This case study involves counselling a 23-year-old African American Male who was incarcerated for seven years and has recently been released from. The study took place at Bronx Connect. Mr. Jones has a long history of mental health issues such as anxiety. The goal for the five-week counseling session was to assist the client in finding the necessary skills that will help him combat his anxiety. In helping the client achieve this goal I found a meditation method that has been proven to work on alleviating his anxiety. The method that was used is called the 478 method (Weil, 2011). The counseling sessions mainly focused on how the client would manage his time more effectively and learn how to mediate to reduce anxiety. The counseling sessions where successful because the client wanted the help that was being offered. Furthermore, he learned valuable skills and how to prioritize his time more efficiently. This is a vital step in minimizing anxiety. The sessions have ended; nonetheless, the client is welcome to request more help through the agency.

Anxiety has become normal in today’s society and has had a large impact on the awareness of the illness. Anxiety and incarceration are reviewed separately here due to the tremendous difference in the two. Anxiety is a mental illness while incarceration is the state in being confined in prison (Merriam-Webster’s collegiatedictionary,1999). Though they well be reviewed separately I will with present findings on how they are relatable.

Anxiety disorder differ in types and intensity but have similar characteristic in common: they all carry unwanted thoughts, affect you physically, and mentally. There are five major types of anxiety disorders. General Anxiety Disorder- GAD, Obsessive-Compulsive Disorder, OCD, Post-Traumatic Stress Disorder, PTSD, and Social Phobia, or Social Anxiety Disorder. The struggle that comes with these disorders can greatly affect a person way of living, communication and relationships (Beck, A. T., Emery, G., & Greenberg, R. L. 2005).

Incarceration in the United States is one of the main forms of punishments and rehabilitation. Mass incarceration has been an on-going issue because of the decisions made by policy makers to increase the use and severity of prison sentences and other contributing factors such as rising crime rates here in the United States (Exploring Causes and Consequences, 2014). Today the US hold the highest incarceration rate in the world. In New York alone the population of people I the prison system is 8.6 million today. (CNN, 2018). To understand who the system impacts and the fact that bring the scope of the criminal justice system into focus. The jail system has become the front door to the criminal justice system because they hold people that haven’t been convicted yet. Also, those who can’t post bail are unavoidably trapped until their next court date. The living condition in prison should not be an additional punishment as these prisoners’ sentence is the sanction that holds the individual accountable for the crime committed and protects society.  The living condition in prison plays solely on the dignity and self-esteem of a prisoner. If the goal is to rehabilitate and individual, humane detention conditions will allow prisoner to be more willing and able to respond to rehabilitative programs. Those who experience punitive conditions and mistreatment are likely to return to society psychologically shattered and in poor or worse state of physical and mental health than when they entered. (Mason, Jim 1990)).

If it isn’t hard living in society today can you imagine being in prison for a long time, then reentering society? When in prison you live by protocols. You are told when to wake up, when to eat, when to shower, and when to have down time. All these factors play a major role in a person’s life that has spent a long time in prison and is being released into society. When an inmate is released that has spent a long time in prison can experience “Culture Shock” Culture shock is the disorienting feeling a person can get when they suddenly must adapt to an unfamiliar culture or way of life (Adler, P. S. 1975). Anxiety after incarceration is common. Readjusting to daily life, trying to find a job, and financial stability can be frustrating (Arditti, Parkman 2011). Communication these issues can be difficult as well. Trust is something that must be formed when dealing with a person that has reentered society.

Incarceration and Anxiety Disorders, how are they relatable? As mention above, the living conditions of a prison and the health and safety of a prisoner plays a major part in their release. Many prisoners face assaults daily or are treated poorly. This ultimately affect the mental health of a person. What I will implement into this study are strategies that will help reduce the overall frequency intensity, and duration of anxiety so daily function is not impaired. Anxiety is caused by work; working long hours, being unhappy at your job, having a heavy workload, unclear expectations and poor management, a company that isn’t supportive, and working under dangerous work conditions. Life also is a factor that causes anxiety as well. Whether it is death of a love one, loss of a job, divorce, apartment loss, incarceration and emotional problems just to name a few. To manage anxiety and redirect it there are many things you can do to relive it through stress relieving techniques.

What I will implement in this case study is different ways a person can deal with symptoms of anxiety such as, Meditation by breathing. The 4 7 8 breathing technique is a technique that is easy to use anywhere. It consists of 1) Exhale completely through your mouth, making a whoosh sound. 2) Close your mouth and inhale quietly through your nose to a mental count of four. 3) Holding your breath for a count of seven. 4) Exhaling completely through your mouth, making a whoosh sound to a count of eight. This is all done in one breath. Using this technique will enable the individual the tools to cope with stress that is caused form work and life events (Weil, 2011). These meditation techniques have been proven to work.

Another form of an anxiety reduce strategy is time management. What is time management?

Time management means to optimally use the time available (Bl, Huston 2012) and that includes aspects of planning, goal setting, prioritizing goals and activities, communications and delegation. When dealing with everyday life it is important to manage time appropriately. In relations to time management there are some time management strategies that can help reduce anxiety. 1. Morning strategy- what is asked is that you take 15-20 minutes each morning, either when you wake up or get into work, to plan your day. 2. Deep work- what is suggested is that you set time where you focus solely on one task. Shut the door, take the phone of the hook and put the headphones in. Aim for a period of 45-50 minutes followed by a break of 10 minutes. 3. Recognize the difference between “Urgent” and “Important”- A sense of urgency is what raises our stress and anxiety. By removing ourselves from this urgent need to respond to impetuses as soon as possible, we want to play smart and raise our satisfaction and fulfilment by working on what’s important (Heap, 1979).

