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. 2024 Jun 26;81(11):7231–7244. doi: 10.1111/jan.16298

Translating ‘proportionate universal healthcare’ into meaningful system design to optimize equity in child and family services

Lynn Kemp 1,✉, Kathy Donohoe 1, Prue Matthews 2, Wendy Aspery 3
PMCID: PMC12535313  PMID: 38922956

Abstract

Aim

To conduct a child and family health nursing service redesign to improve pathways of access, response and outcomes for all families with children aged 0–5 years.

Design

The study was conducted as an iterative, mixed‐method study of the process and impact of the service redesign, informed by a participatory action research paradigm and the NSW Agency for Clinical Innovation process for developing a model of care.

Methods

Diagnostic, solution design, implementation and sustainability phases were undertaken. Quantitative analyses were undertaken of administrative data, and child and family health nurse and client surveys. Qualitative analyses were undertaken of design workshops.

Results

The administrative data demonstrated that prior to the redesign service provision was the same for all clients regardless of levels of risk. The design solution, developed through a series of diagnostic and visioning workshops, included multiple new client response pathways. Implementation included development of tools and training. Sustainability of the redistribution of resources to the new pathways was assessed though an evaluation demonstrating a positive impact for families with adversity, with no deleterious effects for families receiving a universal response, and improvements in the emotional labour undertaken by nurses. Despite this, nurse burnout increased post‐redesign.

Conclusion

The shift from equal services (everyone receives the same) to equitable proportionate universal provision in response to need can be achieved and has positive impacts for nurses and families.

Impact

This study shows the value of undertaking a systematic and participatory approach to service redesign. A proportionate universalism approach can ensure that early childhood nursing services are available to all in relation to needs.

Reporting method

The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) check‐list was used to guide reporting.

Patient or public contribution

No patient or public contribution.

Keywords: child and family health nursing, model of care, proportionate universalism, service redesign

1. BACKGROUND

Investments in the early years of life can have substantive and important benefits to health, which extend into adulthood by capitalizing on brain plasticity and optimizing developmental trajectories. Optimal early childhood development not only powerfully affects adult wellbeing, but also contributes to the productivity of society at large (Shonkoff & Bales, 2011). A report into the health of Australian children indicates that children continue to experience significant morbidity (ARACY, 2013). As children begin school, more than 20% are assessed by their teachers as having inadequate skills in at least one learning domain (Commonwealth of Australia, 2022), 20% suffer clinically significant behavioural problems, and 23% are already overweight or obese (Alexander et al., 2015). However, these figures are disproportionately higher in disadvantaged locations. A study of 2500 children within the area of this study, south western Sydney, identified that 40% of infants in the baseline cohort were exposed to at least two risk factors associated with developmental risk (Woolfenden et al., 2016). In response to these concerning health outcomes, Australia has adopted a National Early Childhood Development Strategy (Council of Australian Governments, 2009), which envisions that ‘all children have the best start in life to create a better future for themselves and for the nation’.

Internationally, it is increasingly argued that the best way to ensure early childhood health services are available and accessible to all is through a proportionate universalism approach (Cowley et al., 2012). With this approach, all children and families have access to a universal level of support and services, ‘with additional support commensurate with additional needs’ (Marmot, 2010; Oberklaid et al., 2013, p. 1). The modelling of developmental outcomes demonstrates that when health services are available to all children and families within a population, the differential or inequalities in developmental outcomes narrows and more children attain normal development (Carey et al., 2015), although the practical mechanisms for enacting proportionate universalism remain subject to different interpretations (Francis‐Oliviero et al., 2020).

In Australia, childhood health surveillance and parenting support is undertaken by child and family health nurses (CFHNs) who are postgraduate trained specialist public health nurses; yet service use varies widely and diminishes as children age (Schmied et al., 2014). Many families also use general practitioners (GPs); however, GPs do not routinely assess child growth, behaviour or development during ‘sick‐child’ consultations (Jeyendra et al., 2013). Consequently, many children are do not access health promotion and parental support services (Schmied et al., 2014). Previous research on the CHoRUS (Child Health: Researching Universal Services) study (Schmied et al., 2015) revealed services for children and families are fragmented; workforce numbers, skills and capacity vary widely; and information exchange within and across services is poor. Australian evidence has shown that women were very satisfied with first home visit from the CFHN service, but they did not continue to use the service because it was not convenient and that limited access to the universal CFHN service effects outcomes for both children and parents (Rossiter et al., 2019). For example, analysis of population databases and the case‐files of infants under 12 months of age and their parents admitted to a tertiary‐level residential parenting service suggests the admissions relate to parenting concerns like sleep/settling (83%), feeding (6.3%) and support (10.7%) (Dahlen et al., 2019). These are all issues that can and should be addressed through the universal CFHN service. A failure to systematically prevent and detect child and family health issues poses a fundamental challenge to children's health and long‐term outcomes.

