Cfhi Manual

Child friendly healthcare
A manual for health workers

By Sue Nicholson and Andrew Clarke
Edited by Sue Burr and David Southall
Abridged by Alice and Oliver Ross
Email contacts: office@mcai.org.uk

and andrew@cwsuk.org
Preface
This is an assessment and implementation manual about Child Friendly Healthcare (CFH) written for health
workers who plan, organise, provide or give care to children and their families. The manual defines CFH by
translating the articles of the United Nations Convention on the Rights of the Child (UNCRC) into simple CFH
Standards that are applicable to everyday healthcare practices. It provides a method and process for assessing
these and a simple structure for making any wanted or needed improvements so that children and their families
everywhere can receive the best possible healthcare, regardless of circumstance.
The Child Friendly Healthcare Initiative (CFHI), a child health quality improvement program, was developed by
Childhealth Advocacy International (CAI), Charity No: 1071486, in collaboration with The United Nations
Childrens Fund (UNICEF), The Child and Adolescent Department of Health and Development of the World
Health Organisation (WHO), the Royal College of Paediatrics and Child Health (RCPCH), UK and the Royal
College of Nursing (RCN), UK. The Community Fund, UK funded its pilot project.
The initial pilot development phase for the Child Friendly Healthcare Initiative finished at the end of 2002 and
the manual was written, edited and abridged in the period that followed. Consideration of differing publishing
options delayed the manual and tools being put into an easily accessible format until now. During that time
numerous changes and developments have been instigated and moved forward, at local, country and global
levels including many that have been influenced by the work undertaken and shared by the CFHI project.
However despite the time elapsed, the messages, truths, principles and practical methods promoted by the Child
Friendly Healthcare Initiative remain as valuable and needed as ever.
Dedication
This manual is dedicated to the many hundreds of children and their families and health workers from seven
main countries who participated in the pilot project, and whose thoughts, views and opinions it expresses. In
addition we thank many other individuals from a variety of organisations who have given their valuable time and
support to help develop the CFHI, and to our own families for their patience and understanding over the last
three years.
Abbreviations
AIDS: Acquired Immunodeficiency Syndrome
BFI: Baby Friendly Initiative
CAI: Child Advocacy International
CFH: Child Friendly Healthcare
CFHI: Child Friendly Healthcare Initiative
DFID: Department for International Development (UK)
EACH: European Association for Children in Hospital
EPI: Expanded Program for Immunisation
HIV: Human Immunodeficiency Virus
IMCI: Integrated Management of Childhood Illness
IMF: International Monetary Fund
IFMS: International Federation Medical Students
ORS: Oral Rehydration Solution
ORT: Oral Rehydration Therapy
PQCG: Paediatric Quality Care Group
WFP: World Food Program
WHO: World Health Organisation
WTO: World Trade Organisation
UNICEF: United Nations Childrens Fund
UNCRC: United Nations Convention of the Rights of the Child
UNMIK: United Nations Mission in Kosova
RCPCH: Royal College of Paediatrics and Child Health (UK)
RCN: Royal College of Nursing (UK) UK: United Kingdom
2
How to use this book

This book is intended to help any health planner or health worker assess the level of healthcare received by the
children and their families and make improvements working towards the best possible resulting care. Its
contents may also help parents and other carers of children.
The book is directly relevant to the healthcare of all children and its chapters are designed to be of practical
assistance. It can be read as a whole, but is divided into 5 sections to assist in gaining quicker understanding of
specific topics.
Glossary
Section 1 explains why a Child Friendly Healthcare Initiative (CFHI) is needed, discusses the principles
involved and its relationship with the United Nations Convention on the Rights of the Child (UNCRC).
Child Friendly Healthcare (CFH) is defined.
Section 2 describes and discusses each of the 12 Child Friendly Healthcare Standards and their
supporting criteria.
Sections 3 and 4 explain how to find out if you are Child Friendly and how to use the findings from an
assessment to make it better, that is to plan, make and acknowledge improvements. They also explain
how others can help you. The concepts, ideas and processes in these chapters are not new, but simplified
in this book.
Section 5 explains useful activities that support best possible practice. It contains useful examples
collected during visits to the health facilities participating in the development of the program.
The Appendix which is to be placed on the website www.cfhiuk.org contains The CFH Toolkit.
The tools cover the assessment of all the aspects of healthcare for children and their families. Tool 1 is
designed to help identify, prioritise and select CFH Standards for improvement; Tool 2 provides a more
detailed assessment of the chosen aspect of care including identification of the level of care currently
provided and, if not the best possible, suggests improvements by planning and implementation of
realistic, and sustainable development.
The appendix also contains examples of the following forms and policies:
An evaluation form
A format for writing an assessment report
A policy for preventing and managing a needle stick injury
Data that can be collected to provide information about a populations health
A toy safety policy
A consent form
Essential equipment, medical supplies and drugs for emergencies
Job aides
Organising and running a training course
Writing and funding a project proposal
Biographies
Dr Meriel Susan Nicholson FRCP, FRCPCH, FRIPH
Project Director for the pilot of the CFHI
Sue is a retired Paediatrician with a wide experience of child health and paediatrics. Her working career included time spent
as a family planning doctor, a general practitioner, a community health doctor and a hospital consultant. Although she
practiced as a general paediatrician, special interests have included developmental paediatrics, child protection, school
health, neonatal medicine, infection control, rheumatology, International Child Health and the training of doctors and other
health workers. She was a member of EACD (European Association of Childhood Disability), an associate police surgeon
and a fellow of 3 Royal Colleges. Although interests outside medicine are centred round her 4 adult children and 6
grandchildren, she is also an accomplished skier and gardener.
Andrew Clarke BSc, RN (Child), RHV
Project Officer for the pilot of the CFHI now Honorary CFHI Director
Andrew is a paediatric nurse and Specialist Community Practitioner in public health. He currently divides his time between
the United Kingdom where he works as a community Health Visitor in East Lancashire, and Nepal where he is employed as
Health Advisor (practice and development) for the childrens charity Child Welfare Scheme.
His interests span across international maternal and child health, but particularly in care giving practices (attitudes and
approaches), symptom control, utilising communities as vehicles for change, child protection and clinical innovation with
low resources.
Andrew is married with two young children and a helpful family whose ongoing support makes his international work
possible and whom hed like to thank.
Sue Burr OBE FRCN HFRCPCH RSCN RGN RHV RNT MA
Sue Burr held a variety of posts in hospital, community, and educational settings focusing on the nursing of children prior to
being appointed the Royal College of Nursings (RCN) first Adviser in Paediatric Nursing in 1984 a post she held till her
retirement in 2002.
Sues career spanned many changes and her interest and passion was that the psychosocial needs of the child and their
family, with parents being real partners in care, should progress alongside developments in nurse education and clinical
advances.
As an active member of various national and international organisations such as Board member of UNICEF UK & Trustee
of Action for Sick Children and Contact A Family Sue was committed to multi-agency/multi-professional working.
Sues appointment in 1995 as a Specialist Adviser to the House of Commons Select Committee on Healths Inquiry into
Services for Children was in recognition of her standing and achievements in UK health policy.
Dr. David Southall OBE MBBS MD FRCPCH
David Southall is honorary medical director of Childhealth Advocacy International. He is the chair of the working party for
CFHI. His main interests are the safe and effective management of emergencies in pregnancy, infancy and childhood. He
has published many papers concerning the protection of children from abuse and is active in developing child protection
systems for poorly resourced countries. He is particularly worried about the concept of suffering and how little attention is
drawn to this in current international programs for mothers and children. He is also active in developing palliative care
systems for disadvantaged countries. He has directed the development of many teaching materials for managing
emergencies as well as a textbook of International Child Health Care.
He is a consultant paediatrician active in acute general paediatrics in the UK National Health Service and was Foundation
Professor of Paediatrics at Keele University before his retirement.
Alice Leahy BA, MBBS, MRCP, Msc
Consultant paediatrician at Southampton General Hospital and lead for paediatric resuscitation; mother of five
Oliver Ross MbChb, FRCA
Consultant paediatric anaesthetist at Southampton, medical humanitarian experience, five children (same ones as Alice
above)
CONTENTS
Glossary
Section 1: Why a Child Friendly Healthcare Initiative (CFHI)?
Why is a Child Friendly Healthcare Initiative needed?
A reminder about the United Nations Convention on the Rights of the Child (UNCRC)
What is different about the CFHI?
What are its aims and objectives?
What are its guiding principles?
Its history
Who owns it?
Who has contributed to it?
What has the CFHI already contributed to improving childrens healthcare
What is Child Friendly Healthcare (CFH)?
Section 2: The Standards and their supporting criteria
1. Keeping children out of hospital
2. Supporting the best possible healthcare
3. Giving care safely in a secure, clean child friendly environment
4. Giving child centred care
5. Sharing information
6. Equity and respecting a child as an individual with rights
7. Recognising and relieving pain and discomfort
8. Providing appropriate emergency care
9. Enabling play and learning
10. Protecting children (recognising and supporting a vulnerable or abused child)
11. Monitoring and promoting health
12. Supporting the best possible nutrition
Section 3: How Child Friendly are you? (How to assess the care you give)
A framework for promoting, assessing and improving CFH
To self-assess or use an external assessor?
The responsibilities of a CFH coordinator?
About the assessment process
About the CFH Toolkit
How to identify the quality of healthcare you give
Why meetings and who should attend?
How do children and families contribute to the assessment process?
How do health workers contribute to the assessment process?
Section 4: Making it better (How you can make improvements and how others can help)
Why make it better?
Forces that support change
Barriers against change
How to make improvements
How others can help
Why acknowledge effort?
Section 5: Useful supporting materials (A how to do it series of supporting activities)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Adversity and problem solving

Advocacy
Audit
Cleaning
Clinical guidelines and other job aides
Data Management
Lifelong learning and how to put this into practice
Looking after health workers
Mission Statements with examples
Problem solving
Team working and leadership with an example of a health facility management structure
Examples of the following are on the CFHI website:

An evaluation form
A toy safety policy
A consent form
Job aides
Appendix: The CFH Toolkit

Information about the toolkit
Tool 1 to help with identifying and prioritising areas of care (CFH Standards) for improving
Tool 2 to assess each different CFH Standard in detail to identify the quality of its practice, and for use as a
framework to make improvements
Draft copyright. APRIL 2005 All rights are reserved. The information and photographs in the various pages
of this book are protected under the Berne Convention for the protection of Literature and Artistic works, under
other international conventions and under national laws on copyright and neighbouring rights.
Extracts of the information may be reviewed, reproduced or translated for research or private study but not for
sale or for use in conjunction with commercial purposes. Any use of information in the book
should be accompanied by an acknowledgment of the CFHI/CAI as the source, citing the uniform resource
locator (URL) of the article. Reproduction or translation of substantial portions of this book, or any use of this
book other than for educational or other non-commercial purposes, requires explicit, prior
authorization in writing. Applications and enquiries should be addressed to the CFHI Advisory Committee, c/o
Childhealth Advocacy International, Conway Chambers, 83 Derby Road, Nottingham NG1 5BB. UK
Tel: +44 (0)115 9506662 Fax: +44 (0)115 9507733 Email: office@mcai.org.uk
Website: http://www.mcai.org.uk
Acknowledgements
The CFHI is indebted to the many individuals and organisations that have contributed to its development. It
would not be possible to name everyone, but we would like to especially thank:
Present and former members of the CFHI Advisory Committee:
Dr John Bridson, David Bull, Sue Burr, Dr Patricia Hamilton, Andrew Radford, Robert Smith, Professor David
Southall (Chair), and Dr Tony Williams
6
The Community Fund, UK: For funding the pilot project, especially Ylva Sperling and Martin Wright
Pilot project assistants: Clare McNamara and Carol Rowley
Childhealth Advocacy International Staff: especially Meggie Szczesny
Our contacts at the Ministries of Health, WHO and UNICEF in Kosovo, Moldova, Pakistan and Uganda,
and also those at Dfid and UNMIK in Kosovo and Dfid in Uganda
The leaders, managers and senior health workers at the pilot sites:
Department of paediatrics and child health, Klinika Obstetrike Gjinekologjike, Gjilan Hospital, Kosovo
The Republican Childrens Hospital, Chisinau, Moldova
Childrens Hospital, Islamabad, Pakistan
Department of Child Health, Mulago Hospital Complex and Makere University Kampala, Uganda
Childrens services, Barnsley District General Hospital Trust, UK
Childrens services, Bro Morgannwg NHS Trust, Wales, UK
Derbyshire Childrens Hospital, England, UK
Yorkhill National Health Service Trust, Glasgow, Scotland, UK
Childrens services at Ulster Community and Hospital HSS Trust, Belfast, Northern Ireland, UK
Also childrens services at the Jubilee Hospital, Republic of South Africa and Bihac Hospital, Bosnia.
The CFHI coordinators for the pilot sites:
Dr Zijadin Hasani, Kosovo
Dr Tatiana Raba, Moldova
Dr Farrukh Qureshi, Pakistan
Dr Margaret Nakakeeto, Uganda
Dr Loretta Davis-Reynolds and Theresa Burkhill, Barnsley
Karen Healey, Karen Grant and Elizabeth Jones, Bridgend
Celia Cullen, Derby
Joe Skinner, Glasgow
Liz McElkerney and Roisin Coulter, Belfast
Interpreters for the pilot project:
Dr Mervan Tosca, Kosovo
Dr Evelina Cibotaru-Herghelegiu, Moldova
Dr Nick Jelamschi, Moldova
Nazia Mumtaz, Pakistan
Farida, Uganda
*UNICEF HQ for their interest and support
UK Committee for UNICEF for their sponsorship and support
The Department of Child and Adolescent Health and Development, WHO, Geneva especially Dr Hans
Troedsson and Dr Martin Weber
Action for Sick Children, England, especially Pamela Barnes
Action for Sick Children, Scotland, especially Gwen Garner
The European Association for Children in Hospital, especially Margreet van Bergen
Amberley Hall Nursery, Bristol UK for their active participation and on-going sponsorship, especially Mary
Butler and Ruth Robinson.
The play department Barnsley District General Hospital, UK for their active participation and on-going
sponsorship, especially Josie Evans
The International Medical Students Federation (IMSF)
The International Federation of Infection Control (IFIC)
The Infection Control Nurses Association, UK (ICNA) especially Esther Dias, for sponsoring the Infection
Control Nurse, Winifred Abong, from Uganda to attend the UK, ICNAs Annual Conference 2002
Pixel 8 Design, especially Nigel Dawes, for their sponsorship in designing the CFHI logo and for designing the
CFHI web site
Ann Morgan for designing the toolkit.
And the following individuals who contributed to the pilot project and/or this manual:
Armin Alagic, Mumtaz Begum, Peg Belson, Brigitte, Anne Casey, Shkumbin Dauti, Jane Frank, Dr Assad
Hafeez, Professor Mumtaz Hassan, John Hughan, Professor Mahmood Jamal, Dr Elizabeth Kiboneka, Christine
Kirkham, Dialeta Nela, Tess Little, Aileen McKenzie, Dr Isoke Muzora, Jane Nakaggw, Annette Naluyange,
Robert Nicholson, Dr Bernadette OHare, Angela OHiggins, Dr Christiane Ronald, Alban Rrustemi, Dr Marian
Scmidt, Tom Shearer, Fiona Smith, Dr Ecaterina Stasi, Julie Tate, Kent Thorburn, Dr Jo Venables and all the
others that are not individually mentioned.
CHILD FRIENDLY HEALTHCARE INITIATIVE

GLOSSARY OF TERMS
ADVOCACY in this context means speaking on behalf of children and/or their families who are either
unable or unwilling to speak about their unmet needs, situations, or people that make them unsafe, or
abuse of their rights. It is acting as a voice for someone who has no voice or is unable to use it.
ASSESSMENT /SELF-ASSESSMENT is the process of measuring the quality of an activity, service or
organisation. It is a method for:
Arriving at an objective view of current performance
Finding a base-line for the measurement of continuous improvement
Identifying evidence to validate judgements
Highlighting areas that show where performance is satisfactory or good
Highlighting areas that require further improvements
Seeing the way forward as part of a cycle of continuous improvement
ATTITUDES are complex mental processes that motivate behaviour and are thought to influence the
way we process information.
A CARE PATHWAY (patient pathway) is the exact story of a childs healthcare from the time of arrival
at a health facility to the time of discharge or death.
A CARE PLAN is a written document that is developed with the parent/carer and child, if old enough. It
details the roles and responsibilities of everyone involved in the childs care and when this requires
reviewing.
A CARER is a person nominated by a parent/s or the state to provide care for a child in place of a
parent/s.
A CHILD is a person up to their 18th birthday/the age of 18 years (UN)
An older child is a child around the age of seven and older. Common sense is needed in interpreting an
older child as children will vary in their maturity and willingness to answer questions.
A young child is usually less than seven years of age, although sometimes a younger child will be able to
answer questions designed for the parents and older children
An adolescent is a person in the 10 19 years age group (WHO)
A vulnerable child is a child whose right to survival, development, protection or participation is not
being met or is compromised
CHILD FRIENDLY HEALTHCARE is the best possible health care provided by health workers who
work together to minimise the fear, anxiety and suffering of children and their families by supporting and
practicing the 12 Child Friendly Healthcare Standards promoted in this book, and who advocate for their
child patients.
COLLABORATIVE means working together.
CONSULTATION is a social interaction during which the opinions of everyone involved are sought
before a decision is made.
CORE DATA SET is a minimum set of information related to a specific healthcare problem. It includes
demographic, treatment and outcome data.
CRITERIA provide the more detailed and practical information on how to achieve each CFH standard.
They can be described as structure, process or outcome criteria. They illustrate the standard and provide a
way of measuring it. (criteria describe activities to be performed, whereas standards state the level at
which they are to be performed. An essential criterion is one that must be met)
Structure criteria are the resources required in order to carry out the process stage of a standard
eg policies, procedures, documents, personnel, training, equipment
Process criteria are the actions undertaken by staff in order to achieve certain results. For
examples, assessment techniques and procedures or patient education
Outcome criteria are the desired effect of care in terms of patient responses, behaviour, clinical
condition, level of knowledge, satisfaction with care
DISABILITY is a lack or impairment of a particular capability or skill (The Child with a Handicap by
DMB Hall)
ETHNICITY concerns nations or races, it is about the customs, dress, food of a particular racial group or
cult.
EMOTIONAL MATURITY is reached when a person acts and behaves responsibly, is able to
contribute to the well-being of their community, and understands and is able to meet and support a childs
individual emotional needs.
FOOD SECURITY (GLOBAL) is a state of affairs where all people at all times have access to safe and
nutritious food to maintain a healthy and active life, and where there is no risk of house-holds losing
physical and economic access to adequate food (The State of Food Insecurity in the World 2003 Monitoring
progress towards the World Food Summit and Millennium Development Goals. Food and Agriculture Organisation
of the United Nations ISBN 92-5-104986-6).
GLOBALISATION is the process of increasing economic, political and social inter-dependence and
global integration that takes place as capital, traded goods, persons, concepts, images, ideas and values
diffuse across state boundaries (WHO definition)
A HANDICAP is any condition that prevents or hinders the pursuit or achievement of desired goals.
Sheridan M 1969
HEALTH is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity. (Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the
representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and
entered into force on 7 April 1948. The Definition has not been amended since 1948.
HEALTHCARE is informed advice, assessment, monitoring, assistance or treatment given for health
reasons. It includes preventive, investigative, curative, palliative and supportive care.
Appropriate healthcare is the best possible* healthcare given without compromising the care given to
other children sharing the same health worker, health facility or health service.
Effective health care is healthcare that achieves its objectives.
Evidence-based healthcare is based on a process of systematically finding, appraising and using
contemporaneous research findings to support the healthcare given.
10
A healthcare related policy is a written principle that governs an activity that health workers must
follow, about how to do something that must be followed by all health workers (a must do) for example
an evacuation policy, a drug safety policy, a hand washing policy and others.
A system of care is a clear detailed method for dealing with a situation, event or problem.
A HEALTHCARE ENVIRONMENT is any place where a patient is given informed advice,
assessment, monitoring, assistance or treatment.
A HEALTH FACILITY (HF) is an environment designated and funded for providing health care.
An In-patient HF is a hospital or other institution where users stay overnight for health reasons (ie. are
resident)
A HEALTHCARE PROVIDER is any organisation or individual that is in any way responsible for
planning, organising and/or providing health care.
A HEALTHCARE ORGANISATION is any authority that is responsible for providing healthcare
services.
Primary or community services are those health services whose health workers usually see the child and
family first. They are usually located near the childs home and give basic health care to a child living at
home whose health problem is not serious enough to require admission to a health facility, or an opinion
from another more skilled health worker.
Secondary/referral level/specialist services are those provided and given by childrens health workers
who see a child referred from primary care for a second opinion, or a specialist opinion, about their health
problem. They are usually able to admit a child for overnight healthcare and include all types of hospital
care.
A HEALTH WORKER is any person employed to give any form of health care, or who is working as a
volunteer.
A professional health worker is any person with a health or health related qualification who is employed
to give any form of health care, or who is working as a volunteer.
A skilled health worker has experience and special training to equip them for the job they are doing.
They may or may not have a professional qualification relating to childrens healthcare.
A key health worker is an identified individual with special responsibility, for example for a
child/family or a project/program such as infection control
HYGIENE is the principles and practices relating to cleanliness

An INDUCTION TRAINING/PROGRAM is a program of learning activities designed to enable new
health workers to a clinical area, type of health care or employment to function effectively in their new
job.
An INFECTION is the state or condition in which the body, or part of it, is invaded by a pathogen that,
under favourable conditions, multiplies and causes a health problem. A pathogen is a micro- organism
capable of producing disease.
Infection control is a program of activities that investigate, prevent and control the spread of infections
and the micro-organisms which cause them.
A healthcare acquired/related infection is an infection acquired while receiving any type of healthcare
or related to receiving healthcare. A hospital acquired/related infection is an infection acquired while
attending or resident in a health facility.
A pathogen is a micro-organism that can cause disease.
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The INTEGRATED MANAGEMENT of CHILDHOOD ILLNESS (IMCI) is a World Health

Organisation Program for delivering healthcare to children. It has very clear management, treatment and
referral pathways and an associated training program for the health workers who implement it.
(www.who.int/child-adolescent-health/integr.htm)
MONITORING is the process of collecting information about performance. Monitoring may be
intermittent or continuous.
OUTCOME is a measure of the effects, beneficial or adverse, which a person experiences as a result of
care, treatments or services they have received.
PEER REVIEW is a review of a service by those with expertise and experience in that service, either as
a provider, user or carer.
A POLICY is a principle about how to do something that must be followed by all health workers, for
example, a hand washing policy. It is usually written.
A PROGRAM is a planned series of events for a purpose
A PROTOCOL is a written recommendation, rule or standard to be followed in a situation where a
rational procedure can be specified. For example, a plan of action, an antibiotic protocol for a certain
condition/s, assessment and treatment of shock
PSYCHO-MOTOR DEVELOPMENT is a combination of motor and psychological (mental,

social, behavioural and emotional) development
RISK ASSESSMENT and MANAGEMENT is a systematic approach to assessing and managing risk.
Its aim is to reduce loss of life, financial loss, loss of health worker availability, health worker, child and
carer safety, loss of buildings, equipment or reputation.
A SAFE MOTHERHOOD PROGRAM includes healthcare during pregnancy, during delivery, after
delivery and advice given about sexual health, breastfeeding and family spacing.
SANITATION means the infrastructures and equipment for preserving public health and protecting
people from harmful contamination; for example keeping the water supply and waste disposal safe and
secure.
SKILL MIX is a term given to a general process of reviewing and, if necessary, changing the ways in
which traditional health care is delivered to patients.
SOCIAL WORK is the provision of advice and practical help for problems resulting from social
circumstances. A social worker supports vulnerable people.
A STANDARD is an agreed level of performance, appropriate to the population addressed. It is
observable, achievable, measurable and desirable
Generic STANDARDS are standards that apply to most, if not all clinical services
A SYSTEM is a clear detailed way of dealing with a healthcare situation, event or problem.
12
A TOOL assesses performance against a standard. Tools include interviews (open, semi-structured or
structured), questionnaires, structured observations, checklists and benchmarking.
13
Section 1
Why a Child Friendly Healthcare Initiative (CFHI)?
An introduction
Why is Child Friendly Healthcare important?

The aims and objectives of the CFHI are to improve the quality of health care given to children and
families across the world and to reduce unnecessary fear, anxiety and suffering during and because of a
healthcare experience. It does this by promoting the CFHI standards that define Child Friendly
Healthcare and through an assessment and improvement programme, with designated Gold, Siver and
Bronze standards support health workers in providing the best possible healthcare for children and their
families.
Despite the huge efforts of many health workers, a large number of health improvement programs at local,
national or international level, and the humanitarian aid provided to disadvantaged countries by the
international community, children are still:
Needlessly dying, or becoming disabled, from treatable diseases and accidents

Suffering unnecessary pain
Experiencing unnecessary fear, anxiety and suffering during and after a healthcare experience,
because their mental and psychosocial health needs are being overlooked.
Such healthcare contravenes the articles of the United Nations Convention on the Rights of the Child
(UNCRC) and continues in every country in the world, rich and poor. During the pilot project for this
initiative over six hundred health workers, parents, carers and children in hospitals in eight countries were
interviewed between May 1999 and December 2002. Even in the most disadvantaged health facilities,
there were many examples of excellent care, but everywhere there was care that can only be described as
very child unfriendly.
14
It is not surprising if health workers do not meet a childs mental, emotional and social health needs when
many children in the world do not have even their basic health needs met, but it is even more unforgivable
if these needs are overlooked when resources are such that a high level of healthcare is possible.
The first duty of a nurse is to the patient do no harm Florence Nightingale 1889
Worldwide most childrens health workers work hard to provide the best possible health care for each
child and their family. However many feel overwhelmed, undervalued and uncared for and many do not
know what the best possible care could be. The result is a lack of incentive to make the efforts required
for change. Allied to this is the belief that many resources are needed for change, leading to a sense of
helplessness when these are absent or hard to come by.
Care of critically ill

children in Africa
Others feel that they do not need to change, failing to recognise that good care can always be better. There
is always the need to constantly review provision of care to meet changing needs as the needs of any
society and its children change in response to new threats to health, such as changes in the economy or
population movements.
The quality of healthcare varies enormously between countries, between different healthcare
environments in the same country and within different clinical areas in the same health facility. It is
usually more dependant on the health workers responsible than on the resources available. Many
improvements can be made without an increase in existing resources by changing behaviours and
15
attitudes, creating more opportunities for sharing knowledge and skills, better leadership and team
working and understanding and practicing the articles of the UNCRC.
During the pilot study, many of the health workers interpreted what Child Friendly Healthcare means
differently. There was a lack of awareness about the UNCRC and many misconceptions about the
contents of its articles. Senior health workers in positions of authority, believed that childrens rights and
Child Friendly Healthcare (which they often thought was only about play and communication) were not
important priorities as they were much too busy looking after ill children. These health workers when
questioned more closely knew little about the articles of the UNCRC. In many of the countries visited the
UNCRC was not in the nursing or medical school curricula, nor was it a topic usually covered by lifelong education/training opportunities.
Every health worker in every country from the Government Minister to the health worker that cleans the
toilets, often the lowest paid and least valued health worker yet amongst the most important, has an
essential contribution to make to the provision of healthcare. Virtually all the worlds countries have
ratified the UNCRC, so health workers have a responsibility to follow its philosophies during their daily
work. The CFHI has developed simple Child Friendly Healthcare Standards that translate its articles
into every day health practices.
Promoting, assessing and supporting these CFH Standards will contribute to sustainable improvements
in the quality of healthcare received by children and families across the world, whatever the
circumstances.
A reminder about the United Nations Convention on the Rights of the Child
UNCRC adopted by the United Nations assembly on 22nd November 1989, is a legal International
document of unprecedented scope. The convention with its 54 articles is the most widely accepted
International convention in the world with all but one country ratifying it. It is about a childs right to
Survival (to life and healthcare),

Protection (from all forms of abuse, exploitation or neglect),
Development to their fullest potential physically, mentally and socially),
Participation (to be informed, able to express their opinions freely and to have their views taken
into account).
In the middle of difficulty lies opportunity Albert

Einstein)
A reminder about the UNCRC

found in a ward in a hospital in
Pakistan
16
The articles of the Convention, which were developed following wide global consultation and research,
apply to every child from birth to 18 years of age without discrimination. They focus on a childs best
interests and, although they reinforce the role of the family as the main carers and protectors, they also reaffirm the States responsibility to provide legal and other protection. The Convention is different from
other human rights laws as it recognises that, because of the special vulnerability of children, they need
special laws and care to support their nurture and protection. It respects cultural values but also highlights
the importance of international cooperation.
By ratifying the Conventions 54 articles, 192 governments of the worlds 193 countries have pledged to
review their national laws and practices to comply with these. A democratically elected International
Committee monitors compliance via mandatory five-year progress reports from these countries.
The Convention is divided into three parts.
Part 1 (the main part) contains the 41 articles that relate to childrens rights.
Part 2 has four articles that are concerned with a countrys implementation and monitoring of the
convention; in particular a countrys obligations to actively inform their citizens about the
convention and to contribute to the monitoring committee.
Part 3 contains nine articles about its administration.
The articles that relate directly to childrens health care are:
Article 2: Equal rights to care with no discrimination for any reason
Article 3: Whenever an adult makes any decision about a child or takes any action that affects the child
this should be what is best for the child
Article 6: The right to live
Article 7: The right to a name and nationality, and to be cared for by parents
Article 9: The right to remain with parents, or in contact with parents, unless this is contrary to the childs
best interests
Article 12 and 13: The right to receive information and express views and ideas freely
Article 19: The right to be protected from any form of harm including violence, neglect, and all types of
abuse
Article 23: The right of those with a disability (physical or mental) to lead a full and decent life within
their community
Article 24: The right to the highest standard of health and medical care attainable (the best possible
healthcare). In this article States are advised to place special emphasis on the provision of primary and
preventive health care, public health education, and the reduction of infant mortality, to encourage
international cooperation in this regard and to strive to ensure that no child is deprived of access to
effective health services
Article 27: The right to a standard of living adequate for physical, mental, spiritual, moral and social
development
Article 28: The right to education (school-type learning)
Article 30: The right of a child belonging to an ethnic, religious or linguistic minority to enjoy their
culture practice their religion and use their language
Article 31: The right to rest and play
Article 38: The right to be protected from and during armed conflicts, and not to be recruited to take part
in hostilities, especially before 15 years of age
Article 42: Is about the duty of the state to ensure that childrens rights relating to health are made known
17
In countries that have ratified the UNCRC, all health workers at all levels have a duty to ensure that its
principles are followed during their day to day delivery of healthcare to children and families. The CFH
Standards enable them to do this by translating the articles into everyday healthcare practices
What is different about the CFHI from other programs?
It has a global mandate since it derives its principles from the articles of the UNCRC
It is not prescriptive or dictatorial (imposed by a higher authority) but belongs to all health
workers
The suggested practical approaches of the assessment and improvement program are relevant and
applicable to health workers and health planners at all levels, in any healthcare environment and
in any country, as they have been developed with the help of health workers and families in
many different countries and health care environments.
It can be used for self-assessment or can be supported by invited external assessors
Its assessment process seeks the ideas and possible solutions to problems from the health
workers, children and their parents/carers thereby giving them a voice in helping to develop their
own services and healthcare systems
It enables and empowers local health workers to solve their own problems and find a way
forward, however small, to improve the care they give to children and their families
Any health care improvements made as a result of the program reflect what health workers want,
what children and families want and what is feasible
It raises levels of awareness by promoting what is possible and sharing good ideas
It is a vehicle for other local, country and international programs, especially those seeking
standards. It aims to promote all other validated programs.
It can easily be modified and adapted to suit local circumstance
It is low-cost or cost-neutral
What are the programs guiding principles?
1. Child Friendly Healthcare at its best possible level of practice
2. All activities to be based on the rights of the child linked with the responsibilities and duties of
health workers in partnership with parents/carers, other significant family members and friends to
meet these rights within the healthcare context.
3. Planned improvements arising from the program to be compatible with a countrys own plans for
health and acceptable to the countries health care providers at organisational level.
4. To be a positive, encouraging and motivating experience for children, families and health
workers.
5. To seek the views and opinions of children and their families in the assessment process and
reflect these in the prioritising, planning, and implementing of improvements.
6. The views and opinions of all involved health care workers (managers, health professionals,
other types of health worker such as ward cleaners, porters, security staff, engineers etc) to be
sought in developing and implementing the program and to be reflected in the prioritising,
planning, and implementing of improvements.
7. Barriers to providing the best possible CFH and the forces to create changes that achieve this to
be identified by the assessment process.
18
8. The focus for improvement to be on making the best and most appropriate use of existing
resources and systems of care, facilitating changes of attitude and behaviour, and optimising the
skills, approaches and knowledge of health workers.
9. Planned improvements in healthcare to be:
Facilitated by encouraging the sharing of good ideas, examples of good practice, skills and
knowledge within a healthcare environment and from other healthcare environments in the
same country and other countries
Facilitated by empowering health workers to identify and prioritise their problems, find their
own solutions to these and to function better by raising their awareness to the possibilities
Enabled by promoting team problem solving approaches
Acceptable to the religious, ethnic and cultural beliefs of the people involved providing these
are compatible with the articles of the UNCRC
Appropriate, sustainable and where possible achievable within the available resources
Implemented in a prioritised staged way
Any support for improvements from outside the healthcare environment to be provided first
by harnessing and coordinating any existing international humanitarian aid and other possible
in-country support.
10. Advocacy to be encouraged and used at an appropriate level to seek more resources or additional
support (new humanitarian aid projects), when without such input the healthcare available is
significantly compromised.
11. Regular review and evaluation of all activities
The history of the CFHI program
The idea for a global initiative dedicated to improving the healthcare experiences of children and their
families originated within the medical and nursing professions in the UK in the early 90s following the
adoption by the United Nations General Assembly of the Convention on the Rights of The Child
(UNCRC) on 22nd November 1989.
The concept of developing Standards of care based on the articles of the UNCRC was influenced by the
work of a number of other non-medical organisations dedicated to the well being of children.
In 1996 a small delegation presented a proposal for a CFHI based on such Standards to UNICEF New
York, who supported the idea. In 1999 a grant was received from the Community Fund UK by Child
Advocacy International (CAI), a non-governmental organisation and now the lead agency for the CFHI,
to undertake a pilot project for the Initiative in hospitals in the UK (also funded by a small grant from
UNICEF UK) and in hospitals in five other countries.
In November 2000, a first draft of these Standards was published in Pediatrics 1 and later the same year
the Child and Adolescent Department of Health and Development of the World Health Organisation
offered technical support to the project followed by help with identifying hospitals in four countries, in
addition to those in the UK, where the pilot project was acceptable to the regional and country UNICEF
and WHO representatives.
The remit of the pilot project was to research and consult widely to develop the CFH Standards and their
supporting criteria, to promote and support child friendly healthcare practices, and with the help of the
health workers and families in the chosen hospitals to develop the methodology and processes to assess
19
and improve Child Friendly Healthcare. These are described in this book. The CFHI is guided by an
Advisory Committee.
The number of sites that contributed to the pilot project was limited by the time and resources available.
More countries and health facilities have requested inclusion in any second phase pilot. However the
tools and methods developed have been designed to help health workers make progress with Child
Friendly Healthcare themselves without the need for an officially supported program.
Who owns CFH?
Wisdom, like knowledge and skills, is for sharing not owning
Child Friendly Healthcare does not belong to any organisation or individual, it belongs to every health
worker who practices it. The initiative to promote CFH and the program to assess and improve care has
no formal accrediting body and is therefore currently owned by the health workers who use it.
What is Child Friendly Healthcare?
The best possible integrated health care provided by health workers who minimise the fear, anxiety and
suffering of children and their families by supporting and practicing the 12 Child Friendly Healthcare
Standards.
Who else can promote Child Friendly Healthcare?
Any committed health worker who is familiar with its practices and principles can promote CFH by
sharing information about the CFHI and the UNCRC with others in the same healthcare environment, in
other healthcare environments in the same country and with health workers in other countries. Child
Friendly Healthcare belongs to every health worker that looks after children and families whether they
are involved in planning, organising, providing or giving care.
What is the best possible healthcare?
The practice of CFH Standards at their best possible level of practice.
The best possible:
Considers the childs best interests
Covers the preventive, investigative, curative and palliative aspects of health care taking into
account the most up-to-date evidence-base for each care given
Is affordable and effective
Is appropriate, taking into account the resources (human and material) and technology available
and the needs of other children sharing these
Is child centred* (see below)
What are a childs best interests
For healthcare to be in a childs best interests, any action or decision taken on behalf of a child must:
- Accommodate the circumstances of the situation
- Consider the childs needs and safety to be paramount
- Consult the child (whenever possible) and relevant others
- Balance this with the wishes and needs of the parents and other carers wherever possible
- Incorporate common sense
- Look at both present and future needs
- Be reviewed regularly and revised if circumstances change (be flexible)
20
*What is child centred health care?

