The Development and Implementation of Standards in Prenatal, Postpartum and Early Childhood Public Health Nurse Practice in Manitoba (January 2020)
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Learn about how Manitoba Health, Seniors, and Active Living developed and implemented standards for prenatal, postpartum, and early childhood public health nurses to address this gap.
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The Development and Implementation of Standards in Prenatal, Postpartum and Early Childhood Public Health Nurse Practice in Manitoba (January 2020)
- 1. Follow us @nccmt Suivez-nous @ccnmo Funded by the Public Health Agency of Canada | Affiliated with McMaster University Production of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada.. Peer-to-Peer Webinar: Success Stories in EIDM Featuring: The development and implementation of standards in prenatal, postpartum and early childhood public health nurse practice in Manitoba Dr. Cheryl Cusack, Breanna Harms, April Gage, Jodi Unger January 23, 2020 1:00-2:00 PM EST
- 2. Follow us @nccmt Suivez-nous @ccnmo 2 Housekeeping Use Chat to post comments and/or questions during the webinar • ‘Send’ questions to All (not privately to ‘Host’) Connection issues • Recommend using a wired Internet connection (vs. wireless), • WebEx 24/7 help line • 1-866-229-3239 Participant Side Panel in WebEx Chat
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- 7. Follow us @nccmt Suivez-nous @ccnmo 7
- 8. NCC Infectious Diseases Winnipeg, MB NCC Methods and Tools Hamilton, ON NCC Healthy Public Policy Montreal, QC NCC Determinants of Health Antigonish, NS NCC Aboriginal Health Prince George, BC NCC Environmental Health Vancouver, BC 8
- 9. Registry of Methods and Tools Online Learning Opportunities WorkshopsVideo Series Public Health+ Networking and Outreach NCCMT Products and Services 9
- 10. Follow us @nccmt Suivez-nous @ccnmo The EIDM Casebook • Collection of success stories in public health • Available at http://www.nccmt.ca/impa ct/eidm-casebook 10
- 11. Follow us @nccmt Suivez-nous @ccnmo 11 Presenters Dr. Cheryl Cusack, RN, PhD Jodi Unger, RN, BN, IBCLC Breanna Harms, RN, BN April Gage, RN, MN
- 12. Prenatal, Postpartum and Early Childhood PHN Practice in Manitoba NCCMT Webinar January 23, 2020
- 13. Polling Question • What area most closely aligns with your work? A. Nursing B. Health Promotion C. Primary Care D. Management E. Research F. Other
- 14. Webinar Goals Discuss Manitoba PHN standards • Background/Rationale • Objectives • Initiative • Implementation • Evaluation/Impact • Lessons Learned
- 15. Background and Rationale • Lack of perinatal competency-based standards • Need for role clarity/ full scope of practice • Manitoba Public Health Nursing Standards launched in 2015 • CHNC national standards, competencies, and roles and activities documents foundational
- 16. Provincial Objectives • Short-Term: Articulate consistent and measurable activities for PHN roles • Long –Term: Development of tools and resources for all PHNs to support the standards “Standards represent “a vision for excellence” and articulate measurable PHN benchmarks.” (CHNC 2019)
- 17. Initiative PHN Standards National Collaborating Centre for Methods and Tools. (revised 2012).
- 18. Initiative • Understanding key concepts: • Population health • Primary health care • Primary care • Medical or health care • Universal and targeted programs and services
- 19. Public Health Expertise Standards Development: 0-5 Macro • Government – Funding and leadership • Front-line PHN leadership • Coordination across regions Meso • Local Org Culture • Shared vision/ • Communication: workshops, literature, newsletters, Micro • Mgmt Practices – Planning informed by evidence, literature; supported PHN leadership/scope/learning; ongoing communication Meagher-Stewart, D., Underwood, J., MacDonald, M., ., Schoenfeld, B., Blythe, J., Knibbs, K., . . . Crea, M. (2010).
- 20. EIDM: Community/Political • Population: <1.4 million • Diverse Geography • 5 Regional Health Authorities • Winnipeg – 2/3 population • Growing immigration: >130,000 = Culturally diverse • Highest provincial rate of Indigenous People (Government of Manitoba, n.d.)
