups were suggested to attend counselling. Follow up case conference date was organised
Child protection conference was carried out, in accordance with children First National Guidelines for the protection and welfare of children (2017). The author attended the conference with her preceptor. The purpose of this meeting was to facilitate the sharing and evaluation of information between professionals and parents, in order to identify risk factors, protective factors and the child’s needs. To determine if the child is at ongoing risk of significant harm and to develop child protection plan when it has been determined that a child is at risk of significant harm. Children first recognise that people working with children irrespectively of their position the hold in the organisation the work for have a responsibility for all children’s health and welfare and are in an ideal position in identifying any child protection issues. A collaboration of knowledge can contribute to making an informed decision in the health and welfare of the child. Attending was chairperson, social worker team leader, hospital social worker, GP, PHN and the author, women’s refuge manager, mother and father. Good Multi-disciplinary team decision making is required and any concerns voicer and to determent if the child is at ongoing risk of significant harm due to the unresolved risk of emotional abuse by exposure to parental domestic violence, attributed by inappropriate or inadequate care from parents. Prior to the conference the PHN submitted a detailed writer report. in conclusion a decision was made Baby Fay was deemed to be at risk of significant harm including neglect attributed to inappropriate or inadequate care from parents. Category being emotional abuse. Therefore, baby Fays name would be listed on the Child Protection Notification System (CPNS), The CPNS records the names of children who have Child Protection Plans agreed at a Child Protection Conference, which can only be accessed by a very small group of people, such as doctors or Gardi, who might need to make important decisions about the safety of the child, TUSLA (2017). A child protection plan was developed. The risk factors included parent’s unstable relationship and confirmed incidents of domestic violence. A plan was put in place following the Child Protection conference, Baby to be placed on child protection register, mother to stay in women’s refuge and comply with social workers safety plan dad not to be left alone or unsupervised with baby and Kate can meet Frank without baby and refuge staff too help Kate mind baby Fay. Partner in agreement with this, Kate to comply with refuge rules regarding payment of rent and returning at agreed times, and both parents to engage in counselling. It was advised that the PHN to review weight every week, GP to review at 2 and 6 weeks, a date confirmed for next case conference.
Public Health Nurses (PHNs) work under the remit of the Health Services Executive (HSE) which provides health and social services to the population of Ireland and which had, until June 2013, sole responsibility for all child protection issues, Hanafin 2013. The role of the PHN is of great significands in the community, for the welfare of children and families who can be the first point of access to other services. The PHN is viewed as a none treating and a non-stigmatising service from the point of view of family and parents, providing family support, child welfare and protection, Hanafin and Coyne (2015). The PHN carries out the first visit of a birth notification usually within 48 hours of discharge from hospital and undertakes 5 developmental assessments as set out in Best Practice Document Best Health for Children 2005. The role includes early detection of abnormal development and referral onwards to other members of the multidisplinary team as necessary, providing advice and support to parent’s .This places the PHN in a prime position to identify child protection concerns or issues from birth. PHN have a unique opportunity to identify, prevent, and participate in early intervention for children and families, with focus on prevention of problems from arising in the first place. If problems are identified the PHN have the policies and guidelines in place to refer to and or escalate to other members of the primary care team or to other services if required , Hanafin and Coyne (2015).Delivery of a comprehensive PHN services to families with children are not without their challenges arising from the impact of deep recession resulting in a mortarium of staff replacement and from competing demands on the public health nursing service itself which is responsible for other client groups, Hanafin and Coyne (2015). Despite these challenges in 2011, 80 percent of all new-borns were visited by PHN within 48 hrs of discharge from hospital and 82 percent of their 7-9 months development checks on time according to the DOCYA (2012). This shows a strong positive commitment to the PHN team to the health and welfare of our Irish children and families.
It is a legal and professional responsibility for a PHN to work under the available legislation and policy’s guidelines to ensure best practice to ensure and safeguard the protection and welfare of children, this is of the utmost importance to advocate the rights to a safety. PHN s works under the following legislation.
• Child care act (1991).
• Protection for Persons Reporting Child Abuse Act (1991).
• Children First Act (2015).
• The Children First National Guidelines Document (2017).
• The Children Act (2001).
• Criminal Law act (1997).
• Criminal Justice Act (2012).
• Domestic Violence Act (2018).
• Offences against the State (1998).
• National Standards for the Protection and Welfare of Children (2012)
The HSE has also provided a handbook containing current Irish legislation related to current child protection and welfare guidelines, this helps users to support the children first guidelines. This allows PHN to access recent Irish legislation relevant to practice in relation to the role and professional responsibility of a PHN.
TUSLA child and family agency are a statuary organisation, established in 2014 under the Child and Family Agency Act 2013. Tusla agenda is to support and promote the development, welfare and protection of children and support and encourage the effective functioning of the family, Tusla (2015). As per Schedule 2 of the Children’s First Act 2015 specifics all Register Nurses and Midwifes within the meaning of section 2(1) of the Nurses and Midwifery Act 2011 are have a legal obligation to act as a Mandated person. The responsibility of a mandated person is to report harm of children to TUSLA and to assist TUSLA in assisting a concern that has been the subject to a mandated report, TUSLA 2017. PHNs provide a comprehensive legally entitled child health surveillances program for all children living in Ireland, Hanafin and Coyne (2015). Ultimately intending to safeguard children and support families in doing so, ensuring a safe and secure environment.
An evidence based action plan which could be used to improve care in future similar cases will be discussed. The important of role identification, communication and documentation can impacts on the overall outcome of similar cases.
As a PHN we work in collaboration with the primary care team and other disciplines. Working collaboratively to achieve unified goals. Reeves et al (2013) stated, “While working collaboratively we aid the reduction of duplication of efforts, improves job satisfaction of staff, help overcome fragmentation of service delivery and improve patient’s safety and quality” .
It is required of PHNs to use distinctive language to communicate which allows us to demonstrate our unique contribution to care. This will justify the role and responsibility of the PHN role giving authority over our nursing care. With the use of North American Nursing Diagnosis International (NANDA I), Nursing Outcomes Classification (NOC), Nursing Interventions Classification (NIC), aid nurses in the process of naming nursing clinical phenomena. This allows PHNs to make a “clinical judgement about individual, family or community experience/response to actual or potential health problems/life processes”, Herdman (2014). This allows for better communication among nurses and other members of the multidisciplinary team, highlights PHNs professional identity and how PHNs impact on clients care, and contribution to the case.
Each member of the MDT should have a clear set of guidelines outlining their role and responsibility in the case and absolute clarity is required. This prevents overlapping of work and crossover of paths, where responsibility is left in a grey area. As a PHN we have a clear responsibility for the health and welfare of the child and it is our ultimate goal to protect the child from harm or neglect. Recommended from The Monageer Inquiry recommended that the head of each discipline should be responsible for the management and professional practice of their team and audits should be taken in this regards (Hanafin, 2013).
In conclusion the author has examined the complexity of case load management in the area of domestic violence and child protection. Domestic violence in Ireland is of growing concerns. Domestic violence has a signifying impact on the lives of children and on their current and future wellbeing, (Hester et al 1996). Leaving a considerable long term impact on children health and welfare, children often are left frightened and guilty leading on to physical, emotional, psychological and /or behavioural problems, Humphreys et al (2007). The role of the PHN is of great significands in the community, viewed as a none treating and a non-stigmatising service from the point of view of family and parents, providing early intervention of family support, child welfare and protection, Hanafin and Coyne (2015). PHN work within their scope of practice guided by the policies and legislation set in place. Effective communication, role responsibility and clarity is imperative in effective case management.