Health care that:
- Meets the needs of the individual child and their family
- Is given by skilled health workers in partnership with parents/carers and children
- Is given in areas that are suited to the needs of the individual child and family
- Takes account of a child and familys normal daily routines and experiences and attempts to ensure
that these are disrupted minimally only in the best interests of the child
- Supports a child and familys response to their individual problems
The CFH Standards cover all aspects of childrens healthcare so inevitably overlap. Although numbered
they are of equal importance. They apply to:
A child of any age
A child of any developmental level, including whether or not the child has a disability
Any type of health care problem
Health workers in any country
All types of health worker
References:
Southall DP, Burr S. The Child-friendly healthcare Initiative (CFHI): Healthcare Provision in Accordance with
The UN Convention on The Rights of the Child. Pediatrics 2000; 106(5): 10541064.
Clarke A, Nicholson S. How Child Friendly are you. Paediatric Nursing 2001(13) 5:1215.
Southall DP, Coulter B, Ronald C, Nicholson S, Parke S, Editors. International Child Health Care - A
practice manual for hospitals worldwide.Child Advocacy International. London: BMJ Books; 2002.
Duke T, Tamburlini G. Improving the quality of Paediatric Care in peripheral Hospitals in Developing
Countries. The Paediatric Quality Care Group. Arch Dis Child 2003; 88: 563 565
UNICEF. State of the Worlds Children UNICEF; 2005
United Nations Convention on the Rights of the child (UNCRC). London: The UK Committee for
UNICEF; 2000.
United Nations General Assembly: Convention on the Rights of the Child. New York: United Nations;
1989.available from http://www.unicef.org/crc/crc.htm
21
Section 2
The Standards and their supporting criteria
Child Friendly Healthcare is the best possible integrated healthcare provided by
health workers who minimise the fear, anxiety and suffering of children and their
families by supporting and practicing the following 12 standards:
1. Keeping children out of hospital (and other health facilities or institutions) unless this is best for the
child: Relates to CRC Articles 9, 24, 25, 3
2. Supporting and giving the best possible healthcare: Relates to CRC Articles 2, 6, 23, 24, 37
3. Giving healthcare safely in a secure, clean child friendly environment: Relates to CRC Article 3
4. Giving child centred healthcare: Relates to CRC Articles 5, 9, 14, 37
5. Sharing information and keeping parents and children consistently and fully informed and involved in
all decisions: Relates to CRC Articles 9, 12, 13, 17
6. Providing equity of care and treating the child as an individual with rights: Relates to CRC Articles 2, 7,
8, 9, 16, 23, 27, 29, 37
7. Recognising and relieving pain and discomfort: Relates to CRC Article 19
8. Giving appropriate resuscitation, emergency and continuing care for very ill children: Relates to CRC
Articles 6, 24
9. Enabling play and learning: Relates to CRC Articles 6, 28, 29, 31
10. Recognising, protecting and supporting vulnerable or abused children: Relates to CRC Articles 3, 11,
19, 21, 20, 25, 32, 33, 34, 35, 36, 37, 39
11. Monitoring and promoting health: Relates to CRC Articles 6, 17, 23, 24, 33
12. Supporting best possible nutrition: Relates to CRC Articles 3, 24, 26, 27
There are four supporting criteria common to all the CFH Standards, and although omitted from the
beginning of each of the descriptions of the 12 standards below, in the interests of space, their importance
cannot be overemphasised.
Each of these 4 topics are covered in detail in Section 5
Mission statements.
Education and training. Healthcare standards will not be met unless all healthcare workers have
the motivation and the facilities to keep up to date with current practices. They must also receive
training to allow them to work in line with improved standards.
Data collection and management. This a key component of an effective, functioning health care
system.
22
Audit Participation in audit is an essential process for all those involved in provision of
healthcare. It ensures that necessary changes are made to meet with accepted standards, and that
all aspects of healthcare are kept continually under review
23
STANDARD 1: Keeping children out of hospital (and other health facilities or institutions)
unless this is best for the child
Health care providers, organizations and individual health care workers, share a responsibility to
advocate for children and to reduce the fear, anxiety and suffering of children and their families by
ensuring that they keep a child in a hospital, or other health facility, only when this is in the childs
best interests.
A day care unit in Pakistan for children with respiratory illness

Children are observed through the day and sent home at night if well enough
Supporting criteria
1. Primary (community) and secondary (specialist) health workers for children and pregnant women
work together to provide services that:
Are accessible
Are free or easily affordable
Share policies (such as Integrated Management of Childhood Illness)
Use jointly agreed referral pathways
Include the views of children and families and consult health workers in primary or secondary
facilities when they plan these services
Are needs based
2. Health services for pregnant women and children (including the newborn) with any type of health
problem that includes:
Primary (community) health services
Secondary (referral level/specialist) out-patient services with policies for admission, review (to
see if it is in the childs best interests to remain under the care of the secondary service), and
discharge (referral back to back to the community services):
Secondary in-patient services with admission, daily review (to see if it is in the childs best
interests to remain in the health facility) and discharge policies, day care, and outreach services
that support care in the childs home:
24
3. Programs to prevent illness and injury (preventive services) that include:

Systems/policies to identify and support vulnerable children and their families:
Health monitoring, screening and promotion programs
Strategies to protect unborn children such as a safe motherhood program
Discussion
Best practice is to recognise and treat children with illnesses, disabilities and other physical or mental
health problems in the community as soon as possible as this can prevent children needing a hospital visit
or admission. Also to admit children, or place children in institutions, only if appropriate health care
cannot be given at home. Care at home is always preferable. When care at home is not appropriate, fear
anxiety and suffering can be minimised by making the hospital experience as child friendly as possible.
A child friendly ward entrance (looking from the ward to the hall and lifts)
Good community preventive health programs that include health education, to help parents recognise
when their child is ill, health screening, the monitoring of childrens growth and development and the
close monitoring of pregnant women (safe motherhood programs) can limit the number of children
needing hospital care. Ideally this type of high quality health care is provided by comprehensive primary
health care services that are appropriate, effective, affordable and easily accessible to all families,
regardless of their financial status.
Doctors and nurses are expensive to train and employ. Overseas training programs in rich countries are
not always appropriate for disadvantaged countries. Doctors and nurses receiving training in rich
countries may want to use the skills they have acquired in the well resourced health services they have
become accustomed to and be inclined not to return to their own poorly resourced country. The
International Community has a responsibility to discourage, not encourage, this migration, and to
advocate for better working conditions for health workers in their own countries rather than poach
workers to support their own health services.
A team comprised of different types of health worker with appropriate delegation of tasks can make
health care more accessible to more people. In countries where doctors and nurses are scarce, or not
affordable, effective early healthcare can be given to children by generic health workers (ideally from the
local community) trained to provide a lower level of basic care using guidelines for managing the
25
common conditions (for example WHOs Integrated Management of Childhood Illness (IMCI) Program
with its clear referral guidelines and early management/treatment strategies). The few trained doctors and
nurses can then be deployed to support them and provide a higher level of care in the centres. This system
is cost-effective and works well in Nepal with its sparse population and remote villages.
Such innovative systems to use skills effectively can also improve the delivery of healthcare in
communities in advantaged countries. For example, a peripheral hospital under threat of closure in
Northern Ireland, UK is now staffed solely by nurses who use guidelines to assess and treat minor
accidents and emergencies, and have tele-communication support from doctors in the nearest large centre.
Tele-medicine technology that enables doctors working many miles away to see x-rays and give advice
to the nurses providing the service locally
.
In advantaged countries, even when accessible, affordable integrated health services do exist, children are
still admitted to and remain in hospital unnecessarily. Some of these admissions can be prevented by:
Effective triage when first seen
Rapid same day access to a referral level (specialist) opinion if needed
Appropriate emergency management and treatment
Good communication between all health workers to limit unnecessary delays in treatment and
discharge
Specialist care supervised by referral level/specialist health workers given at home when possible
Referral/specialist level day care facilities whenever possible for assessment, investigation and
treatment so that children can sleep at home if they live nearby
A Child Friendly day surgical unit
26
Many children with complex or chronic illnesses (for example mental health problems, asthma, diabetes,
disability and others) can be successfully managed at home if there are specialised referral services with
attached out-reach services that can provide the necessary support for parents. Care in the home is of
course only feasible when these resources are available, the children live within easy reach of these
services and home conditions are satisfactory.
Standardised admission, daily review and discharge policies, and verbal and written discharge plans can
reduce the length of time a child remains an in-patient. Best practice is to develop these in collaboration
with parents and primary care and/or other relevant community professionals. To be effective they need
to include a diagnosis or reason for the childs admission, a prognosis and clear instructions concerning
any actions, treatment or follow-up necessary that will have implications for carers and health care staff in
the community. There are clear advantages to writing this information into parent-held child health
records
Arrangements for follow-up by the hospital, if this is necessary, and/or prescribing and dispensing drugs
for taking home need to be made well before the child is due to leave so that unnecessary delays for a
family are minimised. Delay in dispensing drugs or a long wait to be discharged for any reason is
unacceptable practice.
Best practice is for the length of stay in an in-patient health facility to depend on research evidence
integrated with local knowledge, and evidence based treatment regimes which should be adopted for the
common childhood conditions. Children should not be kept in hospital for unethical treatments such as
painful intra-muscular injections (when oral drugs would work equally well), for treatments that can be
given at home, or for the convenience of health workers.
In all countries, but particularly in many poorly resourced countries, children are sometimes abandoned in
health facilities. These children often receive inadequate nutrition with minimal stimulation
(developmental and play opportunities) and no normal one-to-one care. An attachment to a single carer is
essential for a childs long-term mental health and development so discharge rapidly to caring foster
families rather than institutions is best practice.
Advocacy by health workers for early fostering and/or adoption for abandoned children and/or those in
need of protection and care is important.
Finally good data management, regular audit leading to evaluated change, and joint education/training
opportunities for all health workers (community health services and the referral level services) will all
contribute to meeting this Standard thereby keeping children with their families at home as much as
possible.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 9, 24,25, 3. New
York: United Nations; 1989 available from http://www.unicef.org/crc/crc.htm
Hall D, Elliman D, editors. Health for All Children. 4 th ed. Oxford: Oxford University Press. 2003
Department of Child and Adolescent Health and Development, World Health Organisation. Management
of the Child with A Serious Infection or Severe Malnutrition, Guidelines for care at the first referral level
for developing countries. Department of Child and Adolescent Health and Development. Geneva: WHO,
2000
27
Southall DP, Coulter B, Ronald C, Nicholson S, Parke S, editors. International Child Health Care - A
practice manual for hospitals worldwide. Child Advocacy International. London: BMJ Books; 2002.
Department of Child and Adolescent Health and Development, World Health Organisation The Integrated
Management of Childhood Illness (IMCI) - a World Health Organisation Program for delivering
healthcare to children, supported by UNICEF. Geneva: WHO. Available from http://www.who.int/childadolescent-health/integr.htm
Swartz L, Dick J. Managing chronic disease in less developed countries. BMJ 2002; 325:914-5
28
STANDARD 2: Supporting and giving the best possible healthcare

Health care providers, organisations and individual health workers, share a responsibility to
ensuring that they support the best possible healthcare.
A board with information for parents/carers about how they can ask questions or share a concern. It
gives information about who to contact and how, showing photographs of those responsible for the
different aspects of management and healthcare.
Supporting criteria
1. A transparent (open) management team for a health facility who delegate:
The management of all the important support services to lead health workers who are accountable
and responsible for the organisation, quality, budget and training for their service
Important healthcare tasks (such as immunisation, infection control, breast feeding, resuscitation
child protection, audit, lifelong learning and others) to lead health workers who have
responsibility for the policies, job aides, quality of practice and training
2. Open management of health workers that:
Appoints and dismisses health workers, validates qualifications, assesses suitability for
employment, has a health worker identification system, enables safe staffing levels, identifies and
addresses intimidation (bullying) and has system for disciplining health workers
Screens health workers for health problems, provides advice about the prevention of work related
medical, psychological and emotional problems and supports those in individual health workers
when these occur
3. Provision of effective investigative and therapeutic health support services relevant for the level of
care given.
4. Provision of effective general support services (such as security, food preparation, laundry, cleaning
and other services) relevant for the level of care given and the type of health care environment.
29
5. Essential material resources relevant for the level of care given and the type of health care
environment, including:
Health facilities that are suitable for the level of care given and needed
Appropriate, effective, safe and sustainable clinical and non-clinical equipment (essential list of
equipment compatible with WHO recommendations)
A free or affordable, safe, secure supply of essential drugs and disposables with standardised
policies for their use (essential lists compatible with WHO recommendations)
6. Appropriate evidence-based systems of care, policies, clinical guidelines and other job aides that
are known about and used by all the health workers working in the same healthcare environment.
7. Lifelong (during and after training) learning (education/training) opportunities (self, internal and
external) about the UNCRC and Child Friendly Healthcare and access to published research and other
healthcare literature.
9. Effective management of written information (data) that includes the use and organisation of health
records, coding systems for health problems and the collection and examination of reliable data for
important key indicators about childrens health.
10. Multidisciplinary clinical audit linked to evaluated change/s for all health workers (See Section 5).
11. Access to ethical advice on clinical and research issues for all health workers
12. Risk management procedures owned and run by local health workers linked to wider risk analysis at
hospital and national level. Covered in Standard 3
Discussion
In order to give the best possible care to children and families, health workers need to integrate the
highest quality scientific evidence with clinical expertise and the opinions of the family
(Moyer VA. Elliot EJ. Preface in Evidence Based Paediatrics and Child Health).
Health care of any type that is in a child and familys best interests has to be balanced with what is
possible, and with the needs of other children sharing the same health worker, health facility or health
service.
It is the responsibility of health workers at an organisational level to ensure these services, structures,
resources and activities are in place. It is the responsibility of the health workers who give the care in
partnership with the child and family to access, use and participate in these. If this is not possible because
they either do not exist, or are of low quality, health workers have a responsibility to advocate for these
and to continually try to make it better. Advocacy is an individual and collective responsibility inspired
by strong, but open and accountable leadership that delegates.
There is evidence to show that support services and generic clinical tasks (such as immunisation,
breastfeeding advice, infection control, child protection and others) are usually of higher quality when
delegated, providing the nominated health workers are also given the authority to effectively coordinate
the task and to develop, monitor and maintain the quality of its practice. When developing their services
best practice for these coordinators is to:
30
Follow any existing evidence-based recommendations made by WHO and other International and
National Organisations
Acquire and regularly update their skills and knowledge
Consider the evidence-base for their actions and policies
Lifelong learning opportunities and access to the evidence that supports best possible healthcare are
essential requirements for health workers if they are to increase their skills. Best practice is therefore for
all professional health workers to have access during working hours to a library that has up to date
medical and nursing books and journals, to the Internet, and to general and specialist professional
continuing life-long education/training. However it is important to remember that access to evidence and
other learning opportunities does not necessarily lead to a change from poor practice to good practice.
Policies, standardised systems of care, clinical guidelines and other job aides all contribute to supporting
the best possible healthcare. However to be used successfully they need to be owned and their value
recognised.
Job aides in Pakistan showing

pathways of care to be followed
in emergencies
Danger signs in pregnancy from Bangladesh
Health workers, both professional and non-professional, are valuable. Striving to provide the best
possible healthcare is challenging and stressful, physically, intellectually and emotionally. It is therefore
not surprising that health workers are more likely, than the general population, to develop work-related
physical and mental health problems. Open terms of employment and being mentored and nurtured by
employers helps prevent their loss to the country, health service and health facility. Systems for the
support and care of the care givers are essential if they are to provide the best possible service.
Good data management is also important as reliable and appropriate data are needed to support all aspects
of health care planning and provision, audit and advocacy. This starts with the clinical record, includes
the recording of high quality information, the effective organisation and management of records, the
reliable coding of disease and the collection and examination of this information to produce reliable
statistics for the key childhood indicators of health. All health workers have a vital part to play in this
chain.
31
Effective manual data management in Moldova reflected by this well organised low-cost storage system
The final criterion for providing the best possible health care is to have access to reliable independent
advice on the many ethical issues associated with clinical practice and research.
However difficult, best practice is to allow and make time (without compromising patient care) for these
important support activities during normal working hours. All these support activities are described in
more detail in later sections of this book, especially in Section five which explains the best way to do
these.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 2, 6, 23, 24, 37. New
Nunez O, Carroll W, Hopkins M, Southall DP. Ethical systems within the hospital. In Southall DP,
Coulter B, Ronald C, Nicholson S, Parke S, editors. International Child Health Care-A practice manual
for hospitals worldwide. Child Advocacy International. London: BMJ Books; 2002.p11-15
.
District Health Facilities Guidelines for Development and Operations. WHO Regional Publications,
Western Pacific Series No 22.WHO 1998. Available from
http://www.wpro.who.int/pdf/pub/2003catalogue.pdf
Moyer VA, Elliot EJ, Davis RL, Gilbert R, Klassen T, Logan S, Mellis C, Williams K, editors. Evidencebased Paediatrics and Child Health.London. BMJ Books; 2000.
Meates M, Duperrex O, Gilbert R, Logan S, editors. Practising Evidence-based Child Health. Abingdon:
Radcliffe Medical Press; 2000
32
Committee on Quality of health care in America, Institute of Medicine. Crossing the Quality Chasm: A
new health system for the 21st century. Washington, DC: National Academy Press; 2001.
World Health Organisation. Maintenance and Repair of Laboratory, diagnostic imaging, and hospital
equipment. Geneva: WHO; 1994.
World Health Organisation. Counterfeit drugs guidelines for the development of measures to combat
counterfeit drugs. Geneva: WHO; 1999
World Health Organisation Model Formulary, Geneva: WHO; 2002. Available from
http://www.who.int/medicines or
http://www.who.int/medicines/organization/par/edl/expcom13/eml13_en.doc
Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs. BMJ 2002; 324: 800 - 801.
Salvatierra-Gonzalez R, Benguigui Y. Antimicrobial resistance in the Americas magnitude and
containment of the problem. Washington DC: Pan American Health Organisation. 2000
Kraesten E; Vandepitte J. Basic Laboratory Procedures in Clinical Bacteriology. 2 nded. Geneva: WHO;
2001.
World Health Organisation. Manual of Basic Techniques for a Health Laboratory, 2 nd ed. Geneva: WHO;
2002.
World Health Organisation. Medical Records Manual A guide for Developing Countries. Geneva:
WHO; 2002.
Tamburlini G, Ronfani L, Buzzetti R. Development of a child health indicator system in Italy. Eur. J. of
Public Health 2001; 11: 11 17
Williamson A, Marcovitch H. Getting ADC to paediatricians in developing countries. Arch. Dis. Child.
2001; 85(1).
Vincent C, Taylor-Adams S, Chapman EJ, Hewitt D, Prior S, Strange P, Tizzard A. How to Investigate
and Analyse Clinical Incidents: clinical risk unit and association of litigation and risk management
protocol. BMJ 2000; 320: 777- 81.
Davis D A, Thompson M A, Oxman A D, Haynes B. Evidence for the effectiveness of CME. A review
of 50 randomised controlled trials. JAMA 1992; 268: 1111 1117
Weindling AM. Education and Training: continuing professional development. Current Paediatrics 2001;
11: 369374
33
STANDARD 3: Giving healthcare safely in a secure, clean child friendly environment

ensuring that they give healthcare safely in a secure and clean child friendly (See Standard 4)
environment.
Supporting criteria
1. Effective security and general safety policies and systems of care to protect children, carers, visitors
and health workers from accidents or other dangers while they are in a health facility.
2. Policies and systems that are used by everyone to keep equipment and health care environments clean
enough to minimize the risk of acquiring a healthcare related infection
3. Other general infection control policies that are used by all health workers to minimize the risk of
acquiring a healthcare related infection
4. Systems and policies that are used by all health workers to minimise work related physical, emotional
and mental health problems in health workers
5. Evidence-based clinical guidelines and other job aides that are followed by all professional health
workers in the healthcare environment. These include ones about hand hygiene, fire safety and
evacuation, no smoking where there are children, the dangers of advertising, safe sharps disposal, and
management of needle stick injuries, lifting patients, food safety, laundry safety, safe waste disposal and
radiation protection. (See also standard 2)
Discussion
Every health worker has a responsibility to give healthcare safely and to make sure that the places where
they give care are as secure, clean and child friendly as possible.
Clean, safe Child Friendly ward in a hospital in Wales
34
It is very important to protect themselves and the children and families from dangers, also to protect
possessions from damage, loss or theft. Possible personal dangers for children, parents/carers, visitors
and/or health workers include:
Physical harm, for example abduction or a deliberate injury
An accidental injury from unsafe equipment, fittings, electrics, furniture, buildings
An unwanted side-effect from any system of care or treatment program
A healthcare related infection
A work related injury or illness such as HIV/AIDS, hepatitis, back injury or a stress related
mental health problem.
To prevent all these dangers best practice is for health workers and families to work together to identify
possible problems and solutions to prevent these. Health workers need to be able to report openly about
any security or safety concerns, without fear of losing their job or harming their career prospects. Families
need to be able to voice their concerns without fearing that their childs healthcare may be adversely
affected. Best practice is for all health facilities to have an effective system to assess, prioritise and
investigate these concerns properly.
To give healthcare safely there need to be enough health workers to look after the children that need
healthcare throughout the twenty-four hours. All too often in many of the countries visited during the
pilot project many health workers were present during the working day but very few during the late
afternoons, evenings and nights. Children are ill throughout the 24 hours, therefore staff need to be
allocated in safe numbers for every time period. Best practice is always to have enough health workers on
duty to ensure each individual childs safety. When there are few health workers it is even more important
to distribute these sensibly
To help limit the number of clinical mistakes, best practice is for everyone to use the same policies and
guidelines for giving healthcare programs and treatments, and also to use other job aides as reminders. To
develop a sense of ownership these need to be developed and introduced following wide consultation. It is
also important for clinical guidelines and other job aids to be compatible with WHO and/or other
International guidelines, and with any country and/or regional guidelines.
Examples include:
security, cleaning, waste disposal, hand washing and the control of infection.
common investigations and clinical procedures, blood transfusion.
lifting patients
the use of drugs and disposables and quality control measures for these that will minimise harm
caused by unnecessary or inappropriate treatment.
safe and appropriate use of blood and blood products
A hand washing reminder, but the sink is unsafe as it has a taped

crack
35
Responsibility for these and the management and prioritisation of risk can be delegated to named lead
health worker/s who is/are given the authority to develop, monitor and change these as well as coordinate
related activities.
Safety and security for people and possessions will also be helped by:
The use of name badges by health workers and a method for identifying inpatient children, such
as wrist bands
A security system and/or security health workers at the entrances of health facilities
Lockable storage facilities: but not for emergency equipment as this needs to be immediately
available
Having a system for children, families and health workers to report and investigate accidents,
drug administration errors and infections acquired during an in-patient stay
Accounting for health facility property
Accountability for, and secure storage of drugs and other disposables
Giving an individual named health worker the responsibility for protecting equipment, books and
other items
Using a structured system to reduce or eliminate losses due to accident or misadventure (Risk
management). The aim of risk management is to improve the quality of care by identifying and
reducing risks that might result in damage to a patient, visitor or health worker, or result in a
complaint and/or litigation
To minimise the dangers associated with a fire or other disaster, best practice is for all individual health
workers to:
Know about evacuation, fire management and other general safety measures, and to contribute to any
disaster practices.
Other ways to reduce accidents and harm include:
Keeping the utilities (electrical circuits and plumbing), buildings, fittings, medical and other
equipment and furniture in a good state of repair by good organisation and management, regular
maintenance, risk-prioritised repairs and funding.
Protecting children, their carers and health workers from radiation by using safe x-ray machines, lead
aprons, gonad protectors and guidelines for which health problems need an x-ray and which do not
Gonad protectors of different sizes
36
Safety gates to help prevent children leaving a ward and on stairs that children may use.
Safety gates on the

third floor of a building
Window safety catches or locks to prevent children falling from opened windows.
Banning possibly harmful advertising from a health facility, for example of formula milks
Not allowing smoking in areas where there are children, oxygen cylinders or flammable
liquids/gases
No smoking sign on a childrens ward in Eastern

Europe
Reducing healthcare acquired infections

Healthcare related infections cause unnecessary deaths and suffering in children and their families and
also incur large costs to a health service. They affect at least 10% of all hospitalised patients in the
advantaged countries and probably a higher percentage of patients in the disadvantaged countries. These
infections may be acquired because a child shares the same facilities and equipment with others, from the
environment, especially the work surfaces or directly from health workers. Only a very small number are
caused by visitors or by other patients.
37
The effectiveness of hand washing and the cleanliness of the washing facilities and toilets in a health care
environment correlate well with the healthcare acquired infection rate.
The infections are caused by the micro-organisms that are always around in a healthcare environment.
They contaminate the hands and uniforms of health workers and colonise the sinks and other equipment.
Why is cleaning so important?
At least half of healthcare related infections can be prevented if health workers keep their hands, their
uniforms, the environment and the equipment scrupulously clean to reduce the number of organisms
around. It is essential that each individual health worker examines their own practice, keeps up-to-date
with infection control policies, especially hand-washing and follows such policies themselves as well as
ensuring that other health workers also comply.
Effective hand washing is the most important way a health worker
can prevent a healthcare acquired infection
A bucket used to flush an adjacent nurses

toilet: there are no spare parts to repair the
flush mechanism, which broke a year
previously, no soap and no method of hand
drying
What is needed to keep hands clean?

Enough clean toilets with nearby sinks for hand washing and a facility for hand drying
Enough clean sinks and showers that are easy to use
Knowledge about the importance of hand washing
Strict hand-washing policies.
Hand washing reminders at all sinks (when and how)
A secure and adequate supply of soap
Soap on a string: An effective

way to prevent it from being
stolen
38
The only facility for washing

kitchen utensils and hands in a
hospital kitchen in Eastern Europe.
An effective, clean, accessible

resource for hand washing in a
childrens ward in the UK There is
no excuse for not keeping your hands
clean if you have this resource.
When there are no resources for buying

paper towels, cut up material squares used
once only, then laundered are just as
effective
A method for drying hands properly

Effective methods for handling and disposing of bodies, specimens, human waste, body fluids
and other waste, including a method for separating the different types of rubbish.
A good example set by senior health workers (the pilot project confirmed that they are the worst
offenders) and a culture for hand washing
A water supply that is:

1.
2.
3.
4.
Secure (never runs out)

Clean and safe to drink (and is regularly tested for dangerous micro-organisms)
Adequate in amount for drinking and for cleaning
Hot for washing and cleaning procedures (For safety ideally hot water should be stored at
65 degrees C, distributed at 60 degrees C and then reduced to 43 degrees C to be used
from the taps)
5. Accessible in all areas where children are given healthcare
39
An alcohol based product to use for hand cleaning when it is not possible or practical to wash
hands
Clean clothes always worn by health workers
A no touch policy that is followed by everyone. This means not touching anything or anyone
unless essential (the affectionate hugging of children is an essential act that must be allowed) and
only after hand washing.
What else needs to be clean?

Food
Hygienic food preparation, handling and storage (see The World Health Organisations ten steps to
Hygienic food preparation) will reduce the possibility of a food-born illness. Poor hand washing,
frequency and technique, is strongly linked to food poisoning.
Unhygienic, unsafe
parents/carers kitchen
Laundry
All bedding/curtains/towels/flannels must be regularly washed with a detergent/disinfectant. Access to
Industrial quality washing machines is preferable. Water temperatures of at least 60 degrees C and
preferably above should be used to destroy the micro-organisms on clothes and other materials. The
uniforms of health workers need to be kept clean and used only in the same clinical area to prevent
moving micro-organisms from one clinical area to another. If health workers visit more than one clinical
area they should change uniforms or clothes between each area or wear disposable protective clothing
over their own clothes when they move to a different clinical area
Unhygienic personal laundry facilities

at a hospital in Asia
40
The equipment and furniture and the whole of the hospital including the grounds must also be kept
scrupulously clean.
A scrupulously clean environment is the responsibility of each and every person in the health care
environment
Health workers who clean are best supervised by professional health workers and given adequate status
and pay that recognises the importance of the work they are doing. They need access to sufficient
cleaning agents and materials, preferably colour coded for the different areas to be cleaned and induction
training about the health facilitys policies and cleaning systems.
Effective and supervised cleaning policies and systems for cleaning the entrances, corridors, wards
(floors, walls, window-sills, light fittings and curtains), toilets and washing facilities, kitchens and all
other areas in a health facility will contribute to reducing risk of acquired infections and should cover:
Cleaning methods used for all these different areas, also fittings, fixtures, furniture, bedding and
other non-clinical equipment
Cleaning frequency
Cleaning materials and for what - colour coding of cleaning cloths/materials for use on different
surfaces can be helpful.
Use of cleaning agents, including disinfectants in appropriate dilutions for the task
Effective management of spills of body fluid (blood, urine, vomit, faeces and saliva etc.)
The cleaners or, if cleaners are not always available, others need to be trained and supervised by
the senior health worker for the clinical area.
Waste disposal systems and waste separation. Safe waste disposal systems and policies will
prevent body fluids, faeces, drugs and disposables being a danger to others .
A budget for cleaning is essential.