- 21. EIDM Community/Political Health System Transformation Manitoba Health, Seniors, & Active Living. (2017).
- 22. EIDM: Community Health Issues/ Local Context (CBC News, 2015)
- 23. EIDM: Community Health Issues/ Local Context • Surveillance data • Community health reports • Peer reviewed literature 23 Brownell M, Chartier M, Au W, MacWilliam L, Schultz J, Guenette W, Valdivia J. (2015)
- 24. EIDM: Research Healthy Child Development..... Harvard University, 2018
- 25. EIDM: Research Healthy Child Development..... • What is the Evidence - Negative impact of child poverty - Equity from the Start - Failing to Act Jutte, D. P., Brownell, M., Roos, N. P., Schippers, C., Boyce, W. T., & Syme, S. L. (2010).
- 26. EIDM: Public Health Resources National (Government of Canada, 2018)
- 27. EIDM: Public Health Resources National PHN Role PHN Practice: Population-Based Standards of Practice/ Professional Practice Model Discipline Specific Competencies Leadership Competencies PHN Roles & Activities
- 28. EIDM: Public Health Resources National PHN Role • Knowledge from public health science, primary health care, nursing, and the social sciences; • Focus on promoting, protecting, and preserving the health of populations; • Links the health and illness experiences to population health promotion practice; • Recognizes that a community’s health is linked to its members and is reflected first in individual and family health experiences; • Recognizes that healthy communities and systems contribute to opportunities for health for individuals, families, groups, and populations; and • Practices in increasingly diverse settings
- 29. Implementation Provincial PHN Standards: Components: 1. Core Document: minimum provincial standards and practice expectations for PHNs 2. Supplemental Document I: PHN Practice Examples 3. Supplemental Document II: Toolkit – Documentation tools, CPGs, web resources (MHSAL, 2015)
- 30. Implementation Provincial PHN Standards: Manitoba Webinars • Provincial Webinar series for MB’s PHN’s • Background & Context • Prenatal • Postpartum/Newborn • Documentation
- 31. Evaluation and Impact Survey Round 1 Revised Consensus Statements Final Round to Gain Consensus Delphi Methodology
- 32. Evaluation & Impact Evaluation of Readiness
- 33. Evaluation & Impact PHN Readiness A. Polling Question – Individual / Team B. Considering the Adkar model, where are you as an individual? C. Awareness =recognition of provincial standards and tools D. Desire = motivation to base your practice on the standards E. Knowledge =understanding of how apply the standards into your PHN practice F. Ability = able to implement the standards in practice G. Reinforcement = organizational structures and culture exists to sustain use of the standards in practice
- 34. Polling Question What has the greatest population impact? A. Long-lasting protective interventions (immunization) B. Changing the context to make individuals default decisions healthy C. Counselling and Education D. Socioeconomic Factors E. Clinical Interventions
- 35. Population Impact (Frieden, 2010)
- 36. EIDM Public Health Resources: Manitoba PHN Role in 0-5? Population-based- Upstream/ Primary Health Care Universal screening Targeted / Equity Individual/ Primary/Medical Care Inter-professional Public Health Nursing Service Delivery Health care: Prenatal, Postpartum, Early Childhood
- 37. Lessons Learned Let’s Talk…Moving Upstream What are roles for PHNs? (NCCDH, 2014)
- 38. Lessons Learned • Collaboration is essential in developing a shared vision • Complexity of PHN practice - Evidence-informed • Highest impact – Upstream/Population focus • Importance of articulating PHN value for and roles in Equity, Social Justice, Advocacy, Community Leadership • PHN practice situated within whole system approaches based on principles of Primary Health Care • Standards are a necessary starting point • It takes Time…
- 39. References Brownell M, Chartier M, Au W, MacWilliam L, Schultz J, Guenette W, Valdivia J. (2015) The Educational Outcomes of Children in Care in Manitoba Winnipeg, MB. Manitoba Centre for Health Policy Canadian Public Health Association. (2010). Public Health ~ Community Health Nursing Practice in Canada. Roles and Activities (4th ed.). Ottawa, ON: Canadian Public Health Association CBC News (2015). Manitoba gets poor grade in Canadian health report. Retrieved from https://www.cbc.ca/news/canada/manitoba/manitoba-gets-poor-grade-in-canadian-health-report-1.2954500) Community Health Nurses of Canada. (2019). Canadian Community Health Nursing Professional Practice Model & Standards of Practice. Ottawa, ON: Community Health Nurses of Canada Community Health Nurses of Canada. (2009). Public Health Nursing Discipline Specific Competencies. Ottawa, ON: Community Health Nurses of Canada. Freiden, T. R. (2010). A framework for public health action: The health impact pyramid. Am J Public Health, 100(4), 590-595. Government of Canada. (2018). Vision and areas of focus Retrieved from https://www.canada.ca/contet/dam/phac- aspc/images/corporate/canadas-chief-public-health-officer/CPHO-Priorities-Placemat-Tags-EN.pdf Government of Manitoba (n.d) About Manitoba. Retrieved from http://www.gov.mb.ca