Bronx Connect is a community and faith-based program that offers alternative-justice, cure violence, and re-entry programs to help communities build from within. They believe that every young person has gifts, talents and interests that need to be nourished and supported. When young people experience growth, competency and purpose in exercising their gifts and pursuing their interests, they will be far less likely to continue with risky behaviors that could lead to re-arrest or gun violence. The organization draws on its deep roots to develop community as the only Bronx-based alternative justice program with close to two decades of experience. They build on the strengths of the community, identifying those who are its pillars and working with them to change the atmosphere. Bronx Connect organizes community events around issues that affect our youth and overall wellbeing. Their goal is to awaken the voice of the urban community to speak out against injustice. The near 2,000 Bronx Connect youth we have served, and their families’ voices, are being organized to be heard.

Mr. Jones sought out help at Bronx Connect due to past imprisonment. He currently battles with depression and anxiety and is seeking a therapist that he deems fit for him based on knowledge of his depression, anxiety, active listening, and close therapeutic relationship. He will choose a clinic that fits best through Bronx Connects referral. Mr. Jones is a 23-year-old male who’s is average height and weights 140 lb. Mr. Jones is a well-groomed individual. Presently Mr. Jones is a single man with no children. When Mr. Jones was fourteen, he committed a violent crime, which lead to his imprisonment. Mr. Jones spent seven years in jail his only know relationship was while he was in prison. After his release, Mr. Jones attempted to finish his high school equivalency at Monroe College but faced distractions due to drugs and alcohol. His current relationship with his family is not great but he’s looking to repair his relationship with them. When Mr. Jones was young his mother was addicted to cocaine and most of his family members where alcoholics. Because of his mother’s addiction, Mr. Jones was abused often. Mr. Jones currently suffers from seizures due to a car accident that happened when he was thirteen leaving him with a metal rod in his right leg. Mr. Jones suffers from asthma which requires him to take his inhaler as prescribed. Mr. Jones believe he’s bipolar but has not been properly diagnosed. Mr. Jones is a hardworking person who wants to complete his high school equivalency degree and go to college but continues to battle with distractions that’s stopping him from doing so.

Mr. Jones primary need and what I will help him work on is how to combat anxiety. Anxiety is a normal reaction to stress. Anxiety disorders can cause people to avoid situations that may trigger or worsen their symptoms. This actively affects job performance, school work and relationships. Mr. Jones’ fist notice his anxiety when he was released from prison. Mr. Jones spent seven years in prison where he became accustom to prison life. However, spending a lengthy time in prison. He gained a positive perspective from his experience. He feels he’s more punctual.

The goal I’m aiming to reach with John is reducing his anxiety after five counseling sessions.

John will learn what make him anxious and how to manage his time.

John will learn how to meditate using Dr. Wails breathing technique. John will keep a journal and write down and describe situation, thoughts feelings and actions associated with anxieties and worries, their impact on functioning, and attempt to resolve them. John seems frazzled and doesn’t manage his timewell. John will learn time management to reduce anxiety (Willms,2016). John will learn how to implement calming skills to reduce overall anxiety and manage anxiety symptoms using the 478-breathing technique (Weil, 1994).

I will evaluate Mr. Jones by counting and record the amount of time he shows up late for his counseling sessions. I will do this by creating a log that will require sign in with date and time when he’s scheduled to come in. Researchers found that poor time management can increase anxiety. When dealing with your everyday life it’s important that your time is managed accordingly, or your life will be in disarray. People that tend to have heightened anxiety normally don’t function as well. The inability to function is based on the amount of stress/ anxiety the client is facing.

Mr. Jones and I discussed his goal for our sessions. He specified that he’s willing to learn the necessary strategies in order to combat anxiety. Those strategies will include meditation time management and journaling.  John has suffered from anxiety after his release from prison. He never took the necessary steps to try and get help until he enrolled into Bronx Connect. Our work began by giving him a journal. In the journal he was to write what he did on a day to day basis. It was up to him if he wanted me to read it. During our counseling session he briefly discussed what made him anxious and one of his triggers was time management. Therefore, I suggested after he wrote in what he did on a day to day basis that he prioritizes his schedule. From there, I had him sit at a computer to generate a schedule. This schedule will alleviate some of the anxiety he’s experiencing. We also discussed a breathing technique to help reduce anxiety. Prior to ending our session, I briefly discussed what we would be focusing on during our next session and gave him homework. I asked that he look up a meditation method called on the 478-breathing technique (Weil, 2011). Towards the end of our session Mr. Jones seemed more relaxed and interested in my ideas.

His negative attitude towards following a schedule, journaling, and meditating was apparent in the first session. Despite his temperament towards keeping a schedule, Mr. Jones showed the willingness to receive help. Mr. Jones was willing to accept homework I gave him. He also looked interested in looking up the method that will help reduce his anxiety.

In the second counseling session with Mr. Jones, I reiterated what we discussed as far as the goal in helping him managing his anxiety and the different method that will help him combat it. We met in and empty room in the building. I sat at the desk with him adjacent to me. This session was different from the last because Mr. Jones seemed calmer from our last session.

• Student Intern: Have you started following the schedule you put together and has it been working?
• Mr. Jones: Yes! Oh my god I’m able to get so much done.
• Student Intern: Did you look the mediation exercise by Dr. Wiel?
• Mr. Jones: The breathing technique? Yes. I have trouble understanding and want to know if you can explain more?
• Student intern: Sure, how about we look it up together
• Mr. Jones: ok.

Mr. Jones seemed more eager and interested to learn about mediating. He expressed that though he’s leaning how to manage his time better he still has periods where he becomes anxious. I explained that it will take time and he has to get used to doing things different form when he was in prison. This can also be a reason why he’s anxious. He doesn’t have anyone to dictate what he does. I expressed for the following session we will practice the exercises.