Entrances of health facilities should screen visitors' shoes for dirt, corridors need to be cleaned at least
twice a day with a disinfectant and ward areas need to be kept scrupulously clean. The priority is the
adequacy and state of the toilets and washing areas/bathrooms. Best practice is for these to be kept
scrupulously clean throughout the twenty-four hours by frequent cleaning and disinfection (See also
Section 5 for more information about how to clean).
All these issues may be seen as costly for a health service but save costs when balanced against
the cost of the increase in hospital stay due to infection, the additional medications needed and
the sometimes unnecessary deaths.
41
A method for using different coloured

cleaning cloths for different surfaces
What else can be done to reduce the risk of a healthcare related infection?
Micro-organisms become more difficult to treat if they develop a resistance to antibiotics. This occurs if
antibiotics are used indiscriminately. Best practice is for every health facility to develop and use an
antibiotic policy to control and restrict the use of antibiotics. For this to be effective all prescribing health
workers need to respect and follow the policy.
Other ways of reducing infection include:
Limiting the number of people who look after a child. The risk of cross contamination is
reduced if a childs parent/carer does as much of the childs care as possible and the number of
health workers who have contact with the child is limited, particularly in high-risk areas such as
intensive care
Avoiding crowding. Adequate space between beds will also limit the risk of cross-infection
Unnecessary over-crowding of babies in a

ward in Eastern Europe
42
Having a system to ensure that equipment, surfaces and other objects are cleaned before use by
another child
Having a lead health worker and when resources permit an infection control team to develop and
supervise all the infection control practices following wide consultation.
Having a wound management policy (including an umbilical cord management policy)
Having healthy staff
Best practice is for all health workers to have regular training about these security and safety issues and
an opportunity to audit compliance with the policies to see if these are achieved at the best possible level
with the resources available.
References:
United Nations General Assembly: Convention on the Rights of the Child. Article 3. New York: United
Nations; 1989 available from http://www.unicef.org/crc/crc.htm
OHiggins A, Nicholson S. Prevention of hospital-acquired infection. In Southall DP, Coulter B, Ronald
C, Nicholson S, Parke S, editors. International Child Health Care- A practical manual for hospitals
worldwide. Child Advocacy International. London: BMJ Books; 2002.p16-18.
Clinical Risk Management/risk management programmes. Available at riskmanagement@mps.org.uk
The International Federation for Infection Control. Infection Control: Basic Concepts and Practices. 2 nd
ed. Available at http://www.ific.narod.ru/Manual/toc.htm
Infection Control Nurses Association. CD-ROM training programme for heath workers: Hospital
Infection Control Principles and Practice. Available from www.icna.co.uk
Infection Control Nurses Association . Hand Decontamination Guidelines. Available from
www.icna.co.uk
Pellowe C, Pratt R, Loveday H, Harper P, Robinson N, Jones SRLJ. The epic project: updating the
evidence base for national evidence-based guidelines for preventing healthcare-associated infections in
NHS hospitals in England. A report with recommendations. The Journal of Hospital Infection. 2005;
59(4):373-374.
World Health Organisation. Tools for Assessing the Operation and Maintenance Status of Water Supply
and Sanitation in Developing Countries. Geneva: WHO 2001
Foodlink The Food and Drink Federation. The A to Z of food safety. Available at
http://www.foodlink.org.uk.
Pan American Health Organisation. The WHO Ten Golden Rules for Safe Food Preparation: WHO: 1989.
Available at http://www.paho.org/english/ped/te_gold.htm
Adams M, Motarjemi Y. Basic Food Safety for Health Workers. Geneva: WHO 1999.
World Health Organisation. Foodborne Diseases: a focus for health education. Geneva: WHO; 2000
World Health Organisation. Safe Blood and Blood Products Distance learning materials, WHO revised
edition. Geneva: WHO 2002.
43
World Health Organisation Blood Transfusion Safety. Clinical use of blood-Handbook and CD-Rom.
Geneva: WHO; 2002.
Safe blood starts with me. Blood saves lives. WHO. Leaflets from Department of Blood safety and
clinical Technology. www.who.int/topics/blood_safety/en/
Department of Health. Better blood Transfusion 2002: www.doh.gov.uk/blood/bbt2
Professional Core Competencies for Infection Control Nurses. ICNA Nov 2000. www.icna.co.uk
World Health Organisation. Maintenance and Repair of Laboratory, diagnostic imaging, and hospital
equipment. Geneva: WHO; 1994.
DAlessandro U. Insecticide treated bed nets to prevent malaria. BMJ 2001; 322: 249-250
Abdulla S, Schellenberg JA, Nathan R, Mukasa O, Marchant T, Smith T, et al. Impact on malaria
morbidity of a programme supplying insecticide treated nets in children under two years in Tanzania:
community cross-sectional study. BMJ 2001; 322: 270-273
World Health Organisation. Counterfeit drugs guidelines for the development of measures to combat
counterfeit drugs. Geneva: WHO; 1999
World Health Organisation Model Formulary, Geneva: WHO; 2002. Available from
http://www.who.int/medicines or
http://www.who.int/medicines/organization/par/edl/expcom13/eml13_en.doc
Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs. BMJ 2002; 324: 800 - 801.
S Ratanawijitrasin S, Wondemagegnehu E. Effective Drug Regulation A Multicountry Study. Geneva:
WHO; 2002.
Mangum SS, Gruendeman B,. Infection Prevention in Surgical Settings. London: Elsevier; 2001.
World Health Organisation. WHO global strategy for the containment of Antimicrobial Resistance.
Geneva: WHO; 2001. Available from http://www.who.int/csr
Kraesten E; Vandepitte J. Basic Laboratory Procedures in Clinical Bacteriology. 2 nded. Geneva: WHO;
2001.
Appel W, Engbaek K, Heuck CC. Basics of Quality Assurance for Intermediate and Peripheral
Laboratories, 2nd ed. Geneva: WHO regional publications; 2002.
World Health Organisation. Manual of Basic Techniques for a Health Laboratory, 2 nd ed. Geneva: WHO;
2002.
Committee on Quality of health care in America, Institute of Medicine. Crossing the Quality Chasm: A
new health system for the 21st century. Washington, DC: National Academy Press; 2001.
Vincent C, Taylor-Adams S, Chapman EJ, Hewitt D, Prior S, Strange P, Tizzard A. How to Investigate
and Analyse Clinical Incidents: clinical risk unit and association of litigation and risk management
protocol. BMJ 2000; 320: 777- 81. Available from bmj.com.
44
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in medicine. BMJ
1998; 316:1154-7
45
STANDARD 4: Giving child centred healthcare

advocate for children and to reduce the fear, anxiety and suffering of children and families by
ensuring that they provide child centred care.
A child should not be separated from their parents, unless this is in their best interests
Article 9 of the UNCRC
Excluding parents can add significantly to the worry of both child and carer. In contrast, involving
them has been shown to reduce many potential stress factors, improve coping mechanisms and
compliance, and reduce time spent in hospital
Supporting criteria
1. Healthcare that meets each individual childs needs given by skilled and named health workers in
partnership with children and carers:
2. Healthcare ideally given in areas separate from adult patients. These areas will have facilities and
resources that are suitable for children of different developmental ages, their carers, breast feeding
mothers and visitors:
3. Supportive care (general and psychosocial) for children and families:
Discussion
In some countries children are still separated from their parents and families when admitted to a hospital
and in others, although mothers are allowed to stay with their children during the daytime, they are often
unable to sleep near their child at night. In most, fathers have little if any access to their hospitalised baby
or child, despite a lack of evidence to support the many reasons given for their exclusion given to us
during the pilot project for the CFHI. It costs very little, or nothing, to allow families free access to their
children in hospital and the benefits of this are far greater than any possible disadvantages. In countries
where fathers have free access, concerns have not been realised.
If a young child with limited understanding is separated from a parent they feel abandoned. This feeling
can cause intense suffering, similar to the suffering and grief felt by an adult when a loved person dies,
and may have a permanent impact on future mental health. To avoid this emotional damage, care given at
home and by familiar carers is always best whenever possible. When this is not possible and inpatient
care is in the best interests of the child, emotional suffering can be minimized if a parent (or another
carer familiar to the child chosen by the parents) is encouraged to remain with and support the child at all
times, especially during procedures, If a child is asleep, unconscious or anaesthetised it is even more
important that a parent/carer is there when they wake. An ill child needs the reassurance of their familys
love and care even more than they normally do. Best practice is also to enable other family members and
close friends to visit frequently and freely, with restrictions only when this is in the childs best interests.
46
Child Friendly hospital ward
Health workers need to always respect the parents role as the main carers. This means helping
parents/carers to care for their child as they would at home by working in partnership with parents/carers.
This includes enabling the child to follow their familiar routines wherever possible.
Mother using her own mosquito net
Mother contributing to the special

care of her premature baby
47
Elements of partnership include:

Openness and honesty
Respect and trust on the part of both
Freedom to express oneself
Sensitivity
Commitment to sharing
Understanding
Mutual support
Empowerment
Flexibility
Sharing, including rights and responsibilities
Mutual accountability
Agreeing to sometimes disagree
Being challenging
Accepting of each others reality
Sharing a vision
Listening to each other
Not being manipulative
A kind welcoming attitude that shows respect for the individual child and family costs nothing but
can minimise anxiety and fear making healthcare and treatment easier.
Best practice is to centre healthcare for each individual child and family round the needs of the child, not
round the needs of the health workers or the systems of care and includes giving healthcare that is
appropriate for the childs age and level of understanding. This is best planned in partnership with the
child, if old enough, and with their parents/carers. Daily individual care plans made in partnership with
the child and their parents/carers are also more likely to ensure that the care planned really does meet the
childs needs.
Healthcare that meets a childs needs is more likely when this care is given by health workers who only
look after children, and by those who are skilled and familiar with childrens differing needs. For example
a neonate will need a very different type of care to a child or a young person, as will children of differing
ages who have a physical or learning disability. Unskilled, unqualified or newly qualified or appointed
health workers, benefit from initial supervision by more experienced and/or skilled staff, as do the
children and families they care for.
Looking after ill children of differing ages is a challenging task. Skills, experience and Child Friendly
behaviours and attitudes are best gained by:
Learning about children during initial training
Attending specialised education/training programs about childrens healthcare
Obtaining a specialist childrens professional qualification
Receiving induction training when starting a new appointment or starting work in a different
clinical area
Regular education/training that continues after qualification or basic training (continuing
professional development - CPD)
Personal life and family experiences.
The anxiety of children can be further reduced if a child becomes familiar with their main health workers.
This familiarity can be achieved by allocating the same health worker to a child whenever possible so that
48
the number of different health workers each child sees is reduced (a patient allocation system). The use of
this system can also help with the organisation of care and improve information sharing between health
workers and families.
A simple reminder given to a child
about their nurse for the day
Note: In some countries it
might be more appropriate
to use Nurse and surname
Research shows that a welcoming, stimulating, pleasant environment that provides opportunities to play
and learn contributes to a faster recovery from illness, and faster catch up growth and development after a
slowing or stopping due to illness. The minimum quality for a healthcare environment is one that is
appropriate to the childs age and level of development and similar, or better, than found in the average
familys home.
Such suitable environments are easier to provide when children are cared for in childrens areas or wards
with different specialties going to the children rather than children going to adult areas for specialist
services. Many in-patient facilities do have separate areas for caring for children of different ages. It is
best if this age separation is flexible and more concerned with developmental age than actual
(chronological) age. If it is in the childs best interests to be cared for on an adult ward, it is important to
ensure that the children are cared for in a special area of the ward and that they have access to the same
range of stimulating opportunities, environment and care as provided in childrens wards.
To minimise fear, anxiety and suffering during investigations and treatments, best practice is for treatment
areas, X-ray departments and other areas used by children also to have Child Friendly environments,
and be staffed by health workers with Child Friendly behaviours and attitudes. Stairs, long corridors,
waiting areas and treatment rooms can all be especially frightening for children. These can be made
Child Friendly at little cost by using local materials and resources thus reducing a childs fear, anxiety
and distress.
Child Friendly stairs, UK hospital
Child Friendly laboratory corridor in

Moldova
49
Child friendly play corner in a waiting area, UK
Child Friendly treatment room, UK
It is important that healthcare environments for children are easy for families to reach. Often childrens
wards are on the high floors of multi-storey buildings. Even if there is a lift, it is still difficult for parents
to access these, especially if they are carrying their children, other children and/or other possessions. It is
difficult to escape down many flights of stairs if the building needs evacuating, especially when carrying
frightened children. It is important to provide access to and supervise outside play areas (especially
beneficial to children recovering from illnesses).
Hospitals need to have suitable and adequate facilities for resident parents/carers including somewhere to
sleep, preferably near the child (particularly if the child is breast fed or very young). For young children
beds that provide enough room for both child and parent to sleep together can be beneficial. Best practice
is to have a chair at the bedside for the parent/carer to sit on during the day, storage for their possessions,
adequate washing and toileting areas, food and drink provision and a suitably furnished area for
relaxation. Best practice is for these to be of the same standard as found in the average family home.
50
Mothers able to sleep opposite or next

to their child/baby
It is also important to have private, suitably furnished areas for giving explanations and other sensitive
information to parents/carers and for mothers to breastfeed, the latter with facilities for expressing breast
milk The support, care and understanding parents/carers and families need if their child dies is best
provided by their familiar health workers in an environment that is as pleasant as possible. Best practice
is always to advise parents/carers about all the facilities, and to provide written or pictorial instructions
about their use
Poverty is repeatedly shown to have a direct link with a childs health, educational achievement and
emotional development. When a poor family is unable to meet their childs needs, the State has a duty to
intervene by providing financial and other support. Health workers are ideally placed through their
intimate knowledge of a family to identify poverty and other adverse psychosocial circumstances, and to
support a familys response to their individual problems. Best practice is to identify any special
difficulties or problems for the child and family by asking about these early, ideally in the initial history
taking. Any special difficulties and problems need to be taken into account when planning care and
supported as much as possible. This support includes referring a child and/or their family to a social
welfare or similar service, if these exist.
To prevent additional anxiety, fear and suffering, it is particularly important to support the emotional
needs of all ill children and their families.
Audit can include children and parent satisfaction surveys, looking at the number of children cared for
in adult wards without access to the facilities available to children compared with the number cared for in
separate childrens areas
Finally health workers also need support if they are to cope with the considerable stresses imposed by
giving this child centred care in partnership with parents. Access to support systems enable health
workers to avoid the burn-out that may lead to incapacity and/or deprive the health service of their skills
and experience (See also Section 5).
References:
United Nations General Assembly: Convention on the Rights of the Child. Articles 5, 9, 14, 37 New
Royal College of Paediatrics and Child Health. Helpful Parenting. London: RCPCH; 2002
Stenbak, E. Care of children in hospital : a study. Copenhagen Albany: WHO Publications; 1986.
Lansdown R. Children in Hospital. A guide for Family and Carers. Oxford; New York: Oxford University
Press; 1996
Bowlby J. A secure base-clinical applications of attachment theory. London: Routledge, 1988
Bowlby J. Maternal care and mental health. Geneva: WHO; 1951
Bowlby J. Child Care and the growth of love. 2 nd ed. Harmondsworth: Penguin; 1965
51
Goldberg S. Attachment and Development. London: Arnold; 2000

Robertson, J, Robertson, J. Separation and the Very Young. London: Free Association Books; 1989
National Institute of Child Health and Human Development. Factors associated with fathers care-giving
activities and sensitivity with young Children. Journal of Family Psychology 2000; 14(2): 200-219
World Health Organisation. Giving adolescents a Voice: Conducting a Rapid Assessment of Adolescent
Health Needs A Manual for Health Planners and Researchers. Manila: WHO Regional Office for the
Western Pacific; 2001.
Cassidy J, Shaver P, editors. Handbook of Attachment. New York: Guilford Press; 1999
Currer C, Stacey M. Concepts of Health, Illness and Disease-a comparative perspective. New York: Berg;
1986
Erickson MF, Weinberg R, editors. Attachment Theory and Research: A Framework for practice with
infants, toddlers, and families. Zero to three 1999; 20(2).
Winnicott DW. The maturational process and the facilitating environment: Studies in the theory of
emotional development. London: Hogarth Press and the Institute of Psychoanalysis, 1965.
Spitz R A. Hospitalisation: an inquiry into the genesis of psychiatric conditions in early childhood. Psy
Study Child 1945; 1: 53-74
Prugh DG, Staub EM, Sands HH, Kirshbaum RM, LenihanEA. A Study of the emotional Reactions of
Children to Hospitalization and illness. American Journal of Orthopsychiatry 1953; 23: 70-106
Pilowsky I, Bassett DL, Begg MW, Thomas PG. Childhood hospitalization and chronic intractable pain in
adults: a controlled retrospective study. Int J Psychiatry Med. 1982;12(1):75-84.
Hall DJ, Stacey M, editors. Beyond Separation: further studies of children in hospital. London; Boston:
Routledge and K Paul; 1979
.
Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for providers to promote a
patient-centred approach in clinical consultations (Cochrane review). Cochrane Database Syst Rev 2001;
4:CD003267
52
STANDARD 5:
Sharing information and keeping parents and children consistently
and fully informed and involved in all decisions.
Health care providers, organizations and individual health workers, share a responsibility
to advocate for children and to reduce the fear and suffering of children and their families
by ensuring that they keep parents and children consistently and fully informed and
involved in all decisions
Supporting criteria
1. The wearing of name badges by all health workers who also introduce themselves to children and
families:
2. A system for making children and families aware of their rights to information:
3. Policies, systems and/or practices that ensure children and families are given sufficient understandable
information about:
Their specific health problem/s
Any changes in their condition
Investigations and procedures
(these make it easier for them to contribute to decision making, to give fully informed consent and to
share any necessary special care)
4. Giving information to children and families about the ward facilities and routines, and about relevant
general health issues:
5. Interpreters who are available, and used when necessary
6. Systems to investigate and address complaints, positive comments and to seek the opinions, views and
ideas of all health workers, children, their parents and families
7. The sharing of healthcare related information by health workers in a way that enables consistency of
information giving to children and families, confidentiality, and clinical effectiveness
8. Ways of sharing non-clinical (general) information between health workers that are effective.
9. Having and using communication tools, appropriate for the circumstances, to aid effective
communication (information sharing), especially for summoning help urgently
Discussion
People who use health services need to know what to expect, how to use the services provided, who to
complain to if something goes wrong and how to do this, and to be fully informed in a way that they
understand about anything that might affect them. These issues are best covered in a written statement
that is prominently displayed in the healthcare environment
53
Successful organizations are good at sharing

information, ensuring the participation of all their
employees and clients and of meeting their clients
individual needs. This culture for information
sharing minimizes misunderstandings, mistakes,
disappointments and complaints. To provide the
best possible healthcare, information needs to be
shared effectively with parents/carers and children
so that they understand what will happen to them,
and are able to share in the decision-making and
fully participate in the healthcare needed.
Ward rules
An example of a mission statement
Early morning meeting in Moldova for all

senior health workers to share
information.
To share information effectively, it is necessary to have:

A culture in the healthcare environment that encourages the sharing of information and enables
participation
A chain of responsibility and accountability that prioritises information sharing
A positive attitude to sharing information (the desire to share), and to work together with
colleagues (team working) in partnership with children and parents
The skills to share information effectively (so that it is fully understood) and consistently
54
A system that keeps sensitive information confidential. Protecting confidentiality is vitally

important unless this is not in the child best interests, or you have permission from the child
and/or their parents to break this.
Different methods of information sharing for different circumstances
Job aides for use as reminders, such as how to break bad news
Tools to aid information sharing, such as information boards, telephones, pager systems etc
Privacy, mutual respect, compassion, time, and patience.
Health workers know the names of their patients and their families. Children and families want and have a
right to know the names of the health workers looking after them. Best practice is therefore for all health
workers to wear identification (such as name badges) and to introduce themselves to the child and family.
Information for parents about

their childs anaesthesia and
what will happen after surgery
The information health workers give to parents/carers and children may not be understood for a variety of
different reasons. These include:
The language is not the first language of the child or parent receiving the information
The information content is not understood as knowledge of the subject matter is limited
The format and/or words used are not easily understood
The parent/carer or child does not want to hear what is said or is not ready to hear this
The parent/carer or child is partially deaf
Too much information is given at once
The recipient is distressed, anxious or upset and therefore is not receptive (does not hear)
There is not enough privacy
To avoid these problems, best practice is for health workers to have education/training opportunities for
learning communication skills, about the importance of protecting confidentiality and about the evidence
based suggestions for giving information, particularly for transmitting bad news.
These rules include:
Privacy and no interruptions such as a telephone ringing, a knock on the door and other interruptions.
Introducing yourself, say who you are and what your role is
Making sure the child or parent/carer has a close family member or friend with them if possible
55
Having a second health worker present (a doctor/nurse combination works well)

Explaining what information you intend to share and finding out before giving this what the child or
parent/carer already knows
Giving information honestly and kindly in the child or parent/carers first language (via an interpreter
if necessary)
When it is appropriate, trying to give any positive or reassuring information first, before giving
information that children and families will find difficult
Using words that child or parent/carer is likely to understand without being patronizing. Use of
pictures or mime or sign language may be helpful
Getting regular feedback by asking child or parent/carer to tell you what you have said
Giving the recipient the opportunity to ask questions
Remembering that small amounts given at frequent intervals are better than too much at a time or
large time gaps without information
Backing up with written or pictorial information whenever possible
Arranging a time to give more information
Asking if there is anyone else in the family the child or parent/carer would like you to share the
information with
Showing compassion but remaining in control of your own emotions
Getting permission to share with others as necessary
Children and families need to feel confident about the abilities of those
who look after them. Loss of this confidence can cause much anxiety
and distress.
Some individual health workers can feel protective about the families they look after. While this is
usually good, it can sometimes create a dependence that causes families to lose confidence in the care
given by other health care providers. This is made even worse if a competitive atmosphere develops
between different health workers and health care environments, especially when one undermines the care
of the other. Such undermining makes it difficult for families who may need the care that can only be
provided by the denigrated health workers or health facility at some future time. It is therefore important
for health workers working in different situations to support and communicate well with each other, to
share and promote consistent good practice and to be positive about all who contribute to providing
healthcare for children and families, even if mistakes have been made.
A simple way of telling mothers they are welcomed

and supported to see their babies, also a hand
washing reminder
56
Communication tools vary depending on the technologies available and the task. Even basic low cost
tools such as hand bells for summoning help and hand made hospital signing systems will achieve
objectives. The important priority is to identify what needs to be communicated and then to decide what
method or tool to use. It is up to individuals to employ the technologies available in the most appropriate
way. A well-sited communication board for sharing non-clinical information may be as effective as
individual more expensive handouts. The important issues are that the information is put on the board, the
board is easy to see, the information is understandable and in large enough print for people to read, or in
pictorial format for families unable to read.
It is also important for parents/carers to be able to share information about their child with other family
members and friends. The resources for and a system to enable this are of paramount importance,
especially for distant family members.
A low-cost private manned telephone in a childrens
hospital in Eastern Europe. This enables parents/carers
to contact their friends and relatives. Until the retired
health worker in the picture persuaded the authorities to
allow him to install the telephone, parents/carers had no
secure way of contacting their relatives.
Finally best practice is to audit compliance with the policies and systems for information sharing and
participation to make sure they are achieving their objectives.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 9,12,13, 17 New
Leavitt L. When Terrible Things Happen A parents Guide to Talking with Their Children. American
Academy of Pediatrics, Johnson & Johnson Pediatric Institute LLC. Available from www.jjpi.com
Gillick competence. Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402
(HL).
Flatman D. Consulting children: are we listening? Paediatr Nurs. 2002 Sep;14(7):28-31.
Richman N, Save The Children Fund. Communicating with Children. Helping Children in Distress.
London: Save the Children; 1993.
Richman N. Helping Children in difficult circumstances-a teachers manual (Save the Children,
Development Manuals). London: Save The Children; 1996.
Reddy N, Ratna K, editors. A journey in childrens participation, Bangalore: The Concerned for Working
Children;2002. Available from www.workingchild.org
57
Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. Abingdon: Radcliffe Medical
Press; 1998
Misteil S. The Communicators Pocket book. Management Pocket Books Laurel House, Station
Approach, Alresford, Hants, SO24 9JH. UK; ISBN 1 870471 41 5
58
STANDARD 6:
rights
Providing equity of care and treating the child as an individual with
ensuring that children have equity of health care and by treating them as individuals without
discrimination giving them culturally and developmentally appropriate rights to privacy, dignity,
respect and confidentiality.
Supporting criteria
1. Policies and systems of care that ensure equal access to and opportunities for preventive, investigative,
curative and palliative health care that meet the needs of the individual child
2. Policies and systems of care that ensure there is no discrimination concerning age, sex, race, ethnicity,
legitimacy, disability or any other reason
3. Policies and systems of care to ensure individuality (that include birth registration and use of the date
of birth, a clinical record number, use of preferred name and language, provision of personal space,
knowledge of personal preferences, access to and use of personal possessions and clothes).
4. Policies and systems of care that ensure respect and preservation of dignity from degrading and
unnecessary procedures and treatments.
5. Policies and systems of care that ensure cultural and developmentally appropriate visual and sound
privacy (especially when dressing, washing, toileting, when undergoing procedures, being given
treatment and when dying; also provision of privacy for possessions):
6. Policies and systems of care that ensure written and verbal confidentiality.
Child recovering from pneumonia and

receiving additional inspired oxygen
through nasal cannula. He is tied to the
bed to prevent him pulling out the
cannula but this is unnecessary.
Discussion
Despite ratification of the UNCRC, inequity and discrimination continue to occur in most countries
regardless of resources. A childs right to survival should not be dependant on their sex, age, legitimacy,
whether or not they have a disability, their family wealth, racial origin, religion, ethnic origin or any other
59
factor. Health workers are ideally placed to set an example to others by developing systems and policies to
ensure there is no discrimination.
Equity of health care for children is dependant on many things. How far the family live from a health
facility, whether there are health workers to provide care near a childs home, whether there is transport to
a health facility and/or whether there is a health facility within easy reach, all influence equity. However
the two most important influencing factors in many of the worlds countries are the individual familys
wealth and their knowledge about health.
In many countries there are often good private health services but inadequately resourced public services
that are inaccessible to many families. Even if a child from a poor family does access the services,
inequity remains if the family cannot find the money for investigations, necessary drugs and treatments or
experience a lower level of nursing and medical care than others.
In well-resourced countries there can still be differing qualities of care given in different geographical
areas and by different services in the same health facility. Children who are admitted to separate
childrens hospitals or to childrens wards generally get better care and opportunities than children cared
for on adult wards; for example they have better access to play facilities and specialised nursing skills.
Some children looked after in a childrens ward are also seen in adult facilities such as accident and
emergency, x-ray and some surgical outpatient departments. These departments may not always meet the
needs of the differing age groups of child patients who use their services.
Country and global inequity also exists for investigation and treatments, particularly regarding the
availability and affordability of appropriate essential drugs and other clinical equipment. Advocacy to
drug companies to make drugs more affordable in the disadvantaged countries often helps and needs to
continue. Drug donations need regulation to ensure they are needed, appropriate for their purpose, of good
quality and in-date. Drugs should not be tested without informed consent in any country and continued
advocacy will be needed to ensure patient safety.
Equity is not only about giving the same care to each child, but is also about giving the care necessary to
meet the individual childs health needs.
A child has a right to be recognised and respected as a unique person with individual physical, emotional,
social and spiritual needs. Health workers can respect a childs individuality by ensuring that they:
Approach a child in an age and developmentally appropriate way
Use the childs preferred name
Give a child their own health registration number at birth and ideally also a written birth
certificate when there are the resources to do this
Ask about and accommodate when possible and appropriate a childs likes and dislikes
Allow personal space and personal possessions such as clothes and toys
Seek, listen to and acknowledge the childs opinions, views and ideas
Ensure that a child feels he or she always matters.
Include any special needs in a childs daily care plan and make this plan in conjunction with the
child and parents
A child also has the right to have their dignity preserved, their privacy respected and confidentiality
maintained (all appropriate to age and culture). Frequently, these rights are not respected for a child. In
addition to having policies and systems of care, constant vigil is needed by health workers to ensure that
they do not contribute to any unnecessary fear, anxiety or suffering by failing to respect these rights.
60
Screens used to give visual privacy for a

treatment area. Screens do not protect
sound privacy.
The inclusion of education/training about the articles of the UNCRC and other human rights topics in the
core training curriculum of students and in the regular life-long learning for health professionals will help
all health workers understand and meet this Standard.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 2, 7, 8, 9, 16, 23, 27,
29, 37. NewYork: United Nations; 1989 available from http://www.unicef.org/crc/crc.htm
Dimond B. Patients rights, responsibilities and the nurse. 2nd ed. Salisbury: Quay Books; 1999.
Human Rights Act 1998. London: The Stationery Office; 1998. Available from
http://www.hmso.gov.uk/acts/acts1998/19980042.htm
Marshall K. Childrens rights in the balance. London: Stationary Office Books; 1997
Verhellen E. Monitoring Childrens Rights. The Hague; Boston: Martinus Nijhoff; 1996
Franklin B. The handbook of childrens rights: comparative policy and practice. London, New York:
Routledge; 1995
British Medical Association. Consent, Rights and Choices in Healthcare for Children and Young People.
London: BMJ Books; 2000
Aldridge M, Wood J. Interviewing children a guide for child care and forensic practitioners. Chichester,
New York: Wiley; 1998
Sheikh A, Gatrad AR, Editors. Caring for Muslim Patients. Abingdon: Radcliffe Medical Press; 2000
Alderson P. Young Children's Rights, Exploring Beliefs, Principles and Practice. London: Save the
Children. Jessica Kingsley Publishers; 2000
61
STANDARD 7:
Recognising and relieving pain and discomfort
ensuring that they recognise, assess and relieve the physical and psychological pain and discomfort
of children.
Supporting criteria
1. A separate pain and other symptom management/palliative care service/s with lead health
professionals and/or multi-disciplinary team/s
2. Systems of care, guidelines and job aides (for example tools to assess and relieve pain) to help with
symptom recognition, symptom assessment and restraint for procedures
3. Written guidelines, evidence based wherever possible, used by everyone to help with symptom relief,
that include advice on the relief of different types of pain and other distressing symptoms (both physical
and psychological), and on how to use non-pharmacological and pharmacological pain relieving
strategies in the different ages groups:
4. Material resources including:
A safe, secure supply of free or affordable essential drugs for symptom relief that includes opiates
and non-opiates
Distraction toys and other resources to aid non-pharmacological pain and other symptom
management
5. The use of individual pain (and other symptom) plans made with the children and their parent/carer
6. Psychosocial support for children, families and health workers
Dressings of extensive burns,