- 40. References Jutte, D. P., Brownell, M., Roos, N. P., Schippers, C., Boyce, W. T., & Syme, S. L. (2010). Rethinking what is important: Biologic versus social predictors of childhood health and educational outcomes. Epidemiology, 21(3), 314- 323. doi: 10.1097/EDE.0b013e3181d61e61 Harvard University (2018) A framework for reconceptualizing early childhood policies and programs to strengthen lifelong health. Retrieved from https://developingchild.harvard.edu/science/deep-dives/lifelong-health/ Manitoba Health, Seniors, & Active Living. (2017). Acheiving a high performing provincial healthcare system. Retrieved from https://www.gov.mb.ca/asset_library/en/rightcare/pho.pdf Manitoba Health, Healthy Living and Seniors, & Manitoba's Regional Health Authorities. (2015). Provincial public health nursing standards: Prenatal, postpartum, and early childhood. Winnipeg: Manitoba: Manitoba Health, Healthy Living and Seniors. Meagher-Stewart, D., Underwood, J., MacDonald, M., ., Schoenfeld, B., Blythe, J., Knibbs, K., . . . Crea, M. (2010). Organizational attributes that assure optimal utilization of public health nurses. Public Health Nursing, 27(5), 433- 441. doi: 10.1111/j.1525-1446.2010.00876.x National Collaborating Centre for Methods and Tools. (revised 2012). Evidence-Informed Public Health: A Model For Evidence-Informed Decision-Making in Public Health [fact sheet]. Retrieved from https://www.nccmt.ca/uploads/media/media/0001/01/d9f5cec8637db62f8edda6a6a2551b293a053e de.pdf. ‘National Collaborating Centre for Determinants of Health. (2014). Let's talk… Moving upstream. Let's Talk Series. Retrieved from http://nccdh.ca/resources/entry/lets-talk-moving-upstream Prosci. (n.d.). What is the ADKAR Model? Retrieved from https://www.prosci.com/adkar/adkar-model
- 41. Questions 41
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- 43. Follow us @nccmt Suivez-nous @ccnmo Webinar Feedback Your responses will be completely anonymous to other Webinar participants. Please indicate your level of agreement with the following: 1. Participating in this webinar increased my knowledge and understanding of the application of EIDM. 2. I will use the tool/method from today’s webinar in my own practice. 3. Which of the following statements apply to your experience with the webinar today (select all that apply): The webinar was relevant to me and my public health practice. The webinar was effectively facilitated The webinar had opportunities to participate The webinar was easy to follow along The webinar met my expectations 4. Can we contact you in the future to discuss how NCCMT can improve its webinar series? Yes No 5. If yes, Please provide your name and email address: Name: ____________________________________________ E-mail: ____________________________________________ 43 Strongly agree Agree Undecided Disagree Strongly Disagree Strongly agree Agree Undecided Disagree Strongly Disagree
- 44. Follow us @nccmt Suivez-nous @ccnmo Webinar Series from NCCMT http://www.nccmt.ca/capacity-development/webinars • Spotlight on Methods and Tools • Topic-Specific Methods and Tools • Online Journal Club • Peer-to-peer Webinars 44
- 45. Follow us @nccmt Suivez-nous @ccnmo Funded by the Public Health Agency of Canada | Affiliated with McMaster University Production of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada.. For more information about the National Collaborating Centre for Methods and Tools: NCCMT website www.nccmt.ca Contact: nccmt@mcmaster.ca
Editor's Notes
- the NCCPH program is dispersed across the country with 6 National Collaborating Centres the National Collaborating Centre for Methods and Tools is located at McMaster University, in Hamilton 4 of the other NCC’s support the use of research evidence in specific public health content areas NCCMT and NCC Healthy Public Policy work across content areas the focus of NCCMT improving access to, and use of, methods and tools that support moving research evidence into decisions related to public health practice, programs, and policy in Canada.