For the third session he seemed a bit uncomfortable. He seemed bothered and didn’t want to sit and talk with me. Prior to us meeting he sent me an email asking if he could meet me on a later day and replied sure I will reschedule. When Mr. Jones sat to speak with me, I was surprised.

• Student Intern: We can sit here and just relax if you want
• Mr. Jones: I know I said I wanted to reschedule but I really need to talk to someone.
• Student Intern: Ok. I’m here. When you’re comfortable to talk we can start.
• Mr. Jones: I don’t Really have nothing to talk about I just want to sit here
• Student Inter: Ok

For the remaining time spent with Mr. Jones We sat. Mr. Jones was bothered and upset. I can see he has been working on meditating because he would close his eyes and breathe while we were seated. After his departure he assured me that we could pick up where we left off the following session

For the fourth session Mr. Jones suggested that we met outside. I was okay with it. He explained to me that he really didn’t have enough time to just sit outside. Prior to us meeting Mr. Jones sent me an email apologizing about our last session. He mentioned that he’s been looking for work but he’s still having issues with his anxiety. This would be the perfect time to go over the meditation method by Dr. Weil.

• Student Intern: Good day Mr. Jones, I would like to show you the meditation method to help with your anxiety.
• Mr. Jones: Sure. But, outside?
• Student Intern: This is something that you can do anywhere
• Mr. Jones: Ok. I’m ready when you are!
• Student Intern: This method requires you to breath in for a count of 4 and exhale for a count of 7, 8 times
• Mr. Jones: Ok can you show me?
• Student Inter: Okay.

After showing Mr. Jones the meditation method, he seemed calmer and more excited. He reported that he can feel himself becoming calm. He requested that we do the meditation method for our next session that that he may become more familiar with the technique. I assured him that with practice he will get used to it and will be able to do this alone.

For our fifth session Mr. Jones seemed so eager to talk to me. He seemed calm and full of life. This is the most positive I’ve seen him since I met him. For this session, we met in the conference room at Bronx Connect Mr. Jones sit in and we began. Before our session began, I wanted to set the tone to a more relaxing setting. I played some mediation music to flow with our session

• Student Inter: Good afternoon Mr. Jones
• Mr. Jones: hello! It looks so relaxing in here.
• Student Inter: how’s your scheduling coming along?
• Mr. Jones: it’s coming along well. I find that I’m able to actually get things done without stressing myself out
• Student Intern: That’s great! Do you want to start off where we left off?
• Mr. Jones: Ok. But, can I lead?
• Student Intern: Ok.

The Session with Mr. Jones went smooth. He took lead for this session showing that he’s become familiar with what triggers his anxiety. He showed that he’s been managing his time and overall, he seems calmer.

In the human service field, it is important that you possess the qualities of attaining self-knowledge, a positive attitude, and proper skills set in order to work in this field. These qualities are vital to your clients. There will be people you deal with and situation that will test your judgment, strength and weakness. As a result, if I’m not in the state of mind to help myself, problem solve, or knowledgeable how to help my client it will greatly affect Mr. Jones.

My values class taught me that it’s imperative to be attentive of my own values prior to counseling a client. Knowing what my vales are it was important that I didn’t force that on the client. There were so many similarities I seen in the client that reminded me of my brother, so I had to make sure I didn’t display emotions in our sessions. In the beginning he had a very obnoxious and loud personality that reminded me of my brother. His attitude towards learning how to cope with his anxiety was not always positive. If anything, he had a lot of doubt, but as the sessions wen on he gained positive outlook on what I was trying to help him achieve.

In my system class I learned that certain systems could help a person in acting a form a support. Being able to use what I knew and what the organization offered helped him with knowing his triggers and helped him with managing his time more effectively. As a counselor I was able to help him address the underlying issues that was causing him to have anxiety. As a result, he was able to use the internal system in achieving his goal.

Throughout the course of the case study I was able to learn that people go through things in life that are relatable.  As people we tend to judge people without knowing what that person is going through. My perception of Mr. Jones was that he was a man that was gong though a lot. Men that are exonerated form prison face many hardships once they are released into the community. Not only are they being stigmatized as an ex-offender they are also implicated as a major barrier to a successful community reintegration. Criminals are one of the most stigmatized groups in society, yet the large body of research on stigma rarely considers offenders. Mr. Jones and I worked extensively to help him combat his anxiety.

References

• (2018). Incarceration. Retrieved from
  
  https://www.encyclopedia.com/social-sciences-and-law/law/law/incarceration
  
• 
  Beck, A. T., Emery, G., & Greenberg, R. L. (2005).
  
  Anxiety disorders and phobias: A cognitive perspective. New York, NY, US: Basic Books.
• Kann, D. (2018, July 10). The US still incarcerates more people than any other country. Retrieved from https://www.cnn.com/2018/06/28/us/mass-incarceration-five-key-facts/index.html
• Mason, J. (1990, Dec 07). INMATE GLAD TO ESCAPE PRISON’S LIVING CONDITIONS. Richmond Times – Dispatch Retrieved from
  
  http://ezproxy.mcny.edu/login?url=https://search-proquest-com.ezproxy.mcny.edu/docview/423423411?accountid=38814
  
• Adler, P. S. (1975). The transitional experience: An alternative view of culture shock. Journal of Humanistic Psychology, 15(4), 13-23.
• Human Services Administration, University of Baltimore, 1420 N. Charles St., Baltimore, MD 21201.
• Conrad, A., Müller, A., Doberenz, S., Kim, S., Meuret, A. E., Wollburg, E., & Roth, W. T. (2007). Psychophysiological effects of breathing instructions for stress management. Applied Psychophysiology and Biofeedback, 32(2), 89-98. doi:
  
  http://dx.doi.org.ezproxy.mcny.edu/10.1007/s10484-007-9034-x
  
• Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing. 7th ed. Philadelphia: Lippincott; 2012
• Heap, N. (1979). Time Management–an effective tool for management development. Journal of European Industrial Training, 3(3), 27–28. Retrieved from http://ezproxy.mcny.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=eue&AN=5230564&site=ehost-live

Successful implementation of a paediatric community home nursing service as a model of service delivery in acute paediatric care

Abstract

Aim: The aim of this pilot service development was determine if CommunityChildren’sNursingOutreach Team (CCNOT) service as a model of care was effective in its delivery of reducing unscheduled care and admissions to hospital and improving patient satisfaction.