changed without adequate pain
relief and without a parent
present.
Discussion
The pilot project found large numbers of children in the participating countries suffering from
uncontrolled pain and other distressing symptoms, both physical and psychological.
62
Improved technology and potential advances in care do not always protect or improve the treatment of
these distressing symptoms and can on occasion be an additional cause. Routine procedures (without pain
relief), such as dressing wounds are frequent causes of unnecessary pain and suffering for a child. In some
countries it is common for a child to be paralysed by drugs or partially sedated without concurrent and
appropriate pain relief.
The State has a role to play in making it better for children by not restricting or blocking the availability
of vital pain relieving drugs (including opiates) due to security concerns or outdated and mistaken beliefs
about their appropriateness for use in children and misplaced concerns about risks of addiction.
In countries where opiates are available, there may be a reluctance to use them due to these misguided
beliefs and also a lack of understanding about how to use them. Whilst it is upsetting for health workers
when they are unable to help a distressed child, the effects on the child and their family are much worse
and can only be imagined, especially if the child has a chronic illness, a terminal illness or any other lifelimiting condition.
It is ethically wrong and a failure of a health professionals duty for a child to suffer from uncontrolled
pain or other distressing symptoms. This is particularly the case for a child who has a permanent
disability that is associated with chronic symptoms or one who cannot be cured of their illness and may
be near the end of their life. Relieving pain and distressing symptoms is not always about cure, but is
about making the experience of living now more bearable (that is improving the quality of remaining
life).
Effective relief from pain and other distressing symptoms from birth to adulthood could be better if health
workers:
Were more aware of the suffering and discomfort that all children may experience (including
newborn babies) due to pain and other distressing symptoms
Always anticipating a childs pain and other distressing symptoms
Gave a higher priority to relieving each individual childs pain and other distressing symptoms
Made greater use of pain and symptom relieving drugs, both non opiates and opiates
Understood and used simple non-pharmaceutical methods that can help (supportive, cognitive,
behavioural and physical)
Knew about and anticipated all the things that can make the experience of pain or other symptom
worse.
To make it better best practice is for health workers to have core (during initial training) and regular
education/training opportunities on the recognition, assessment and treatment of pain and other
distressing symptoms. Best possible practice is also facilitated by having, whenever possible, separate
skilled health professionals who lead and guide the treatment of pain and other symptoms. Having a
multidisciplinary team dedicated to symptom relief and other aspects of palliative care, and using
standardised guidelines for managing pain and other distressing symptoms, are known to be effective
ways of improving care and sharing good practice.
The childs normal health worker working together with the child and their carers (who know the child
best) can often reduce pain and other distressing symptoms by:
Planning each individual childs care as each child responds differently to pain and other
distressing symptoms.
63
Anticipating pain and taking effective measures and/or giving drugs before the symptoms occur,
for example before a procedure or operation. Children with recurrent distressing symptoms
should not wait for these to re-occur before receiving relief.
Using pain/symptom assessment tools to help them recognise and assess a childs symptoms and
guide the care they need.
Giving drugs in a way that does not cause more pain and distress. Drugs are often still given in a
way that is painful for the child, for example by intra muscular injection. The same drugs are
frequently available and equally effective as an intravenous or oral preparation, often at a lower
cost.
Advocating for the childs needs to be met, if they are unable to meet these needs themselves.
Before using drugs, or where they are unavailable there is much that can be done to relieve suffering and
make an unpleasant experience more bearable, such as:
Being honest with the child and preparing them for what might be a painful experience can help
them to cope. Anxiety and mistrust of health workers will make the experience worse
Using appropriate play, stimulation and distraction to help in the management of pain and other
symptoms
Using heat, cold, touch and other comfort measures as these can sometimes help the distress of
pain and other symptoms.
Giving psychological support, simple kindness and involving parents and other familiar carers
where possible.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 19. NewYork: United
Nations; 1989 available from http://www.unicef.org/crc/crc.htm
Southall D. Pain control in children. In Southall DP, Coulter B, Ronald C, Nicholson S, Parke S, Editors.
International Child Health Care- A practical manual for hospitals worldwide. Child Advocacy
International. London: BMJ Books; 2002. p87-107.
World Health Organisation. Cancer Pain Relief and Palliative Care in Children. Geneva: WHO; 1998
World Health Organisation. Symptom relief in terminal illness. Geneva: WHO; 1998.
Vessey J, Carlson K, McGill J. Use of distraction with children during an acute pain experience. Nursing
research. 1994; 43(6): 369-372
Royal College of Paediatrics and Child Health. Prevention and control of pain in children. A manual for
healthcare professionals. London: BMJ books; 1997
Doorbar P, McClarey M. Ouch! Sort it out: Childrens experience of pain. London: Royal College of
Nursing 1999.
64
STANDARD 8: Giving appropriate resuscitation, emergency and continuing care for very
ill children
Healthcare providers, organisations and individual health care workers, share a responsibility to
giving appropriate emergency care to children.
*Emergency signs in children that need immediate assessment and treatment include:
An obstructed airway (obstruction to breathing/choking)
Severe respiratory distress (severe problem with breathing)
Central cyanosis (blue mucous membranes)
Shock (weak fast pulse + capillary refill longer than 3 seconds)
Coma (unconscious and unresponsive)
A convulsion (fit)
Signs suggesting severe dehydration in a child with diarrhoea (any two of the following: lethargy,
sunken eyes, very slow return of skin after skin pinching)
*Priority signs in children that need assessing and treating urgently (ideally within thirty minutes of
arrival) include:
Visible severe wasting
Oedema of both feet
Severe pallor of the palms of the hands
Lethargy, drowsiness or reduced level of consciousness/responsiveness
Continual irritability and restlessness
Major burns
Any signs of respiratory distress (any breathing problem)
A sick young infant 2 months old and a child with an urgent referral note from any other health
facility/health worker should also be considered a priority.
*Reference:
The Management of the child with a serious infection or severe malnutrition guidelines for care at
the first referral level in developing countries, Department of Child and Adolescent Health and
Development, World Health Organisation.
Supporting criteria
1. Provision of appropriate resuscitation/emergency and continuing care for very ill children, coordinated
by lead health workers and, in a hospital, given by safe numbers of skilled health workers throughout the
24 hour period:
2. In any healthcare environment a system for triage (seeing the sickest children first) with:
A policy for placing children into categories of severity
Essential equipment such as thermometers, soap and towels, weighing machine, stethoscopes etc
Job aides that include the WHO emergency and priority signs*, oral re-hydration volumes and
methods of reducing a fever and managing convulsions, shock, respiratory failure, coma etc.
A system for getting help:
And in a health facility also:
A separate child and family friendly area for triage
65
A suitable child and family friendly area for waiting families that has a free and adequate supply
of safe oral fluids
A private area for children who have died and their families
3. In any healthcare environment a system for providing appropriate resuscitation and emergency care
with:
A resuscitation policy
Job aides for life support:
Standardised (used by everyone) clinical guidelines for managing the common emergencies
Oxygen available at all times and in sufficient amounts with the equipment to administer it safely
Essential* appropriate resuscitation equipment (clean, regularly checked and accessible)
A secure supply of essential emergency drugs and standardised guidelines for their use:
A system for getting help
And in a health facility also:
A separate child and family friendly area for resuscitating a child and giving emergency care
preferably near the triage and/or assessment area
A suitable child and family friendly area for waiting families
A private child and family friendly area for children who die, and their families
*Essential means that all the equipment and drugs that are on the countrys essential equipment and drug
lists for providing acute care, if such lists exist, are available. For examples of essential equipment and
drugs refer to International Child Health, Pocket Emergency Paediatric Care and/or WHOs
Management of the child with a serious infection or severe malnutrition and/or the Emergency Maternal
and Child Healthcare (EMCH) programme.
4. In a hospital, a system for providing appropriate continuing care to very ill children in a child and
family friendly area, ideally separate from adult patients, that has:
A monitoring policy that includes essential monitoring of vital parameters (for examples
depending on resources heart rate, respiratory rate, oxygen saturation, blood glucose levels and
temperature) and monitoring parameters
Appropriate monitoring equipment
Monitoring charts for recording vital parameters
Oxygen available at all times and in sufficient amounts with the equipment to administer it safely
Appropriate resuscitation equipment (clean, regularly checked and accessible)
A secure supply of essential drugs and standardised guidelines for their use
Child and family friendly waiting area/s for families
A separate child and family friendly area for children who die and their families with culturally
appropriate privacy
5. Systems for transferring very ill children with:
Written policies for transfer to a hospital from the community or from a health facility, internal
transfer within a hospital and for transfer from one hospital to another
Standardised clinical guidelines for managing the common emergencies
Transfer of clinical information
Skilled health workers for accompanying a child during transfer
Access to safe and reliable transport for transfer
Monitoring and other equipment for use during transfer
Portable oxygen supply for transfer
66
Portable suction equipment
6. Access to a service/s or system/s for providing psychosocial support to children, their families and
health workers when suffering life threatening illness or injury
Discussion
The early onset of appropriate resuscitation and emergency healthcare in neonates, both before and after
birth, and for very ill or injured children is essential as delays not only cause harm that may result in
unnecessary death or handicap, but may also make early treatment less effective and more prolonged.
Immediate triage to detect emergency and priority signs on arrival at a health facility (in a hospital
available for the whole twenty-four hours), is essential. Children with emergency signs need to be treated
immediately and those with priority signs urgently and before registration, to minimise unnecessary
deaths and disabilities. (SEE WHO ETAT programme and the CAI/ALSG EMCH project).
As a childs condition can change rapidly,
close monitoring by skilled health care
workers is essential to detect the early
warning signs of deterioration in very ill or
injured children, also those undergoing
surgery and those who have been given
systemic analgesia and/or sedation
A childrens area for
giving emergency care in
an adult accident
Department
Summary
The most important issues for the care of an acutely ill child are in sequence:
1. Early recognition of severe illness by the family and community health care workers.
2. Immediate treatment where the child is living, by the community health care workers.
3. Early and efficient transport to the nearest primary or secondary referral health care facility for
treatment, ideally with appropriate health care given during transport by health care workers.
4. Effective triage, that is available 24 hours a day, given on arrival.
5. Regular and effective monitoring of children at risk of deteriorating, with appropriate
preventative interventions effective care of very ill children.
6. Immediate implementing of any necessary emergency health care in the primary or secondary
referral health care environment, by health care workers who are trained to do this and also have
the necessary material resources readily available.
67
Monitoring in a high
dependency/intensive care unit
in Pakistan
Triage in a Ugandan hospital
The above system needs to be integrated and is dependant on a well-managed collaborative network of
health care services, effective health education for parents, effective training for all health workers,
efficient transport services and the necessary human and material resources. (See EMCH programme)
To ensure that health workers give the best possible emergency care and critical care, best practice is to
develop and use guidelines and other job aides that act as reminders for life support and the common
illnesses that can cause severe illnesses in children. Guidelines and job aides need to be accessible and
evidence-based and used by everyone. Community, outpatient, and inpatient staff should all be trained
together in emergency care.
68
Job aides for providing life

support: see website for what is
written on the charts
Training in emergency care in Kosova
Emergency equipment laid out for

immediate access in the emergency
department of a hospital in a poor
country
Working together is vitally important to ensure the provision of the best possible care for the very sick
pregnant woman and child in order to reduce mortality and morbidity.
The systems used should draw on the programs of Safe Motherhood, the Integrated Management of
Childhood Illness, essential antenatal, perinatal and postpartum care, essential care of the newborn, basic
life support (neonates and children), neonatal and paediatric life support and advanced paediatric life
support and the new Emergency Maternal and Child Healthcare (EMCH) program.
To provide the best possible and appropriate care, best practice is also to have regular meetings to review
the systems used to ensure they are achieving their objectives. All those involved in providing triage,
resuscitation, emergency and critical care need to attend these audit meetings. Specific issues for audit
must include the circumstances leading to childhood deaths.
69
European Resuscitation Council Guidelines for Basic and Advanced Paediatric Life Support . Available
from www.resus.org.uk
D Carapiet, J Fraser, A Wade, P W Buss, R Bingham. Changes in paediatric resuscitation knowledge
among doctors. Arch Dis Child 2001; 84(5) :412-414
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G et al. Confidential enquiry into quality
of care before admission to Intensive Care. Br Med J 1998; 316(7148): 1853 8
71
European Resuscitation Council Guidelines for Basic and Advanced Paediatric Life Support . Available
from www.resus.org.uk
D Carapiet, J Fraser, A Wade, P W Buss, R Bingham. Changes in paediatric resuscitation knowledge
among doctors. Arch Dis Child 2001; 84(5) :412-414
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G et al. Confidential enquiry into quality
of care before admission to Intensive Care. Br Med J 1998; 316(7148): 1853 8
71
STANDARD 9:
Enabling play and learning
Health care providers, organizations and individual health workers, share a responsibility to
ensuring that they enable children to play and learn.
Supporting criteria for play

1.
Support for play that includes:

For all children who are well enough - encouraging and helping children to play when they are
awake, especially at the bedside when a child is too ill or unable to get to an area set aside for
play.
In a hospital, a play service with a play worker/s who has been trained, or a lead health worker
with the skills to set up and supervise play and the play materials
2. In a health facility, resources for play that include:

A separate, safe and clean place to play in each clinical area, providing there is space available,
that can be used by all children who are well enough
Providing safe and culturally appropriate play materials. Alternatively, or in addition,
encouraging parents to bring and use the childs own toys
Secure storage for play materials so that they do not get stolen
3. Provision of advice to all children and families about safe and appropriate play materials (including
toys) for use at home

4. The promotion and use of strategies involving play for:
Recreation and stimulation of development
Helping children to cope with their health problem (therapeutic play), for example play to distract, for
procedure preparation, to help in the giving of information, for stress relief, for expression
Helping to manage pain and other distressing symptoms.
Discussion
State parties recognise the right of the child to rest and leisure, to engage in play and recreational
activities appropriate to the age of the child. UNCRC: Article 31
Play is a natural part of childhood and a vital factor in the mental, social and emotional growth of
children - National Association of Hospital Play Staff, UK.
Play is not just a way of passing time and entertaining children, but is an important way for well or ill
children to make sense of the world around them. It also helps them cope with any special problems and
difficulties and enables them to develop to their full potential. It is important to remember that an ill child
is a normal child in an abnormal situation, so having sensory stimulation and the opportunity to play is
even more important when a child is ill.
72
Child patient playing

in a hospital corridor
in Pakistan
Play and sensory stimulation within health care is often thought of as trivial or of little importance,
despite its many benefits and the low cost involved. Many health workers (and sometimes parents) feel
that an ill child has no need to play or be stimulated, and that this should wait until they are better.
However, this underestimates the importance of play and its role in helping an ill child.
Malnourished
children and their
mothers learning
how to play in a
Ugandan
Hospital.
Some of the reasons why play and sensory stimulation are important enough to be given a higher priority
by health workers include:
1. A faster recovery from illness
Research evidence shows that ill children who are given the opportunity to play get better faster than
those that dont. Play is a normal part of every childs life, whether it is spontaneous (free) or
helped.
2. Better physical, mental, emotional and social development
The physical and mental stimulation of play is vital to help children develop to their full potential.
Body growth, muscle development, fine and gross motor skills, sensory skills and a childs ability to
learn, interact socially and make sense of the world around them are all helped by play. Children who
73
are ill, injured, malnourished, developmentally delayed or who have a disability have an even greater
need for play and the help to do this.
3. Reduction of a childs anxiety and stress
When a child is ill or in a healthcare environment, such as a hospital, many of the things that were
familiar to the child disappear and are replaced with unfamiliar and often frightening situations,
environments, people, smells and sounds that the child has no control over. Play helps a child to
regain some familiarity and control over their surroundings and to understand some of the things that
might happen to them by pretend playing, drawing and talking. Bringing a familiar toy from home
can also help. For children admitted for non-emergency treatment, an earlier visit to the hospital is
helpful. Although play may happen spontaneously, a child who is anxious or frightened often
withdraws and may need help to play.
4. Easier assessment, treatment and procedures leading to improved outcomes

When a child is ill, distressed, anxious or frightened it can be difficult for health workers to make a
good examination and assessment of the
mmnd
i )
/
d
gip t
74
en dr t
From the childs point of view, refusing to comply with unpleasant treatments is reasonable
behaviour. By using play many potential difficulties can be overcome, thereby improving compliance
and the eventual outcome for the child.
5. Better communication with the child
Health workers need to be able to communicate effectively with children to find out how they feel
and to gain their views and opinions about what is happening to them or may happen in the future.
This is difficult for health workers if a child is ill, frightened, anxious or distressed. Many children
find it easier to express their feelings and distress through play rather than by using words. A child
might also find it easier to talk about how he/she feels when they are playing. Play allows a child to
express their anger or sadness, frustrations, fears and also happiness.
The aims of a health facility play service are therefore to aid normality, help children develop,
communicate and contribute to and cope with their healthcare experience in the best possible way,
in order to improve their health outcomes.
In a hospital some ways play can be supported are by:
All health workers acquiring the skills to enable children to play
Providing the best possible play opportunities in every clinical area used by or visited by children.
Supervising play at the bedside where necessary and appropriate
Employing skilled play specialists or nominated health workers to organise and supervise play by
working together with health workers and parents/carers.
Identifying separate and supervised play areas for child patients and for child visitors (who are
not patients) where they can be left by a carer for a limited period of time.
Bare playroom before improvements
Same playroom after improvements
Best possible or gold standard(see later) play areas include:

A separate supervised play area for all children in or near every clinical area.
A noisy indoor play area
A quiet indoor play area for activities such as reading and computing
An outside play area for child patients and child visitors
A room for watching television or videos or listening to the radio
Appropriate and safe play materials
75
Health workers visiting the home or working in a community also have an important role in encouraging
and supporting play to make it an enjoyable, stimulating and learning experience for the children and their
families.
Supporting criteria for learning
A school room in a large childrens hospital in

the UK
1. Support for school type education/learning includes:

Making possible continuing school type education (learning) for each school age child who is in
a hospital for more than a few days and is well enough
Supporting and encouraging learning for children in other healthcare environments
2. Resources in a hospital or other residential health institution (such as those for children with physical
and mental health and other learning disabilities found in some countries) that include:
A lead health worker with teaching skills, or a specially supported teacher who comes into the
health facility, to support learning and liase with a childs parents/carers and local school
A separate place to learn that is safe and clean in the clinical area where continuing school type
education can be given
Actively encouraging children and parents to bring their own education materials or providing
education materials
3. Systems to provide:
Relevant information to individual schools about every individual child with a disability or health
problem that affects or may affect their education
Advice and information to schools about general health issues.
Discussion
Health problems and disabilities often interfere with a childs learning opportunities and their ability to
learn. This may compromise their chances of reaching their full developmental potential. Many children
in these situations are able to carry on school type learning if this is promoted, enabled and supported by
health workers.
Examples of compromised education include:
The short periods of missed education during illness at home, for healthcare attendances and when a
child is in hospital
Long periods of disrupted school attendance due to a long hospital admission because of a severe
illness or trauma.
76
Frequent missed school attendance because of physical illness, learning difficulties or mental health
problems
The non-attendance of children who will be living (and dying) from chronic deteriorating diseases.
Every ill and disabled child has the right to a stimulating school-type education (UNCRC). It is
important that they are enabled to learn when they are able to, and for as long as they are able to.
Health workers can support this by:
Providing a place for learning in the healthcare environment
Encouraging children and families to bring their own learning materials when they are admitted
to a hospital for more than a few days.
Supervising learning for periods of time during the day
Liaising with a childs teacher about health problems that may interfere with a childs school
attendance or make learning difficult. For example many children have a variety of temporary or
permanent physical disabilities, hearing or visual difficulties, or mobility problems.
Best practice is for health workers to have education/training about learning difficulties in children and
about the implications for learning of some health problems and disabilities.
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 6, 28, 29, 31.
NewYork: United Nations; 1989 available from http://www.unicef.org/crc/crc.htm
World Health Organisation. Department of Child and Adolescent Health and Development/Unicef.
Management of the child with a serious infection or severe malnutrition guidelines for care at the first
referral level in developing countries. Geneva: WHO; 2000
Adams J, Gill S, Mcdonald M. Child Health. Reducing fear in hospital. Nursing Times 1991;87(1): 62-64
Azarnoff P. Preparation with Medically-oriented Play. In: Medically-oriented play for children in health
care: The issues. Paediatric Projects Incorporated, Monograph No 3, 1986: 21-34 (cant find this in any
more detail)
Barnes P. Thirty years of play in hospital. OMEP International Journal 1995; 27(1): 48-53
Bates TA, Broome M. Preparation of children for hospitalization and surgery: A review of the literature.
Journal of pediatric nursing 1986; 1(4): 230-239
Beardslee C, Kotchabhakdi P, Tlou S. Nursing care of children in developing countries: issues in
Thailand, Botswana and Jordan. Recent Advances in Nursing. 1987; 16: 31-60
Chan JM. Preparation for Procedures and Surgery through Play. Paediatrician 1980; 9(3-4): 210-219
Chaturvedi S, Prasad M, Singh JV, Srivastava BC. Mothers attitude towards childs health education and
play in ICDS and non-ICDS areas. Indian Pediatrics 1989 Sep;26(9):888-893
Moyles JR, editor. The Excellence of Play. Buckingham, Philadelphia: Open University Press; 1994
Curtis A. Play in different cultures and different childhoods. In: Moyles JR. The Excellence of Play.
Buckingham, Philadelphia: Open University Press; 1994.p27-36
77
Doverty N. Therapeutic use of play in hospitals. British Journal of Nursing 1992, 1(2): 77-80
Henkins MA, Abbott, DA. Game playing: A method for reducing Young childrens Fear of Medical
Procedures. 1986 (cant find this one)
Randall P. Encouraging childrens development through play. Prof Care Mother Child 1994;4(3): 81-83
Shields L. A review of the literature from developed and developing countries relating to the effects of
hospitalization on children and parents. Int Nurs Rev 2001;48(1): 29-37. Review
Vessey J. Therapeutic play and the hospitalised child. Journal of Ped Nurs 1990; 5(5): 328-333
Visintainer MA, Wolfer JA. Psychological Preparation for surgical pediatric patients: The effect on
childrens and parents stress responses and adjustment. Pediatrics 1975; 56(2):187-202
Zahr LK. Therapeutic play for hospitalised preschoolers in Lebanon. Pediatric Nursing 1998; 24(5): 449454
Withey H. The role of the Hospital Play Specialist within the multi-disciplinary team. June 2000.
available from http://www.nahps.org.uk/HPSroleMDT.htm
Northop D, Lang C, Whitman CV. Local action: creating health promoting schools. Geneva: WHO; 2000.
Hall DBM. The Child with a handicap. Oxford, Boston, St Louis, Mo: Blackwell Scientific
Publications;1984
McCarthy GT. Physical disability in childhood-an interdisciplinary approach to management. Edinburgh,
New York: Churchill Livingstone; 1992
78
STANDARD 10: Recognising, protecting and supporting vulnerable or/and abused

children
ensuring that they recognise, protect and support vulnerable and abused children.
Supporting criteria
1. The following important primary, secondary and tertiary activities are aimed at preventing ill treatment
and abuse:
Giving advice on parenting and other related issues to pregnant women, carers, young people,
children and others.
Systems to identify vulnerable families in which abuse might occur:
Referrals to systems in the community (if they exist) to support vulnerable families:
The prompt but confidential sharing of information and concern with other relevant disciplines
such as other health workers, social welfare services, police, schools, playgroups etc.
A knowledge of the countrys legal framework for child protection
Referral to a social welfare service (or similar support service-if it exists) that provides general
and emotional support to vulnerable families, and to abused children and their families
2. For suspected abuse:
A written statement (policy) to guide health workers which includes clearly defined procedures
for managing children suspected of being abused
Lead health workers (doctor and nurse) to coordinate activities with responsibility for policies,
clinical guidelines for managing the child and family, monitoring the quality of the service and
training
Clinical guidelines to help with the recognition, diagnosis and investigation of child abuse that
are available to all health workers
Systems for protecting and supporting an abused child
Systems for protecting and supporting the families of an abused child.
3. Keeping confidential written information about vulnerable families, abandoned children and abused
children. Best possible practice is to have a confidential register of all abused children which can be
accessed twenty-four hours a day:
Discussion
Many health strategies and other primary, secondary and tertiary prevention activities can support
vulnerable children and families and help prevent child abuse and ill treatment.
79
Examples of activities aimed at preventing of child abuse include (WHO):

Primary prevention
Secondary prevention
Tertiary prevention activities
Pre-natal and perinatal

health programs
Child health
monitoring programs
Promotion of good
parenting
Raising public
awareness about child
abuse
Raising community
awareness about the
UNCRC
A social welfare
system
School activities re:
non-violence and the
prevention of bullying
A system for
identifying vulnerable
families
Family support
systems eg home visits
Clear referral systems
to support services for
vulnerable families
Substance abuse
treatment programs
Community based
family centred support
assistance and
networks (social
welfare system)
Accessible information
about community
services available for
all families
Support services based
in schools
Early diagnosis
The working together of all
organisations involved with
abused children to ensure:
- medical treatment
- healthcare
- counselling
- management and support
of victims
- management and support
of families
- re-integration into the
community and schools
Adequate child protection laws
Child Friendly criminal justice
systems, including facilities for the
court attendance and participation
of potentially abused children
Children are more likely to be vulnerable, abused and/or ill-treated when environmental factors are
adverse, when parenting is not good enough or when they themselves have problems that make their
families more stressed, or their care more difficult.
Risk factors include:
Environment factors
Absolute or
relative poverty
War or other
natural
disasters (eg
famine,
earthquake, flood
etc.)
Family
displacement or
refugee status
Confinement to a
prison or other
institution
Excessive family
mobility
Parent factors
Child factors
Absence of one or both birth

parents
Substance (drugs, alcohol etc)
abuse
Domestic violence and/or marital
relationship/family problems
Poor experience of parenting by
parent/s
Very young or immature parent/s
Physical or mental health
problems/emotional disturbance
in one or both parents
Family already known to social
welfare system
Evidence of poor parenting of a
sibling/s
80
A disability or learning
difficulties
Low birth weight/premature
birth
Prolonged separation from a
parent (such as admission to a
hospital) especially in the
neonatal period
Female sex (in some cultures
females are at risk of infanticide
and have limited opportunities
for education.)
One of a multiple birth
A difficult baby or child or
one who cries incessantly
WHO multilevel risk factors for child abuse

PARENT
CHILD
Young age
Single unsupported
parent
Unwanted pregnancy
Poor parenting skills
Early exposure to
violence or abuse
themselves
Substance abuse
Inadequate pre-natal
care
Physical or mental
illness
Learning difficulties
Relationship problems
FAMILY
Female Sex
Prematurity
Separation or poor
bonding in neonatal
period
Unwanted
Disabled physically or
mentally
Delayed development,
particularly soiling and
wetting past
developmental age
Difficult temperament
(persistent screaming,
attention
deficit/hyperactivity
disorder etc.)
Size/density
Poor socioeconomic status
Social isolation
High levels of
stress
Family
abuse/history of
domestic violence
COMMUNITY/SOCIETY
Non-existent, non-enforced
child protection laws
Decreased value of
children (minority, gender,
disabled)
Social inequalities
Organised violence (wars,
small arms, high crime
rates)
High social acceptability of
violence
Media violence
Cultural norms
The legal framework required to protect children varies in different countries. In some there may be no
framework at all despite ratification of the UNCRC, and in others advanced laws especially for children,
for example the 1989 Children Act in England and Wales. Some countries that do have legislation do
not have any framework for enforcing this and others have minimal legislation. Child abuse is often
interpreted very differently and some countries do not have laws to protect children from enforced labour,
recruitment as soldiers or to protect them if they are refugees.
Many disadvantaged countries place child protection programs low on their priority list, as they have so
many other problems to solve such as border security, the provision of safe water and sanitation,
affordable education and health systems, adequate employment prospects and securing their economy.
However there is an obligation following ratification of the UNCRC for governments to move towards
protecting children in a transparent way, whatever their problems. The International Community must
continue to advocate for the global rights of children to be protected and the introduction of laws that will
protect children where none exist.
Abuse, neglect or exploitation is less likely to occur if a country:
Provides financial and other support for vulnerable children and families
Ensures equal access to, and opportunities for, free healthcare and education for all children
Supports educational programs that will improve parenting skills for the whole population
Programs that identify and support vulnerable children and families (see Standard 1)
Uses integrated, collaborative and standardised methods to diagnose, protect and support abused
children.
Health care providers have a key role, together with other groups that work with children and families, in
identifying, protecting and supporting vulnerable and abused children and their families. To do this
effectively individual health workers have a responsibility to acquire the skills necessary to understand
and use the preventive, diagnostic, protective and support systems that exist in their country, to advocate
for these when they are absent and to collaborate with their colleagues in the other agencies and
organisations that are involved with children.
81
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 3, 11, 19, 20, 21, 25,
32, 33,34, 35, 36, 37, 39. NewYork: United Nations; 1989. Available from
http://www.unicef.org/crc/crc.htm
Southall DP, Coulter B, Ronald C, Nicholson S, Parke S, editors. International Child Health Care-A
practical manual for hospitals worldwide. Child Advocacy International. London: BMJ Books; 2002.
Report of the Consultation on Child Abuse Prevention WHO, Geneva, 29 31 March 1999. Available
from http://www.yesican.org/definitions/WHO.html
Parton N, Wattam C. Child sexual abuse: responding to the experiences of children. Chichester, New
York: Wiley; 1999
Polnay JC, editor. Child Protection in Primary Care. Abingdon: Radcliffe publishing; 2001
Reece R. Ludwig S, editors. Child Abuse: medical diagnosis and management 2 nd ed. Lippincott
Williams and Wilkins 2001
Meadow R. ABC of Child Abuse 3rd ed. London: BMJ Books; 1997
Goldstein S. The Sexual Exploitation of Children 2 nd ed. CRC Press 1998
Schwartz LL, Isser NK. Endangered Children: neonaticide, infanticide and filicide. CRC Press 2000
Benger JR, Pearce AV. Quality improvement report: Simple intervention to improve detection of child
abuse in emergency departments. BMJ 2002; 324: 780-782.
Peckover S. Domestic Violence and Children. BACCH Newletter, Spring 2002, p12-13. Available from
www.bacch.org.uk
Royal College of Paediatrics and Child Health. Fabricated or induced illness by carers. RCPCH, UK
Febrary 2002 (updated april 2003). Available from www.rcpch.ac.uk
Pereira D, Richman N. Helping Children in difficult circumstances A Teachers Manual (save the
children development manuals). London: Save the Children; 1996
Hobbs CJ, Wynne J. Physical Signs of Child Abuse A colour atlas. 2nd ed. London, Philadelphia:
Saunders; 2001
Unicef UK. End child exploitation faces of exploitation. Available from
http://www.endchildexploitation.org.uk/resources_publications.asp
Southall DP, OHare B. Empty arms: the effects of the arms trade on mothers and children. BMJ 2002;
325:1457-1461
Golden MH, Samuels MP, Southall DP. How to distinguish between neglect and deprivational abuse.
Arch Disease Childhood 2003:88 (2):105-107
82
Southall DP, Samuels MP, Golden MH. Classification of child abuse by motive and degree rather than
type of injury. Arch Disease Childhood 2003: 88 (2):101-104
Southall DP, Samuels MP, Bridson J. The police should take the lead on protecting children from
criminal abuse. BMJ 2003: 326:343
Southall DP, Plunkett MCB, Banks MW, Falkov AF, Samuels MP. Covert Video recordings of Lifethreatening Child Abuse: Lessons for Child Protection Pediatrics Nov 1997, Vol 100: No 5 :735-760
83
STANDARD 11 Promoting and monitoring health

ensuring that they monitor and promote health.
Supporting criteria
1. A system for immunising children, scheduled and catch-up immunisations that complies with the
countrys program is coordinated by a lead health worker. Includes the safe storage and transport of
vaccines and has standardised guidelines for the administration of vaccines and the management of
adverse effects.
2. A system for monitoring the nutritional status of children, including growth, ideally part of a
comprehensive integrated country program. The system includes standardised strategies for managing
children with problems.
3. A system for monitoring a childs physical (motor and sensory) and psychomotor (mental, emotional,
behavioural and social) development that is ideally part of any existing country program. It includes
standardised strategies for referring children with suspected problems to specialist referral services for
investigation and treatment.
4. Compliance with a countrys health screening programs for children and systems for providing advice
and healthcare for children with detected problems.
5. A health education program for children, and their carers that is appropriate, accessible and provides
relevant advice and information in understandable language and format
6. A safe motherhood program whose health workers liaise with skilled childrens health workers when
there are problems with an unborn child and a child at birth or after birth.
A nurse making health education and other

child friendly materials in Pakistan.
Discussion
A child has a right to the nurturing (the word nurse comes from to nurture) and care that will help him
or her survive, develop to his or her full potential and participate responsibly in society.
The responsibility for nurturing a child until they are fully developed lies with all adults. The childs
parents, supported by the State when this is necessary, have the major responsibility but all adults who
work with children also have a nurturing role. This is necessary if a child is to become a mature adult
84
capable of being a responsible member of their society, able to contribute to this societys development
and well-being, and themselves to be an adequate parent.
Best practice is for the State to support the child and parents through legislation that protects the child,
and also through other child and family services such as education, health and social welfare. The shared
efforts of all the services and agencies that work with and for children are needed if a childs development
is to be monitored and supported effectively. Preventive health services for children, such as a safe
motherhood program to protect the unborn child, the preventive component of WHOs program for the
Integrated Management of Childhood Illness (IMCI) and immunisation, health monitoring and health
screening programs for children are therefore of great importance.
Screening activities, whether or not they are part of a countrywide program, need to be supported by
systems that provide advice, counselling, support and appropriate healthcare for the child and family if a
problem or abnormality is detected.
Monitoring nutrition in the unborn baby and child is an essential component of any health provision. Best
practice is for the health worker to do this every time a pregnant woman or child is seen.
Monitoring child development is equally important and not costly. If one or more areas of development
are thought to be delayed this needs early confirmation, investigation, and effective treatment, with
standardised referral to specialist services where necessary. Unnecessary suffering due to a second child
having the same genetic health problem might be prevented if the problem is detected early.
Health education materials used by health workers in