- NCCMT offers a products and services to help apply research evidence in decision making This presentation today is going to provide an overview of the Online Learning Opportunities that NCCMT offers.
- Welcome to today’s webinar. Thank-you for joining us. As we get started, we would like to recognize many of the individual PHNs who worked on various components of this initiative, leaders who always continued to support and advance this. In particular, we would like to acknowledge the leadership of Jan Schmalenberg, Michelle Johnson and Cheryl Cusack.
- This presentation is focused on PH nursing standards, so we are interested in understanding the roles of individuals joining the webinar. Which of the following areas most closely align with your work?
- This presentation will describe the process undertaken in Manitoba to increase consistency in PHN prenatal, postpartum, and early childhood practice. The process was initiated in 2013 as an idea of the provincial managers network. A lot of work has taken place since that time, but implementation remains ongoing. Today we will describe what has taken place, the outcomes and tools developed, the engagement required at multiple levels, and methods used for evaluation at multiple points.
- The background and justification to begin this work, was the variation in PHN practice. At that time in 2013, competency-based standards specific to the Public health nurses in the perinatal health period did not exist in Canada. Simultaneously, in the literature, national experts identified role clarity and the development of a common vision based on the full scope of Public health nurse practice a priority. In response to this issue and in consideration of the local context, Manitoba developed provincial PHN standards. These standards, launched in 2015, built upon national documents by the Community Health Nurses of Canada (CHNC), and the Canadian Public Health Association. For these reasons, while the Manitoba standards reflect the provincial context, they may be of broad interest to others in Canada.
- According to the Community Health Nurses of Canada, standards represent “a vision for excellence” and articulate measurable PHN benchmarks. The short-term objective of this initiative therefore was to develop consistent and measurable activities for PHN roles in prenatal, postpartum and early childhood practice. The long-term outcome was development of tools and resources to support implementation and attainment of the standards by all PHNs in the province. A provincial paraprofessional home-visiting program was a component of Manitoba public health practice, so it was reasonable to aim for greater consistency in the other components of perinatal PHN work.
- The development of the provincial standards was the beginning of this initiative and work in Manitoba. Perinatal standards were critical to depict the role of the PHN in promoting health equity in a population based early childhood practice. The model for evidence informed decision –making in public health was used as a framework. The national collaborating centre states: “Evidence-Informed Public Health (EIPH) depends on sound evidence, which involves integrating the best available research evidence into the decision-making process. Additional factors – community health issues and local context; community and political preferences and actions; and public health resources – create the environment in which that research evidence is interpreted and applied. This model was crucial in guiding numerous workshops, webinars, and the process over the years to come. It helped us to frame and consider different types of evidence, and challenged us to remember that public health evidence is more than randomized control trials. While those are important, a key finding was the importance of the local context, experiential knowledge, and application of the research based on community and political preferences.
- At the outset, it was identified that an important first step would be developing a common vision. A key component of developing that shared vision was consistent understanding of concepts. There had been an erosion of the PHN role in practice; and it became clear that complex concepts such as population health, primary health care and primary care were not understood in the same way. To work to full scope in a population-based practice, PHNs had to understand the distinctions between these concepts and be deliberate in in their daily clinical decisions. In Manitoba, based on the Families First Home visiting program, a universal screening tool has been tested and proven to identify individuals who would benefit from focused public health interventions and follow-up to promote population health and equity. Conversely, individuals who are knowledgeable and capable of accessing primary care and/or medical care independently could be referred by PHNs for their health care services.
