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Assessing children's needs.

Conducting a needs assessment of a child and their family is a complex process. It involves working in partnership with families/ whanau and taking into account a number of factors.

It is now commonly accepted that the traditional "expert" approach to health needs assessment and care planning for families with infants and young children has limitations. Working collaboratively and in partnership with children and their families is now considered much more beneficial and is the standard practice for Plunket nurses. (1,2) How, then, is needs assessment and planning care for families achieved in this new context? Evidence in the literature states that learning more about the important issues from the parents'/whanau perspective and identifying the strengths and resources within the family can change outcomes for families, despite the complexity of their situation. (1)

A child's needs must be considered within the family context, as the child relies on their parents/whanau to provide care. Research suggests that, to perform an accurate needs assessment, analysis of the information obtained through observation and interaction with the family/whanau must include both child- and parent-focused assessments of health needs. It is also important to understand that multiple definitions of "needs" exist. (3,4)

Plunket nurses are ideally positioned to assess the needs of the families they work with. They use an holistic definition of health and work within a socio-ecological framework, recognising the importance of the extended whanau and the community in which the family lives.5 The literature shows nurses are influential in their work with families and, as such, they must approach this assessment of need and planning of care from a strengths-based, empowering and supportive perspective. (6,7)

When working with a family to plan care, a Plunket nurse must have a good knowledge of the community in which the family lives, as this is the context in which professional judgements are made. Further, the approach taken to information-gathering to inform needs assessment is critical to the outcome of the interaction. There are a number of themes evident in the literature related to the "how" of exploring family/whanau need, including:

* The type of questions asked during interactions may shape the responses.

* A nurses' responses can block, diminish and minimise client concerns.

* Lists detract from listening to concerns and may result in missed cues.

* The agenda of the professional must not dominate the interaction.

* Effectiveness results from openness in the professional.

These themes need to be foremost in the practitioner's mind to optimise the potential health outcomes when working with families.

Plunket staff work with the family in a negotiated partnership, to develop a plan of care that will optimise health outcomes for that family. While the child is central to the assessment, the family and environmental factors are critical components. Some of these factors include socioeconomic health determinants and those things that contribute to the family's well-being, eg links to the community. Also integral to assessment and planning is acknowledging and considering the family's protective and resilience factors, and consideration and analysis of any risk factors. The Family Partnership Model, introduced to Plunket in 2006, underpins every interaction with tamariki and their whanau. (8)

Defining the categories

While the majority of parents and their children need support during the first five years of a child's life, not all parents need the same level of involvement and support as others. There are a number of environmental factors critical to a complete needs assessment, and acknowledging health determinants (including both risk factors and protective/resilience factors) is crucial. This provides the basis for understanding the unique and ongoing health and development of any child within their family context.

Needs assessment and care planning is about improving the health of all children. One group should not have better health to the detriment of another, as this reinforces inequity. The challenge for Plunket nurses continues to be that of meeting needs and reducing inequity in health outcomes within available community resources. Each situation must be analysed, so the level of health need and an effective intervention plan can be agreed and implemented for each family, with the negotiated aim of improving the health of that whanau. The purpose is to promote family health and reduce inequity. Assessment must include analysis of parenting methods and care-giving competency. Decisions about the level of service needed to meet identified need are relevant to this process of analysis. To achieve optimal outcomes for families, a collaborative approach to practice is essential, both in and outside the Plunket service.

The needs assessment process uses three terms to describe the definition of need: low; high, short-term; and high, long-term. The term "medium need" has been redefined as high need, short-term. This makes the definition more explicit and removes the term "medium", which could be used as a default position, rather than a clear indication of the assessed need. The definition is based on the enduring or modifiable nature of the need, as assessed by the Plunket nurse in partnership with the family (see "The definition of need", facing page).

In assessing a family's level of need and applying clinical judgement to decisions about care planning, Plunket nurses recognise that the level of need a family/whanau has, can and often does, change quickly during the first two years of a child's life. Needs assessment is a continuous process of observation, discussion and decision-making, most effectively undertaken in a respectful relationship between parents/whanau and practitioner.

Professional judgement is a critical skill in needs assessment and care planning, and is based on the combined consideration of four factors (see table 1). Clinical decision-making can be clearly justified and articulated on the basis of this framework for analysis and assessment. Plunket nurses have a responsibility to clearly document the analytical process and the factors considered in an assessment and development of a care plan.

