Child & Youth Health: Case Studies

1 November 2013

Being at the right place and right time is the focus of our child & youth health stories this edition.  We look at nurses working in the playgrounds and classrooms of high needs primary school communities and working alongside young adults with type 1 diabetes on a university campus.


MOKO project: from itchy kutu-infested head to playground advocate

The tale of one little girl sums up for Ivy Tan the difference a school-based nurse can make.

“We had a little girl come to us riddled with kutu (head lice)… her head was down, her hair was all knotted, and she just looked miserable. When we checked her head, she had sores on her head infected from just being attacked by all these kutu.”

“So we started her on antibiotic treatment, and every day, she would come to us and we would do the kutu combing,” says Tan, one of two nurses working for the MOKO project serving Kaitaia schools.

The MOKO team rewarded the little girl for enduring the daily combing sessions with little lucky dip gifts and watched her blossom as they got on top of her kutu and sores.

“Now she’s bubbly and bouncing around. Every time we go to the school, she’s the MOKO advocate. She says, ‘MOKO’s here – whose got an itchy head’ and brings up friends and children from the playground to be checked.”

Tan says this once sad little girl not only has greater health awareness but also helps bridge the gap between the other kids and the service, and the roll-on effect is seeing less kutu infestation in the classroom.

The MOKO project also carries out skin condition checks and treatments along with regular throat swabbing and for Tan the reward is not only better health but the difference it can make to a child’s demeanour and learning.

“Having impetigo, scabies, or kutu – it’s really distracting when they are in the classroom,” says Tan.

“Actually being able to see that progress when children can actually sit and learn without scratching heads or sores [is inspiring].”

The Manawa Ora, Korokoro Ora (MOKO) project comes under the umbrella of award-winning GP Lance O’Sullivan’s Navilluso Medical practice.

The project began a year ago from a base at the old dental clinic at Kaitaia Primary, after earlier winning Ministry of Health funding to deliver rheumatic fever throat swabbing programme to initially ten, and now 14, schools in the Kaitaia area, covering about 2,000 children in all.

Project manager Lisa McNab says it also gained additional ministry funding to assess and treat skin conditions at eight of those 14 schools, but with the support of children’s charity KidsCan, delivers skin services to the full 14 schools.

MOKO has two nurses and five kaiarāhi (health workers) who work in three teams across the 12 primary and two area schools that are all within 30 minutes drive of the project’s base.

Each school has a MOKO nurse visiting at least once a week, and three times a week, they are visited by the kaiarāhi, who go into each classroom to ask whether anybody has a sore throat, itching head, or any sores they are worried about.

Using smartphone technology means the “awesome” kaiarāhi are in constant contact with the nurses and are trained to take temperatures, oxygen saturation, and can take and send a photograph of any hakihaki (skin disease or suspected scabies) they are concerned about. Tan says she also has remote access to MedTech so she can check out any patient notes or relevant history before making a decision on whether the child needs to be seen that day or can wait a day or two.

The nurses also operate under standing orders, overseen by O’Sullivan, so they can generate prescriptions for not only antibotics for confirmed strep throat but also for skin conditions like impetigo or scabies. Thanks to KidsCan – who also provide assistance like shoes and kutu treatment packs for children – the prescriptions are free.

Tan says that is one of the aspects she loves about work: being able to act and follow through if she sees a child with bad hakihaki by not only providing an antibiotic prescription, but if need be, picking up the medication and dropping it directly to a whānau that may struggle with transport. She also says that Dr Lance O’Sullivan is available if a child needs urgent attention.

Each week, they meet with O’Sullivan for case reviews and to discuss issues like whether a whānau may need support cleaning their house to overcome an MSRA outbreak or other healthy housing or family support.

Tan, a former well child health nurse, says the MOKO nurses also have good working relationships with the public health nurses, who also visit schools usually once a week, and refer on issues outside of the MOKO focus.

McNab says the ministry contract funding skin services runs until mid-2014 and MOKO is in negotiation with the district health board about continuing the service beyond that date.


Mana Clinic: the way it could and should be?

For more than 13 years, Wesley Primary School’s Mana Clinic ­­has been quietly modeling what many nurses would love to follow.

They whisk an undiagnosed asthmatic from the playground to the local GP in time to stop hospitalisation, conduct a health check on a child with learning problems, and fit in an opportunistic blood pressure check on a worried mum.

It is not unique work for a community nurse, maybe, but few are at a primary school day in day out and only a knock on the door away…

Back in 2000, following a community research project, and with the school’s enthusiasm and the support of Auckland District Health Board (ADHB), a public health nurse was appointed at the multi-cultural, decile 1 school. The purpose was to run a free health clinic for the school and its nearby Wesley Intermediate school pupils (about 300 pupils in all).

Although not a typical role for a public health nurse, it remains a unique community nursing position in ADHB. Much of the bread and butter work remains skin health. However, a daily presence also opens up the opportunity to do much more. This can range from acute care for playground accidents to providing health advice and support to otherwise hard-to-reach families.

When experienced PHN

Sarah Williams stepped into the role more than a year ago, she became quickly convinced of the benefits of being a familiar face in the school playground and staff room. Having a permanent physical clinic at the school so children, teachers, parents, and grandparents know where to come for help facilitates better and timelier access to health services.

“I see this as potentially the way forward”, says Williams of the Mana Clinic model.

She says student nurses who visit tell her they love their Mana Clinic placement and the chance to be involved with family-centered care, as parents and children of the predominantly Pacifica school pop into the clinic.

Considered one of the staff and being able to mix closely with the teachers also assists in building relationships and working together supporting the health curriculum and health promotion activities. Teachers not only refer children to Williams with skin sores and other health complaints but also to check for health issues that could be affecting learning and behaviour in class. This is work Williams has a particular passion for as her recent master’s thesis on the role of the nurse in the B4 School check looks closely at the relationship between health and learning.