- Public health expertise was gathered using a variety of sources of evidence. In the following section, we will outline an example of how the model and information was used to develop the standards and greater knowledge of the PHN role. Canadian researchers describe optimal attributes to support PHN practice under headings of macro, meso, and micro. The macro level refers to government. The Manitoba Public Health Branch provided leadership and funding to support the project. A front line PHN, Michelle Johnson, was hired to lead the project and provide provincial coordination . The meso level refers to the local organizational culture, including values and leadership characteristics. Multiple stakeholders were included on an ongoing basis. There were multiple workshops, advisory groups and teleconferences. Different forms of communication were utilized, that included newsletters, e-mails, and feedback to develop a shared vision. Lastly, the micro level pertains to the day to day mgmt practices. PHNs from across the province informed the development of the standards. Work time was allocated for participation, PHNs were supported to attend workshops and participate in teleconferences, and the project team travelled across the province. The focus was competency rather than task based and promoting autonomous full scope of PHN practice
- The evidence informed decision making (EIDM) model was used at multiple points over the years. The next few slides provide examples of how the model was used. The EIDM model identifies the 4 areas that contribute to public health expertise. The first we considered was Community/ Political section. Manitoba has unique geography, and population demographics. The population of Manitoba has been growing annually and is now just under 1.4 million. A few fun facts….Manitoba has a diverse geography, which extends from the 49th to the 60th parallel, that is an area of close to 650,000 square km or the distance from Paris France, to Oslo Norway. Manitoba is larger than the country of Japan and twice the size of the United Kingdom. So when we think of PHN practice across the province, that’s a huge area to cover! While the geography is vast, Winnipeg is the largest city, accounting for close to 2/3 of the population of Manitoba. Culturally, Manitoba is also extremely diverse. Immigration is one strategy for population growth, which has brought more than 130,000 newcomers from around the world to Manitoba in the past decade. Lastly, of all the provinces, Manitoba has the highest proportion of Aboriginal people per capita in Canada, which is a young and growing demographic (Healthy Child Manitoba, 2013a).
- In terms of the political considerations, similar to other Canadian jurisdictions, Manitoba is in the midst of health system transformation. Recent reports identified that for a province the size of Manitoba, our health system is overly complex, expensive, and not achieving expected outcomes. Regional health authorities (RHAs) will focus on being excellent service deliverers, aligned with a provincial clinical and preventative services plan, and divest functions most effectively and efficiently served in a provincial shared health organization. If we think back to the geography slide, with 2/3 of the population living in Winnipeg, the outcome has been that the majority of services health services are situated in Winnipeg. Manitoba Health, Seniors and Active Living: will focus on Policy and Planning, Funding and Oversight of the provincial health system
- The next component of the EIDM model used was community health issues and the local context. Manitoba has been in the headlines reporting some of the worst child health outcomes in the country including high rates of Infant Mortality and children in CFS care in comparison to the rest of the provinces in Canada. Media headlines have included: : Almost half of newborns seized in MB had developmental and addiction issues 'It's torturous': Young mother joins calls from MMIWG (Missing and Murdered Indigenous Women and Girls) advocates to stop apprehensions at birth. Manitoba should focus more on prevention to reduce kids in care: report
- The local context can be further understood using surveillance data, community health reports and peer reviewed literature. When considering maternal and child health in Manitoba, there is an abundance of data identifying gaps based on socio-economic status. For example: While national rates of smoking during pregnancy are decreasing, rates in Manitoba are increasing and well above national averages (Public Health Agency of Canada, 2013). Manitoba has disproportionate rates of teen mothers. One-third of teens reported drinking alcohol; one in five used illegal drugs; and close to 50% smoked cigarettes (Healthy Child Manitoba Office, 2013) Manitoba negative birth outcomes such as low and high birth weights, are more prevalent among teen mothers (Healthy Child Manitoba Office, 2013). Some of the highest rates of neonatal, infant, and childhood deaths across Canada, are reported in Manitoba’s lowest income quintiles (Brownell, Chartier, Santos, Ekuma, Au, Sarkar et al., 2012; Heaman et al., 2012). Manitoba also has some of the highest rates of children in care in the world. Indigenous children represent 26% of the population but more than 90% of kids in care.