Methods: The following outcomes were determined:1)reducing length of hospital stay 2) reducing Accident and Emergency admissions 2)reducing non-elective admissions 3) reducing readmissions and 4)improving patient satisfaction.

Results: The data indicates that A&E attendances had reduced by 5% per month, NEL admissions had reduced by 15.8%, readmissions had reduced by 17.3% and the overall LOS was increased by 2.3%. The results of the patent satisfaction survey shows overall a high patient satisfaction for the service.

Conclusions: Paediatric CCNOT service as a model of service delivery in acute paediatric care is effective in reducing hospital admissions and increases patient and carer satisfaction with care provision for sick children in the home environment.

Key Phrases:

• Paediatric community home nursing service as a model of service delivery within acute paediatric care is effective in reducing A&E admissions, non-elective admissions and readmissions.
• It significantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment.
• Paediatric community home nursing should be implemented with nurses trained in paediatrics and with clear clinical governance, pathways and robust documentation.

Introduction

Paediatric emergency admissions and length of stay in hospitals in the United Kingdom are increasing (Kyle

et al

. 2013). Community home nursing service or CommunityChildren’sNursingOutreach Teams (CCNOTs) have been developed to manage acutely ill children athome, to reduce length on inpatient hospital stay andto reduce demand for unscheduled care (Hall

et al.

2005). The CCNOT model of care has been shown in a previous randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care as a clinically acceptable form of care for management of acute paediatric illness (Sartain

et al

. 2002). Referral pathways to CCNOTs may reduce avoidable admissions and minimise the psychosocial impact of hospitalisation on children and families, and reduce the financial costs to the National Health Service (NHS). Paediatricians and commissioners face considerable challenges in light of recent budget cuts in the NHS. Research undertaken by the University of Central Lancashire and the University of the West of England for the Department of Health described the importance of reliable, accessible expert community home nursing provision to families to enable them to care for their child at home and recorded the families’ deep frustration at the patchy, fragmented postcode lottery provision of services that currently exists (Department of Health 2011).

Background

Services that meet the needs of children and their families must continue to be provided in a safe, high quality and sustainable manner. In our desire to improve the quality of care in paediatric services in the face of rising public expectations, there is a need for change within new working hours and new ways of providing. The case for change can be complex, with decisions made to balance key areas of clinical effectiveness, best practice, patient safety, accessibility, staff retention and sustainability. The Royal College of Paediatrics and Child Health (RCPCH) recognises the importance of ensuring that services for children are designed to provide high quality care as close to home as possible and that such services need to adapt and respond to the demands and needs of the patient. The College’s current work to model the future configuration of paediatric services discussed the move towards delivering acute care within the community such as community home nursing service (RCPCH 2005). The aim of this pilot service development was determine if CCNOT service as a model of care was effective and efficient in its delivery of reducing unscheduled care and admissions to hospital and improving patient satisfaction.

Methods

Clinical Commissioning Groups (CCGs) are responsible for planning and designing of the local health services in England. Within a dual-site integrated care organisation Southport and Ormskirk NHS Trust, a pilot CCNOT service was developed in March 2013 following negotiations between the Trust and the CCGs in Sefton and Lancashire. The remit of the pilot service specification aims were to determine the effectiveness of CCNOT in the following outcomes 1) reducing length of hospital stay 2) reducing Accident and Emergency admissions 2) reducing non-elective admissions 3) reducing readmissions and 4) improving patient satisfaction. Funding was sought for 7.2 WTE paediatric trained nurses at band 5 to 6 and 0.5 WTE admin and Clerical support staff.

CCNOT referrals were taken from accident and emergency, the short stay paediatric admissions unit (SSPAU), the inpatient ward and from the tertiary hospital Alder Hey Foundation Trust for patients residing in North Sefton, Formby and West Lancashire, which covers a population of approximately 300,000. Collaborations were made with Pharmacy, IT and specialist services to develop robust e-discharge summaries from the community and the ability for CCNOT to deliver three times daily intravenous antibiotics in patient’s homes 7 days a week. The service ran from 7am to 10pm seven days a week. It was also necessary to set up all the operational aspects of the team including admission criteria, clear clinical governance and pathways, robust documentation and purchasing necessary equipment. The service was managed overall by the Paediatric and Neonatal matron.

The CCNOT was led by the paediatric matron with regular supervision and mentorship of a lead CCNOT Consultant Paediatrician. Clear clinical criterias for referrals made to CCNOT were developed and clinical pathways were followed to ensure that each referral pathway was safe and robust. (see Figure 1) Any referral was discussed with the CCNOT between a Registrar or a Consultant. Each diagnostic pathway was clearly followed by the CCNOT team with any deviation discussed with the lead Consultant Paediatrician. Daily handovers from the medical teams were attended by a lead CCNOT member of the day to ensure that any referrals made were handed over verbally and any potential referrals during the day were anticipated. The handovers were also an opportunity to discuss the progress of any patient who remained under the care of the CCNOT.