Pakistan to teach all pregnant women attending the
hospital about childcare
Growth monitoring facility in a

childrens out patients department in
Pakistan
Children with disabilities are often discriminated against within families and communities. Health
workers have an important role to play in increasing the communitys understanding of the capabilities
and needs of each individual child with a disability as well as increasing the communitys awareness of
some of their common causes.
85
Avoidable health problems, accidents and childhood pregnancies cause great fear, anxiety and suffering
to children and families. All health workers have an additional responsibility to provide health education
on these and other topics that promote a healthy lifestyle, to raise awareness in parents so that they can
give their child the best possible care and to act as advocates for children when necessary.
However, it is important that health advice is not prescriptive, that it is relevant to the individual child and
family and given at an appropriate time. For example it would not be appropriate to give such advice
when a child was very ill, but to wait until the child was recovering and the parents less distressed.
Health education materials made by health workers play workers and children.
Both primary and secondary health workers need to have education/training opportunities that equip them
with the knowledge and skills to meet these health preventive responsibilities. Audit of compliance with
policies, programs and systems of care is important if their objectives are to be achieved in the best
possible way.
References:
United Nations General Assembly: Convention on the Rights of the Child. Articles 6, 17, 23, 24, 33,
NewYork: United Nations; 1989. Available from http://www.unicef.org/crc/crc.htm
Integrated Management of Childhood Illness (IMCI) - a World Health Organisation Program for
delivering healthcare to children, supported by UNICEF. Geneva WHO available from
http://www.who.int/child-adolescent-health/integr.htm
Rootman I. Evaluation in Health Promotion: Principles and perspectives. Copenhagen: World Health
Organisation, Europe; 2001
Hall D, Elliman D. Health for all Children. 4 th Ed Oxford: Oxford University Press; 2003.
Unicef. A League table of Child poverty in Rich Nations. Innocenti report card issue no. 1 June 2000.
Unicef Innocenti Research centre, Florence, Italy. Available from www.unicef-icdc.org
A Critical Link: Interventions for physical growth and psycho-motor development. A Review.
Department of Child and Adolescent Health and Development. Geneva: WHO; 1999.
The State of the Worlds Children 2001-Early Childhood. UNICEF. Available from
http://www.unicef.org/sowc01
86
Hogg C. Health Services for children and young people. London: Action for sick children; 1996
World Confederation for Physical Therapy, World Federation of Occupational Therapists and WHO
Rehabilitation. Promoting the Development of Young Children with Cerebral Palsy a guide for mid
level rehabilitation workers. Geneva: World Health Organisation; 1993
McCarthy G. The Physically Handicapped Child: An Interdisciplinary Approach to Management.
London, Boston: Faber and Faber; 1984
WHO Recommended Surveillance Standards. 2nd Ed .Oct 1999. Available from www.who.int/emcdocuments/surveillance/whocdscsrisr992c.html
Howard G, Bogh C. Healthy Villages : A guide for Communities and Community Health Workers.
Geneva: WHO 2002.
McMaster P, McMaster H, Simunovic V, Selimovic N, Southall DP. Parent and young person held child
health record and advice booklets and their use in Bosnia and Herzegovena. International Child Health.
1995; 6:121-131
McMaster P, McMaster H, Southall DP. Personal child health record and advice booklet programme in
Tuzla, Bosnia Herzegovina. J. Royal Society of Medicine 1996:89(4): 202-204
Fuerstein M. Turning the Tide, Safe Motherhood, A District Action Manual. Oxford: MacMillan
Education Ltd; 1993
www.safemotherhood.org
Hubley J. Communicating Health, An action guide to health education and health promotion. Oxford:
TALC. MacMillan Education Ltd; 1993
87
STANDARD 12
Supporting the best possible nutrition
Health care providers, organizations and individual health workers, share a responsibility to
ensuring that they support breastfeeding and the best possible nutrition for children.
Supporting criteria
1. Lead health worker/s for giving support and advice about breastfeeding, feeding and nutrition using
locally available foods
2. Systems of care and policies for:
Protecting, promoting and supporting breastfeeding (The WHO/UNICEF Baby Friendly Ten Steps to
Successful Breastfeeding).
Assessing a childs nutritional status to identify a malnourished child and a child who is not growing
normally:
Meeting each childs nutritional needs, including, where necessary, giving micronutrient (vitamins
and minerals) supplements and advice on special feeds and diets
Ensuring safe food preparation and storage:
The management of malnutrition, including providing enteral and parenteral feeding when
appropriate.
Outreach programs from the hospital to the community in managing and preventing malnutrition.
3. Support for breastfeeding is provided:
In a maternity unit the Ten steps to successful breastfeeding have been implemented. Formal
accreditation as a WHO/UNICEF Baby Friendly Hospital is the best possible level of practice if this
is available in the country
In the community all systems of care are compatible with the Ten Steps to Successful
Breastfeeding. Formal WHO/UNICEF baby Friendly accreditation is the best possible level of
practice if this is available in the country
In a health facility providing secondary care support for breastfeeding for children attending or
resident in a health facility, or their siblings, is compatible with the Ten Steps to Successful
Breastfeeding. Formal WHO/UNICEF baby Friendly accreditation is the best possible level of
practice if if this is available in the country for paediatric wards
4. Other support for nutrition includes: in every health care environment enough safe drinking
water for every child, parents/carer and health worker
Provision of the following medically indicated dietary supplements at no cost to parents/carers:
Oral rehydration solutions, including ones appropriate for children with co-existing malnutrition
Oral and parenteral micro-nutrient supplements
Protein and energy supplements
Special feeds and diets
Usually (intravenous) parenteral fluids
The oral preparations required for the management of malnutrition
And in a hospital or other residential healthcare facility also includes:
Food security for children, pregnant women and breast feeding mothers
A separate health worker/s to prepare food in dedicated clean areas
88
The equipment to prepare and store food safely

Supervision and assistance for a child who needs help with feeding
5. The use of guidelines and/or other job aides for:
The nutritional composition of food

Giving micronutrient supplementation
Giving intravenous fluids
Safe food preparation and storage
Giving special dietary requirements
Treating a child with severe malnutrition
Discussion
The term food is used generically to describe all forms of provided nourishment
Under and over nutrition has a huge impact, not just on childhood survival, but also on the physical and
psychosocial health of children and their health and survival as adults. The commonest global cause of
death in the under fives is malnutrition, either alone or associated with diarrhoea, respiratory infections,
measles, malaria, and HIV/AIDS. Children who fail to grow to their full potential in the first two years
are unlikely ever to catch up (growth stunting). This stunting, which carries a later cost for adult health
and quality of life, is still prevalent in many countries.
Under nutrition increases the severity and length of an illness and can cause apathy, depression and
deterioration of social interaction. This is of particular significance in young children who would
normally be developing their physical, social and other skills at a rapid rate. There is substantial evidence
to show that under nutrition in young children, particularly in association with illness, leads to the
stopping or slowing of development and even a loss of skills that may never be fully regained.
At the other end of the scale, largely in the developed countries, over-nutrition and childhood obesity are
causing increasing health and quality of life problems.
Nutrition for a child begins ante-natally with attention to the mothers lifestyle and health during
pregnancy. This is also a good time for health workers to give health education about breastfeeding and
childcare as the quality of early nutrition is directly related to survival and later health. Following a recent
review of the evidence, the recommendation of the Global Strategy on infant and young children feeding
is: exclusive breastfeeding until six months of age followed by continued breastfeeding alongside
complementary feeding up to two years of age.
89
Breastfeeding is best supported if maternity Units, childrens wards and community childrens services
follow the UNICEF/WHO Ten Steps to Successful Breastfeeding which are.
1.
2.
3.
4.
5.
Have a written breastfeeding policy that is routinely communicated to all healthcare staff
Train all healthcare staff in the skills necessary to implement the breastfeeding policy
Inform all pregnant women about the benefits and management of breastfeeding
Help mothers initiate breastfeeding soon after birth
Show mothers how to breastfeed and maintain lactation even if they are separated from their
babies
6. Give newborn no food or drink other than breastmilk, unless medically indicated
7. Practice rooming-in, allowing mothers and infants to remain together 24 hours a day
8. Encourage breastfeeding on demand
9. Give no artificial teats or dummies to breastfeeding infants
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
from the hospital or clinic
During the initiation of complementary feeding at or after six months of age, safe water, food security,
food safety and hygienic preparation of appropriate foods are paramount. Best practice is to recommend
and use foods that are locally available and suitable for the age and developmental level of the individual
child.
To encourage an appetite in ill children, food also needs to taste good and be well presented.
Parents/carers need to be responsive to the childs demand and pace of eating. An ill child may not have
their normal appetite, or be able to eat the foods normally accepted. Avoiding further deterioration by
encouraging and helping them to eat is a simple but important part of care that is often overlooked by
health workers.
It is essential that during every health contact:
The childs nutritional state is assessed, including evaluation of growth
The childs nutritional needs are correspondingly assessed, particularly in early childhood and
during an illness
Advice is given to carers about:
- How to meet the childs needs in a stimulating age-appropriate way using locally
available foods that are affordable
- Safe food preparation and storage
- Feeding techniques.
Mothers preparing low-cost local nutritious

foods for their children in the nutrition
ward in a Ugandan Hospital
90
To gain the necessary skills to provide this nutritional care, all health workers need to learn about
nutrition as part of their core and continuing training programs. Best practice is for this training to include
learning about the management of lactation, a knowledge of what is meant by nutrition and nutritional
status, what is needed for children to grow and develop normally and how best to treat a child with severe
malnutrition. It is also important to acquire the practical skills that will enable health workers to identify
and help a child with a feeding difficulty.
Malnourished children need nutritional support. The simplest and most cost-effective nutritional support
is to provide enough appropriate local food for each individual child. In occasional very severe cases,
when appropriate, the use of enteral or parenteral nutrition needs consideration. Parenteral (IV) nutrition
is only likely to be available in well-resourced health facilities and should only be used when there is
gastro-intestinal failure and nutritional needs cannot be met via the gastro-intestinal tract.
To minimise the deaths of children from severe malnutrition it is essential that all health workers have
received education/training in the management of severe malnutrition and follow the WHO recommended
procedures. In the early stages of treatment the risk of dying is high, sometimes because the treatments
and foods given are inappropriate, or associated dehydration, hypothermia, hypoglycaemia, infection and
electrolyte imbalance are not correctly treated
References
United Nations General Assembly: Convention on the Rights of the Child. Articles 3, 24, 26, 27
NewYork: United Nations; 1989. Available from http://www.unicef.org/crc/crc.htm
Golden MHN. Severe malnutrition. In Southall DP, Coulter B, Ronald C, Nicholson S, Parke S, editors.
International Child Health Care-A practical manual for hospitals worldwide. Child Advocacy
International. London: BMJ Books; 2002. p241-252
Department of Child and Adolescent Health and Development, World Health Organisation. Management
of the Child with A Serious Infection or Severe Malnutrition, Guidelines for care at the first referral level
for developing countries. Department of Child and Adolescent Health and Development. Geneva: WHO,
2000.p 80-91
World Health Organisation. Management of severe malnutrition: A manual for physicians and other
senior health workers. Geneva: WHO; 1999
A Critical Link: Interventions for physical growth and psycho-motor development. A Review.
Department of Child and Adolescent Health and Development. Geneva: WHO; 1999.
World Health Organisation. Nutrition, Health and Child Development research advances and policy
recommendations. Washington, D.C: PAHO, Pan American Sanitary Bureau, Regional Office of the
World Health Organization; 1998
Unicef UK. Bright Futures. Malnutrition: the news. UNICEF UK, Western Union; 2002.Available from
www.unicef.org.uk
World Health Organisation Division of child health and development. Evidence for the Ten Steps to
Successful Breast Feeding. Geneva: WHO; 1998
Royal College of Nursing. Breast Feeding in Paediatric Units: guidance for good practice. London: Royal
College of Nursing;1998. Available from http://www.babyfriendly.org.uk/paedunits.asp
91
Palmer G. Politics of Breast Feeding.2nd ed. London: Pandora press; 1993.

World Health Organisation. Prevention and Management of the Global Epidemic of Obesity. Report of
the WHO Consultation on Obesity. Geneva: WHO; 1998
Adams M, Motarjemi Y. Basic Food safety for health workers. Geneva: WHO 1999
Unicef. Facts for Life., 3rd ed. New York: Unicef; 2002 Available from www.unicef.org
Puoane T, Sanders D, Ashworth A, Chopra M,, Strasser S,McCoy D. Improving the hospital management
of malnourished children by participatory research. Int J Qual Health Care. 2004. 16:31-40 (2004)
Michaelson KF. Feeding and Nutrition of Infants and Young Children. Guidelines for the WHO European
Region. Copenhagen: WHO Regional office for Europe; 2000
World Health Organisation. Foodborne disease - a focus for health education. Geneva: WHO 2000.
Bhan MK, Bhandari N, Bahl R. Management of the severely malnourished child: perspective from
developing countries. BMJ 2003; 326: 146-151.
Commission on the nutrition challenges of the 21st century. Ending malnutrition by 2020. An Agenda for
Change in the Millennium. Food and Nutrition Bulletin 2000. 21(3): (supplement)
World health organisation. Training in the management of severe malnutrition. Available from
who.int/nut/documents/manage_severe_malnutrition_training_fly_eng.pdf
www.babyfriendly.org.uk
92
Section 3: How Child Friendly are you?

(How to assess the care you give)
This program for assessing and improving Child Friendly Healthcare has been developed and piloted
with the help of nine hospitals in seven countries. It works well in diverse countries and health services
and although not dependant on health workers being familiar with the articles of the UNCRC or the
concept of Child Friendly Healthcare can be enhanced by this knowledge.
COMMIT to CFH
PROMOTE CFH and PLAN an ASSESSMENT
ASSESS
Stage 1 Optional preliminary CFH assessment
Meeting for feedback and selection of Standard/s
ASSESS
Stage 2 Detailed assessment of level of practice of a selected Standard/s
(Basic, bronze, silver or gold level of practice)
Meeting for feedback and planning, if improvements are needed and wanted
IMPROVEMENT PLAN
IMPROVEMENTS
(With support if needed)
ASSESS
Stage 3 Re-assess selected Standard/s for progress
Meeting for feedback and/or further planning
ACKNOWLEDGE PROGRESS / IMPROVED LEVEL of PRACTICE

(to bronze, silver or gold)
PLAN MORE IMPROVEMENTS
Repeat Stages 2 and 3 until all the CFH Standards are practiced
at the best possible level (gold)
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Does the program work in any type of healthcare environment?

The program is easy and flexible enough to be used in any type of healthcare environment the home, a
primary care surgery/clinic/health house, a refugee camp, referral out-patients or any level of hospital or
other residential facility that provides healthcare. It can be adapted to suit the circumstances.
Who can use the program?
It works equally well for all types of health worker who plan, organise and deliver healthcare either in the
community or secondary/specialist environment. It can be used for self-assessment or for use by an
outside assessor appointed to help.
Who else can promote Child Friendly Healthcare?
Any committed health worker who is familiar with its practices and principles can promote CFH by
sharing information about the CFHI and the UNCRC with others in the same healthcare environment, in
other healthcare environments in the same country and with health workers in other countries.
Child Friendly Healthcare belongs to every health worker that looks after children and families
whether they are involved in planning, organising, providing or giving care.
How long does it take to achieve the best possible Child Friendly Healthcare?
Healthcare is a continuum of change. Improvements will always be necessary because of new discoveries
and research. The programs simple methods and processes can be used indefinitely.
How to start the program?
The health workers responsible for managing and planning childrens healthcare:
1. Commit their health facility or health service to Child Friendly Healthcare and the CFH quality
improvement program it works best if all the senior doctors and nurses in a participating clinical
area or other healthcare environment are motivated to improve and change. During the pilot
project, less motivated health workers, who initially didnt want their clinical area to participate,
saw the progress made in participating areas and then became keen for their clinical area to
become involved too.
2. Appoint a CFH coordinator or coordinators
3. Decide whether to self-assess or to appoint an experienced external assessor/s to help
4. Plan an assessment
Who should coordinate the program?
A volunteer or a person selected from among the senior doctors and nurses working in the participating
healthcare environment. The pilot project revealed that the program works best when coordinated and
facilitated by a health worker who has the respect of their colleagues, and the authority to make decisions
and initiate change. In order to engage the two largest professional groups, a nurse and doctor team works
best. Good leadership, team working and problem solving skills are also of paramount importance.
The responsibilities of a CFH coordinator
The most important responsibilities of a coordinator are to:
Promote Child Friendly Healthcare
Be committed to the best possible level of practice for all aspects of healthcare for children and
any changes that may be needed towards achieving this
Supervise and contribute to the program
What other responsibilities does a CFH coordinator have?
For self-assessment the responsibilities include:
94
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Organising and doing the assessments, including the administration and logistics
Organising the planning meetings and inviting the relevant people
Coordinating a collaborative plan for making improvements
Facilitating and supervising progress work in the participating clinical area/s
Liaising with the health workers responsible for support services and other key jobs relevant to
the Standard chosen for improvement
Supporting colleagues in the participating clinical areas who are trying to improve the care they
give
Co-ordinating education/learning if this is identified as needed by the assessment
Acting as a mentor for any health workers from another country working alongside local health
workers to help with the planned improvements
Providing regular feedback/reports on progress and prompt sharing of any problems or concerns
with relevant others, including the external assessor
Sharing information regularly with other important stakeholders in childrens health, including
the director of the health facility or service, relevant supporting organisation and other senior
childrens health workers.
If an external assessor helps, the coordinator contributes to the program by:

1. Acting as the link person with the external assessor/s, before, during and after an assessment
2. Providing the external assessor with any requested pre-assessment information and any relevant
in country research relating to Child Friendly Healthcare
3. Looking after the external assessor during their visit
4. Acting as an interpreter or appointing an interpreter if one is needed
5. Organising translation of documents or other program related materials and distributing these.
Important jobs best led and coordinated by a named lead health worker/s include:
Rights issues:
Standards 4, 6
Family welfare:
all Standards (1,3, 4, 5, 6)
Disability/rehabilitation:
all Standards
Hygiene Promotion/Infection Control:
Standard 3
Pain and symptom control (Palliative Care):
Standard 7
Resuscitation and emergency care:
Standard 8
Play:
Standard 9.
Education /school-type learning:
Standard 9
Child Protection:
Standard 10
Immunisation:
Standard 11
Health Promotion:
Standard 11
Breast Feeding:
Standard 12
Nutrition:
Standard 12
Clinical guidelines and job aides:
Standards 2, 7, 8, 10, 12
Continual Professional Development:
All Standards
Audit:
All Standards
Data management:
All Standards
Ethics:
All Standards
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To self-assess or use external assessor to help?

Self-assessment works best when the healthcare environment:
Is managed transparently
Is good at team working
Has transparent employment and disciplinary procedures
Has senior health workers who understand CFH and are committed to a continuum of assessing
and improving practice
Has adequate human and material resources
Finds that most of the systems of care, facilities, policies, guidelines, educational opportunities
etc. in the initial check-list (Tool 1, Part 1) are in place
Delegates the responsibility for the support services and most of the important clinical jobs to
different health workers
Values all its health workers
Respects and values the views and opinions of children and their families
Although self-assessment can work well there are many advantages to using in addition external
assessors (health workers who do not work in the same health facility).
External assessors are more likely to:
Be unbiased
Protect confidentiality, especially of the senior health workers
Gain a more open and honest expression of views and experiences
Provide reports that are less open to challenge or manipulation
Share information openly
Raise awareness levels by sharing their wider experience
Act as a catalyst or lever for change
Provide a role model for team working if this is a new concept for the healthcare environment
Empower health workers and families
Have the contacts and skills to contribute to, facilitate and support change
Who should be an external assessor?
A childrens health professional or manager with assessment skills who commands professional respect
and is committed to CFH. In our experience it works best if an external assessor understands the culture
and languages of the Country, although it can sometimes work well using interpreters.
About the CFH assessment improvement program
The objectives of a CFH assessment are to:
Raise awareness about CFH thereby enabling and empowering change
Help prioritise areas of care for scrutiny
Assess the current level of practice of these prioritised areas
Identify local problems and their possible solutions
Identify barriers against, and forces for change
Facilitate making it better (making healthcare improvements)
Where relevant, identify appropriate aid projects to support local health workers in making it
better
Identify issues for advocacy
Identify change and/or progress after an agreed period of time
96
Acknowledge changes, however small, so that health workers are motivated to continue making it
better for the children, their families and themselves
About assessment
Before an assessment it is important to:
Obtain consent for the program from the director (or equivalent) of the Health Facility and, if
relevant, also the countrys Ministry of Health. In some countries it is also useful to ask for
support from the WHO and UNICEF Regional and/or country offices.
Share information about the CFHI with the Health Facility director, and if relevant with the WHO
and UNICEF country representatives and the Ministry of Health
Do an initial brief self-audit against the CFH Standards. This is useful as it sensitizes other health
workers to CFH, identifies areas of health care that the health workers think they do well and
areas of care that health workers want to improve
Pre-assessment information for an external assessor that is helpful includes:
The language/s used in the health facility
A brief report on the services provided for children
The number of children born, seen and/or admitted during a year in the health facility
Mortality and morbidity statistics, if collected and any other data routinely collected
The number of doctors, nurses and others employed
The names of relevant service and other managers and coordinators of important jobs
The names of the senior doctors and nurses with important responsibilities
The results of a brief self audit carried out by the CFH coordinator and others
A prioritised problem list
After an assessment the assessor/s:
Bring/s together the results of the assessment and present/s these at meetings
Provide/s a written report of the assessment and circulate/s this to all involved (See appendix on
website for an example of a format for writing a report)
Contribute/s to any plan for improvements decided on by health workers in participating areas
Facilitate/s improvements if and when possible
The assessment process achieves these objectives by using a toolkit that seeks to understand by
observing, listening to and questioning the people who use and deliver the health care for children and
their families. The toolkit finds the problems and the possible solutions to them from the children, their
families and the health workers, and identifies the quality level of practice.
The assessment process focuses not on resources, but on how health workers manage and use the
resources that are available to them, and on their attitudes, skills, practices and knowledge levels.
How long does it take to do an assessment?
The number of assessors and the time needed for an assessment is dependant on the size of the healthcare
environment and the number of health workers employed. For most healthcare environments it should be
possible for two assessors to carry out both a first and a second stage assessment within one week, and a
third stage progress assessment in 2 3 days.
The views and opinions of a sufficient number of people will be needed to gain true representation. In a
large healthcare environment it helps if the number of participating clinical areas is initially limited,
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choosing those with the most motivated health workers. Other clinical areas can join the program at a
later date.
The time needed can be minimized by:
Meticulous pre-assessment information gathering
Meticulous planning of an assessment, including estimating the number of questionnaires and the
number of interviews with senior health workers and managers that will be needed
Translating materials in advance if necessary
Arranging interpreters in advance if these are needed for the interviews
Why are there three stages to the assessment process?
There are three stages because each has a different objective.
A Stage 1 assessment is optional but is particularly relevant in countries where Child Friendly
Healthcare is least developed, resources are scarce and the level of practice for many aspects of
healthcare is likely to be basic. It gives preliminary information about the level of practice of all twelve
CFH Standards and complements the self-audit. It specifically:
Finds out which Standards are practiced well and which not so well
Identifies examples of good practice to share with others
Identifies areas of care that could be easily improved
Identifies the barriers to and forces for change
Identifies issues for advocacy
This information helps health workers choose and prioritise areas of healthcare within the CFH
standards for a more detailed assessment of how well they are practiced.
In disadvantaged countries a Stage 1 assessment can be used to help plan humanitarian aid
projects. It has advantages over an unstructured assessment as:
It is transparent and repeatable
Systematically identifies missing or limited essential resources
Seeks the views of all types, and levels of health worker
Seeks the views and opinions of the families that use the service, therefore provides a balance
between the needs and wishes of the families and the aspirations and wants of the health workers.
The CFH program may be the best way to identify appropriate sustainable humanitarian aid projects
A Stage 2 assessment assesses the chosen and prioritised Standard in detail. It will:
Identify a quality level of practice (basic, bronze, silver or gold)
Identify examples of good practice to share with others
Find out the problems and their possible solutions
Provide a framework to help health workers prioritise and plan needed, feasible and wanted
improvements
Further clarify issues for advocacy
A Stage 3 assessment is done after improvements have been made. It will:
Find out if the planned improvements have happened or not
Find out if the improvements made have achieved their objective: to make things better
Find out if the quality of practice is higher (for example has changed from basic to bronze)
Identify barriers to progress and problems encountered during improvement activities
Identify strategies for change that worked and the reasons why so that these can be shared with
others
Further clarify issues for advocacy
98
Stages 2 and 3 can be repeated indefinitely until Child Friendly Healthcare is practiced at the best
possible level (all twelve Standards practiced at Gold level).
Achieving objectives and a higher level of care motivates health workers to make
further staged improvements
Levels of performance
Going for Gold is a well-known and used concept that works especially well in encouraging athletes to
strive for excellence and their best possible performance at the time and in the circumstances. The
concept of using a medal system to identify excellence therefore seemed appropriate and complied with
our objectives.
The three qualities of performance are gold, silver and bronze, with all other levels of practice called
basic practice.
99
Diagram illustrating four levels of quality of care for each Child Friendly Standard.
Standard 12
Standard 1
Standard 2
Standard 11
Standard 10
Standard 3
Standard 4
Standard 9
Standard 8
Standard 5
Standard 7
Level 1
Basic
Level 2
Bronze
Standard 6
666
Level 3
Silver
Level 4
Gold
About the CFH Toolkit

The CFH Toolkit used for the three stage assessment program contains check lists about services,
facilities, resources, systems of care, written statements about care, clinical guidelines and other job aides,
data management, especially the quality of medical record keeping and monitoring charts,
education/training opportunities, the quality of audit, and all other activities necessary to practice the
Standards. These check lists are supported by structured observations, interviews (open, semi-structured
100
and structured), questionnaires (including knowledge based questionnaires for some CFH Standards),
and, after a stage 2 assessment, benchmarking for any planned improvements.
Child Friendly Healthcare Tool 1
For use in the Stage 1 assessment. It has three parts.
Part 1:
This is a short yes/no check-list. It is to be completed either by the local CFH coordinator with help from
senior health workers responsible for the childrens services, the support services, important jobs (for
example palliative care, play etc), and other relevant health workers such as the senior childrens doctors
and nurses.or by an external assessor/s after he/her has talked to these senior health workers
If an external assessor completes the list, it is advisable for them to confirm what they have been told by
direct observation. To do this, the external assessor needs to visit all the clinical areas in a health facility
used by children and to see the facilities, systems of care, written statements about care, systems for data
management, audit and educational opportunities and all the written protocols, policies and clinical
guidelines. .
Part 2
This represents a semi-structured interview with health workers of all levels and types (professional and
non-professional, including students). It contains questions designed to find out about their concerns,
attitudes, opinions, knowledge levels and use of existing resources
Part 3
This is a semi-structured interview with parents/carers and when possible children, using short openended and semi-structured questions. This enables parents and children to express their views, ideas and
opinions about their healthcare experiences; both good and bad.
Child Friendly Healthcare Tool 2
This is used in the CFH Stage 2 and 3 assessments. It has four parts.
Part 1
This is a detailed check-list that systematically reviews the organization and management of facilities,
resources and other activities relating to each CFH Standard chosen for assessment
Part 2
This is a structured questionnaire (or interview) for each chosen standard . This is given to a random
selection of professional health workers to complete. It helps assess the skill levels, attitudes, practices
and education/training needs of health workers. For some of the Standards it includes knowledge related
questions.
Part 3
This is a semi-structured interview for each chosen standard with a random selection of parents/carers
and/or children concerning their experiences relating to this Standard.
101
How to identify the quality/level of practice of a CFH Standard?

The first three parts of the Tool 2 have been designed so that in addition to providing useful qualitative
information about attitudes and experiences to help health workers prioritise and plan improvements, they
can also be scored/quantitatively. Quantitative scoring makes it possible to identify and consistently
standardise four proposed qualities of care (basic, bronze, silver and gold).
A scoring system that excludes questions seeking only ideas and possible solutions to problems needs to
be developed and agreed by health workers in the participating country or individual health facility before
they apply the program
This also makes monitoring changes easier and more accurate, and allows for comparisons to be made
with other similar health facilities.
An example of a possible scoring system for a question from Tool 2: Part A for Standard 8
Question 8
Data management
Score =
Health workers:
Make timely and detailed records about every resuscitation
Collect and examine the outcomes of every resuscitation
Collect and examine the outcomes for children who are very ill
Collect and examine information about the probable cause of
the death
Total score = 4 Total possible score = 4 Percentage score is 100%
Yes
Yes
Yes
1
1
1
Yes
The total possible score for each part of the 3 of Tool 2 (A, B and C) is best calculated as a percentage of
the total score possible. The percentages for each of the three parts can be added and divided by 3 to
identify an overall percentage score that can be used to determine the level of practice (0 - 25% is basic
care, 26 - 50% is bronze, 51% - 75% is silver and 76 - 100% is gold).
Score as a percentage
Quality level of care for a Standard
0 25%
Basic care
26 50%
Bronze
51 75%
Silver
76 100%
Gold
For example:
The scores after Standard 3 was assessed in the Childrens Ward of hospital X (before
improvements made) were as follows:
Part A: Score = 45% = Bronze
Part B: Score = 75% = Silver
Part C: Score = 15% = Basic
Therefore average score = 45% = Bronze
After improvements were made, the scores for Standard 3 in this ward were:
Part A: Score = 55% = Silver
Part B: Score = 85% = Gold
Part C: Score = 40% = Bronze
average score = 60% = Silver
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Part 4
This is a series of benchmarks made for a Standard that is prioritised for making improvements
Benchmarking is the process of measuring the current status of an organisation or an individuals
performance and comparing it with either past performance or to the accomplishment of others.
Benchmarking works best if each planned improvement is given four benchmarks.
The first is a statement about the current situation (basic care), the second and third stages are steps
towards the goal (bronze and silver), and the fourth is the best possible quality of care hoped for after
improvements have been made (gold)
Example of a benchmark
Basic practice
Current practice
Bronze
A first step towards
best practice
Silver
A second step
towards best practice
Toilet for health workers

never clean
Toilet clean some of

the time
Toilet clean most of

the time
Gold
Best possible practice
(The improvement
planned)
Toilet scrupulously clean
throughout the 24 hours
Part 4 provides the framework for improvements. This framework can also be used as a simple way to
regularly monitor progress. It is a rapid method for seeing which objectives have been achieved either
partly or in full, and which have not.
An example of an improvement
Sink in neonatal ward before (basic quality)
)))quality)
Same sink after improvement (now bronze)
Assessment meetings
Multidisciplinary meetings are essential before an assessment, for assessment feedback, and for planning
improvements. They need to be attended by the key people, have an agenda and a chair (leader),
usually the CFH coordinator.
103
Information about the meeting, and any decisions made during the meeting, need to be shared with the
health workers they affect.
A meeting is useful before an assessment to:
Introduce an external assessor to key people, and sometimes the key people to each other as in
our experience health workers in important roles have not always met all the people they relate to
(putting names to faces).
Share information about CFH and the CFH assessment process
Answer questions
Plan a realistic timetable and the logistics for the assessment processes
The main objectives of a meeting after an assessment are to:
Provide feedback
Answer questions
Discuss issues and problems
Share ideas
Collaboratively plan prioritized, feasible and staged improvements
Plan a realistic timetable for these planned improvements
Decide a date for review of progress (a CFH Stage 3 assessment)
A CFH meeting in Uganda to plan

healthcare improvements
The people who attend CFH meetings could include:

WHO and UNICEF Country staff (if relevant and perhaps only to the first meeting)
The director/chief of the healthcare environment or the deputy director
The manager of childrens services if there is one
The senior childrens doctor and nurse
Senior health workers who manage clinical areas
The senior health workers who manage support services or coordinate important clinical jobs
(such as the coordinators for immunization, infection control, the management of pain, breast
feeding, child protection and others) if relevant
The CFH coordinator
The external assessor/s
Representatives from any NGOS already working in the healthcare environment or country who
might provide help and support
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How do children and their parents/carers contribute to the assessment process?