Embedded in the school community, Williams works hard to establish good relationships with local doctors and nurses to ensure children with acute skin and other conditions get access to antibiotics and appointments when needed, particularly when money and unpaid bills may be an issue. Another strength as a DHB employee is her established links with DHB referral services and professional support networks.

Williams is able under standing orders to prescribe amoxycillin for children with Group A positive throat swabs, as Wesley has been part of the Rheumatic Fever Prevention Programme for the past two years. Standing orders to be able to treat common skin conditions are due to follow shortly, which will be warmly welcomed by Williams.

An early evaluation study early on of the Mana clinic, led by Dr Jill Clendon and published in 2004, found the nurse-led clinic had led to a decreasing number of children requiring treatment by ENT specialists and general medical care.

“The provision of holistic, culturally-appropriate primary health care in an environment acceptable to children and their families that targets specific health needs is enhancing health outcomes for children in the area,” concludes Clendon.

Williams agrees. “I believe that this is a model worthy of further review. Although it is not always easy to quantify health outcomes, I do think having a nurse based in a primary school setting offers an accessible, efficient, and cost effective way of delivering health services to low decile, high-need communities.”


Aranui Neighbourhood Nurse: Kids open the doors to families in need

Jenny Herring’s nursing day starts each morning at 8.30 with a stroll through the playgrounds and classrooms as children and their parents flock through the school gates.

“Kids come to me to show me anything from a picture they have drawn to a sore on their knee,” says the Aranui neighbourhood nurse.

“One student told me about their mum who is at home with a sore chest and asked if I could go and see her.”

The latter conversation was particularly poignant as the child had lost their father to a heart attack about six weeks previously and was understandably frightened for their mum.

Being a familiar face in the schools and preschools opens doors into homes for this neighbourhood nurse, whose working day includes school sores to blood pressure and getting children to specialist appointments to hanging curtains in cold, draughty homes.

The first Aranui neighbourhood nurse role was former nurse academic, Jackie Cooper, who won three-year pilot project funding from the Canterbury District Health Board to deliver health care to high need, low socio-economic community based at the Aranui Community Trust office.

When the project funding ended in mid-2006, neither the district health board nor the local primary health organisation were ready to step in to continue funding. But Aranui Community Trust manager Rachael Fonotia says the position had proven its worth to the community so the trust went hunting for funding and Herring’s salary is 45 per cent paid for by the Canterbury Community Trust and topped up by money from other trust contracts.

Aranui is browner, younger, and poorer than the generally whiter, older, and reasonably comfortably-off Christchurch. It has five times the city average of Pacific people and three times the city average of Māori. It is also in the heart of east Christchurch, which was hit hard by the quakes – losing water for three weeks and the first portaloos not arriving for a fortnight – and it is still surrounded by dust and roadworks.

Herring has been the neighbourhood nurse since 2007 and visits the community’s primary schools weekly – Aranui, Wainoni, and more recently, Avondale primary school (all three primary schools are to merge into a “super school” on the Aranui High School site in 2017), and she also visits neighbouring St James School. Aranui, Wainoni, and St James have roughly 400 pupils between them and Avondale has a further 350 pupils.

For the first two and a half years she would take the trust’s colourful Rotary-funded van to the schools which was an initial drawcard for children to come and see the nurse but it now only gets an airing once a month.

“The reason for doing that is because with the van I had to wait for people to come with me – and I was getting the same children every week,” says Herring. But she does take the van to Avondale school as she is still building relationships with children and families at the the new school and the van is a focal attraction. “It’s a bit like Mr Whippy!”

Her last port of call during her morning school visits is to pop in to the school office to see what children need to be seen, and on average, she has one to three children to see with boils or school sores or an ongoing head lice problem. Some will need follow-up visits to meet with the family.

Fonotia says it is often the children who invite Jenny into the home to follow-up their scabies or head lice. Once through the door, there may be a baby, pregnant teenager, or grandfather with heart problems she can talk to about their health needs and refer them to relevant health providers or agencies.

Herring also regularly visits three local preschools.

“At the kindergarten, I usually sit and play with the kids for an hour or half-an-hour. So the children get to know me, to want to meet up with me each week to tell their stories, and once again, the children lead into the households if I feel anything needs to be followed up.”

Now that she’s a familiar face in the community, most days she gets stopped by a parent in the playground or on the street – or they pop in to the trust office to find out when Jenny will be available, like the older man who had popped in that day to discuss his recent emergency visit to hospital.

Herring works closely with the hospital paediatric departments and local practice nurses to try and ensure the children and their families get to their specialist appointments. Sometimes, she takes her patients to appointments herself.

Fonotia points out that none of this is funded by the DHB, but there’s an expectation from the general practices and schools (particularly as the area at the time was one public health nurse short) that Jenny as neighbourhood nurse will step in.

The quake aftermaths have added a new level of complexity to the work, but Fonotia and Herring say Aranui is a resilient and connected community, with the trust having first opened its doors a decade earlier, so it has been a natural home for coordinating local responses, support, and community-building events.

From the start, Cooper and then Herring after her have also been keen to avoid doubling-up of services and to facilitate a two-monthly nursing network meeting at the trust’s office of 30-plus local practice, Plunket, district, and public health nurses, with often a guest speaker and always a chance to network and discuss families they are working with. Herring says the meetings are popular and her role is a welcome addition to the high needs community.

“I’m the only one of a kind in New Zealand,” says Herring.

“Well you are darling – you are different,” says Fonotia – only mildy tongue in cheek.

Having spoken about the neighbourhood nurse model around the country many times, she says the audiences’ consistent response is “yes, that’s how it should be”.