Based on national and local research and current service challenges, the Australian CFHN services are experiencing in meeting the needs of children and families, and there is an urgent imperative to redesign the CFHN service system. Several CFHN service innovations have been studied, including improved pathways for the transition of care from maternity to CFHN services; new ways for nurses collaborate with other professionals to assess child development and parenting support; and advocating for improved nurse–client relationships and continuity of care (Wightman et al., 2022). However, many of these innovations are acting as a ‘bandaid’ to an inflexible, poorly responding system. This study reports on a project undertaken within one health district in Sydney, Australia, to redesign the service system and translate proportionate universal healthcare into meaningful service responses related to families' risks and needs, that will ultimately optimize outcomes for families with young children.

The overarching aim of this project was to optimize the wellbeing of children in south western Sydney by translating the concept of proportionate universal healthcare into a service system that ensures equity of provision for families with young children. The project was driven by concern by the child and family health nurses that the existing service was ‘one size fits all’; that is, equal, but not equitable, and that the inability to differentially respond to families' needs was a driver of staff burnout. The project addressed the following objectives and associated a priori hypotheses that drove the redesign project:

  1. Examine community child and family health nursing (CFHN) services for children, aged 0 to 5 years (inclusive) with a focus on the equity of service provision, and CFNH and families' experiences
    1. Hypothesis 1: existing (pre‐redesign) service provision is inequitable and not responding differently to families with differing levels of risk

  2. Redesign a child and family health nursing service system that optimizes proportionate universalism and equity in service provision to promote child wellbeing, particularly ensuring that those with higher levels of risk and need receive greater support.

  3. Develop a suite of change management strategies to facilitate the translation of the redesigned service system into practice

  4. Evaluate the impact of the redesign on CFHN and families' experiences.
    1. Hypothesis 2: The redesigned service will improve CFHN emotional work in their relationships with clients, co‐workers and managers, and reduce burnout.
    2. Hypothesis 3: The redesigned service will not negatively impact on the service experience of families with low levels of risk.
    3. Hypothesis 4: The redesigned service will improve the service experience and impact for families with higher levels of risk.

2. METHODS

The study was conducted in one local health district in Sydney, Australia. This health district in characterized by large areas of socioeconomic disadvantage, including public housing, is one of the most culturally diverse areas in Australia and has a large number of Aboriginal and Torres Strait Islander residents (NSW Government, n.d..).

2.1. Research design

The research design was informed by the NSW Agency for Clinical Innovation process flowchart for developing a model of care (Agency for Clinical Innovation, 2013; see Figure 1) and participatory action research frameworks (Baum et al., 2006), with an emphasis on participation, collective action, experiential learning, implementability, scalability and sustainability (Klaic et al., 2022). Detail on the interrelated phases is described, as follows.

  1. Diagnostic phase. This phase defined the problem and, importantly, the root causes of the problem, through:
    1. Consultation with service providers and service users: Five consultation forums were held with CFHNs and managers. Participants were asked to detail the CFHN service journey for infants/children and their families from birth to 5 years of age. Through a series of provocative statements (e.g. ‘describe service success/ failure’), participants described what currently worked well, problem areas and the ideal journey. Field‐notes and minutes were documented during small and large group discussions. A survey of 106 service users was undertaken in‐person by an independent fieldworker in the waiting rooms of CFHN clinics being conducted in the district. Demographic data were collected, and families were asked about their experiences and the impact of the CFHN service.
    2. Analysis of routinely collected, administrative data: Administrative data were used to map the pattern of pre‐redesign CFHN service provision.
  2. Solution design phase. In this second phase, the information from the diagnostic phase was used to support the district to develop a vision for services and a range of solutions. The solutions were developed into scenarios to be tested, including the investment and disinvestment needed, through:
    1. Visioning workshops: Visioning workshops inspire participants to think creatively about possible futures and develop a shared vision towards preferred options – ‘Visioning is intended to capture the imagination and the commitment of the workforce, being shared and owned by the workers. It is also an opportunity to compare ‘where are we now’ with ‘where do we want to be’' (Boomer et al., 2008, pp. 71–72). Two workshops were facilitated with CFHNs and managers from the district to (1) enable participants to share their vision for the CFHN service; (2) develop a collective vision; and (3) agree to a common vision for this project.
    2. Solution and scenario testing: Based on the diagnostic phase and visioning workshops, a proposed redesigned service structure and support tools were developed. These were workshopped with the CFNH service leadership and child health service management teams in the district. Scenario testing was undertaken by hypothesizing patient journeys through the redesigned system to ensure that no family could ‘fall through the gaps’.

  3. Implementation phase: This third phase was conducted in participatory action research cycles with the solution design phase, supporting experiential learning and the testing of solutions, the redesign of solutions, or the development of new solutions, and retesting, as needed. This phase was conducted in one region of the health district that pilot tested the redesigned service. This included a survey of the CFHNs' readiness for change and qualitative assessment of areas requiring change management; resource development; training activities; and workload allocation and caseload building.

  4. Sustainability phase: The final phase presented here was evaluating the impact on CFHNs and on clients engaging with the redesigned service. This included mapping of nurse caseload against projected targets, a pre‐ and post‐redesign survey of the CFHNs in the pilot implementing region, a second survey of 100 CFHN clinic service users, and self‐report surveys with families receiving a sustained nurse home visiting programme.

FIGURE 1.

FIGURE 1

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Research design.