A structured patient satisfaction questionnaire was conducted with participants who were referred to CCNOT at the time of discharge. Hospital admissions between April 1, 2012 and September 30, 2013 from the Hospital Episode Statistics (HES) were obtained. HES is the national administrative database for hospital activity in England and contains data on all inpatient admissions in the National Health Service.

Results

The data collected shows activity from April 2012 to September 2013. The results of the pilot service for 1) average length of hospital stay (LOS) 2) Accident and Emergency (A&E) admissions 2) non-elective admissions (NEL) 3) and readmissions are summarised in Table 1 comparing the period before CCNOT was implemented (April to September 2012) and the period after CCNOT was implemented (April to September 2013), during the same months of the year. The data showed that there were 28.3% referrals made from A&E, 38.7% from inpatient ward, 11% from SSPAU, 8.9% from outpatient clinics, 12.5% from the regional tertiary centre and 0.6% from another district general hospital.

The data indicates that following the implementation of the pilot, A&E attendances had reduced by 5% per month, NEL admissions had reduced by 15.8%, readmissions had reduced by 17.3% and the overall LOS was increased by 2.3%. Figure 2 shows that there has been a 5% reduction in A&E attendances since the introduction of the CCNOT team. NEL admissions was reduced by 15.8% a shown and although the drop in A&E attendances will be reflected in the reduction in non-elective admissions, this will only account for 5% of the over 15% reduction. The readmission rate has significantly reduced by 17.3% since CCNOT service was implemented. The sources of referral overall were 28.3% from A&E, 38.7% from inpatient wards, 11% from SSPAU, 8.9% from outpatient clinics, 12.5% from the regional children’s centre and 0.6% from other district general hospitals out of area. Overall patient satisfaction was very high and the results are shown in Table 2.

Discussion

CCNOT pilot service had a positive impact on the performance of the paediatric department in reducing Accident and Emergency admissions, reducing non-elective admissions and reducing readmissions. It was noted that there was a very slight increase of LOS by 2.3% which were noted to be an average of 0.88 days compared to 0.9 days which were not significant. The CCNOT service also improved the patient and family experience considerably from the results of the patient satisfaction survey. The confidence in CCNOT’s competence to safely manage acutely ill children athomeand secure rapid referral to the medical team if a child’s condition deteriorated were supported by clear clinical pathways and the regular supervision given by the matron and Consultant Paediatricians. The effectiveness of ‘hometreatment’ were evident from the results of the patent satisfaction survey. The National Service Framework for Diabetes have advised clinicians and Trusts to achieve current targets by providing high quality care with novel strategies. One instrument to meet these challenges is the development of a paediatric community home nursing service with CCNOT teams as a service model of care in acute paediatrics in the face of reconfiguration of paediatric services.

We have shown in this pilot service that CCNOT has been highly successful in achieving the targets for reducing length of hospital stay, reducing hospital admission from accident and emergency and improving overall patient satisfaction. CCNOT service compared to inpatient hospital stay have been found to be acceptable and preferable to parents and children although there is limited evidence about the clinical and cost-effectiveness of paediatric home care (Sartain

et al

. 2001, Spiers

et al.

2011,Bagust

et al.

2002). Concerns have also been raised that children’s emergency admissions in England may indicate that parents often bypass primary care when seeking care for their acutely ill child, perhaps due to lack of availability of out of hours services within primary care (Gibson

et al

. 2010) The option of referral to CCNOT provides care to children at home by nurses with paediatric training, and has the potential to avoid some onward referrals and preventable admissions. The CCNOT service may be further expanded to provide support within primary care service, however, within the remit of our pilot service specification, the current funding is not sufficient to allow coverage for the populations of GP referrals unless the number of WTE staff is further increased. The relative success of our CCNOT in securing high referrals suggests that an incremental approach to encourage GP referrals is likely to result in increased GP referral rates. This development must be underpinned by financial and organisational investment.

In light of modern NHS in England, and in similar health systems, it is generally agreed that the main focus of paediatric acute services should be the care and support of vulnerable children and young people in the community and as close to home as possible (RCPCH 2009). Financial and organisational investment in the development of CCNOT in acute care pathways are a prerequisite for the success describe in this pilot scheme. It is anticipated that in the future, paediatric services will be delivered by consultants leading a team of trained doctors, nurses and health care professionals working within a multi-disciplinary and skill-mixed team delivering care in the community. Pressures in delivering acute paediatric care also relates to changes in the way junior doctors are trained and the recent years application of European Working Time Regulations have required an increase in numbers of trained doctors to provide 24/7 cover in hospital. This increase has sometimes been at the expense high vacancy rates for medical staff and in particular a national shortage of middle grade paediatric medical doctors is experienced across England, Scotland and Wales (Royal College of Paediatrics and Child Health 2011). There remains limited existing research on the cost effectiveness, development, design and distribution of CCNOT service across acute paediatric care in the UK.

Conclusion

Paediatric CCNOT service as a model of service delivery in in acute paediatric care is effective in reducing A&E admissions, non-elective admissions and readmissions. It also significantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment. Our findings identify key factors that may inform the development of a CCNOT service in acute paediatric care to safely manage children at home.

Relevance to clinical practice

Delivering acute care within the community such as community home nursing service may reduce demand for unscheduled care and reduce the financial cost to the National Health Service in UK. Paediatric community home nursing service as a model of service delivery within acute paediatric care is effective in reducing A&E admissions, non-elective admissions and readmissions. It significantly increases patient and carer satisfaction with care provision for sick children with appropriate conditions in the home environment. Paediatric community home nursing should be implemented with nurses trained in paediatrics and with clear clinical governance, pathways and robust documentation.

References

Bagust A, Haycox A, Sartain SA, Maxwell MJ, Todd P. Economic evaluation of an acute paediatric hospital at home clinical trial.Arch Dis Child.2002;87:489–492.