- Contrary to the previous slides, we know that there is substantial research that the early childhood period is critical is setting the trajectory for lifelong wellness. The Centre on the Developing Child at Harvard University has an excellent website on healthy child development and the impact of adverse childhood experiences, or ACE indicators of toxic stress. There is irrefutable evidence that positive early experiences are necessary to for sturdy brain architecture and the development of skills and learning capacities. As shown in this framework, healthy child development is a causal chain—on the left hand side, policies and programs can enhance the capacities of caregivers and communities. The skill and knowledge of the caregiver and community in turn, enable the foundations for health, which trigger physiological adaptations or disruptions that influence lifelong outcomes in health, learning, and behavior. This life course trajectory is depicted in the circle on the right Many of these components are applicable to PHN practice. In particular, the foundations of health in the middle consist of A stable and responsive environment of relationships. - providing young children with consistent, nurturing, and protective interactions with adults, which helps them develop adaptive capacities that promote learning and well-regulated stress response systems. Safe and supportive physical, chemical, and built environments. -providing children with places that are free from toxins and fear, allow active and safe exploration, and offer their families opportunities to exercise and form social connections. Sound and appropriate nutrition. This includes health-promoting food intake and eating habits, beginning with the future mother’s preconception nutritional status.
- Child poverty is a powerful determinant that perpetuates intergenerational inequities. One of the most important protective factors is development of a nurturing environment and healthy attachment to a caregiver. Some more Manitoba data – above is another Manitoba Centre for health policy study that looked at data from all children born in Winnipeg, from 1984, to 2003 On the bottom of the graph at the right, you can see the social risk factors which they compared to clinical risk factors for example prematurity. The study concluded that “Social risk factors for subsequent hospitalization and scholastic failure are as threatening as, and more common than, routinely documented biologic risks… Brownell M, Chartier M, Au W, MacWilliam L, Schultz J, Guenette W, Valdivia J. (2015) The Educational Outcomes of Children in Care in Manitoba Winnipeg, MB. Manitoba Centre for Health Policy
- Public health resources are the final component contributing to PH expertise. In Canada, we have national bodies that shape the provincial resources. This is a recent info graphic from the chief public health officer of Canada outlining her vision and priorities The national public health office champions the reduction of health disparities in Canada by focusing on the needs of the poorest and most marginalized Canadians. The ultimate goal is to help level the playing field and to contribute to all Canadians reaching their optimal health. Areas identified on the right for prevention and promotion consist of problematic substance use in areas of Cannabis, opioids, alcohol,Eliminating Tuberculosis, Healthy children & youth, Sexually transmitted & blood-borne infections, Anti-microbial resistance and healthy built environments On the left, Action on Factors Influencing Health are addressed. This consists of Income, Education, Social environment, Physical environment, Social support networks, Sex & gender, Healthy child development And Culture They state that addressing health inequities can only happen by addressing their social determinants. In fact, social determinants of health, such as income, have a bigger impact on our health outcomes than genetics, the healthcare system, or most health care services.”
- PHNs represent the largest group of public health practitioners and action on the social determinants of health is foundational. Full scope is based on a population level practice, achieved by working in collaboration with other professionals and agencies, and incorporating a social justice approach. . In fact the PHN role is thought to be ideally positioned for this practice. This practice has been outlined in a number of documents developed by the community health nurses of Canada, which have built upon core competencies developed by the Public health agency of Canada in 2007. These include standards of practice and professional practice model, as well as competency documents, and a roles and activities document. Competencies have been developed for leadership in public health practice, as well as competencies which are discipline specific. Competencies are the integrated knowledge, skills, and attributes required of a public health nurse to practice safely and ethically. Attributes include, but are not limited to attitudes, values and beliefs. While we have documents articulating PHN roles, literature depicts a lack of clear vision and advocates for role clarity (Keller et al., 2011; Schofield, Ganann, Brooks, McGugan, Dalla Bona, Betker et al., 2011; Truglio-Londrigan & Lewenson, 2011). Incongruence in practice represents a significant theory-practice gap (Cohen & Reutter, 2007; Lind & Smith, 2008). There are continued PHN reports of a growing disconnect between the desired practice and their daily activities (Beaudet, Richard, Gendron, & Boisvert, 2011). Population level practice is constrained by under-resourced organizational structures that prioritize clinical and curative services.