All phases were underpinned by evidence‐based change management strategies. Process improvements involved: (1) understanding and involving service providers and service users; (2) identifying key problems; (3) identifying, working with, and supporting change leaders; (4) sourcing ideas from beyond child and family healthcare; and (5) using rapid‐cycle testing to establish effective changes.

2.2. Analysis

As an emergent, participatory design, analyses were conducted as appropriate to the data collected, including quantitative and qualitative analyses. In quantitative analyses, both significance (p value) and effect sizes are provided for small samples, as effect size is a more useful indicator of the importance of any differences tested, regardless of sample size (Hojat & Xu, 2004). Data were triangulated by: inclusion of data from different individuals, collected at different locations, at different times, using different research methods; and the collection, analysis, and integration of different data types (McBride et al., 2018). For example, a descriptive analysis of service‐user data, using R, was triangulated with the qualitative perspectives of service providers and service users, which was thematically analysed using NVivo.

Ethics approval was provided by the Human Research Ethics Committee of South Western Sydney Local Health District, approval number LNR/17/LPOOL/30‐HE17/16.

3. RESULTS

3.1. Phase 1: Diagnostics

The diagnostic phase commenced with the hypothesis that the service approach prior to redesign offered high levels of care to families with lower psychosocial risk (higher resources and capacity), while crisis management is offered to those with the lowest capacity, and that, overall, response was not proportionate to risk. It was expected that service redesign would change this to a proportionate universal pattern of service investment where all families received a service, but those with greater risk and/or support needs, and lesser personal capacity and resources to meet those needs, would receive additional support (Cowley et al., 2012).

3.1.1. Analysis of administrative data

Administrative data on service use prior to the redesign were extracted for babies born in 2014 and their mothers and included service use until the children were 5 years old in 2019. The total number of babies born in 2014 was 18,019 (including 280 multiple births) born to 17,740 mothers.

Psychosocial risk level

Psychosocial risk is routinely assessed by midwives when the mother presents for their first prenatal visit. The risks recorded in the data were categorized according to their severity, as per the guidelines for categorizing risk that were in place at the time. Table 1 presents the categories of risk. Over half (51.4% n = 8852) of the mothers presented with low/no risks, 23.3 per cent (n = 4011) with one or more moderate risk (and no high risk) and 25.3 per cent (n = 4353) with one or more high risk.

TABLE 1.

Risk categories.

Risk Moderate High
Involved with social care — Yes
Partner Single ‐
Drug intervention Past Current or referred
MH treatment Yes MH Issue but no treatment
History of child abuse — Yes
EDS a score 10–12 Yes —
EDS a score 13 or over or thoughts of self‐harm — Yes
DV hit or frightened — Yes
Smoking during pregnancy Yes —
Drinking during pregnancy Yes —
Partner emotionally supportive No —
Home support Minimal or Partner support only No postnatal home support
Late antenatal care (>20 weeks) — Yes
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a

Edinburgh depression scale.

Post‐birth CFHN service use

The guidelines for universal services in early childhood provided to families at birth (the ‘Blue Book’) that was in place prior to redesign recommended eight assessments from birth to 5 years, at 1–4 weeks; 6–8 weeks; 6, 12 and 18 months; and 2, 3 and 4 years. Commonly, the 6‐ to 8‐week check is undertaken by general practitioners; thus, the ‘minimal’ universal service should be seven visits. A total of 3042 women (17.1%) received no post‐birth CFHN service contacts; 6360 (35.8%) received 1 to 7 contacts (universal provision); 5430 (30.6%) received 8 to 20 contacts (extended provision); and 2918 (16.5%) received more than 20 contacts (intensive provision), including 14 who received over 100 contacts. It was noted in the consultations that the only performance indicator for the CFHN service in the district was the proportion of newborn babies who received a home visit within 1–4 weeks post‐birth.

In accordance with the diagnostic hypothesis, the pattern of service use for each level of risk was assessed to determine whether service provision varied by risk, with an expectation that mothers presenting with higher risks should receive a higher number of contacts if the service were proportionally universal. Figure 2 shows the proportion of mothers receiving differing numbers of service contacts up to child age 5 years for each risk level. The pattern of service contacts was very similar for all levels of risk, albeit with some evidence of a slightly increased proportion of those with moderate risk receiving an extended provision of 13–20 contacts and a slightly increased proportion of those with high risk receiving intensive provision of more than 30 contacts. This evidence, however, was not considered in the workshops to represent an adequately proportional response based on risk.

FIGURE 2.

FIGURE 2

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Proportion of families receiving different numbers of service contacts up to child age 5 years by risk level.

The results of the diagnostic consultations are presented in the following section in conjunction with the solution design. The service user survey is presented in phase 4, where the pre‐redesign and post‐redesign results are presented for evaluation of the pilot implementation of the redesign.

3.2. Phase 2: Solution design

The diagnostic consultations identified a number of issues and current challenges that needed to be addressed in redesigning the CFHN service (Table 2). Table 2 also shows the response to these issues from the visioning workshops and the identified potential responses required for implementation.

TABLE 2.

Issues, current situation (diagnostics), potential future (visioning) and service design response (solution design).