Department of Health 2011; NHS at Home: Community Children’s Nursing Services.

Gibson NP, Jelnek GA, Jiwa M, Lynch A-M. Paediatric frequent attenders at emergency departments: a linked-data population study.J Paediatr Child Heal.2010;46:723–728.

Hall D, Sowden D. Primary care for children in the 21st century.BMJ.2005;330:430.

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Spiers G, Parker G, Gridley K, Atkin KP. The psychosocial experience of parents receiving care closer to home for their ill child.Health Soc Care Comm.2011;19(6):653–660

Supporting Paediatric Reconfiguration: A Framework for Standards RCPCH 2009

Sartain SA, Maxwell MJ, Todd PJ, Haycox AR, Bundred PE. Users’ views on hospital and home care for acute illness in childhood.Health Soc Care Comm.2001;9:108–117.

Royal College of Paediatrics and Child Health 2011 Medical Workforce Census

Table 1: Outcomes

Table 2. Results of the patient experience survey

Number of responses: 33 (54% return)

Legends:

Figure 1: Referral pathway to CCNOT service

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April 2012-September 2013

This essay discusses the public health issue of smoking during pregnancy in England. The purpose for selecting this public health issue will be described, utilising government statistics that highlight the extent of the problem. Current smoking cessation interventions in this population will be critiqued, with a focus on Motivational Interviewing (MI) and the acceptability and feasibility of this technique compared to other techniques. Based on the evidence, a programme for tackling smoking during pregnancy will be established, including consideration of those agencies and organisations required to conceptualise, plan and deliver the programme. Indicators of how the programme can be assessed for outcomes and efficacy will be discussed.

Introduction

Smoking is the single greatest cause of preventable illness and premature mortality in the UK, as well as being the most important preventable cause of a range of adverse outcomes of pregnancy. (1-3) Indeed, smoking during pregnancy is one of the main causes of premature births and miscarriages. It has been shown that women who smoke during pregnancy have 1.5 to 3.5 times more chance of miscarriage when compared to non-smoking women. (4)

The implications of smoking during pregnancy go beyond affecting the mother and her baby, creating additional burden on an already overstretched national health service (NHS). It has been estimated that the increased cost to the NHS of smoking during pregnancy is £1,500 per smoker. (5) Reducing the prevalence of smoking in the general population as well as among higher risk groups, such as pregnant smokers, has become a government priority, as is emphasised in the National Tobacco Control Plan and the Public Health Outcomes Framework. (6)

Given the extent of the problem, as well as current government efforts to address the problem, there is a requirement for evidence-based smoking cessation initiatives specifically targeted at pregnant women. (7) Research conducted by the British Market Research Bureau (BMRB) in 2005 demonstrated that 32% of mothers in England smoked during the 12-months before pregnancy and continued to smoke during pregnancy. (8) Although nearly half (49%) quit smoking before giving birth, three out of ten (30%) started smoking again less than a year after giving birth. It has been proposed that this is because women are usually motivated to stop smoking for the sake of the baby rather than for personal, long-term health reasons. Therefore, not only is there concern for the one in six (17%) women continuing to smoke during pregnancy, but there is also a need to promote long-term abstinence within public health initiatives. Of note, rates of quitting are generally lower among heavy smokers who are unmarried, on a low income, and poorly educated. (9) Therefore, pregnant smokers who meet this demographic profile are a key target group.

Smoking Cessation Interventions

There are already a number of interventions being used to tackle smoking during pregnancy, the majority of which are delivered individually. (10) They include psychological and behavioural interventions, as well as pharmacological treatments. Psychological and behavioural strategies comprise cognitive behaviour therapy (CBT), motivational interviewing (MI), offering incentives, and giving feedback to mothers on foetal health status. Pharmacological strategies comprise nicotine replacement therapy (NRT) and other medication. There remains, however, a need to establish those interventions that are most acceptable, feasible, and cost-effective. There is also a need to identify the intensity level required of such interventions in terms of achieving long-term smoking cessation outcomes, since this has a direct impact on costs of service delivery. It has been established, via a Cochrane systematic review of 30 trials (n=7,000 participants) of individual behavioural counselling for smoking cessation, that there appears to be no significant difference between intensive counselling compared to brief counselling (5 trials, Relative Risk [RR] 0.96, 95% Confidence Interval [CI] 0.74 to 1.25). (11) Significant benefits were found for individual counselling, but not in terms of counselling intensity.

The findings from this Cochrane review contradict the recommendations by the NHS Centre for reviews and dissemination that intensive advice should be offered to pregnant women to support smoking cessation. They specify that a combination of prenatal counselling, 10-minute face-to-face contact, and the provision of tailored written material, can double quit rates to about 15%. (12)

Taking into consideration the evidence and recommendations pertaining to intensive versus brief counselling for smoking cessation, a plausible compromise is the utilisation of MI in smoking cessation initiatives. MI is more intensive than brief counselling and requires specialist communication skills training; however, it is brief in comparison to the more intensive counselling approaches, and is thus likely to offer greater cost-effectiveness.

Motivational Interviewing

Motivational interviewing is a patient-centred style of communication designed to help people resolve any ambivalence they might have about changing an unhealthy behaviour. It attempts to guide people towards personally choosing to change their unhealthy behaviour, rather than imposing expectations of change upon them, something which is frequently experienced by pregnant women who smoke. (13) This technique is based on the premise that if a person chooses to stop smoking themselves, they are more likely to be successful in their attempts to quit smoking.

The MI technique is based on the transtheoretical model of behaviour change, which posits that to achieve permanent change people go through a process of five distinct stages: pre-contemplation (i.e. not yet acknowledging an unhealthy behaviour that needs to be changed); contemplation (i.e. acknowledging the unhealthy behaviour, but not yet sure whether one is ready or wants to change); preparation (i.e. getting ready to change, perhaps setting a quit date); action (changing the unhealthy behaviour); and, maintenance (i.e. remaining abstinent). (14) Thus, interventions are individually tailored to stage of readiness or levels of motivation to change.