- In the roles and activities document, The Canadian Public Health Association provides the following definition. It states: A public health nurse has a baccalaureate degree in nursing and is a member in good standing of a professional regulatory body for registered nurses. The public health nurse: • combines knowledge from public health science, primary health care (including the determinants of health), nursing science, and the social sciences; • focuses on promoting, protecting, and preserving the health of populations; • links the health and illness experiences of individuals, families, and communities to population health promotion practice; • recognizes that a community’s health is closely linked to the health of its members and is often reflected first in individual and family health experiences; • recognizes that healthy communities and systems that support health contribute to opportunities for health for individuals, families, groups, and populations; and • practices in increasingly diverse settings, such as community health centres, schools, street clinics, youth centres, and nursing outposts, and with diverse partners, to meet the health needs of specific populations
- The Manitoba PHN standards were published in 2015, however the long-term vision was additional documents and tools to support their implementation. The standards documents, available on the Manitoba Health website, included the 3 components above – the core or standards document, and two supplemental documents.. The core document articulates the minimum standards practice expectations for PHNs…the benchmark Supplement 1 illustrates standard statements and practice expectations at the individual/family level, and the community/ population level in the prenatal, postpartum and early childhood periods. Each practice expectation is linked to a PHN competency statement, as defined by the Community Health Nurses of Canada. Supplement II is the toolkit consisting of multiple documents and webinars to support PHNs in their implementation and attainment of the Province of Manitoba Public Health Nursing Standards: Prenatal, Postpartum and Early Childhood. It includes forms for PHN documentation of prenatal, postpartum, and newborn assessment which are to be used in conjunction with the evidence informed care pathways. Detailed instructions, evidence based information, and access to resources and services is contained in each document. .
- A final implementation component was a series of webinars to disseminate information across the province. PHN champions participated in the development of the 4 webinars, which were held between August and September 2018. The first webinar provided the background and context, recognizing that the project had been ongoing for several years. The second webinar focused on prenatal, the third on postpartum and newborn, and the last on documentation forms and processes. Again, the EIDM model was used as a framework to guide the webinar content and development. The webinars were recorded and are available on the Manitoba Health website, along with the supporting documents. PHNs continue to access them and they are used in the orientation of new staff
- The initiative has been evaluated a number of ways. Before publication of the standards in 2015, survey data were gathered using a modified Delphi technique. The survey consisted of all of the standards statements followed by a five-point Likert scale. Participants were asked to rank their level of agreement with each statement and boxes were also provided for written text. The intent was to have three survey rounds to revise and gain consensus on standards statements with less than 70% agreement, however results after the first round found that 90% of participants agreed or strongly agreed with the majority of the statements. The few statements where levels of agreement were in the 80% range pertained to timing of PHN follow-up. Comments in the text boxes reflected concern with the ability to meet the benchmarks within existing resources, as opposed to the content of the statements. As there were no statements with less than 70% agreement, subsequent rounds of the survey and revisions to the standards statements were not required. On the first round there were about 250 respondents, which we believe is a very high number of PHNs and managers in Manitoba.
- Another method of evaluation took place during the webinars. During each of the four webinars, participants were asked via polling questions to gauge their readiness to implement the standards based on the ADKAR model. We used the Prosci ADKAR Model, of change management to gauge PHN’s readiness for change to the new Stds. The model, provides a detailed description of how an individual successfully moves from their Current State to their Future State. In this case the current state was based on regional and individual differences in PHN practice and conceptualization of the role. The future state that we were aiming for, was a more consistent PHN practice based on the provincial standards and supporting tools and documents. The ADKAR Model describes the five building blocks of successful change from the current to future state, recognizing that it is a continuum and individuals are in different places: The first is Awareness of the change Next Desire to participate and support the change Knowledge is understanding how to change Ability is the implementation which is requires applying the skills and behaviors Finally Reinforcement is needed to sustain the change Consistent with the earlier feedback, participants generally reported that they had the knowledge to implement the standards. Methods to evaluate the impact of standards in practice are under development.