Issue Current Future Potential response
Workforce numbers and infrastructure Number of nurses and accompanying resources Increase number of nurses and accompanying resources needed for sustained home visiting Reallocation—look at numbers across the district—or growth—or appropriate targeting/flexibility in service responses for families (see Figure 2)
Capacity for working with families with complex needs Limited opportunity to practice skills: risk of burnout Mixed, proportionate universal caseload Training, supervision, case review
Risk versus response Risk not static—flexibility Risk determined pathways Response and goal determined pathways Enhanced assessments based on parent capacity to parent well and aspiration, and family capacity to adapt and self‐manage (requires tool development)
Integration Workers (who may or may not work as a team) around the child Team around the worker/key worker model Engaging General Practitioners, multicultural workers, Aboriginal health education officers, government and non‐government providers through HealthPathways
Community and broader system capacity Single home visit potentially negating/delaying/abrogating community responsibility to support families Broader community response and support for families Community and broader system engagement in redesign process. Engage Population Health in redesign. Service/system mapping. Improved promotion of the role of CFHN service
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The visioning consultations identified several principles that needed to be reflected in the redesigned service pathways—these included:

  • A focus on families' capacity and resources to adapt and self‐manage (based on the Health Council of the Netherlands (2009) revised definition of health as ‘The ability to adapt and self‐manage’ (Huber et al., 2011)) and parent effectively despite identified risks (Kemp et al., 2016).

  • A proportionate universal response, with CFHN services prioritized to families with lesser capacity and fewer resources to adapt and self‐manage and parent effectively despite identified risks.

  • A recognition that risk and families' personal resource are not static, but can change over time to both improve or reduce capacity to adapt and self‐manage and parent effectively, which thus requires:
    • ‐
      flexibility in the service response to families;
    • ‐
      pathways for families to access support when needed; and
    • ‐
      a platform of case finding, case planning, and case reviewing.

  • Promoting families' capacity to adapt and self‐manage and parent effectively despite identified risk requires a skilled workforce that is supported to work in partnership with families and be reflective. This is best achieved through quality clinical supervision and case review processes.

  • An integrated, multidisciplinary, multiagency and community approach to prioritize CFHN services to families with lesser capacity and a CFHN focus on promoting families' ability to adapt and self‐manage and parent effectively despite identified risks. This integrated approach would foster:
    • ‐
      the management of families' identified risks (that is, the ‘despites’), allowing CFHNs to focus on families' parenting capacity and child health and development within their scope of practice;
    • ‐
      pathways for family support; and
    • ‐
      engaging the broader professional and community services in the provision of universal prevention.

Figure 3 illustrates the proposed service pathways model that was developed to be explored and pilot tested in one region of the health district.

FIGURE 3.

FIGURE 3

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Proposed service pathways model.

The redesigned model was grounded in existing processes of psychosocial risk assessment and categorization undertaken by midwives during pregnancy and CFHNs on the first post‐birth contact, but included a new range of service responses including sustained nurse home visiting and shorter‐term ‘packages of care’ pathways. These additional service responses were supported by new processes of transition and response assessment (described further in Phase 3) that extended ‘triage’ to care response pathways for each family beyond consideration of only psychosocial risk. The district also decided to implement the Maternal Early Childhood Sustained Home‐visiting (MECSH) programme, which had been trialled and shown to effective in the district (Kemp et al., 2011) and in a subsequent large multi‐site trial (Goldfeld et al., 2019). The MECSH programme focusses on families experiencing adversities that impact their ability to adapt and self‐manage and parent effectively despite. The MECSH programme commences in pregnancy or within 8 weeks after the baby comes home, and provides a structured home visiting programme up to when a child is 2 years of age, or the families has achieved their goals, including the ability to adapt and self‐manage despite adversity, and parent effectively despite (see phase 3 for further description of these concepts and their measurement). Thus, the MECSH programme could be provided as a shorter‐term package of care for families that initially presented as needing a sustained response, but who, upon implementation of MECSH, were found to have latent capacity. This was in addition to other short‐term packages of care in response to identified care needs, for example, breast‐feeding support.

3.3. Phase 3: Implementation: Support the health system to make the changes

The diagnostic and solution design phases identified a need to explore CFHNs’ attitudes to change to inform a change management strategy, as well as develop resources to support the new assessment processes and subsequent training in both the use of the assessment tools and the new models of care: short‐term packages of care and sustained structured nurse home visiting.

3.3.1. Change management

The attitudes towards change instrument (Dunham et al., 1989) was used to assess the CFHNs' attitude to see whether the workforce would be generally amenable to change. It consists of 18 items assessing three dimensions—cognitions about change; affective reactions to change; and behavioural tendency towards change. Response scores ranged from never = 1 to always = 4, with negatively worded questions reversed. Higher scores indicate a positive attitude towards change. In 2017, staff in the implementation region (n = 24) reported moderate to high positive attitudes towards change. The behavioural component was highest (mean 3.06, SD: 0.48), followed by the affective component (mean: 2.98, SD: 0.39), then the cognitive component (mean: 2.72, SD: 0.45). The qualitative data collected during the diagnostic and solution design phases was then reanalysed to determine attitude to the proposed redesign. This indicated that the CFHN workforce in the implementation area was very keen to change their service provision to better serve the needs of the more vulnerable and at‐risk population of the region, so long as that change was supported by adequate resources, training and workload changes. The change management undertaken thus focussed on these issues as detailed below.