The most frequently adopted MI approach has been one in which smokers are provided with feedback, in a non-confrontational manner, intended to develop a discrepancy between their smoking behaviour and their personal goals. (15) Such a discrepancy is likely to lead to the uptake of any support that is offered to the pregnant woman as she commences attempts to quit smoking.

Evidence for the efficacy of MI in helping pregnant women to stop smoking is growing. Recently, Karatay, Kublay and Emiroglu (2010) found that 39.5% of pregnant women (n=38) taking part in a MI, stage-based smoking cessation intervention, were able to give up smoking, whilst 44.7% were able to reduce their rate of smoking by 60%. (16) Rates of passive smoking pre-intervention, which were 86.8%, decreased to 55.3% post-intervention. Interestingly, mean self-efficacy (confidence to quit) increased substantially from 61.36 pre-intervention to 93.34 post-intervention. Not only had MI facilitated smoking cessation in some of the women, but it also reduced passive smoking and increased confidence in one’s ability to stop smoking and remain abstinent. It could be argued that continued abstinence is a more useful measure of intervention efficacy than smoking cessation per se, since the former offers data on long-term efficacy.

In a trial conducted in Scotland, during maternity booking, all smokers were referred to an opt-out smoking cessation intervention delivered by midwives trained in MI. (17) This involved utilising MI skills over the telephone in order to engage pregnant smokers. Women contemplating quitting were provided with a face-to-face follow-up clinic meeting. Women who had set a date to quit smoking were offered withdrawal oriented therapy with adjuvant NRT. Of 1,936 pregnant smokers referred to the service, face-to-face meetings with midwives were arranged with 20%, 19% set a quit date, and 6% had remained abstinent 4-weeks after their quit date. A total of 117 out of 370 women (32%) who had set a quit date remained abstinent at 4-weeks follow-up. It is important to note, however, that outcomes were not due to MI alone and that augmentation with NRT might be necessary alongside MI. Furthermore, a problem confronted in the delivery of this intervention was that midwives found it difficult to approach pregnant women about smoking, which raises concerns with feasibility.

Additional research has highlighted that the efficacy of MI is dependent on baseline smoking levels. For example, Stotts et al. (2009) found that the effectiveness of MI alongside real-time ultrasound feedback focused on the potential effects of smoking was effective for nearly 34% of light smokers (<10 cigarettes/day), and yet heavy smokers (>10 cigarettes/day) were unaffected by the intervention (n=360). (18) Since pregnant women who are heavy smokers have been identified as reporting lower quit rates (19), further research comprising larger cohorts are required to establish the overall effectiveness of MI with this target group.

There is a paucity of research examining the cost-effectiveness of MI and smoking cessation interventions in general, but those studies that do report such data are, in the main, favourable. Indeed, in a systematic review examining the economic outcomes of smoking cessation interventions for pregnant women (n=51), no incremental cost-effectiveness studies or cost-utility studies were identified. (20) However, a narrative synthesis of the eight studies that met the inclusion criteria found favourable benefit-cost ratios of up to 3:1; for every 61p invested, £1.84 is saved in health-related costs. The researchers suggest that the return on investment will far outweigh the costs for smoking cessation initiatives for this population.

Another study that supplies data on cost-effectiveness is a randomised control trial (RCT) where women (n=302) were assigned to receive MI or usual care. (21) The MI intervention comprised education about the impact of smoking, help with evaluating their smoking behaviour, and the teaching of skills designed to increase self-efficacy for smoking cessation and abstinence. The women were also provided with information on how to reduce passive smoking. At 6-months postpartum, the cost-effectiveness of MI for relapse prevention compared to usual care was estimated to be £523 per life-year (LY) saved and £386 per quality-adjusted life-year (QALY) saved. For smoking cessation, MI cost more without providing additional benefits to usual care. The authors report that the incremental cost-effectiveness of MI versus usual care would have been £71.98/LY saved and £53.05/QALY saved if 8% of smokers had quit. Therefore, MI has the potential to be cost-effective if uptake can be increased.

MI versus Other Smoking Cessation Interventions

When evaluating the utility of MI for tackling the public health problem of smoking during pregnancy, a key consideration is how the technique compares to other interventions. In a study comparing brief advice (3-minute personal talk with a clinician regarding the dangers of smoking) with MI (three successive 20-minute interviews), 3.5% of smokers in the brief advice group were abstinent at 6- and 12-months follow-up compared to 18.4% at both time points in the MI group. (22) The MI intervention was 5.2 times more successful than brief advice.

In contrast, Ahluwalia (2006) compared MI to a health education approach, with the findings favouring the health education approach (RR 0.51; 95% CI 0.34 to 0.76). (23) However, the participants recruited for this study were already actively making quit attempts and using nicotine gum, thus MI might have been inappropriate for this population. MI was designed for motivating quit attempts, thus little is known regarding its effectiveness in facilitating smoking cessation with already motivated individuals.

In a Cochrane systematic review of seventy-two trials comprising over 25,000 pregnant women, the use of incentives was offered the most effective intervention, helping approximately 24% of pregnant women to quit smoking. (24) This was in comparison to CBT, MI, giving feedback to mothers on foetal health status, and NRT or other medications. It could, however, be argued that MI comprises an incentives component since motivation is based on a perceived beneficial outcome (i.e. an incentive that evokes motivation to quit). Thus, the results of this review might not accurately reflect the efficacy of MI.