The input of children and families is essential, welcome and sought during all three stages of the
assessment process. It is a key aim of the CFHI assessment process and itself assesses communication and
liaison with parents.
A mother asking to talk to the

CFH coordinator in Pakistan
To a certain extent, the issues raised by children and their families will always be influenced by
expectations and awareness of possible alternatives. However basic issues fundamental to either easing or
increasing fear, unhappiness and distress can usually be identified.
It is vitally important to protect the anonymity and confidentiality of everyone who is interviewed as this
allows children and families to express their views and opinions more freely. There are inherent problems
with seeking information wherever there is a likely imbalance of power between assessor and
participant. This is a particular problem within a health care setting, where participants may feel their
answers are not confidential or that care could be adversely affected. Families in many countries may
have never been asked for their opinion in such a way before and may live in a climate of
disempowerment and justified mistrust of officialdom. The interviewer must be impartial and trustworthy,
with an independent translator if necessary (not relatives of the family or healthcare staff). Any verbal or
written information acquired must not be traceable to an individual parent or child.
Families will respond best if they feel at ease, have privacy during an interview, are shown respect,
understand the purpose of the interview and feel able to interrupt or stop it if they or their child needs
attention.
The purposes of an interview should always be remembered. It is to gain an understanding of what is
important to each individual child and family, what has been particularly good or difficult, what might
make their experience better and what their ideas are about how to make things better for others with the
same problems, if they think this necessary. It is best to explain the program in a way that is
understandable. The interviewer needs to check that the child or parent/carer understands why they are
being interviewed, and what will happen to their contribution, by getting feedback and welcoming
questions. It is important to obtain consent for the interview after this explanation.
Questions need to be easily understood and may need to be omitted if they are not relevant, appropriate,
cause distress or the parent/carer or child does not wish to answer. It is important not to coerce any child
or family member into giving information or answering questions they feel uncomfortable about. If using
an interpreter, look at and talk to the child or parent, rather than to the interpreter, and look at the child or
parent when listening to the answers given through the interpreter to see if they are correct by watching
105
their body language. Use empathetic body language yourself, as showing care and respect will encourage
a child or parent to say what they really think or feel
It is useful to have some form of distraction, such as a toy or a picture, to engage and amuse younger
children when interviewing their parent.
Points of note concerning an interview with a young child
It is not appropriate to ask young children questions about every aspect of care (questions
developed during the pilot project were about Standards 4, 5, 6, 7 and 9).
It is always best to interview young children when they are with their parents or other familiar
carers.
The person asking the questions needs to be skilled at interacting with children
If a child appears upset or develops any distressing symptoms, it is best to thank them for their
help and withdraw rather than persist with the interview
Interviews need to be short.
The words used need to be simple and easily understood by the child
Interviewers checklist:
Find a private place to conduct the interview
Make sure the child or parent is sitting comfortably
Tell the child or parents/carers your name,
Explain who you represent and what work you normally do
Explain the reason for the interview giving a brief explanation of the CFH program (better
healthcare)
If you are an external assessor explain that you do not work in this healthcare environment and do
not personally know any of the health workers
Explain that anything they say will be confidential, and that although important things they say
may be shared with others, no-one will know who said these things
Ask the parent/s or carer if they still agree to talk, or will allow their child to talk to you-(if they
say no, respect this decision)
Get signed consent for the interview or a thumb print (this still represents an individual, and may
be more acceptable) - in some countries verbal consent is sufficient (See section 5 for an example
of a consent form).
How many children and parents/carers should be interviewed?
As many as possible from each healthcare environment that is being assessed and best chosen randomly
from those available (if only volunteers are interviewed there may be some bias in the answers they give.)
Ideally the same number of parent/carer/children as health worker interviewers provides balance.
It does not matter if different parents/carers and children are interviewed before and after improvements
are made. This commonly occurs due to time constraints, and will still allow comparative data to be
gained
How do health workers contribute to the assessment process?
Involving as many health workers as possible in an assessment reveals how they manage and use their
resources, helps understand their attitudes and assesses their skill and knowledge levels.
Senior health workers

Assessors need to work closely with the senior health workers in the healthcare environment
responsible for childrens services, the managers of support services and any coordinators for the
important clinical jobs to complete the Part 1 check lists. Relevant senior health workers are also
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asked to contribute in the same way as others by completing questionnaires for chosen CFH
Standards.
All other Health Workers

All types and seniority of health worker both professional and non-professional, including those in
training, are either interviewed or asked to complete questionnaires. The detailed questionnaires for
some parts of some Standards will be most relevant for doctors and nurses; the views and opinions
of other health workers will be needed for other parts.
Results may not genuinely reflect collective views if some health workers do not wish to participate or are
unable to. It is therefore important to gain prior authority from senior health workers to ensure that full
cooperation at all levels is possible.
Checklist for assessors:
Decide on the total number of questionnaires needed and then number these
Distribute and collect the numbered questionnaires
Explain the program to the participating health workers or design an information leaflet to be
handed out with each questionnaire
Arrange a collection time or deadline for completing the questionnaires
Agree on a method of collection
Keep a record of the name of each health worker who has been asked to complete a questionnaire
to check whether or not they have returned it
Make sure the questionnaires are confidential and an individual cannot be linked to a specific
questionnaire (no names or other identifiers on questionnaires)
Follow up any questionnaires not returned
How many completed questionnaires are needed?
In a small health facility or clinical area all nurses and doctors should complete the Stage 2
questionnaires.
In larger health care environments or clinical areas a representative sample is sought. Ideally this sample
is a manageable percentage of each type and seniority of health worker selected systematically and
randomly from employment or duty lists. In practice unless careful planning is possible, selection may be
more dependent on availability. In larger clinical environments ten nurses and doctors is the absolute
minimum number needed.
References
Department of Health. The essence of care Patient focussed benchmarking for health care practitioners
2001. Available from www.publications.doh.gov.uk/essenceofcare/essenceofcare.pdf
Gosling L, Edwards M. Toolkits: A practical guide to assessment, monitoring, review and evaluation (Development Manual 5).
Richman N, Save The Children Fund. Communicating with Children. Helping Children in Distress.
General Medical Council UK. Confidentiality: Protecting and providing information. London: General
Medical Council; 2004
Nursing and Midwifery Council UK. The NMC Code of Professional Conduct: standards for conduct,
performance and ethics. Nursing and Midwifery Council 2004. Available from http://www.nmcuk.org/nmc/main/splash.html
107
Section 4
Making it better
How to improve the care you give
Child Friendly Healthcare belongs to every the health worker that looks after children and
families whether they are involved in planning, organising, providing or giving care.
The first photograph shows a chaotic, poorly

organised, child unfriendly working
environment. Mothers were not welcomed, only
allowed to visit at certain times and did not share
in the care of their babies. The mortality rate was
high, health workers were de-moralised and both
mothers and health workers unhappy.
The second photograph taken less than a year later shows

a cleaner, well organised ward (although still
overcrowded), unstressed health workers, parents free to
come, go and share their babies care, a much improved
environment with more information on the walls, childfriendly curtains and wall frieze. This was achieved by reorganising the way care was given, developing a team
approach, sharing knowledge and skills, changing old
behaviours and attitudes and making the environment
friendlier and cleaner. All was achieved by the health
workers themselves.
Important reasons for making it better are:

Children are still dying and suffering needlessly when receiving healthcare
There are always problems that need solving, regardless of circumstance or resource level
It is always possible to improve on current practice as research evidence continues to show better
outcomes from new or different methods of care and treatment
Society is continually changing, bringing with it both new benefits and new threats to the health of
children and families that need to be considered
.
Making it better for children by improving the care you give means making changes
Barriers to change
To make changes happen the barriers against change and the forces for change need to be recognised and
fully understood. Some of the barriers to change are found outside and some inside the healthcare
environment and some are more outside the control of ordinary health workers than others. They are also
found in individual health workers.
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It's not the strongest of the species that survive, not the most
intelligent, but the one most responsive to change (Charles Darwin)
External barriers (usually outside the control of the health workers in a healthcare environment)
Adverse circumstances in the country (natural and man-made disasters)
Complex healthcare bureaucracy
Constantly changing policies at local and governmental level (instability)
A low budget and poor planning for childrens healthcare
Poorly integrated primary and secondary healthcare services
Many demands for change imposed by others
Low salaries. Low pay means that supplementary income generation, such as private practice, is
an important priority. This inevitably leads to inequity of care and a low commitment to provide
the same standard of healthcare to all children.
Poor job security so health workers fear voicing their opinions.
Limited opportunity for professional advancement and little recognition of worth.
Poor work environment (low investment in equipment and infrastructure)
The unreasonable expectations of people who use the health services (complaints/litigation)
A blame culture in society
Internal barriers (within the healthcare environment (can often be influenced by health workers)
Little or no consultation with the children, their families and the health workers giving or
supporting the care, by those planning services or systems of care. Often non-professional or
junior health workers lack a voice.
Poor sharing and unequal distribution of resources
Poor organisation of the material resources that are available
Poor maintenance, especially cleaning, of the healthcare environment
A vertical management structure with little delegation. This can restrict innovation and
development
No opportunities for education and for health workers to learn effective management and
organisation skills
No fair and open system for employing, dismissing or disciplining health workers
No system for the recognising and praising the contributions of individual health workers or
clinical areas
Poor organisation and no standardisation of systems of care
Poor organisation of human resources (frequent changes of carers, poor skill mixes)
Poor support systems for health workers
No, or little access to the world literature and the evidence-base for healthcare changes.
Few standards, policies, guidelines and other job aides
No opportunities made to review existing policies and guidelines to see if they achieve their
objectives (audit)
Barriers in individual health workers
A negative attitude and low morale
Difficult personal circumstances that are taken to work and affect performance or time spent
working
Poor time management
A lack of respect for others
Lack of knowledge and skills or awareness of what is possible
Reluctance to share skills, knowledge and resources
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Forces that support change

Despite facing many of these barriers, health workers are frequently able to make simple but effective
improvements in the care they give. Forces for change include:
External forces
Stabilities in government (including Ministers of Health), in situation and in the countrys
boundaries
Political vision within a country for improving childrens healthcare (for example the Kosovan
Department of Health and Social Welfares visionary health policy for Kosova, February 2001).
This vision works best if it is:
o Shared by all the main stakeholders in childrens health.
o There is a detailed plan for its implementation with funding where necessary
o Individual health workers are encouraged and supported to achieve the vision
The desire and the support of the wider community
Good working relationships with other stakeholders in childrens health such as WHO, UNICEF
and non-governmental organisations (NGOs)
Internal forces
A collective commitment to make things better
Sufficient skilled health workers to provide safe care. If there are too few health workers, it is
difficult to introduce any changes that require extra effort or time, although many health
workers does not always mean the best possible care or a collective commitment to change.
Consistency of staffing in a ward or other clinical area, especially the senior staffing. However
consistency of staffing can also be a barrier to change. Health workers often prefer to stay with
what they know, rather than embrace new skills and change well-tried working practices
A change of leader/s
Fair and open management with delegation
A culture of team working, especially team problem solving
A system to consult service users (the children and families) and respect their views
A collective respect for human rights and a named health worker responsible for coordinating
related activities.
Regular training/educational opportunities for all health workers and good human resources
Good systems for sharing and disseminating information between health workers, such as in
Moldova and Kosovo where all senior health workers meet to share information at the beginning
of the working day. These meetings work best when they are not dictatorial or proscriptive and
are attended by representatives of each type of health worker, each service and each clinical area
concerned
Established forums for discussion and case review, such as regular audit meetings. Those
responsible for coordinating audit need to encourage attendance and ensure that everyone
understands why audit is so useful.
Access to the evidence base for practice.
Clear standardised (the same and used by everyone) policies, guidelines and job aides with
training (See Section 5: Information Sheet about Job Aides)
A satisfactory, well-maintained working environment raises morale.
Sharing resources and equipment
An effective and efficient system for managing data (collection, circulation, collation and
examination), Good data are essential for supporting plans for change, for showing that change
works and for supporting advocacy for more resources.
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In individual health workers

Visionary leadership able to share visions, motivate and organize others. For example, the
visionary leadership of a paediatrician in Mulago Hospital Complex, Uganda that improved care
for the newborn, a new ward sister in Mulago that improved the care given on her ward and of a
single-handed Cuban paediatrician in The Jubilee Hospital in South Africa who improved the
care of very ill children.
Ability to participate in team problem solving. Best practice is to organise staffing to meet the
needs of children and their families and not to accord with the needs or traditions of health
workers. It is best to use a team approach to decide how best to use the human resources
available.
Wanting and being given the responsibility and authority to coordinate an important healthcare
task in a clinical area, such as infection control.
Working well together with respect for the different skills of others.
An individual commitment to making improvements
All the senior health workers in a clinical area are committed to making changes/improvements as
wanted and planned changes can be sabotaged if there is a powerful senior person not fully
committed.
An individual commitment to human rights, especially to the rights of children as others can be
influenced by this, and by sharing knowledge about human rights.
Trying to keep morale high by being a positive and good employee (See Section 5: Information
Sheets on Adversity and Keeping Health Workers Happy). When the collective morale is high
there is a collective desire to do better, such as found in the relatively small childrens
departments in Barnsley and Bridgend hospitals in the UK.
During the pilot project for the CFHI when most of these forces that support change existed in a pilot
hospital, improvements in healthcare were continually being made and change was a process not an
event. When many of these forces were absent, although there were many visions for making it better,
very little actually happened.
About improving care
To make changes that lead to improved healthcare for children and their families the barriers need to be
overcome, and any forces that may help recognised and effectively used
Great works are performed not by strength but by perseverance Samuel Johnson
What helps to start, or speed up, the change process?
Any type of unfavourable assessment or audit
The setting of new Standards for undertaking aspects of healthcare by a countrys health
planners
The influence of an important person or group of people, such as a government minister or a
parents group
The appointment of a new health worker with vision, particularly if this new health worker is in a
position of authority in the organisation
A difficult or unpleasant experience that causes health workers to look back at what has happened
A complaint or suggestion made by a child or parent. In many countries children and parents are
still not listened to or heard
A learning opportunity or exposure to new experiences, such as a visit by an outsider who raises
awareness about some issue or opens the eyes of health workers to what is possible
111
New research evidence that shows that there is a better way of giving a particular aspect of care
Large changes need to be planned and resourced by those who plan and organise healthcare, but it is
important to remember that many small low, or no cost, improvements can always be made by each and
every health worker and often very small changes can have a huge impact on childrens well-being It is
these changes that the CFH improvement program focuses on.
An example of a small low-cost improvement of the environment
Child friendly curtains, cot covers and some balloons have improved the environment and
motivated health workers to do more in this excellent day care unit in Pakistan
Regarding change, remember that people can be excited about change but do not like to feel they are
being changed.
A smile costs nothing (The Minister of Health, Pakistan and others)
Positive welcoming child and family friendly behaviour in health workers can make a big difference to
how well a child and family respond to their individual health problem. Changing the negative attitudes
found in some health workers, however difficult; can be of huge benefit to children and families.
Attitudes and beliefs influence all aspects of healthcare. They are difficult to change but best practice for
every health worker is to have child and family friendly attitudes and behaviours, and to continually try to
change any negative or destructive attitudes seen in others, especially those that interfere with providing
the best possible care. You can do this by sharing your knowledge about Child Friendly Healthcare and
the evidence for this. This costs nothing except commitment and time.
When making improvements
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Prioritise aspects of care and start with a small but feasible project.
Use a staged (step by step) approach. Completing a project successfully and seeing how it makes
things better, gives the motivation, strength and confidence to tackle the next thing on the list.
Use a team approach to planning and implementing your ideas and solutions with a representative
from each group of health workers affected, and a representative to speak on behalf of the children
and families.
Share ideas, problems and solutions, both locally, nationally, and internationally, through
publications, advertisements, the media, and at paediatric meetings
Use human and material resources effectively (see section 5 looking after health workers). In
countries that have few, or not enough, skilled health workers or cannot afford to pay them, it is best
practice to train and employ less skilled people as basic health workers (not nurses or doctors). This
enables the more expensive skilled doctors and nurses free to see only the very ill children and those
with the most complex problems. In some countries such as Nepal , local people in isolated rural
areas are trained to provide basic healthcare, helped by clear guidelines that are designed to help them
recognise the patients that need to be referred to more skilled health workers at a distant centre. It is
also important to recognise that older retired very experienced and skilled health workers can still
contribute, but in less onerous ways than previously.
Actively support and acknowledge your colleagues
(See also Section 5 for more information about adversity and how to look after health workers)
Ill or unhappy health workers are not able to provide the best possible care and may leave the health
service. So best practice is to support others actively and also to have formal systems for supporting
and looking after the physical, mental and emotional health needs of health workers. This is cheap
compared to the cost of the loss of health workers to a health service. So support and value each of
your colleagues.
A paediatric surgeon in Eastern Europe who,

although over 80 years old, is still employed
to use her diagnostic, but not her surgical
skills. She is well respected by her colleagues
and prevents many children from having
unnecessary surgery
A health worker sharing skills in

Bosnia
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Sharing knowledge in Barnsley, UK. Reading materials

relating to childrens healthcare found by individual
health workers, and information learnt during courses
and talks, were routinely put in this special area on a
childrens ward enabling all the other health workers on
the ward to benefit.
Why acknowledge effort?

Acknowledging effort is of huge importance for many reasons. For children to learn and develop to their
full potential, they need approval and sometimes rewards for the things they have done well, and
guidance, not criticism or blame, for the things not done well. This is also best practice for adults as in
this respect we do not change. Most health workers will improve their performance and skills if they are
given approval, respect and reward for who they are and what they do. If they already have this, they will
try to keep it; if they do not have it or are not given this in response to their efforts, they will become demotivated, perform poorly and have no incentive to change.
A motivated acknowledged health

worker in Uganda planning more
improvements.
Acknowledgement of health workers by both individual families and communities is also important as
appreciation of their care confirms that they are doing a good job. A culture for blame has a destructive
effect on all aspects of the healthcare provided. It can also cause great distress and disillusionment in the
health workers concerned.
Finally, public acknowledgement of good healthcare brings it to the attention of others, and by doing so
can validate a previously unrecognised or under-valued health service or activity. This acknowledgement
may also attract the resources needed to make it even better and enable the good healthcare to be shared
with others.
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How others can help (including humanitarian aid)

Others who can support improvements in healthcare include individuals, groups, organisations
(governmental and non-governmental), different healthcare environments and health services. These
others may be from the same country, from a different country or from the international community.
Advice and assistance that supports change includes:
Agreed Standards for childrens healthcare (international, country, health facility and/or
professional)
Systems for monitoring, recognising and rewarding achievement of these Standards
Health improvement programs
Donations of money and/or material resources.
Sharing expertise and opportunities for learning and skill-building
Sharing good practice and solutions to problems that have been found effective in similar
circumstances.
Sponsorship
Advocacy
There are many excellent global health improvement programs such as the Baby Friendly Initiative (BFI),
the Integrated Management of Childhood Illness (IMCI), the Expanded Program for Immunisation (EPI),
the Safe Motherhood Program and others. To work in the best possible way these programs need to
reach and support every health worker. They need to be easy for health workers to use and inexpensive,
especially if new resources are not linked them. Unfortunately some are costly and need to be supervised
by others making them difficult to introduce unless funding is provided by outside donors.
Very few health workers ever admit to having enough resources. Those that do are more likely to work in
an advantaged country and/or in the private healthcare sector. In disadvantaged countries, even if scarce
resources are managed and used in the best possible way, these are still unlikely to support the sort of
healthcare that health workers ideally wish to give.
Donated money and material resources can help if they are appropriate to the circumstances, are only
needed for a temporary period or are sustainable after the donor leaves or discontinues their support.
Donations need to be accompanied by advocacy for a higher healthcare budget for children and pregnant
women. This must be part of every aid project, as in the long-term, a country cannot rely on aid, but needs
to solve and resource its own problems.
The short-term unsustainable aid given in emergencies is very different to the sort of aid required to help
develop childrens healthcare services. It is important for donors to recognise and understand the
distinction between the purpose, limits and features of emergency aid and that of aid for development.
Best practice for donors is always to question the appropriateness and context of their donations, to
consider the possible negative impact of their actions with equal (if not greater) energy as they do the
positive impact, and to ensure that those receiving aid are in a position to identify their real needs and also
to recognise and say no to inappropriate donations.
Some of the examples of inappropriate aid seen during the pilot project:
Cupboards full of donated infusion pumps in one countrys main neonatal unit. All said to be
broken but in reality all were in working order. These were incompatible with the local electric,
115
supply, the local health workers did not know how to use them, nor were they ready to change the
basic way they gave fluids. They were also unaware of the benefits such a change could bring.
An impassioned plea from a maintenance engineer asking that donors consult him before
donating equipment that he would have to maintain (no repair manuals in his language came with
the equipment), and in any case he would not be able to mend it as had no budget for spare parts.
Out of date drugs and disposables that were unfamiliar and not prescribed in the country. These
had to be destroyed at a cost to the health facility.
A donation of adult resuscitation and basic monitoring equipment to a childrens ward. There
was no training on how to use it the donation. The equipment was not passed on to the adult unit
where it could have been used more appropriately,
A donated computer system for medical records not in use for over a year as there was no funding
for it to be repaired, nor was the expertise available in the country to do this.
Ten suggestions for the donation of equipment

Only donate if this is:
1. Wanted by most, ideally all, of the health workers involved (always consult widely with those who will
be responsible for using it and maintaining it, before donating).
2. Appropriate for the level of care that the local health workers are currently able to give (for example if
health workers currently give fluids through giving sets without chambers, it is more appropriate to give
paediatric giving sets with chambers before donating syringe pumps that they may not be able to
understand the need for or be able to use)
3. Able to meet the local needs and circumstances (for example donated anti-malaria tablets would be of
no use in some countries)
4. Compatible with the local electricity supply (for example make sure that the donated item has the right
type of plug, that there are sockets and that it will work with the local voltage)
5. New or in a good state of repair, and preferably a make whose manufacturer has servicing and spares
arrangements with the country or a nearby country
6. Accompanied by training for the health workers (including education of a trainer who can train
others).
7. Compatible with any existing similar equipment, if possible
8. Accompanied by instructions in the local language about what it is for, how to use it, how to mend it,
how to clean it and where to get spare parts (ideally spares should be affordable and available in-country
wherever possible)
9. Accompanied by funding for spares and maintenance if this cannot be provided by the recipients
10. Within its expiry date if there is one
These rules apply to donations of technology, drugs and other items
Donated learning materials need to be appropriate, wanted by and accessible to the majority of the
recipients. They need to be in the language that is most easily understood, up-to-date and if they require
technology, they should be usable and compatible with the local technology available.
Some examples of systems for getting easier access to low-cost learning materials and evidence
bases include:
The WHO blue trunk library system this delivers WHO and other books to enable a health facility
to set up their own basic library. It also provides training and information about how to run a lending
library, but needs funding by sponsors.
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The UK BMA/BMJ information fund this donates and sends educational materials (BMJ books,
CD-ROMs and journals) to successful applicants. It accepts and funds applications from institutions
not individuals. It also enables more than 100 of the worlds poorest countries to have electronic
access to the BMJ publishing groups 23 specialist based journals including its evidence- based
compendium, Clinical Evidence see www.bmj.com
Book aid international. This is a UK non-governmental organisation that distributes the ABC of
AIDS and The International Manual of Child Health to countries in Sub-Saharan Africa.
www.bookaid.org/resources/downloads/ar.pdf
TALC (teaching aids at low cost) is a UK non-governmental organisation that provides low cost
books and teaching equipment to health workers at all levels in disadvantaged countries. www.etalc.org or info@e-talc.org
FreeMedicalJournals.com www.freemedicaljournals.com
Health Internet Access to Research Initiative. www.healthinternetwork.org
Sharing expertise with other countries

Sharing experience, expertise and knowledge with colleagues in other countries can contribute to
improving healthcare. However, it can also lead to further difficulties if certain factors are not
considered properly. It is important not to impose your own practice unless this is appropriate. It is better
to first identify what is the realistic best possible practice that is appropriate to the environment and
local circumstances, and then to work with local health workers to achieve this by building on their
existing skills.
Locally made low cost drugs

trolley from Pakistan
A visiting health worker also needs to:

Be wanted by local health workers
Know what local health workers want and expect (best understood and agreed in advance by both
parties who must share a purpose if the visit is to be successful).
Be appropriately experienced and skilled. Seniority in one country is no guarantee that a health
worker will be able to work appropriately, effectively and understand the constraints of the different
environment. A relatively junior health worker is more likely to teach others about things that they are
already familiar with, or be bullied in to teaching inappropriate skills and not the appropriate, but
perhaps more basic skills that will benefit the majority of children. For example, in a health facility
117
that provides basic monitoring and care for very ill children, it is more appropriate to focus on
improving this before teaching how to intubate and provide assisted ventilation.
Be capable of achieving the respect of local health workers
Be versatile in their approaches and working methods
Consider gender as this can be a factor that may affect a visiting health workers ability to engage the
local health workers
Be able to communicate well at all levels. If the language of the local people is not spoken this can be
a major handicap unless they are always accompanied by a very good interpreter.
Be able to set realistic goals for themselves
Be able to motivate others and teach by example
Support learning and skill building by providing training and educational materials, especially if these
are not or cannot be provided by the country
Be able to show the reasons why what they do might be better than the existing local practice
To act responsibly by ensuring that any teaching they do, or change they advocate, is appropriate to
the environment and resources and can be sustained after they leave
Be prepared to learn from the health workers they are visiting.
Those responsible for their placement in the country need to:

Facilitate their visit by providing them with as much information as possible about the health facility
and health workers they are visiting and the problems they face. An assessment prior to their visit,
such as the CFH assessment, will provide them with all the information they need. It will guide and
prioritise the help they can give to their disadvantaged colleagues and will help them set realistic
goals to achieve during their visit
Support them and facilitate support from their family and friends. It is important that they are
provided with the resources to keep in regular contact with their family and friends via telephone or
electronic mail where possible, especially if they are on their own in a country that is unfamiliar.
Provide a named mentor or supporter who should contact them regularly to discuss problems, monitor
their well-being and their activities, and provide any support needed.
Ensure that they are protected as much as possible from local serious illnesses
Shared good ideas, good practice and solutions to problems
This does not mean importing inappropriate solutions that may work in completely different
environments and circumstances. These may, and often do, make the situation worse.
Experience reveals that showing photographs and telling stories are useful and popular tools for sharing
ideas and practices from other countries with paediatric health workers. For example after seeing the wall
paintings in childrens wards in other countries, health workers in one hospital arranged for a local artist
to do the same in their wards.
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A CFHI coordinator and interpreter in a ward play area. The same childrens area one year later
Sponsorship
Sponsoring or finding a sponsor for an individual health worker to improve their knowledge and skills in
a more advantaged country is another way of helping to make it better, but only if the health worker
returns to their own country after the learning experience to put this into practice. Often after a period of
sponsorship, a health worker fails to return, or is unable to use their new knowledge and skills as these are
not useful in their own country. Countries that host and train health workers from other countries have a
duty to teach the skills that are needed rather than those only relevant to their own health service. They
must encourage health workers to return to their country of origin.
A diabetic centre in Moldova funded and

maintained by a sponsor from another
country. The centre sees all children with
diabetes, providing them with advice,
counselling and free supplies of insulin,
needles, syringes and blood glucose
monitoring stick.
119
Play in a childrens ward in Uganda

sponsored by a hospital play department
and a private childrens nursery from
another country.
Expertise, resources, advocacy and shared learning opportunities can all be provided within a twinning
arrangement with a similar health facility, department, clinical area, service or individual in another
country. In both advantaged and disadvantaged countries, the sharing of experiences with colleagues can
be both supportive and effective in improving practice.
Advocacy
An important way for others to help is to advocate for health workers, children and families living in
disadvantaged countries. Advocacy by a visiting health worker may be successful, especially if this health
worker is respected. (See Section 5 for more information on issues for global advocacy)
References
Feeney P. Accountable Aid, Local Participation in Major Projects. Oxford: Oxfam; 1998.
Rifkin S, Pridmore P. Partners in Planning - Information, Participation and Empowerment. Oxford:
MacMillan Education Ltd; 2001
Fuerstein M. Partners in Evaluation - Evaluating development and community programmes with
participants. Oxford: MacMillan Education Ltd; 1986
Vas Dias S The complexity of Change: Developing Child and Family Centred Care in a Russian
Childrens Hospital. Clinical Child Psychology and Psychiatry. 1997. London: SAGE; 2 (3):343-352
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Section 5
Supporting materials
CFH Information Sheets
1.
2.
3.
4.
5.
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Adversity and problem solving

Advocacy
Audit
Cleaning
Clinical guidelines and other job aides
Data Management
Lifelong learning and how to put this into practice
Looking after health workers
Mission Statements with examples
Problem solving
Team working and leadership with an example of a health facility management structure
Additional information sheets available on the CFHI website:
An evaluation form
A toy safety policy
A consent form
Job aides
CFH Information Sheet 1: Adversity and problem solving

Life is not the way it is supposed to be. Its the way it is. The way you cope with it is what makes the
difference. Virginia Satir
I believe that it is what you do after a disaster that can give it meaning Christopher Reeve
Adversity can be an event or situation that compromises a childs rights to survival, development,
protection and/or participation. Adversity makes a child more vulnerable to actual physical, mental or
emotional harm, or to abuse through exploitation or neglect.
Adverse events include natural and man-made disasters. Some examples of natural disasters include
earthquakes, floods, hurricanes, extreme weather conditions, drought and personal disasters such as
accidental separation from a parent, accidents, illness, and disability. Examples of man-made disasters
are wars, famines, poverty, separation from a parent through divorce, exploitation or neglect or even just
poor parenting for whatever reason.
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Adverse situations are difficult circumstances, for example, poverty and other social or difficult family
circumstances, including a health problem that requires hospitalisation.
An example of how an adverse situation can make a child feel
Humiliation is the worst feeling, to be excluded and ignored and to be compelled and not given the
space to express our needs, our feelings, our dreams. A working child in Karnataka, India.
Some facts about adversity
Outside intervention and/or help may be needed to stop or resolve the event or situation
It is not the magnitude of the adversity that counts but the effect that it has on the individual - what
may seem a small, insignificant thing for many people that can be easily absorbed, for a few people
may be a catastrophe with far reaching effects.
The impact that an adverse event or situation has on a child is dependant on many factors. These
include what else is happening in the persons life at the time, the persons ability to cope, their
degree of emotional and psychosocial vulnerability and the circumstances surrounding the adversity.
After the adverse event or situation is over, help may be needed to recover fully, especially if
resilience (self-healing) is not good
If adversity involves any type of loss, the grief process has to be endured and supported. Criticism
and comments such as pull your self together are not constructive and cause further damage to a
vulnerable adult or child. Understanding is needed and an ability to listen and be there for that
person until, and if, they are able to reach the other side of the grief process.
Only someone who has grieved themselves can fully appreciate the suffering that cannot be avoided
and is not the self inflicted suffering of choice. To be a victim or not, is more complex than merely
being a question of individual choice. Victims need support if they are to recover, some more than
others.
Coming to terms with adversity and finding forgiveness for ones own possible contribution to this
(if acknowledged), and for the contributions of others, can be a positive experience. It can lead to
more tolerance and understanding of others, and an improved ability to help others (an example set
by Nelson Mandela).
Not all child victims find the forgiveness necessary to come to terms with the adversity they
experienced and to move forwards. This failure to heal can cause long-term developmental and
mental health problems. They might never develop to their full potential, become emotionally
mature or contribute well to society.
Intervention to stop, or help a child cope with adversity, needs to:
Be appropriate to the event or situation
Be by people who have the appropriate resources, skills and attitudes
Build on and promote a childs own protective factors (coping strategies)
Avoid the term victim as this suggests helplessness, passiveness and defencelessness in the face
of adversity
Include listening, but ethical codes are also necessary to avoid further exposure to harm by
insensitive questioning of children after an adverse event
Combine cultural sensitivity and an understanding of developmental pathways
Be evaluated, particularly with regard to later development in childhood
The adverse event or situation usually causes many problems for the child and their family. These will
need solving either by themselves or with the help of their community and others (a team approach).
Some simple rules for solving problems
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1. Define the problem/s after listening to everyone affected (do not make assumptions about the cause of
a problem. If you do, it is likely that your solution will not work. Talking to everyone makes finding
the true cause/s of the problem more likely and therefore a workable solution more likely.)
2. If there is more than one problem, prioritise these (remember that the main problem may be due to
several different problems each with different causes, so break a problem down into all its different
parts and decide which are the most important to solve first)
3. Look for the barriers against solving the problem/s and the forces that may help, such as people
and/or materials (It is best to identify these before you start)
4. Decide on some possible solutions/courses of action (after talking to those affected and if possible
also to others who have faced similar problems. The more complex the problem, the more
consultation is necessary)
5. Consider/evaluate the possible solutions and select the best that is feasible, if possible with
everyones agreement (the problem that is easiest to solve may be best tackled first as success
encourages and motivates)
6. Try this out/implement/put into action (if there are lots of problems it is better to select only a few to
act on first. Trying to solve too many at the same time may lead to failure)
7. Evaluate the results to see if the problem has been solved (think about and identify the lessons
learned/the things that went well and the things that could be done differently or better next time)
8. If not, try out other possible solutions until it is solved
9. Review other problems from the list and repeat the process
10. Always acknowledge everyones efforts and share the solutions that worked for you with others.
CFH Information Sheet 2:
Advocacy
Advocacy in the context of Child Friendly Healthcare means speaking on behalf of children and/or their
families who are either unable, or unwilling, to speak themselves about their needs, safety, or abuse of
their rights. It is acting as a voice for someone who has no voice or is unable to use it.
Some facts about advocacy
Its aim is to make things better for the child and/or their family
It is usually targeted at people who are able to make decisions and have influence
Anyone can advocate and most of us do so in our daily lives, in many different situations. Often we
are not aware of doing this.
Advocacy is for someone or some people.
It is usually done by someone, or done together with someone else, including with the child.
It can also be done through systems such as a law, healthcare standards or a health improvement
program (the UNCRC is the most important law that advocates for children).
It can be about anything, even small things, if these are causing a difficulty or a problem for a child
Advocacy can be at many different levels. It can be to other health workers in your daily work, the
family, the community, the local government or local organisations, the country government or
country organisations, the international organisations or to religious organisations.
Health workers are ideally placed because of their unique knowledge of a childs needs and best
interests. They have a responsibility to act as advocates for them.
It is important to have as many facts as possible concerning the problem consult widely beforehand
if possible and if the circumstances allow this
Advocacy must always consider a childs best interests
Best practice, if possible, is to use advocacy with the childs and/or their families consent/agreement
If done with the child or their family it can empower them, however care must be taken to avoid
making things worse for the child
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Some simple examples where advocacy can be helpful:

Advocating to the ministry of health about the absence or shortage of an essential drug such as
morphine or oxygen
Advocating to a social services support system (if it exists) about a family in need
Using publications or other communication methods to highlight a problem in a health facility
Advocating to government about the need for a health service which is equally available to all
families regardless of their ability to pay
Complaining to a manager about inadequate facilities for children, for example toilets which are
unclean or the absence of play
Some global issues for advocacy
Health workers also have a responsibility to speak out about some of the important global issues that can
affect children and families. These controversial issues include:
Antiretroviral drugs: Advocacy for these for the millions of children who live in Africa and are HIV
positive has led to decisions that will improve this situation. It is widely believed that poor countries
do not buy generic drugs because they are threatened by penalties in the form of reduced trade or
reduced aid. This should be investigated and reported if this is the case.
Specially prepared formulations of drugs for children: health workers need to advocate to
pharmaceutical companies (trade and generic) to produce drugs in doses and forms that can easily be
prescribed for children to take once or twice daily. For example Cipla, the Indian generic drug
manufacturers, will soon make available odivir, a once daily, three drug combination of anti-retroviral
medication for adults. A similar preparation would be very beneficial for children with HIV infection.
Reduction of mother to child transmission of HIV: Investigate the reasons behind not making
nevirapine available to all mothers in Africa and one dose to their child. The concern stated about
resistance is surprising as less than 50,000 of 30 million receive anti-retro viral drugs.
The Orphan issue: In the next 20 years we are going to see a large rise in the number of orphans in
Africa due to AIDS. There are currently 11 million and it is predicted that there will be 20 million by
2010. Family systems are already becoming saturated as the grandmothers (who often become the
main cares) die. The orphan numbers swell about 10 years after the height of the prevalence in any
country. For example in Botswana the current prevalence is near 40%, in 10 years there will be a
terrible crisis. We should advocate at a national level that as for all children orphans should
receive free education, free essential healthcare and be fed at school and that this be supported
by the large bilateral and multinational donors. The alternative will be more children unsupported
and unsupervised, in poverty, with poor health and vulnerable to abuse. This in the long term, one
could argue, may provide the background for threats to social stability and security.
The Arms trade: The arms trade is a disaster for poor people and civilians, especially children.
Amongst many campaigners health workers from Child Advocacy International (CAI) * have
written a paper that is quoted widely both in the press and in medical journals. The fact that several
rich countries promote (and gain huge financial benefits from) this trade by selling a large percentage
of their products to developing nations, often on both sides of a conflict, needs to be further
highlighted.
Debt: The effect that debt has on healthcare and education for children has been widely reported and
should continue to be a focus for advocacy. .
Trade: The tariff barriers to trade and subsidies have a huge impact on poverty and child health.
There is a continuing need to raise peoples awareness about ethical shopping and the impact this has
on a countrys ability to provide healthcare and education. (See paper on Africas children by Child
Advocacy International B OHare, J Venables, and D Southall Child health in Africa: 2005 a year
of hope? Arch. Dis. Child., Aug 2005; 90: 776 - 781.).
IMF and the World Bank: The introduction of user fees and other structural adjustments made by the
International Monetary Fund (IMF) and the World Bank are widely believed to have a devastating
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effect on healthcare. There is a need to find an independent tool to assess the impact of many of these
initiatives and report them. (See in Press Archives of Disease in Childhood)
Trans-nationals: This power is highlighted by their lobbying of the World Trade Organisation
(WTO) and the influence they have. There is a need for advocacy to ensure that the needs and
interests of the less powerful (usually the poor) are represented.
Foreign Aid: Some foreign aid does not actually result in sustainable development.
References
OHare BAM, Venables J, Southall DP: Child health in Africa: 2005 a year of hope? Archives of Disease
in Childhood in press
Fustukian S, Keith R, Penrose A. 80 Million Lives, Meeting the Millenium Development Goals in child
and maternal survival. London: Grow Up Free From Poverty Coalition / Save the Children; 2003
CFH Information Sheet 3: Audit what is it and how to do it?