3.3.2. Resource development

The redesigned service pathways model (Figure 3) required new assessment tools for use by the CFHN service to identify the ‘best’ service pathway for each client. To better ‘triage’ families to be prioritized for the two new formats of universal services (transition group or client‐initiated support), a transition assessment was developed to identify those making a first transition to parenting defined as either having a first baby, having a baby for the first time in the implementation study region (e.g. migrant/refugee families, or those who have moved to the region and had limited social or service connections), or having a baby for the first time with new or significantly changed circumstance (e.g. a new partner, or major change in socioeconomic circumstances). A tool was developed by the authors in collaboration with CFHNs for use during the first telephone contact with the family post‐birth that gathered this information. This allowed the duty CFHN to offer the appropriate universal service.

For families identified with risks, a tool was developed to further understand the impact of the risks on families' capacity and resources for parenting effectively despite risk and adversity. The tool, known as the ‘adapt and self‐manage tool’, was developed by exploring these concepts in the literature and identifying surveys measuring these concepts. A bank of potential tools and items for use was workshopped with the district CFHN leadership and management teams. Criteria for the tools and items chosen were that the tool was free to use and adapt. Self‐management items were selected and adapted from the chronic disease self‐efficacy scales (Self‐Management Resource Center, 1996), and adapt items were selected and adapted from the self‐regulation questionnaire (Carey et al., 2004). The tool was piloted by the CFHNs for client acceptability, with 88 per cent of clients finding the tool acceptable and the remaining 12 per cent reporting the tool was neither acceptable nor unacceptable. In addition to the tool completion by the family, the CFHNs reported how they would have assessed the family against the three potential pathways in the model. The relationship between the family responses and CFHN assessment was used to establish measurement ‘cut‐offs’ for the three pathways, and an online entry and scoring process was developed and implemented.

3.3.3. Training

All CFHNs in the pilot region were trained by the research and CFHN leadership team in the use of the two new assessment tools. This training raised concerns that the tools might miss or wrongly classify families for pathways due to potential bias in answering (particularly for the adapt and self‐manage tool), with families answering the ways they felt the nurse expected them to, rather than honestly. Subsequently, the training emphasized that the tools were to be used as an adjunct and support for clinical decision‐making, but should not override the nursing assessment of the most appropriate pathway for the family. The MECSH programme training, resources and supports were implemented and provided to all CFHNs in the pilot region.

3.3.4. Staff allocation and caseload building

The service redesign required a shift from a universal ‘one size fits all’ model to allocation of greater resources, primarily CFHN time, to families with moderate or high risk and limited ability to adapt and self‐manage. Scenarios based on staff allocating 80 or 60 per cent of their full‐time equivalent to the moderate/high‐risk families were explored, with consideration of the number of families that were expected to be in each pathway (based on the diagnostic data), and the other roles undertaken by CFHNs that were expected to be retained (such as breastfeeding groups and drop‐in clinics). Following exploration, it was decided to allocate 60 per cent of CFHN time to sustained nurse home visiting, supporting a caseload build of 66 new families in the MECSH programme each year.

3.4. Phase 4: Sustainability, monitor and evaluate the impact

Activities to monitor and evaluate the impact included:

  1. A pre‐post study of the impact of the change on CFHNs' emotional labour and burnout testing the hypothesis that proportional universal service provision would improve emotional labour and reduce burnout. These two domains were chosen by the CFHN leadership team for monitoring at the diagnostic phase as the CFHN workforce expressed concerns about the potential impact of the redesign on the emotional labour they undertake in their relationships with clients, co‐workers and managers, with particular concern that increasing intensive engagement with high‐risk families might increase emotional labour and burnout (Eaves Simpson et al., 2018), balanced with expectations that the change management processes and support should mitigate this risk (Lee et al., 2013).

  2. A pre‐post study of the impact of the change on service users, focussed on those using universal prevention services (client‐initiated clinic visits), was conducted. This involved testing the hypothesis that families' access to and the impact of the CFHN clinic service will be unchanged, despite the reallocation of resources to selective and indicated prevention services (short‐term packages of care and sustained nurse home visiting).

  3. An assessment of impact of the redesign on the delivery of sustained nurse home visiting, including the sustainability of the caseload capacity in provision of the sustained home visiting programme, was conducted. Also assessed was MECSH programme client experience, impact, and outcome. These assessments served to test the hypotheses that clients would be satisfied and enabled by the programme and that the programme would improve the ability to adapt and self‐manage:
    1. Satisfaction with the programme (experience) was measured using the modified parent satisfaction questionnaire (Marshall & Hays, 1994), where lower scores indicate greater satisfaction (potential range 10–50), and the performance indicator for the MECSH programme is 100 per cent of clients score <20;
    2. Parent enablement (impact), that is, parents' self‐assessed ability to care for themselves and their baby, was measured using the modified patient enablement index (Howie et al., 1998), where higher scores indicate greater enablement (potential range 0–12), and the performance indicator for the MECSH programme is 100 per cent of clients score >4; and
    3. Ability to adapt and self‐manage at programme entry and exit (outcome) was measured using the adapt and self‐manage tool developed in phase 3. This served to test the hypothesis that for these families, the provision of sustained nurse home visiting improves the ability to adapt and self‐manage and parent effectively despite adversity (overall MECSH programme aim).