In another incentive-based study, women were placed in either an ‘abstinence-contingent condition,’ where they earned vouchers that could be exchanged for retail goods by abstaining from smoking, or to a control condition where they received comparable vouchers independent of smoking status. (25) Rates of smoking cessation throughout antepartum was significantly greater in the incentive group compared to the control group (45.2±4.6 vs. 15.5±2.4, p<.001).

There is also the possibility that taking a stage-based approach to smoking cessation, which is a component of MI, is sufficient without the use of MI skills. In other words, merely identifying stage of readiness via utilisation of the transtheoretical model would enable the delivery of stage-matched interventions. Aveyard et al. (2006) explored this via a three-armed RCT comparing a stage-matched intervention versus a stage-mismatched intervention with pregnant women smoking at 12-weeks gestation. One arm comprised standard midwifery advice and a self-help lea¬‚et on smoking cessation. Two arms were stage-based, with women either being matched or mismatched. (26) Women in the stage-based arms were signi¬cantly more likely to move forward in stage than were women in the control arm; the greater relative bene¬t of the stage-based intervention was seen for women in the preparation stage at baseline, highlighting this a potential time to target women. No significant difference was found, however, between the matched and mismatched groups, suggesting that whilst the theoretical framework of the transtheoretical model is effective in facilitating smoking cessation, stage-matching isn’t necessarily behind its efficacy. It is plausible that MI techniques better account for the efficacy of the transtheoretical model framework, although this is speculation that requires testing via further research.

In the USA, the ‘5 A’s framework’ is advocated for smoking cessation initiatives in pregnant women who want to quit. (27) This is an evidence-based intervention comprising 5-15 minutes of brief counselling delivered by trained clinicians. The ‘5 R’s framework,’ on the other hand, is advocated for women who are not interested in quitting. (28) The utility of these frameworks is their distinction between women who are motivated to quit versus those who are not, which enables clinicians to tailor smoking cessation advice. The 5 R’s takes the same approach as MI in assisting women to negotiate any ambivalence they might have about quitting. The 5 A’s utilises some of the communication skills implicit within MI, such as empathy and the promotion of self-determination.

As demonstrated throughout this critique, the 5 A’s and 5 R’s frameworks are not alone in utilising MI principles. Since so many smoking cessation interventions clearly draw on the principles of this technique, it would seem apt to train healthcare professionals who work with pregnant women in such skills. The evidence suggests that brief counselling is just as effective as intensive counselling, but that some healthcare professionals find it difficult to approach pregnant women about their smoking status. MI provides a stage-based brief intervention requiring specialist communication skills that take it beyond brief counselling but requires fewer resources than intensive interventions. There is a paucity of evidence on its cost-effectiveness, but the evidence that is available shows favourable results.

The Delivery of Smoking Cessation Interventions for Pregnant Women

The need for routine antenatal smoking cessation programmes is unquestionable. (29) MI techniques provide healthcare professionals with the communication skills to target this high risk population. Indeed, as demonstrated in the critiqued literature, MI offers comparable, sometimes better, results than brief counselling, feedback, and NRT for smoking cessation during and after pregnancy.

In order to deliver a training programme for health professionals involved in the care of pregnant women, organisational change is necessary in order for new ways of working to be integrated into everyday practice. This will requires the support of organisation Managers as well as commissioners who might fund pilot studies to test the effectiveness of training staff in MI skills. In addition, input from the NHS, especially NHS Stop Smoking services, is likely to enhance the long-term effectiveness of such initiatives by acting as a resource for professionals to refer pregnant women for follow-up support.

The first step in the delivery of such an initiative would be designing and conducting the initial training, which would be designed to develop communication skills in MI during consultations. Importantly, however, according to a systematic review conducted by Soderlund et al. (2010), follow-up training or ‘refresher’ sessions might be necessary at appropriate intervals and this will need to be considered in terms of resource allocation and cost-effectiveness. (30)

Velasquez et al. (2000) describe the process of training healthcare providers to use MI with pregnant women, demonstrating that public health nurses and social workers are generally enthusiastic about attending training workshops and rate them as effective in preparing them to utilise MI skills in practice. (31) However, the study also highlighted that additional time and resources are required for ongoing skills building and monitoring of intervention delivery, which again raises issues over cost-effectiveness. However, as pointed out by Ruger and Emmons (2008), the projected return on investment of MI is likely to far outweigh the costs for smoking cessation initiatives for this population. (33)

In measuring the effectiveness of this programme of training, a number of outcomes require assessing. The impact of the training on skills development and confidence in utilising these skills could be assessed via interviews or questionnaires with professionals who attend the training. Ideally, this needs to be done pre-training and post-training, as well as 6-12 months later in order to assess the long-term sustainability of changes in service provision for pregnant smokers.

Patient records would also require examination in order to track the rates of smoking in pregnant women, as well as the number of quit attempts (both successful and unsuccessful). Abstinence can be measured via self-reports and tests for carbon monoxide. Furthermore, the monitoring of adverse events related to smoking could provide useful information on the clinical benefits of the programme.

Importantly, patient-reported outcome data can be collected via anonymous questionnaires eliciting information on service user satisfaction with the skills of healthcare workers, the content of consultations, and the usefulness of the support provided for issues such as smoking cessation. This would support government efforts to integrate patient-reported outcomes into assessments of service quality. (33)

Conclusion

This essay has described the public health issue of smoking during pregnancy in England, comparing different smoking cessation interventions with the techniques implicit within motivational interviewing. The evidence presented provides the rationale for a programme of MI training for health professionals who work with pregnant women in efforts to address this problem. MI has been shown to offer comparable, sometimes better, outcomes than other forms of intervention. Furthermore, despite the need for further research on cost-effectiveness, research thus far is favourable in terms of the cost-utility of utilising MI in tackling the public health issue of smoking during pregnancy.

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