For Plunket nurses, assessment is based on the following five factors:

* Client view (subjective data)

* Obtained data from surveillance (objective data)

* Analysis of need (the summary/justification for the plan of intervention)

* Plan of intervention (acted upon on the day and/or in the future) and outcome (stated health gain for individual client)

* Evaluation, which is undertaken at all key decision points (core contacts), and may result in the need for further or modified plans to be developed.

Practitioner qualities and skills

There are a number of recurrent messages in the literature regarding the preparation of health professionals undertaking health needs assessment and care planning. Health needs assessment must comprise a systematic approach, as the Plunket nurse reviews the health of individual clients and their families. This assessment must spring from a wellness approach to health, conducted in partnership with the client in the context of their whanau, and by a health professional who has been educated to undertake such a role. British researchers Jane Appleton and Sarah Cowley have repeatedly advocated that "needs assessment is a multi-factorial complex and ongoing process". (1) They add that accurate assessment of need requires considerable professional knowledge and expertise. Any care plans developed should include input from the parents and extended whanau, if possible.

The emerging themes in the literature suggest that working in partnership with the client in the context of their whanau provides a sound basis for informed needs assessment/ care planning. However, the literature also identifies there is no one tool specifically appropriate to identify and address the needs of children and families.

Providing a universal service to every family, and more service to those who need it, is the pinnacle of effective Plunket service delivery. This can only be achieved through wider understanding of the place that needs assessment has in reducing inequalities. Attention must, therefore, be focused on practice development and increased consistency and understanding to facilitate improved health outcomes for children and their whanau.

This article has been developed and updated from one originally published in Plunket's Care Delivery News in 2010.


(1) Appleton, J. & Cowley, S. (2008a) Health visiting assessment - unpacking critical attributes in health visitor needs assessment practice: A case study. International Journal of Nursing Studies; 45, pp785-797.

(2) Hogg, R. & Worth, A. (2009) What support do parents of young children need? A user-focused study. Community Practitioner; 82, pp31-35.

(3) Appleton, J. & Cowley, S. (2008b) Health visiting assessment processes under scrutiny: A case study of knowledge use during family health needs assessments. International Journal of Nursing Studies; 45: 5, pp682-696.

(4) Cowley, S., Bergen, A., Young, K. & Kavanagh, A. (2000) A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice. Journal of Advanced Nursing; 11, pp640-650.

(5) MacFie, B. (2006) Assessing health needs and identifying risk factors. Kai Tiaki New Zealand; 12: 6, pp16-17.

(6) Talbot, L. & Verrinder, G.K. (2005) Promoting Health. The Primary Health Care Approach (3rd ed). Sydney: Elsevier.

(7) Olds, D., Kitzman, H., Cole, R., Robinson, J. et al. (2004) Effects of nurse home visiting on maternal life course and child development:

Age 6 Follow-up of results of a randomised trial. Pediatrics; 114: 6, pp1550-1559. doi: 10.1542/peds.2004-0962.

(8) Ministry of Social Development, (nd) Family Partnership Model, Retrieved 15/02/15.

(9) Ministry of Health. (2009) Draft Needs Assessment and Care Plan Process for Use in Pregnancy and Well Child Services: Document for Discussion. Wellington: Author.

(10) Diagram adapted from Evidence-based nursing: A guide to clinical practice: DiCenso, A., Guyatt, G. & Ciliska, D. (2005) St Louis: Elsevier Mosby.

The definitions of need

Low: Assessment identifies that the child's health needs can be met by the parents. This group of families requires low-level intervention to maintain/improve a child's health. These families can usually access the education and support they need from core contacts and other sources.

High, short-term: Assessment identifies health needs that are readily modified and require specific, usually short-term, intervention(s) to maintain and/or improve child health outcomes. Examples may include first-time parents adjusting to parenthood, breastfeeding issues, postnatal depression and attachment issues. Protective factors could include support networks, families being open to advice, parenting skills and engaging in healthseeking behaviour.

High, long-term: Assessment identifies enduring health needs that require ongoing interventions, education and support. Risk factors could include unsupported or young parents, transience, family violence, substance abuse, lack of resourses and mental health issues. Achieving health improvements is likely to take longer. Planning for involvement of other agencies or services may contribute to overall complexity. Consequently, a continuum of care will be offered to families. (9)

Karen Magrath, RN, BN, MN, PGDip, PGCert, has been manager of Plunket's clinical advisory team for the last three years.
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Title Annotation:practice
Author:Magrath, Karen
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Mar 1, 2015
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