3.4.1. CFHN emotional labour and burnout

Thirteen nurses completed the pre‐redesign (diagnostic phase) survey in 2017 and 13 also completed the post‐redesign survey (evaluation phase) in February–March 2020, immediately before the impact of the COVID‐19 pandemic. The surveys were completed anonymously, so it is unknown how many CFHN participated at both times. Results are presented as the overall change in scores between the two samples.

Emotional labour was measured using the emotional labour scale (Brotheridge & Lee, 2003), which measures three dimensions: deep acting to provide a genuine display of felt emotions; surface acting using an emotional mask to suppress felt emotions; and faking to demonstrate emotions that are not felt. Surface acting and faking are associated with a reduced sense of wellbeing, emotional exhaustion and burnout, while genuine acting is associated with a more positive sense of self (Brotheridge & Lee, 2003; Glomb & Tews, 2004). Table 3 shows the emotional labour scales before the service redesign in 2017 and post‐redesign in 2020. In all work interactions, the CFHNs reported an increase in deep acting and reduced surface acting and faking. The reduction in faking with clients and surface acting with managers had a moderate effect size, and the reduction in surface acting with co‐workers had a large effect size (significant and clinically meaningul findings highlighted in Table 3).

TABLE 3.

Emotional labour and burnout pre‐ and post‐redesign.

Interaction with Emotional labour subscale 2017 2020 Statistics
Mean SD Mean SD p Cohen's d
Clients Surface acting (suppressed display) 2.79 0.50 2.65 0.71 0.56 0.23
Deep acting (genuine display) 2.72 0.76 3.03 0.90 0.35 0.37
Faking (faked display) 2.67 0.53 2.38 0.64 0.23 0.48
Co‐workers Surface acting (suppressed display) 2.44 0.44 2.09 0.50 0.07 0.73
Deep acting (genuine display) 2.64 0.80 2.85 0.81 0.52 0.25
Faking (faked display) 2.18 0.40 2.08 0.49 0.57 0.23
Manager Surface acting (suppressed display) 2.41 0.60 2.09 0.56 0.17 0.56
Deep acting (genuine display) 2.62 0.83 2.82 0.83 0.53 0.25
Faking (faked display) 2.10 0.39 2.03 0.55 0.69 0.16
Dimensions of burnout
Emotional exhaustion 6.92 3.64 7.46 4.07 0.725 0.139
Depersonalization 1.38 2.06 1.46 2.50 0.933 0.034
Personal accomplishment 15.15 1.63 13.69 2.32 0.075 0.729
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Note: The bold is intended to highlight those pre‐post comparisons that were either statistically significant (p) or clnically meaningful (d).

Burnout was measured using the abbreviated Maslach burnout inventory, which measures emotional exhaustion, depersonalization and personal accomplishment and provides a total score (Maslach & Leiter, 2008). In 2017, staff reported moderate levels of emotional exhaustion, low levels of depersonalization and high levels of personal accomplishment. Emotional exhaustion and depersonalization increased in 2020, and personal accomplishment decreased. These changes were small and not statistically significant; however, the decrease in personal accomplishment was a large effect size (Table 3).

3.4.2. Impact on universal prevention clients

A total of 106 clients were surveyed from February to April 2017; 100 clients were surveyed from August to December 2020 (mid‐COVID‐19 pandemic, after the lifting of the first ‘lock‐down’). Most clients attended a clinic general drop‐in visit. Most clients did not identify as Aboriginal or Torres Strait Islander or as a member of an ethnic/religious group. The main language spoken at home was English, the highest level of education was a Bachelor's degree, and most were the primary carer for one child (45%). There were no significant differences in the sociodemographic characteristics of clinic clients in 2017 and 2020.

Clients were asked how likely they were to seek help. In 2020, fewer clients were likely to seek help from their partner or immediate family member, online resources or others. Clients were also less likely to seek help from CFHNs (92.5% likely to seek help in 2017; 84.0% in 2020), predominantly reflecting an increase in the number who were undecided about seeking help, rather than unlikely to do so. These changes were small and not significant. Significantly more clients were undecided about seeking help from a pharmacy nurse. Clients likely or unlikely to seek help from a pharmacy nurse decreased in 2020, but these changes were not significant. Significantly more clients were unlikely to seek help from a paediatrician. Clients who were likely to or undecided in seeking help from a paediatrician increased in 2020, but these changes were not significant. Clients were also asked about their knowledge and confidence in engaging with and using help from health professionals. Figure 4 shows clients' responses in 2017 and 2020. Generally, clients felt very confident and knowledgeable when seeking help, with slight but non‐significant increases in positive reporting in 2020.

FIGURE 4.

FIGURE 4

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Knowledge and confidence in help seeking.