- This is an example of one of those polls, which we adapted based on the webinar being presented. The polling questions are a fun way to engage the audience during a webinar, but also provide information that is useful going forward. In general, participants generally reported that they had awareness and desire, but lacked the knowledge to implement the standards in their perinatal practice. Imparting that knowledge was the purpose of each webinar.
- This is another example of one of the polling questions used in the webinars. Based on our discussion today and considering PHN practice from the population perspective, where can PHN individual interventions have the greatest population effect? What do you think after our brief discussion today?
- Friedman proposed A 5-tier pyramid best describes the impact of different types of public health interventions and provides a framework to improve health. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socio-economic determinants of health. In ascending order are interventions that change the context to make individuals’ default decisions healthy, clinical interventions that require limited contact but confer long-term protection, ongoing direct clinical care, and health education and counseling. (AmJ PublicHealth.2010;100:590–595. doi:10. Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort. Using the common analogy of the stream, these activities would be considered the farthest upstream with those at the top more downstream. On the right hand side of the slide, I have proposed PHN interventions that I think align with the pyramid. I would love to have further discussion, so please go ahead and use the chat box if you have comments. Do you agree with this list?
- Through the webinars however, we continued to challenge participants to consider the Manitoba standards and the wide variety of evidence that was integrated as a result of the evidenced informed decision-making model, in the context of their PHN practice in Manitoba The PHN aim is to promote population health through work with individuals, families, groups, and communities. We want to be working at the base of the pyramid, as far upstream as we can. Based on the principles of primary healthcare. The Canadian Nurses Association (2015), states primary health care is necessary to transform the health system and improve the health of populations. [8] This involves the principles of health promotion and disease prevention, accessibility, public participation, appropriate technology, and intersectoral collaboration. In applying the national depiction of the PHN role to the Manitoba context this includes understanding the community, and using the Families First screen and parent survey process universally, to determine where to target PHN activities based on foundational values of public health practice, in particular equity and social justice. I have proposed a venn diagram, in which there is a small overlap, but for the most part the services of PHNs do not align with the needs of individuals in the prenatal, postpartum, and early childhood populations. In essence, most work at the individual level is providing clinical care or education, and would be categorized as downstream. Care for individuals is primary care which “focuses on preventing, diagnosing, treating and managing health conditions.”[p. 2 in citation #8]. Primary care requires collaboration among health professionals and is an important aspect of health care services.
- Literature has cited an erosion of the PHN role, and lack of understanding. PHNs must therefore be deliberate in determining where there is value added from PHN interventions, and where PHN practice is situated within a “whole system primary care approach” that is collaborative, inter-professional and integrated. The model for evidenced informed decision-making assisted us in framing the public health expertise. It became clear based on the variety of evidence and growing gaps in equity experienced by some populations, that the value added and uniqueness of the PHN role is the upstream population based work. This document developed by the National Collaborating Centre for Determinants of Health identified upstream, midstream and down stream activities. Public Health Nurses engage in all of these activities, and must consider a range of evidence and activities that go beyond care of the individual to promote the health of communities and populations
- In ending, we learned a great deal from the process of developing these standards. The collaboration of all public health stakeholders, and in particular the expertise of the public health nurses was essential in developing the public health expertise and a shared vision for PHN practice PHN practice is complex – but it needs to be evidence informed and consistent provincially. To develop arguments regarding the value of the PHN role, we need to be able to do this. PHNs are the only nurses working at the population focus – we need to keep thinking about this and how to have the greatest population impacts Population level work depends on narrowing the gaps between those who are the most and least healthy. Which means PHN practice must value and always be grounded in concepts of equity, social justice, advocacy, and community leadership
- I’m happy to take any questions, maybe we can unmute the lines or see if we use the chat function.