Audit is one of the important supporting criteria for the CFH Standards as it improves the care given to
children and their families. This means that it deserves a major commitment from all health workers
It is the systematic critical review of the way a specific aspect of healthcare is provided, managed or
given, to see if:
This is the best possible
The outcome for an individual child and their family is/was the best possible
Any improvements can be made.
Any healthcare activity can be audited in varying ways by a group of health workers meeting to share
information gained from personal experience and/or medical records
Structured audit involves looking at the use and management of resources.
Process audit involves looking at the policies, procedures, clinical guidelines and other job aides to see if
these are being followed and/or are achieving their objectives
Outcome audit involves looking at the way health care is given, its outcome and how the child and
families quality of life is affected by the healthcare experience
Audit meetings provide excellent opportunities for:
Identifying problems
Multidisciplinary learning
Group problem solving
Contributing to medical knowledge
Planning changes that might improve the healthcare given
Updating clinical guidelines and other job aides
Advising managers
Finding issues for advocacy
Identifying examples of good practice for sharing with others
It is important that audit is not used to attach blame, but to identify errors, mistakes and problems,
to learn from these and plan changes to prevent the same things happening in the future.
It is also important to protect the confidentiality of individuals, both patients and health workers.
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The audit cycle has four parts:

1. Setting standards for the quality of care provided and given, if these do not already exist
2. Assessing practice, quality and outcomes against these
3. Making improvements and changing practice where appropriate
4. Looking at what happens after change (evaluating the effects of change to see if they have achieved
their objectives)
Audit is best planned, organised and supervised by a named health worker with this responsibility
(coordinator).
This important coordinator for audit needs to:
Arrange Dates for audit meetings
Decide on the aspect of healthcare for audit (best agreed jointly in advance)
Delegate information gathering and data collection to a named health worker/s for each audit in
advance of the audit date. It is important for this health worker not to forget to ask the parents for
their views and opinions about what has happened to their child and the impact this has had on
their family when this is appropriate to the audit.
Keep a record of meeting dates, aspects of care audited, those present, the findings, how any
changes needed will be implemented, date for effect of changes to be re-audited
Ensure that audit recommendations are reviewed and that recommended changes have been
carried out and have achieved their objectives
Tell all health workers in a health facility or organisation about the results of audit, and about any
changes of practice that are recommended and agreed on by all involved.
If appropriate share audit findings with parents/carers.
It works best if the coordinator for the audit is skilled at:
Problem solving
Facilitating
Dealing with conflict
Sensitively and constructively dealing with health workers who are performing poorly
Basic data analysis
Communicating (adequate and appropriate communication is important part of the audit cycle).
Good data organisation and management are needed for successful audit. Data may be needed about
populations, about service specific issues or about outcomes. Routine data collection is easier if
healthcare records and other forms designed especially for audit meetings are standardised.
For example how to collect information for a mortality audit
Before an audit meeting, review the relevant clinical records and if possible talk to the families of each
case/child before the audit to gain their views and opinions about what happened (this needs to be done
sensitively, preferably by a health worker who the family know well. They need to be seen again after the
audit to be told the outcome. In our experience families welcome this opportunity to express their views,
providing it is not too soon after the death. They also welcome improvements in care that arise because of
their childs death).
The following data are useful:
Days of illness prior to presenting
Date and time of first presentation to a health worker
Date and time of first treatment given
Signs child presented with (were these emergency or priority signs? (See Standard 8)
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The triage category given to the child

The diagnoses made when first assessed
Drug treatment given
Supportive care given
Monitoring (frequency, what was recorded, how was it acted upon)
Place of care within the ward (high-dependency, general ward, outpatients)
Number of skilled health workers on duty at the time (was this safe?)
Whether or not other complications occurred
Date and time of death and who was present
Details of any resuscitation attempt
Any relevant history about the child and family
What happened after the death and how the family were supported
Some of the aspects of childrens healthcare that benefit from audit include:
1. Deaths
2. How specific health problems have been managed, including how each individual child with this
problem has been cared for
3. Patient/carer and child (user) satisfaction (of service standards and other quality issues)
4. Adverse or critical events for example a serious infection acquired in the health facility, an
unexpected death, a prescribing mistake, something that has particularly upset health workers
and others
5. How children are referred to the specialty service/healthcare environment. and/or what happens
when a child is referred
6. Other agreed systems of care, policies, procedures, job aides etc.
How to audit deaths
Agree on how often to do this
Collect the total number of deaths since the last audit and the causes.
If there are more than a few deaths, select a sample of cases for discussion rather then attempting
to cover all cases so that maximum attention can be given to the lessons that can be learned from
each case.
Selection criteria can be based on:
Diagnoses - focus on one or two diagnostic problems at each meeting but covering all of the main
causes of death over the calendar year
Indicators - focus on areas where indicators show problems in care (for example if there are more
deaths in one clinical area, or for one clinical firm compared with another that is looking after
similar problems, focus on the area/team with the most deaths)
Priorities - focus on problems that should be overcome readily with existing resources
Avoidable deaths
Best practice is for everyone who was involved in the care of the child/children to attend. Each death
needs to be discussed and decisions made about:
The probable main cause of death
Other possible causes
Contributing conditions (other health related problems identified by health workers or caregivers)
Modifiable/avoidable factors are then identified and classified as:
- Carer or family related
- Administrative
- Related to poor care given by health workers in primary care
- Related to poor care given by health workers at referral centre - (triage, emergency care,
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diagnosis etc)
When the main causes of any problems have been identified, best practice is problem solving as a team.
Decide what steps can be taken to avoid similar deaths in future, agree on any feasible changes for
improvement, who will be responsible for coordinating these within an assigned time, the date they will
be reviewed and how to share the findings and plans with other health workers.
How to audit specific health problems in an individual child or group of children with the same
problem
It is important to review how health problems have been managed in an individual child or a group of
children with the same problem. This means looking at both the outcome for the child and at how the
case was managed from the onset of symptoms up to the time of the audit/exactly what happened and
when (integrated care pathway audit).
The health problem for audit is best decided on jointly at an earlier meeting and the relevant information
collected before the meeting. The same principles apply in that the purpose is to review each case to see if
there were any errors or problems that can be rectified so that they wont happen in the future and to
identify what did go well to share this.
Child and family satisfaction audit
Ideally each healthcare environment and service will have a mission statement clearly displayed in
clinical areas to inform healthcare users, and remind providers, about what is provided. This statement
may include such things as the intent to:
Have a maximum patient waiting time in outpatients
Have a caring attitude
Explain about health problems and their treatment
Provide child friendly facilities - toilets, cooking, washing, play facilities
Any of these intents can be the subject for an audit. To find out whether parents are satisfied with the
particular aspect of service provided, their views and opinions need to be collected before the audit
meeting. This can be achieved in a number of ways including using a questionnaire or individual
interview with a random selection of parents/carers, for example during routine discharge or exit
interviews.
Examples of possible questions include:
Were health worker attitudes caring/friendly?
Were there any unnecessary delays?
Was everything about your childs illness explained to you?
Were facilities adequate? (for example were the wards and toilets clean; was there always soap;
was there enough privacy; did you feel safe and secure; were the facilities for cooking, washing
and toilet facilities satisfactory)
Were you always asked for consent before a procedure?
The findings from questionnaires/interviews can be discussed at the audit meeting and changes made
if problems are identified.
Adverse or critical event audit
Examples of events that can benefit from this type of audit include:
Re-admissions within 48 hours of going home
Night deaths
Near misses where a child has nearly died
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Acquired infections
Incorrect drug treatment such as either the wrong drug or the wrong dose, or a drug given by the
wrong route.
Newborns with severe birth asphyxia
Serious accidents to patients or health workers
Children running away from a hospital
Self-discharges (children discharged by their family against the advice of health workers)
Other events considered important or distressing by health workers
Referral process audit

Such as audit of IMCI referrals or of other integrated referral strategies. Ideally such an audit is best
attended by the health workers making the referrals as well as by those receiving and managing them.
Other service standards (including the Child Friendly Healthcare Standards*), practices, policies
and guidelines
This type of audit could be about topics such as:
Immunisation coverage
Breast feeding rates at discharge from maternity unit and at other key times if data collection
possible
Malnutrition rates
Obesity rates
Parent smoking rates
Access to relevant health information
Young persons sexual health
Teenage pregnancy rates
Accident rates
Age at diagnosis of different types of disability
Child protection policies and guidelines
Quality of health information provided to schools on individual children
Other national, country, district or local guidelines
Within wards and clinical departments, many infection control activities can easily be audited. These
include:
Compliance with sharps policy
Reporting and management of injuries from sharps
Isolation practices
Decontamination of equipment
Waste management
Hand washing
Cleaning
Food handling and kitchen hygiene
Compliance with antibiotic policy
Practice can also be effectively audited against written, evidence-based procedures e.g. surgical
scrub procedure.
Audit can contribute to making it better for children in many different ways and is a vital support
activity for providing a child and their family with the best possible healthcare.
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CFH Information Sheet 4: Cleaning

Keeping yourself (personal hygiene), the environment (surroundings) and the equipment in a health
facility clean is a very important way of helping to reduce the number of healthcare related infections that
happen in at least ten percent of people admitted to a hospital. It will also reduce the chances of you
becoming infected.
Methods of cleaning include:
1. Normal cleaning
This is the commonest form of cleaning and the one used for most items. Normal cleaning is done using
water and soap or detergent after removal of dust and dirt using a brush or vacuum cleaning system. It is
the most important, but often the most neglected of the three processes. Equipment and materials that
need to be sterilised or disinfected must be first cleaned using this method
2. Disinfection.
This gets rid of many micro-organisms but not the most resistant endospores. Liquid chemicals called
disinfectants are used as cleaning agents. There are many different disinfectants. One of the cheapest and
most effective is sodium hypochlorite (bleach). Disinfectants are active against most micro-organisms
including HIV and hepatitis B, however, they do have a corrosive effect on metals and if used on fabric or
carpet can bleach out colours. Hypochlorites in dilution (usually 0.1% solution) are contained in
household cleaners available in markets throughout the world for domestic use. These household cleaners
can be used in the hospital environment for general cleaning of all surfaces, but stronger solutions need to
be used for cleaning anything that has been in contact with a body fluid such as blood, urine, faeces, and
others, and for cleaning following outbreaks of dangerous infections. Hypochlorites are also available as
tablets that make dilution easier. Chlorine solution should be used in tepid water, not hot, as hot water
increases the release of chlorine vapours that when inhaled may be harmful to health workers.
3. Sterilization.
This gets rid of all forms of micro-organisms completely. The cleaning agents are steam under pressure,
boiling water, dry heat and certain gases or strong liquid chemicals. This method of cleaning is used for
items that need to be sterile. Ideally a single separately organised and staffed system for sterilising should
be present in every healthcare facility that looks after ill children, especially if there is an operating
theatre.
Which method is used for cleaning will depend on manufacturers instructions, common sense and local
policies. As a generality, anything that has been in contact with an infected patient, a patient with a
wound, or anything that is contaminated or likely to be contaminated by body fluids, should be at least
disinfected and if possible sterilised.
Cleaning materials (cloths, mops, sponges and other materials)
Ideally these should be used once only then discarded, but this is not practical in many countries. Where
this is not possible, best practice is to keep cleaning materials such as cloths and mops clean by
disinfecting after each use. Different materials should be used for different areas and surfaces to avoid
spreading the micro-organisms from one area or surface to another. A colour coding system for cleaning
materials helps remind health workers what they should be used for or where they should be used. An
example of colour coding is red for wash areas and toilets, green for isolation rooms, blue for general
ward areas and yellow for kitchens. The same principle can be applied to materials used for different
surfaces.
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How often should things be cleaned?

When buying new items for use in a health facility it is important to use the recommended best practice
cleaning instructions that usually accompanies them. If it is not possible to follow these and it is not
possible to use an alternative cleaning method that is safe, the item should not be purchased or used.
Cleaning should be done as often as is needed to keep everyone and everything in a health facility as
clean as possible.
Who should clean?
Every health worker has a responsibility for making sure that their healthcare environment and all the
equipment they use is clean. If a child is an in-patient, health workers should also ensure that they, their
resident family carer and their visitors have the resources to keep clean (In many countries the toileting
and washing facilities provided in health facilities for families are minimal, and often dirty and
inadequate for the numbers of people using them compared with those allocated to health workers).
Special health workers need to be employed to keep a health facility clean. These health workers
(the cleaners) should:
Be supervised by those responsible for each different area
Be valued and feel valued by having their efforts acknowledged
Receive training about hygiene, infection control and the cleaning practices of the health facility,
which should be easy to understand
Have enough cleaning agents (cleaning solutions such as water, soap, detergents and
disinfectants) and cleaning materials.
Be part of the healthcare team
Information about providing water that is safe to drink
If water is not safe to drink, the micro-organisms that make it unsafe can be destroyed by:
Boiling it for 1 5 minutes (a minimum of one minute is needed)
Disinfecting with:
Iodine 3 4 drops for each litre of clear water mix well and wait 30 minutes before
using)
Chlorine.
The most familiar chlorine preparations are: sodium hypochlorite (bleach), a liquid compound that comes
in packets or bottles or lime chloride, a white powder containing chloride mixed with lime The amount of
chlorine to add to water to disinfect it depends on the strength of the chlorine preparation used. Any
instructions on the packet or bottle relating to making water safe to drink need to be followed.
Frequent and appropriate hand washing, safe food handling and preparation, and safe waste disposal will
help prevent water being contaminated with micro-organisms
Best practice is to have enough clean, safe water for drinking available in every health facility for
children, their families and health workers throughout the twenty-four hours.
Information about cleaning hands/hand hygiene)
To keep hands as clean as possible best practice is:
To have clean, empty sinks, easy to get to and use in each area in a health facility
Soap at each sink
A method for drying hands at each sink
Sink taps that can be turned on and off without using the hands (elbows)
Everyone knows the best way to wash their hands and does this
Everyone knows when to wash their hands and does this
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No rings (except wedding rings), nail varnish or watches are worn and sleeves are short or rolled
up during patient contact
Hand washing reminders at all sinks
An alcohol hand preparation available to use between patients, especially if hand washing is not
easily possible or needed frequently
To have a system to remind everyone to wash their hands (wall charts etc.)
To regularly audit hand washing to see if this best practice is achieved
Information about cleaning spills of blood and other body fluids

To reduce the risk of a healthcare related infection from contact with body fluids these should be cleaned
up immediately, wherever they are.
For spills on hard surfaces best practice is:
1. For each area to have spillage kits immediately available containing all the items needed.
2. Immediately cordon off area where spillage is, to stop anyone getting contaminated.
3. Ask a colleague to bring the spillage kit.
4. Wearing gloves, place cloth/paper towel from spillage kit on to the spill.
5. Wipe up blood from outer edge to inside to avoid excessive spread.
6. Put sodium hypochlorite (bleach) solution, 5.25% 1:10 ratio (1 part sodium hypochlorite to 9
parts water which gives the high level disinfection of 5000ppm that is needed) on the area affected.
7. Leave solution on the spillage for 30 minutes to disinfect both HIV, which only actually takes 10
minutes, and possible hepatitis which takes 30 minutes
8. Wipe spillage area more thoroughly and mop area with the same strength disinfectant solution.
9. Soak the cleaning material for 30 minutes before sending it to the laundry for washing.
10. Finally wash the bucket used with the same disinfectant solution.
If the spillage involves glass first use a dust pan and brush to clear up the glass, then carry on as above.
The dust pan and brush should then be soaked in the same bleach solution before it is used again.
Information about cleaning laundry (laundry means any materials used when giving health care such
as bed linen, towels, flannels, clothing, cleaning materials and others).
If laundry is dirty or soiled it needs washing. Best practice in a health facility is to:
Separate dirty laundry that has been contaminated by body fluids, or is likely to be infected, from
ordinary dirty laundry and store these different types of dirty laundry in separate bags immediately
If possible wear gloves when handling dirty laundry and always wash hands afterwards.
Make sure there are no sharps or other solid items in the dirty laundry
Wash all laundry at temperatures above 60 degrees C (to kill micro-organisms laundry should be
washed at temperatures of not less than 65 degrees C for ten minutes, or not less than 71 degrees C
for 3 minutes) other methods of disinfection before washing are best used for materials
contaminated by body fluids that will be damaged at these temperatures.
Information about cleaning equipment
Best practice is always to read and follow the manufacturers recommendations. If these are not available,
contact the manufacturer and find out how best to clean the item, or if this is not possible, use common
sense and clean as for a similar item.
In well-resourced countries single use equipment for many things is best practice but when this is not
possible, all healthcare equipment should be thoroughly cleaned by the most appropriate method before
being used by another child. If equipment of any sort is shared, there is a high risk of cross-infection.
Best practice is that a bed and mattress is cleaned with disinfectant after each use.
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Information about cleaning the environment, fixtures, fittings and furniture

Water, soap and detergents or disinfectants can be used as cleaning agents according to local availability
and policy. Frequency of cleaning for different areas will depend on the type of soiling and local
circumstances. Toilets and wash areas need special attention; best practice is that they are always clean
throughout the twenty-four hours.
Information about cleaning toys
To reduce the risk of cross-infection toys need to be kept clean, especially if they are likely to be used by
more than one child. Toys that cannot be cleaned, except those are not usually touched or handled by
children (for example those used for distraction), should not be used. Best practice is that the play worker,
or a named health worker, cleans communal toys after their use.
Example of a policy for cleaning and maintaining toys
1. Regularly check and clean all toys, at least once a week.
2. Pay particular attention to toys for babies and toys given to children who are at high risk from
infection.
3. Take extra care with the toys used by children who are known to be infectious. Their toys need to be
easy to clean, or toys that can be thrown away after use.
4. Always sterilise toys that babies put in their mouths, such as baby rattles and pacifiers, between
patients. These must not be shared.
5. Throw away toys that are broken or dangerous immediately.
6. Always follow your infection control guidelines/policies
Hard toys: Clean all surfaces thoroughly with detergent and hot water, rinse and where possible dry to
prevent water retention.
Electrical (battery operated) toys: Wipe all surfaces with either water and detergent or alcohol wipes
and dry thoroughly.
Soft Toys: Wash after being used by a child. These toys must not be shared. Best practice is to machine
wash at the highest temperature practical and dry quickly.
Paper, books, posters, etc: Wipe the surface of books and posters regularly with a damp cloth. Throw
away soiled paper. Check stored books regularly for wear and tear, signs of mildew and any insect
infestation and discard if found.
The control of infections is so important that allocating sufficient resources for effective cleaning is
vitally important. Best practice is to delegate the coordination and supervision of cleaning and other
aspects of infection control to a named health worker for each clinical area. The senior health workers
need to support the appointed person and ensure that they have the authority and time to do this important
job, and receive the respect of others. As health workers frequently change there is a constant need to
train the new health workers, and remind the others, about best practice. Audit of both practice and
policies will help ensure that cleaning is effective.
References
Alvarado, CJ. Sterilization vs Disinfection vs Clean. Nursing Clinics of North America.1999; 34(2): 483491
Pursell E. Preventing nosocomial infection in paediatric wards. Journal of Advanced Nursing 1996;
5:313-31
Wilson J. Infection Control in Clinical Practice. Edinburgh: Bailliere Tindall; 2001
133
Yost, A J, Serkey, JM. Rule-makers who establish infection control standards. Nursing Clinics of North
America 1999;34(2): 527-533
Callaghan I. Bacterial contamination of nurses' uniforms: a study. Nursing Standard 1998; 13 (1): 37-42
Loh W. Ng VV. Holton, J Bacterial flora on the white coats of medical students J Hosp infect.2000.
45(1): 65-68
Neely AN, Maley,M. Survival of enterococci and staphylococci on hospital fabrics and plastic Journal of
Clinical Microbiology 2000 38(2): 724-6
http://clean-air-healthcare.co.uk
Perry C, Marshall R, Jones E.Bacterial contamination of uniforms. J Hosp Infect. 2001; 48(3): 238-41.
Otterstetter H. Water: so much and so little. Perspectives in health 2000: 5 (1) Pan American Health
Organization magazine.
Guidelines for Drinking Water Quality. 2nd ed. Geneva: WHO; 1996.
CFH Information Sheet 5: Clinical guidelines and other job aides - what are they, how to
develop them and how to make sure they are used?
In order to give the best possible care to children and families, paediatricians need to integrate the
highest quality scientific evidence with clinical expertise and the opinions of the family. Moyer VA.
Elliot EJ. Preface to Evidence Based Paediatrics and Child Health
Job aides are written or pictorial reminders about specific aspects of care.(see website for examples and
details) They help, or remind health workers how to, give the best possible health care for a specific
problem or issue. They include:
Guidelines for treating a specific health problem
Algorithms such as those for basic life support (BLS) and the Integrated Management of
Childhood Illnesses (IMCI)
Treatment pathways, drug doses.
Lists of signs and symptoms for triage categories.
Growth charts, developmental milestones.
Hand washing guidelines placed near all the sinks in a health facility
Guidelines and job aides:
Aim to improve healthcare outcomes
Help clinical judgement
Make the treatment of a specific health problem the same (when the same healthcare for a
specific health problem is given by every health worker, evaluation and comparison of care
methods are possible)
Need to be supported by up-to-date evidence.
Need to be linked to audit
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Need to be reviewed regularly

Need to balance the art and science of healthcare
Need to be adaptable to the situation and circumstances
Need to be compatible with existing country and International guidelines
May help to reduce costs or enable comparison of costs
May protect health workers from complaints and litigation
How to develop, introduce and update a clinical guideline or other job aide
1. Create a small multidisciplinary team (see information sheet 11 for information on team working) of
either interested volunteers or elected representatives from all the groups likely to be affected by them,
including a parent and child representative
2. Consult all the health workers likely to be affected by the introduction, or up-dating, of a guideline or
other job aide, and parents and children too, if possible, so that:
Any organisational or individual barriers to their introduction and use can be identified
Attempts to overcome these barriers can be made before their introduction
Ownership is shared (individuals are more likely to use the guideline if they feel they have
contributed to them and therefore share their ownership)
The opinions and views of those on the receiving end can be incorporated
3. Find and review all existing guidelines used by the clinical area, healthcare environment, country or
international community as:
It saves time to use or adapt an existing guideline rather than re-invent the wheel
It is sensible to comply with existing country guidelines, as long as they are evidence based and
up to date.
4. Find and use the evidence to support the proposed guideline/job aide:
For an existing guideline, review the evidence for this to make sure it is up-to-date and correct
(unless the guideline is from a reputable source, is well referenced and dated with a recent date)
Search the literature widely for quality evidence using the internet (if available) and reputable
sources of information
Remember to write down how this search was made and the information source/s
Interpret the evidence wisely and match it to the resources available
Translate the evidence into medical and nursing care for the health workers in the healthcare
environment
Use the written evidence to provide references for the guideline
5. Before introducing the guideline/job aide:
Get agreement from the director/chief of the healthcare environment, the heads of departments
and key clinical task coordinators for its use
Get agreement for the date for starting to use it
Finalise and all agree the content of the guideline and its references
Remember to date the guideline
Arrange education sessions for all health workers likely to be involved or affected
Arrange a date for its review or audit
6. Arrange an early review by the core working party to amend the guideline if necessary as:
The evidence for medical and nursing care can change as new research is published
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Local difficulties with following the guideline may occur and these will need identifying quickly,
as will their solutions
To achieve standardisation of practice, regular audit of compliance with the guideline is needed to
find the reasons for non-compliance and their solutions
7. Arrange regular core working party meetings to;

1. Review existing job aides at regular intervals
2. Create and introduce more job aides
8. Avoid failure:
Most failures to standardise the care given are because:
Those affected by their introduction are not involved in their development. As they do not feel
they own them, they do not use them
A culture collectively to provide the best possible care does not exist in the healthcare
environment
Using guidelines to standardise healthcare makes sense and contributes to giving the best possible
care.
References
Royal College of Paediatrics and Child Health. Standards for Development of Clinical Guidelines in
Paediatrics and Child Health. 2nd ed. London: Royal College of Paediatrics and Child Health; 2001
Janowski RF. Implementing national guidelines at local level. BMJ 2001; 322: 1258-1259
.
Gill G. Clinical Medicine. 1(4), 2001, p 307-308.
Woolf SH, Grol R, Hutchinson A, Eccles MP, Grimshaw JM. Clinical guidelines: Potential benefits,
limitations, and harms of clinical guidelines. BMJ 1999; 318: 527 - 530.
Interagency Guidelines for drug donation. 2nd ed. Geneva: WHO Department of Essential Drugs and
Medicines; 1999
www.drugdonations.org
Guidelines on medical equipment donations: www.echohealth.org.uk and
http://www.medequip.org/guidlines.htm
Royal College of Paediatrics and Child Health. CHERUB = Child Health Evidence Resources Update
Bulletin. quarterly bulletin RCPCH . Available at www.rcpch.ac.uk
Royal College of Paediatrics and Child Health: Clinical Guideline appraisals available from at
www.rcpch.ac.uk
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CFH Information Sheet 6: Data Management

Meticulous and thorough data collection is an essential requirement of each of the CFHI standards
A Health Record is written information about the physical and/or mental health of a patient.
Keeping a written record of the healthcare given, and collecting other important health related
information is an essential part of a professional health workers job.
Reasons for keeping records
1. To inform others (children, parents/carers and health workers) about what has happened to a child
and/or what healthcare is planned. This contributes to consistent and seamless healthcare and avoids time
wasting duplication and unnecessary repetition if all health workers respect and use the health record.
Parents and children often feel frustrated when asked the same questions by a succession of
different health workers.
2. To obtain information about a population of children, for example children with disabilities, so
that their health needs can be assessed and appropriate intervention programs can be planned and
resourced
3. To obtain information about other important indicators for childrens health, such as
breastfeeding and immunisation rates, that can be used to:
Support advocacy for increased resources
Monitor performance of programs, services and individuals e.g. road traffic accidents
Monitor effectiveness of healthcare interventions
Confirm that standards of healthcare have been achieved at their best possible level of practice
Plan or change policies and systems of care
4. To facilitate research
When deciding what information to collect it is important to:
Consider what it is for or why it is wanted/needed and what questions about health issues it hopes
to answer
Only collect what is really wanted/needed, what is possible and practical to collect and not more
than is necessary
Imagine how it will be used and/or presented before designing the method and format for
collecting it. Make this as simple as possible
Consider confidentiality issues
Best practice is that any data collected is:
1. As accurate as possible and of adequate quality
2. Standardised throughout the healthcare environment, health service and/or country
3. Protected (sensitive personal data is kept confidential)
4. It is also important that appropriate data are collected to provide international organisations and
others with the information they request and/or need.
1. Accuracy and quality of information recording is dependent on:
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Understanding the value of recorded information (what it can be used for)

A commitment to recording information, including the completion of forms
The skills to:
- Listen
- Ask the right questions
- Interpret the answers
- Interpret the situation
- Record this accurately
Having enough time to do this. Best practice is to have sufficient time to record information
during working hours without compromising patient care.
How easy it is to use the data collection systems.
Writing in health records legibly, promptly, truthfully, and always signing and dating each entry.
Best practice for a health record or any other information recording system is for it to be:
As simple as possible
Easy to identify so that it can be found quickly when stored (for example each child from birth
can be given a health number that is used for all their health records. This individual numbering
also avoids duplication)
As few as possible for each child. To avoid duplication, best practice is for a single health record
to be used by all health professionals involved with the child.
Easily accessible to all health workers (and to the child and their parents/carers) but secure from
people who do not need to see it
Available when needed.
2. Standardised data collection and examination means that:
The same information is collected by everyone
The same way of recording the information is used (the same format is used for collecting
information throughout a health service)
The same information recording systems (health record, investigation request and other forms or
computer program) are used throughout the health facility/organisation
The data are analysed using the same methods (for example if a coding system is used for coding
health problems, it is best to use the same one throughout a country)
A good example of standardised data collection is for a country to also use parent held child
health records. This requires a policy to use these country-wide. This requires a commitment
from all health professionals to make an appropriate entry each time the child has a significant
health problem or health intervention, for example an immunisation or an admission to hospital.
Such records are especially useful when a child sees many different health professionals in a
variety of different healthcare settings as it ensures there is a complete record of the childs
healthcare with the parents/carers.
3. Data protection means:
Ensuring that sensitive recorded personal health information is kept confidential (cannot be read
or seen by others, or discussed with people who do not need to know).
Having a policy about this that is agreed and followed by all health workers.
Regular training about, and audit of, this policy to enable health workers to see if it is working
effectively.
Including in the policy advice about the storage of records, who is authorised to write in them,
who should be able look at them, what information from them can be shared and with whom.
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Having secure storage for records and a good system for monitoring those who access and borrow
records. Ideally health workers from a different clinical area or service should get permission
from a named person before accessing a record.
Never leaving records in a place where unauthorised others can see them.
Not writing childrens names with their diagnoses, or other sensitive information, in a place (such
as a board) that can be seen by other parents/carers or children.
Understanding and following any legislation about data protection.
The Management of data

To ensure data accuracy, quality, standardisation and protection, these activities need to be managed and
organised effectively. For this to happen, best practice is for all healthcare organisations and healthcare
environments to have a data management team with a lead health worker to coordinate data related
activities.
The team needs to:
Develop, review and update (audit) the policies and systems used for collecting, examining,
protecting (data protection policy), storing and retrieving data (data management policy).
Develop, review and update (audit) guidelines for taking health histories and for making entries
Have the authority to enforce these policies systems and guidelines.
Be able to contribute to decisions on data collecting systems together with their Ministries of
Health (If health workers are expected to complete forms, make entries into data collecting
systems and to understand and value their importance, they also need to be consulted about their
design).
Train all health workers about all aspects of data management. Accuracy and quality is more
likely if health workers receive appropriate and regular training about data management. This is
especially important when new health workers start to work in a new healthcare environment, and
before new forms are introduced or new information is asked for
Be responsible for the record cycle and any computer systems for data recording and/or
examination
Be responsible for the overall quality of data management
Have the necessary resources
The record cycle starts when a child attends. It includes:
Rapid finding of records from any previous attendances
Recording the new attendance to avoid duplicating any previous records
Circulating records
Ensuring that a summary is made of the attendance, and if possible a diagnosis at or before
discharge
Classifying the summary or diagnosis (using a disease coding system such as the ICD)
Examining (analysing) and collating these codes regularly in the format required by the health
organisation, international organisations and government
Sharing this collated information with relevant professional health workers
Indexing and storing/filing the record
Having a policy for who can borrow health records and a system for this that enables them to be
easily found when needed
Protecting data
A commitment from all health workers is needed for this record cycle to be efficient and
effective.
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Inefficient record storage!
Computer systems
Using computers to record, store and collate information can improve patient care as information can be
shared and retrieved quickly thus minimising potentially harmful delays. However it is costly, needs a
back-up system and cannot be used without extra training for all health workers. To use computerised
systems effectively, the following are necessary:
A secure electricity supply
A budget for capital costs
A budget for maintenance and spares
A budget for printers and printer ink
A budget for telephone costs and Internet subscriptions
Standardisation of computer programs
Computer programs that are linked and produce what is needed
The expertise to maintain
The expertise to use
Training programs
A commitment from health workers
Without these, computerisation will cause additional problems for health workers and fail to meet its
objectives.
Data management activities contribute to, and support the best possible health care when
performed well. Therefore they need to be adequately resourced.
References
McMaster P, McMaster H, Simunovic V, Selimovic N, Southall DP. Parent and young person held child
health record and advice booklets and their use in Bosnia and Herzegovena. International Child Health.
1995; 6:121-131
140
McMaster P, McMaster H, Southall DP. Personal child health record and advice booklet programme in
Tuzla, Bosnia Herzegovina. J. Royal Society of Medicine 1996:89(4): 202-204
CFH Information sheet 7: Lifelong learning and how to put this into practice.
Wisdom, knowledge and skills are for sharing not owning
How can you continue learning?