3.4.3. Impact of sustained nurse home visiting

The caseload build of 66 new MECSH families per year should have resulted in 297 families participating in the programme by December 2022. However, most of the CFHNs were redeployed to the COVID‐19 pandemic response from March 2020 to March 2022. During this time, the focus of the service was on maintaining service provision to those already in the programme, and few new clients were commenced. Given this period of redeployment, a revised total MECSH caseload was 181 families. As at December 2022, 184 families had received or were continuing to receive the MECSH programme in the pilot region.

Parent satisfaction and enablement were measured at child age 6 weeks, 6 months, 1 year and 2 years. Table 4 shows the mean and proportion meeting the MECSH performance criteria on each measure.

TABLE 4.

Parent self‐reported satisfaction with and enablement by Maternal Early Childhood Sustained Home‐visiting programme participation.

Time of survey (child age) Parent satisfaction questionnaire Parent enablement index
Mean % <20 Mean % >4
6 weeks 12.3 100 9.8 100
6 months 12.0 83 9.3 75
1 year 10.0 100 11.7 100
2 years 12.4 100 9.5 100
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On enrolment into the MECSH programme, 61.4 per cent of families were assessed as having a good ability to adapt and self‐manage to parent effectively, despite adversity. On exit from the MECSH programme, 72.1 per cent had good ability, and the percentage of those assessed as having a poor ability to adapt and self‐manage reduced from 13.1 to 4.5 per cent (χ 2 2 = 17.2; p < .001; see Figure 5).

FIGURE 5.

FIGURE 5

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Ability to adapt and self‐manage at Maternal Early Childhood Sustained Home‐visiting programme enrolment and discharge.

4. DISCUSSION

This article describes the redesign process to improve CFHN services to better meet the varying needs of the population in a health district in Sydney, Australia, characterized by high levels of disadvantage. Guided by the NSW Agency for Clinical Innovation process flowchart to develop a model of care (Agency for Clinical Innovation, 2013), this was an iterative and participatory process. This discussion is framed around the tested hypotheses.

Hypothesis 1 in the diagnostic phase proposed that the pattern of pre‐redesign service provision would not represent a proportional universal approach (Marmot, 2010); that is, services would not be different for families with differing levels of risk. Worryingly, nearly one in five families with all levels of risk received no CFHN service at all between their child's birth and when their child was 5 years of age. As hypothesized, the pattern of service did not vary by risk, with most clients receiving 5–7 visits, consistent with the minimum number universal provision contacts according to the guidelines provided to families at birth (in NSW known as the ‘Blue Book’). However, it was not possible to know whether the services matched the guidelines in terms of timing throughout the first 5 years of life.

Given that the service was not differentiated by risk, a key component in designing the solution was to determine the basis of the variation for a proportional universal service; that is, should it be proportional to disclosed risks or would a different basis for targeting be more useful? There is limited consensus in the literature about the mechanisms for operationalizing proportionate universalism and the basis for any targeting (Francis‐Oliviero et al., 2020). In this redesign, the decision was to move away from solely risk determined pathways to response and goal determined pathways, determined by two factors: transition; and the ability to adapt and self‐manage (Huber et al., 2011), and parent effectively despite adversity (Kemp et al., 2016). Such pathways are more consistent with the focus on parenting skills and capacity that is the core of CFHN services, which are documented to include ‘child growth and development; maternal mental health; information provision to support behaviour/attitudinal change; and building parent capacity’ (Fraser et al., 2016, p.2559), and a health promotion, rather than risk management emphasis (Wightman et al., 2022).

Hypothesis 2 in the implementation support phase and assessed in the evaluation phase tested the hypothesis that proportional universal service provision would improve CFHNs' emotional labour and reduce burnout; a key driver of the service redesign project. The evaluation suggests that the service redesign, together with its accompanying training and support, did improve the emotional labour for the CFHN with clinically meaningful reductions in faking with clients and surface acting with co‐workers and managers. In all relationships, faking and surface acting decreased and deep acting increased. Deep acting is the ability to draw on and display genuine emotions, and is associated with improved personal accomplishment and reduced burnout (Glomb & Tews, 2004). Despite the improvement in emotional labour, burnout did not improve and there was a meaningful reduction in the sense of personal accomplishment, which was unexpected. Burnout might have been associated with overall workload, rather than only work‐based relationships and thus not directly impacted by the redesign. Further, the post‐implementation survey was conducted in late February 2020, which was characterized by the devastating 2020 Australian ‘black summer’ bushfires that directly impacted the district's geographical area, and the start of the COVID‐19 pandemic. Thus, it is possible that non‐work factors might have caused work‐stress. This finding should be followed‐up in the next round of evaluation and design that is about to commence in the district in late‐2023, recognizing that this future work should focus on identifying, measuring and addressing factors that might be impacting workforce burnout.

In particular, future work might need to note that the designed solution reported here focussed specifically on CFHN service provision and did not directly address two areas of concern identified by the diagnostic and solution design phases: service integration and community and broader system capacity. Focussing on parenting effectively despite adversity and the CFHN's health promoting roles (Fraser et al., 2016; Wightman et al., 2022), without building the broader system to manage risks, might have been a source of stress in the context of CFHNs engaging intensively with families with greater adversity, despite the improved emotional labour (relationships). There is compelling global evidence that community‐based system integration is needed to improve equity of service access and address the social determinants of health for children and their families (World Health Organization et al., 2018).

Hypothesis 3 in the evaluation phase tested the hypothesis that families' access to and the impact of the CFHN clinic service would be unchanged despite the reallocation of resources (workforce hours) to selective and indicated prevention services (short‐term packages of care and sustained nurse home visiting). Overall, this hypothesis was supported. There were no demonstrated differences in clients' sociodemographic characteristics. There were, however, some changes in patterns of families' engaging sources of help, likely related to COVID‐19, and may reflect the uncertainty of availability of health services at that time (Podubinski et al., 2021). Nonetheless, despite the uncertainty of the times, there were slight increases in all measures of positive impact of the clinic service on the clients attending.

In addition to evaluating the impact on universal prevention pathways, hypothesis 4 in the evaluation phase assessed the hypotheses that MECSH sustained home visiting clients would be satisfied and enabled by the programme and that the programme would improve their ability to adapt and self‐manage. This hypothesis was supported with clients exceeding the performance standards in satisfaction and enablement. Positive performance in fidelity was associated with achieving programme aims in the MECSH trials (Kemp et al., 2019). Additionally, there was a significant increase in the proportion of families assessed as having a good ability to adapt and self‐manage and a reduction in the proportion with poor ability. The ability to adapt and self‐manage despite adversity, together with high levels of enablement, are good indicators of family resilience, which is associated with positive outcomes for parents and children, commencing in pregnancy (Davis & Narayan, 2020). It is important to recognize, however, that 28 per cent finished the programme without a good ability to adapt and self‐manage, suggesting that some families might need ongoing support beyond programme completion. These generally positive results for the MECSH clients were achieved in a context of meeting the client enrolment targets and despite the impact of the COVID‐19 pandemic.

Overall, all the hypotheses were supported. The solution designed was implementable, largely had positive impacts on CFHNs and families and was sustainable in that the redesigned service achieved the caseloads of sustained nurse home visiting without compromising the quality of universal services, and there was a demonstrated fidelity in the delivery of the MECSH programme for families with adversity and/or limited abilities to adapt and self‐manage. The redesigned response, the goal determined pathways, the developed tools and models of care to support them have been effective for families across most of the pathways, giving confidence that, with appropriate appreciation of local contexts, the redesigned service would be scalable (Klaic et al., 2022).

4.1. Limitations and future research

In some areas of analysis, the conclusions are limited by small sample sizes albeit representing, in the case of the CFHNs, all the nurses engaged in the pilot region. Ideally, the evaluation would have included a re‐analysis of administrative data post‐redesign to assess service changes by risk; however, these data were unavailable. Further research is needed to determine whether the redesigned service had a proportionate impact on outcomes for families and the population. Future research could use population data, such as the Australian early development census, looking forward to the next census in 2024 when the children most impacted by the redesign will be starting school, and post the immediate impact of the pandemic, to determine whether the redesign positively impacted child health and development. Finally, the evaluation did not assess the impact of all pathways in the designed solution. Specifically, the impact of the new transition groups could not be assessed as group activities were curtailed by the COVID‐19 pandemic. The pathway to treatment services and/or child protection was not assessed due to the focus on the proportionate universal CFHN prevention response. Both these pathways should be investigated in future research.

5. CONCLUSIONS

This study undertook a comprehensive multi‐data, multi‐method analysis of the process and impact of a structured approach to CFHN service system redesign, using the Agency for Clinical Innovation model (Agency for Clinical Innovation, 2013). Using a systematic process, we have documented a clearly structured and inclusive clinical service redesign to promote a proportionate universal approach (Cowley et al., 2012) to CFHN service pathways and provision, and undertaken and evaluated the pilot implementation. The reallocation of resources to families experiencing greater adversity was shown to be feasible and to not incur undesirable impacts for families needing a universal response. Further, there is evidence of positive impacts of the redesign for families' experiencing adversity and/or lacking the ability to adapt and self‐manage despite those adversities and parent effectively, with more research needed in some areas of the design solution. The positive processes and impacts demonstrate the value of using a systematic, participatory process in clinical service redesign. This is the first report of an ongoing process, which has included the implementation of the design solution across all regions within the health district, and a new review to be conducted district‐wide from late‐2023.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest.

PEER REVIEW

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16298.

STATISTICAL STATEMENT

There is a statistician on the author team, Dr Kathy Donohoe. The authors affirm that the methods used in the data analyses are suitably applied to their data within their study design and context, and the statistical findings have been implemented and interpreted correctly. The authors agree to take responsibility for ensuring that the choice of statistical approach is appropriate and is conducted and interpreted correctly as a condition to submit to the Journal.

Kemp, L. , Donohoe, K. , Matthews, P. , & Aspery, W. (2025). Translating ‘proportionate universal healthcare’ into meaningful system design to optimize equity in child and family services. Journal of Advanced Nursing, 81, 7231–7244. 10.1111/jan.16298

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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