Two terms that are often used to describe lifelong learning are:
Continuing Professional Development (CPD)
This means improving skills and acquiring new skills through a continuum of experience and
learning
It is life-long
It needs planning, commitment and access to learning opportunities.
Continuing Medical Education (CME):
This is a systematic process of life long learning and professional development
Its aim is to enable health workers to maintain and enhance their knowledge, skills and
competence for effective clinical practice to meet the needs of children
Essentially these two systems are the same. Lifelong learning applies to everyone and not just to
professional health workers. Everyone has a responsibility to continue learning and improving their
practical and other skills, and also to share their knowledge and skills with others, so that the children and
families will benefit.
Health workers need to look for the evidence for what they do from the published health literature. In
many countries this is impossible or difficult for a variety of reasons.
Health workers who manage organise or plan care need to help others to access learning opportunities and
the health literature. Most countries have large organisations such as WHO and UNICEF as part of their
international community. These organisations and other non-governmental organisations working in the
country do have access to healthcare literature, and can be approached for help.
The principles of lifelong learning include:
Thinking about what you want and need
If you are responsible for others, thinking about what they want and need
Making a plan for your learning/the learning of others (personal development plan/s) then
implementing it/helping others implement their plans
Recording your learning activities, for example keeping a personal diary or portfolio of learning
If you are responsible for others keeping a record of others learning
There are many different ways to learn:
Formal learning such as attending training courses, lectures, conferences, courses, journal clubs,
critical reading groups, workshops and seminars and small group interactive learning .
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Informal learning such as using distance learning programmes, participating in audit, presenting
research, watching others (such as sitting-in with or being closely supervised by someone with
more experience and/or more skills), contributing to confidential enquiry panels, post-graduate
examining, writing books and articles and doing research
Self-learning such as using a library and reading books and journals, using the internet, making
reflective notes
Best practice is to regularly experience a combination of all these different types of learning, although in
practice it will depend on the resources and opportunities available to you.
Before starting to work in a new healthcare environment, it is especially important for a health worker to
be sure they have, or acquire quickly, the skills and knowledge to give the type of healthcare needed
safely. The provision of induction training about the policies, guidelines and systems of care used in the
new environment helps to ensure this. When induction training is not available or possible, close
supervision until the new health worker is sufficiently experienced and knowledgeable is an acceptable
alternative.
How can you put learning or new skills into practice?
Changes of practice and attitude do not always follow learning as:
Doing something differently never feels as comfortable as doing it the same familiar way
It is not appropriate
It turns out to be harder than you expect as:
You do not have the authority to persuade others to change
You have forgotten some of the details
You come up against an unexpected problem
Others criticise your efforts so you give up
You feel you are the only one making an effort
Others dont see the need for change
The system or the hierarchy get in the way
If you are a junior health worker it is easier to do this if you are helped, guided and supported by a senior
colleague (a mentor) who is committed to the changes in practice and attitude needed. Your mentor might
be your manager or a more senior health worker. Their role is to empower, enable and help your efforts
by:
o Supporting and encouraging you
o Making sure you have everything you need
o Helping you anticipate barriers to success and work out ways of dealing with them
o Publicising your successes
Things you can do to help your mentor:
Point out the benefits the children and families will get from the change (for example I know you
are concerned about .., when we make these changes they will do -----------).
Mentors need to know what the mentee and others can expect to see happening differently.
Ask the mentor how much and how often they want to hear about your progress dont assume.
The mentor may need a lot of detail in order to deal with colleagues, or may be happy to leave it
to you. The mentor may have reporting targets and deadlines that you dont know about. Once
you know, make sure you give what the mentor asks for.
Ask if there is any other way you can help
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It usually takes longer than you expect to make any significant changes in your own or others practice.
You can maximise your chances of getting a real and lasting improvement in practice by first planning to
USE what you learn by sharing this with others.
Sharing learning
Start by deciding what you need to share, why you need to share this, who to share it with and how you
can do this. It helps if learning aids are available (such as writing boards, flip-charts, overhead projectors
or power point technology); but these are not essential.
The most important reason for sharing learning is to influence changes in the way care is given to make
this better for children and families.
People you may need to share with include:
Professional colleagues at junior, equivalent and senior levels
Other health workers cleaners, security guards, maintenance, drivers etc
Children and their carers
Other people who can help you teachers, people of standing in the community
People who may disagree with you and can get in your way
Other people who have had the same learning experience
Ways you can share your learning include:
Informally discussing what you have learned with your colleagues
Organising a meeting about it or taking advantage of a meeting thats already happening, for example
a departmental meeting
Putting information on a bulletin board (paper or electronic), giving out leaflets or circulate a note
about it
Writing a newsletter about it (send to others on paper or by electronic mail), or writing an article to go
in an existing newsletter
Making up a story or a song about it, or getting the patients and their families to make one up
Making some pictures about it and using them to decorate the ward
Giving a formal presentation or organising a training course about it
CFH Information Sheet 8: Looking after health workers

To perform well, health workers need to have the best possible physical and mental health. Best practice
to ensure this includes access to:
o Adequate food and clean drinking water while working
o Preventive health measures such as immunisations, needle-stick injury management and lifting advice
o Care of their physical and mental health problems.
The physical health problems of health workers are often well managed, but in many countries, mental
health problems are neglected, especially the stress related problems caused by work.
Health workers only feel happy in their work and free from stress if their job is secure, their working
conditions satisfactory, they feel they are doing a good job and this is acknowledged both on a personal
level by management, and by an adequate salary.
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Being unhappy leads to discontent and demoralisation. Unhappy demoralised health workers are
unlikely to:
Be motivated to change
Be able to express their views and opinions freely, especially if they have no real job security
Improve the care they give to children and their families
Be able to give the best possible care
As it takes considerable effort, time and money for a health worker to become sufficiently skilled to
provide effective healthcare, health workers are a valuable resource for a country. It does not make sense
to have unhappy de-motivated or mentally ill health workers that leave either the health service or their
country.
To keep health workers happy and well it is especially important to have systems in place to protect them
from acquiring mental health problems due to their work, and to look after them when they do have these.
It is also important to have transparent employment procedures (including job security) and adequate
payment. These issues are a priority for those who plan and organise healthcare.
Other factors that contribute to a contented and motivated health worker
Job satisfaction and sense of achievement
Recognition and praise, when deserved
Good leadership with consistency and fairness from managers
Clarity of goals, the purpose of the job and expectations of performance
A culture that encourages flexibility and innovation
Being consulted/having a voice
A sense of belonging and a feeling that what you do matters
Being part of a successful team (team working) and knowing what constitutes success
Working with people who are loyal and supportive, especially if you do not have strong family
support
Pressure within reason
Varied and challenging work
Having the authority, skills and respect to do the job well
Learning new skills and having the opportunities to use these
Opportunities for advancement
Having a sense of morality, ethics, shared values and beliefs incorporated into your work
Being protected from work related health problems (for example being given advice about safe lifting, and
the prevention of and management of needle-stick injuries)
Having physical health problems looked after, especially if the problem is work related
Good terms of employment include:
Clearly stated goals and objectives for the job
Reasonable pay
Job security and transparent, fair and supportive disciplinary and dismissal procedures
Interesting and stimulating work and the opportunity to make good use of your talents and skills
A reasonable workload (that enables a good life-work balance)
Opportunities for advancement/promotion
A supportive culture and colleagues
Learning and skill building opportunities
Security and safety in the healthcare environment
A good working environment
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Healthcare for employees

Adequate resources to do the job
These all depend on the culture in the healthcare environment, the skill of the leaders/managers and the
allocated resources for the job.
More about stress
One of the commonest mental health problems in health workers is stress. Poor terms of employment
make stress more likely in any employee. However there are many additional causes of stress associated
with being a health worker. Stress and anxiety are greater in clinical jobs than non-clinical, and in some
specialities more than in others. Caring for children and families is especially stressful and requires
special attributes that include:
A genuine interest and empathy with children and their families
A friendly down to earth personality
Common sense
A lack of interest in private income, providing the remuneration is sufficient to live at least as
well as the average family. This is not the case in many countries where to survive health workers
have to depend on additional income generation. In these countries, inequity of healthcare is
inevitable.
A broad, all round knowledge of childrens healthcare
The ability to communicate with all types of people well, especially across professional, cultural
and ethnic boundaries and age groups
Particularly stressful events for health workers include:
Carrying out an invasive procedure, such as a blood test, in a child
Carrying out an invasive procedure in an upset child
Not being able to do the procedure (in the case of venous access, it is a good idea to always stop
after a maximum of three attempts, if this is possible, and let someone else try)
Giving parents bad news
Being on call without a senior health worker to provide support
Having to take responsibility before you are confident, or to deal with a situation when you do not
know what to do (doubt in reasonable amounts creates a thorough health worker, in excess a
tortured and inefficient one).
When you do not have the equipment, drugs or treatments that the child needs
When a child is very ill
When a child dies
Coping with distressed parents and families
Making a mistake
Having a complaint made against you
When there is too much to do and as a consequence you know that care is unsafe
Some other facts about the mental health of health workers in some countries:
Deaths from suicide, cirrhosis and road traffic accidents are higher in health workers than in the
general population
Women doctors are more likely to commit suicide than men, possibly as they are more
empathetic and patients increasingly demand empathy
Drug addiction and alcoholism are more common
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There are higher divorce rates and marriages are more at risk as health workers are often torn
between meeting patients needs and family needs (doctors are often described by their partners
as controlling perfectionists)
Mental illness may be present in greater than 30%, women being at greater risk, up to 46%.
Health workers, especially doctors, often feel that sharing their feelings with others is a sign of weakness
and therefore they try to cope alone when stressed and emotionally distressed. However, if their emotions
and feelings become overloaded they are unable to function properly due to associated detachment
(leading to cynicism and carelessness), a loss of short-term memory, sleep disturbance and difficulty with
decision-making. Carelessness leads to mistakes, complaints and in well-resourced countries, litigation.
These make the situation even worse and may lead to a persecutory anxiety. Another reaction to
emotional stress can be to work even harder and to take on more commitments leading to inevitable
burn-out.
Burn-out is the end point of stress. This is a complex of psychological responses to the particular
emotional stress of constant interaction with people in need. It especially affects health workers and other
people with similar work.
Summary of factors that can lead to discontent, stress and burn-out include:
Major changes in workplace
Little personal say about how to do the job
Poor communication up and down
Poor recognition of individual worth
Inability through personal circumstances to work flexible hours
Excessive hours of work
Competing demands on time
Inadequate resources
Lack of support programs
How to protect yourself against these mental health problems?
You can lessen the effects of stress and emotional distress and reduce the risk of burn-out and other
mental health problems by:
1. Structuring and prioritising your time
2. Sharing your responsibilities and commitments (delegating with the authority to undertake the
task)
3. Recognising stress and emotional distress and taking avoiding actions (developing stress coping
strategies)
4. Learning to say no
5. Being open to help
6. Protecting your marriage, family and friendships, and by getting support from those close to you
(secure family relationships and the support of close friends helps protect against stress).
7. Creating a forum for a group of colleagues to support each other (peer group support)
8. Using the local support/counselling services that are available, and if there are none advocating
for these
9. Being in the right job for you
10. Being happy with your job content and terms of employment
Activities that can reduce and/or prevent unhappiness, stress and burn-out include:
1. Regular small group meetings to discuss important current issues
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2. Special meetings after an upsetting or stressful event (such as a mistake, an accident in the health
facility or an unexpected death) to discuss this, stop it happening again and provide support for
those affected by the event.
3. Increased control of ones own job/s and autonomy in daily activities
4. Redesign of job to decrease or increase responsibilities
5. Introduction of flexible working hours
6. Formal orientation and induction training for new health workers
7. Employee support programs that include skilled counselling services
8. Multidisciplinary rehabilitation for those with burnout
9. Early vocational counselling so that a health worker is doing the job that is right for their skills,
talents and level of knowledge
Health workers are valuable; they have a greater risk of health problems therefore need looking
after properly.
Although health workers need to be looked after properly by their employers but they also have a
responsibility to be good employees.
How to be a good employee!
Take care of your work and your work takes care of you (Brigitte, South Africa)
Bad employees:
1. Complain and waste time
2. Are complacent: so be professional and sharpen your skills and add new ones.
3. Are invisible. Make an impression and be visible, volunteer for projects and help when others are
overloaded
4. Are negative. So dont say bad things about colleagues or seniors/managers. This backfires when
your unkind words finally reach their ears. If you have a grievance, control your emotions, calmly
work out what you want to say, then tell your manager or the person concerned.
5. Are unreliable. Managers value employees who are trustworthy and conscientious. Delivering on
every commitment you make is a key indicator of a reliable, responsible employee with integrity; so
do this.
6. Have a poor relationship with their manager. Your relationship with your manager/senior/leader is
critical for promotion. Do you make your managers life easier or harder? Do you take up concerns
directly with him or her, or do you discuss it with others who cannot do anything about it.
7. Blame others. If you make a mistake, take responsibility. Accepting responsibility for your actions
demonstrates your professional maturity.
8. Make the wrong friends. If you are in with the wrong crowd (the whiners, the laziest), break away.
Associate with the successful people.
9. Mix personal problems with the job. Marital problems, financial difficulties or other personal
problems should be left at home and not allowed to interfere with your work. However do tell your
manager if you have got special problems. They may and should be able to help.
10. Are disloyal. You dont have to agree with every decision, but managers and your seniors appreciate
loyal employees who understand the objectives and the problem, and who contribute actively to
meeting the objectives and solving the problems.
11. Are not conscientious or dont do their work properly. For example they do not always know about
or follow policies and guidelines. They spend time too much work time socialising with their
colleagues or they do not look carefully at what they do to make sure it is the best way to do it.
12. Are dishonest, for example use work materials for personal use, make personal telephone calls
without paying or are not honest about what they did or did not do.
147
So make yourself visible, be honest, learn to welcome change, develop new skills, be flexible,
review what you do, respect others property and remember the power of good communication.
Finally a senior health worker or manager can abuse others by:
Arriving late, leaving early or frequently being absent, especially during busy periods
Being constantly away from their desk/office
Using stationery and equipment for personal use and/or making unauthorised private phone calls,
faxes, e-mails, photocopies etc
Making unauthorised trips or detours with company vehicles
Abusing relations with colleagues by constantly borrowing money or using their books, equipment
and other possessions without permission.
Leaving mistakes or unfinished work for others to sort out.
References:
Haman H, Irvine S. Making Sense of Personnel Management, Abingdon: Radcliffe Medical Press 1998
McManus IC, Winder BC, Gordon D. The causal links between stress and burnout in a longitudinal study
of UK doctors. Lancet. 2002 Jun 15; 359(9323): 2089-90.
Maslach, C. & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational
Behavior, 2, 99-113.
CFH Information Sheet 9: Mission statements

What is a mission statement?
A mission statement is a written statement or charter about the health services provided. It includes the
type and quality of care that children and their families can expect to receive and the arrangements for
seeking a solution if something goes wrong.
Best practice is for all healthcare environments and services to have a mission statement about the
healthcare they aim to give. These statements can express the intent of a hospital ward, a clinic, a specific
service such as a palliative care or child protection service, a professional group, or of an individual
health worker.
Why are mission statements important?
Children and their families are often less anxious and frightened about receiving healthcare for their child
if they know what to expect. Health workers also need to know what they should be providing
Where should they be?

Best practice is to put the statement where everyone can see it such as the entrance to the health facility,
department or clinical area.
148
Statements of intent hanging in

a hospital entrance hall
Who owns a mission statement?

It is owned by the health workers that work in the healthcare environment.
Who decides what a statement will say?
They work best if developed and approved by a team representing all the different health workers
involved, parents and older children (See information sheet 11 for more information about team working).
The leader of the service or healthcare environment is ultimately responsible for it.
What does it need to say?
It needs to be short and say exactly what services, or care, are provided as simply as possible. It is easier
to understand if it is written in local languages and uses simple words (or pictures). Ideally it should
include the name of the health worker responsible for the service or healthcare environment and how to
contact them if things go wrong. It needs to include the date it was written and a date for its review.
Examples of mission statements from the CFHI pilot sites
Example 1
The Baby Unit
Our philosophy is to create a warm, welcoming environment to help ease the anxieties encountered by
parents and families when their baby is admitted to the unit. The care provided is holistic, looking at the
physical, psychological and social needs of the newborn and their family. Parents are kept fully informed
of their babys progress at all times. Parents and siblings are encouraged to visit and/or telephone
whenever they want, to touch and hold their baby, and to care for their baby as much as possible. The
care continues from admission to discharge, and then into the community
April 2000
Example 2
Neonatal Intensive Care Unit, Mulago Hospital, Kampala, Uganda The Ten Commandments of the
Newborn
149
The ten commandments of the newborn (written

by health workers on behalf of the newborn)
1. My name is .. please use this when talking to or about me.

2. Wash your hands before examining me; I do not want to get infected
3. Do not lift the lid off, or open, my incubator unless essential as I will get cold and the oxygen and
humidity levels that I need will be lost.
4. If I am born early, do not examine me on your daily round unless strictly necessary in order to change
my treatment, or to confirm or change my diagnosis, as you are exposing me to infection every time you
touch me.
5. Try if at all possible to let me breast feed as then my infections, especially enteric ones, will be fewer,
my weight gain will be better and my hospital stay shorter.
6. Before prescribing medicine think hard about the undesirable side-effects these drugs can cause, and
always make sure you give me the correct dose for my age, weight and level of maturity.
7. Treat me as an individual, and remember that my problem/s may not be straight-forward. Rare
conditions do sometimes occur so watch me carefully.
8. Discuss my care with your colleagues whenever you think this is necessary, sharing knowledge may
provide answers.
9. Talk to my mother and teach her the rules of baby care. Tell her how to look after my special needs.
Tell her how important it is for me to be breastfed, kept clean, immunized at the right times and how to
help me grow and develop.
10. Treat me as if I was a private patient or member of your family. Do not discriminate against me
because of my parents financial or social position. Remember that I am the most important baby in the
world to my parents, just as your baby is the most important baby in the world to you.
Example 3:
A mission statement informing families about a play service in a local hospital in the UK
Play is a necessary and essential part of every childs development and it is through play that children
learn the skills they will use in their adult years.
Here at hospital we recognise the importance of play and through the skills of qualified
child care professionals we offer every child the opportunity of expression through the wide range of play
materials we provide.
By supporting the child and his/her family we use play as a part of the childs normal every day life in a
new and often daunting environment. We offer each child support before, during and after invasive
procedures and offer a play area at ward level free of any medical intervention.
150
Example 4
The childrens unit at Ulster hospital, Northern Ireland Adolescent charter
When you are in hospital:
- Where possible you will be cared for in a separate unit that is furnished to meet the needs of young
people
- You can wear your own clothes and bring in your own things
- You will be cared for by qualified staff who will try to understand your physical and emotional needs,
and respect your needs for privacy and independence
- You will be treated with sensitivity, honesty and tact at all times
- You will have the right to information and to make informed decisions regarding your care
- You will be able to discuss your physical and emotional needs in confidence
- You will be able to have your parents visit at any time and to stay overnight if you wish. You will be
able to have you family and friends visit
- You can refuse to take part in research or student teaching. You can ask for a second medical opinion
if you wish
- You will have facilities for recreational activities and a quiet area
All care will take into account your cultural and ethnic needs, disabilities and chronic illness (as
appropriate)
- You will be given house rules (drawn up by other young people) which you will be expected to follow
CFH Information Sheet 10 How to solve problems?

If at first you dont succeed, try, try, try, again. Then quit. Theres no use being damn fool about it:
W C Fields
There is nothing new about solving problems as we do this every day of our lives. Some problems are
more easily solvable than others. In a healthcare environment problems are often complex and affect
many different people. In this situation it is better to solve them using the advice and guidance of others (a
team approach).
The principles of problem solving include:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Defining the problem/s after listening to everyone affected by it/them

Prioritising these, if there is more than one problem
Selecting/choosing a problem for acting on
Recognising barriers against solving the problem/s and forces that may help to solve it/them, such
as people or materials
Seeking some possible solutions/courses of action from those affected and if possible also from
others who have faced similar problems
Considering (evaluating) these and selecting the best feasible solution/s
Trying out (implementing) possible solution/s
Evaluating the results (audit) to see if the problem has been solved and acknowledging
everyones efforts
Trying out other possible solutions if problem not solved
Reviewing other problems from the list and repeating the process
151
1. Defining the problem

Some problems and their solutions are obvious, but some are difficult to understand and solve.
Some of the reasons for problems may be overlooked, or their significance not properly
understood, unless you talk to everyone affected by it.
The main problem may be due to several different problems each with different causes, so break a
problem down into all its different parts and decide which are the most important and need
solving first. Unless you find the true problems you are unlikely to make it better.
Do not make assumptions about the cause of a problem. If you do, it is likely that your solution
will not work. Talking to everyone makes finding a workable solution more likely, especially if
those you consult know more about the details of the problems causes than you do.
Remember one persons problem list may be very different to that of another!
2. Prioritising problems
Generally the discussions you have when defining the problem will help with prioritising the
problems in order of importance.
Gaining the agreement of all involved (key stakeholders) for the final priority order is the best
approach.
If agreement is not possible an independent view may aid consensus, compromise and agreement.
3. Selecting a problem/s for action
This is usually the one top of the priority list, but not necessarily if this seems too difficult
Involve those that may have to implement the solutions in the selection of which to tackle first
The easier to solve problem may be best tackled first as success encourages and motivates
If there are lots of problems it is better to select only a few to act on first. If you try to solve too
many at the same time you may fail to solve any of the problems.
4. Recognising barriers to solving the problem and forces aiding implementation of possible
solutions
Look at these before you start. It is better to find a barrier earlier than later
Use any forces that may help makes successful problem solving more likely
5. Seeking possible solutions
The more complex the problem, the more consultation and assessment are necessary
Listen and respect the views of those closest to the problem as their ideas about possible solutions
usually work best.
Seek a wide variety of possible solutions
Some people are more able to identify possible solutions than others.
The solutions most likely to succeed are those that are owned by those involved
Ask how health workers in different healthcare environments have solved similar problems
There always are solutions, identifying these is the challenge!
6. Considering all the possible solutions and selecting the best possible (the project)
When deciding which is the best possible it is usually the:
Easiest, providing you think it will be effective
Most feasible with the resources immediately available
Solution favoured by the majority of the team
7. Implementing (trying out) the solution/s selected taking action
Before making the changes it is a good idea to make a detailed plan that states:
152
What the goal is (usually this will be fully to solve the problem)
How it is going to be achieved (the details of the plan/plan the project)
Who is going to do it (delegation)
How you are going to ask or persuade others that it is a good idea and to do it (motivate them)
How are you going to see whether you have achieved the goal/s and solved the problem
When are you going to do the evaluation (usually after completion of the project)
How are you going to acknowledge/reward the team effort. You do not always need money or
materials for this. Open recognition and praise is very effective
8. Evaluating the results

Look at what has happened to see if you have solved the problem in the best possible way. To do this you
can look at the:
Intended and unintended impact/s of the solution you have tried, both good and bad, and the
evidence to support these.
Performance of the planned solution (project) (was it a good solution?)
- How did it work, were the others able to do what was in the plan, was it too difficult, did
the goals need to be clearer?
- Were there enough resources (human and material) to make the plan work?
- Was it affected by unexpected changes?
Lessons learned - think about and identify the lessons learned (the things that went well and the
things that could be done differently or better next time) by the team, organisation and by the
children and families that were affected
Each of these three ways of looking at what happened impacts on the other two. Compare the results you
get against the goals you set and remember that sometimes unexpected findings are very important. Then
make recommendations for next time and share the results/findings with everyone involved.
9. Trying out other possible solutions.
This needs to be done if the problem is not completely solved. If you think that it is not possible to solve
the problem with your existing resources write a project proposal to take to others outside your
organisation.
10. Reviewing other problems from the list and repeating the process. You need to keep doing this as
there are always new problems to solve.
Finally remember to acknowledge and reward everyones efforts and to share the solutions that
worked for you with others. Having successfully undertaken a small local project, for example
implementation of correct hand washing, in your unit/health facility, this might help persuade sponsors
that you have the appropriate skills and experience to warrant their continued funding/support for a larger
project.
CFHI information Sheet 11: Team Working and leadership

When there are a large number of health workers in the organisation, health facility or healthcare
environment, a team approach to problem solving and to planning, organising and delivering healthcare is
best.
A multi-disciplinary team is a team of health workers that may include doctors, nurses, staff from
professions allied to medicine, and others who have contact or involvement with the child in the context of
the teams activities. For example a team may include a microbiologist, an infection control nurse, a ward
clerk, a cleaner, a teacher, a play worker and others.
153
This team approach can be used in many different situations and at many different levels in a healthcare
environment or organisation. If there are many different teams in the same health facility all responsible
for a different vision, or with a different purpose, their team leaders need to communicate with each other.
Wherever possible they need to avoid duplication of activities and report to a leader responsible for all the
teams related to his/her area of responsibility.
Most teams work better when:
There is a leader to manage and coordinate the teams activities.
This leader is approved of and respected by all members of the team, or in a large team by a
clear majority
The team is as small as possible
Team members represent those most affected by its activities (it has a representative from each
group of health workers, or from each area affected, and includes a parent or older child patient
representative, if possible or appropriate)
Team members share a clear vision (such as improving the healthcare given), or purpose (such as
planning healthcare, organising a departments activities, solving problems etc.)There are agreed,
clearly defined goals or aims for achieving the vision or purpose The groups represented by team
members are consulted whenever possible before any action or decisions are taken on their behalf
A team member representing a group of health workers reports back to their own leader or
manager about the teams activities. For example a nurse reports to her senior/head nurse.
An example of a team approach to a

single problem, but who is the leader?
A team approach may solve a single problem quickly (See information sheet 10 for more information
about problem solving), however most teams have long-term visions and purposes. Teams like this need
to meet regularly. Progress with the goals and aims needs to be discussed, and further activities planned.
Great leaders are almost always great simplifiers, who can cut through argument, debate and doubt to
offer a solution everybody can understand: Michael Korda

With the best leaders when the work is done the task is accomplished. The people say we have
done it ourselves: Loa Tsu, Chinese philosopher 700BC
154
A team leaders role is to:

Identify the skills within the team members early
Never underestimate the skills of other team members
Create a defined role for each member that uses their particular skills effectively
Respect and support other team members
Ensure good working relationships between team members and with others
Communicate effectively within the team and with those represented
This team approach can be used in many different situations and at many different levels in a healthcare
environment or organisation. Ideally if there are a large number of teams in the same healthcare
environment all responsible for a different vision, or with a different purpose, their team leaders need to
communicate with each other, avoid duplication of activities and report to an overall manager responsible
for all the teams related to his/her area of responsibility within the environment or organisation.
To ensure a cohesive approach to delivering healthcare a team member who represents a group of health
workers also needs to report to/communicate with their own leader/manager. For example nurse members
of any team in any health environment need to report back to the head nurse of the organisation or health
facility. This applies to all groups of health workers.
Being a leader means:
Recognising that change is needed
Knowing where you want to go or what you want to achieve (the vision)
Enthusing others who may help, or benefit from it, to share the vision
Motivating, empowering and developing others to help you put the vision into practice
Making something complex appear simple and easy to understand
Managing conflict positively
Dedication and hard work
Celebrating success
The skills needed to be a good leader include:
Vision
Courage, a conviction that you are right but the willingness to also accept that sometimes you will
be wrong, and take responsibility for this!
Motivation
Passion and enthusiasm
Energy
Integrity
Consistency
Communication skills
Interpersonal skills (empathy and social skills), understanding people and how to support them
and get the best out of them
Good judgement
Knowing when to concentrate on the vision, when to be flexible and when to focus energies on
the details of the tasks (planning and implementing). Generally the details are best delegated to
others.
The ability to delegate as you cannot do everything yourself. If you try to, it is likely that nothing
will be done as well as it could be. You will not be as effective if you are trying to do too much!
Self-awareness (a knowledge of your own strengths and weaknesses)
Diversity and expertise, although others can provide the latter
155
Ability to finish the tasks required to achieve the vision
There are many different styles of leadership.

These include:
1. Collaborative/democratic the leader shapes, develops and guides a team that leads by consensus
2. Autocratic/dictatorial/coercive everyone does what the leader says without question
3. Laissez-faire the leader delegates to a team allowing the team members to do whatever they want
Each of these three types of leadership work well for specific situations
Collaborative leadership:
Works well when:
There are different issues involved and the problems are
complex
The problems have many possible solutions
The leader does not have the skills and knowledge to deal with
the details of all the issues
There are team members with the skills to deal with each of
the important separate issues
The team member for an issue is skilled and respected and acts
as a representative for those involved in this particular issue
Authority for the different issues is delegated with boundaries
clearly set and known by all
Team members respect each others roles and skills
The team is able to work well together
The team is able to meet frequently
Team members communicate well with those they represent
Does not work well when:

The issues and problems are simple
There is usually a single solution to most problems
The leader is autocratic and think they know best
Team membership does not reflect the important issues
The team member for an issue is not skilled, or not respected
or does not represent the views and opinions of others involved
Authority is not delegated to team members or the boundaries
of the authority are not clearly defined or followed
There is little respect for each others roles and skills
The team are unable to work together well
The team are unable to meet regularly
There is poor communication with those that a team member
represents
Autocratic leadership:
Works well when:
The situation is simple with a limited number of likely
problems
There is a single obvious best solution to most problems
There are a limited number of different issues involved
The situation is replicated in the same way frequently
Followers or team members all agree that the leader has unique
skills, talents, knowledge that is much superior to their own
The leader is willing to get involved in all the details
The leader has the capacity to be involved in the details
The followers changes frequently
The team, if there is one, is remote

The situation is complex with many possible and differing
problems
There are many possible solutions to these problems
There are many different issues involved
The situation is variable
Followers or team members have opinions of their own on the
issues involved and believe they know as much about or more
about some or many of the issues involved as the leader
The leader is not willing to get involved in details
The leader does not have the capacity to be involved in all the
details
The leader is unwilling or unable to be always available to the
team
There is a good pro-active team
An example of when autocratic leadership works well is a ward staffed with temporarily employed nurses
when it is best if there is tight control and rules about how things are done.
Laissez-faire leadership:
Works well when:
The team is composed of a small number of similar individuals
who share the same goals
One solution to a problem is as good as any other
The team members know each other very well and are in
frequent contact with each other

The team is large or diverse
The situation and problems are complex
The team is remote
156
Although there is a place for all these types of leadership, a healthcare environment is usually complex. It
encompasses many diverse issues and activities and is staffed by many skilled health workers leadership
is likely to work best.
If this collaborative leadership model is adopted it will result in more ideas, better insight and
cooperation, more manageable demands on the leader and the projects and solutions are more likely to
work and be sustainable. It is less likely to waste valuable time and energy.
When using this model of leadership, best practice for the leader is to:
Choose team members to represent each of the important functions and activities
Balance the team
Find out the individual strengths and unique skills of each team member
Use these strengths and skills effectively
Communicate well upwards and downwards to other health workers
Delegate authority but make it very clear what and how much is delegated - set the boundaries
clearly
Set up procedures for communicating (See example of a communication matrix)
An example of a communication matrix
Team Meeting
CAI Magazine
Advisory Committee Meetings
Minutes of committee
meetings
E-mail
Web Site
Presentations
Posters
Newsletter
Meeting/Hospitals
Telephone/Fax
Letters
Postal updates/fliers
Reports about pilot sites
Others
CAI Members
Parent Organisations
UK Ethics
Committees
Governmental
Departments
Media
Global Organisations
((WHO, UNICEF)
Health workers from

other sites
Pilot Hospitals and

CFHI coordinators
Other NGOs
Donors
Professional
Organisations
CFHI Advisory
Committee
CFHI Team (Sue,

Andrew and Carol)
Methods
CAI leadership and

support and
operational staff
The methods of communications considered most appropriate to use for the different groups
of people involved with the pilot project for the Child Friendly Healthcare Initiative
Other thoughts on leadership

1. A leadership based on facts is better than leadership based on emotions.
2. Leadership is the shift in moving from developing yourself to developing others. Use your skills
and strengths to gather your team then lead, involve, delegate, manage and enable so that the
visions are implemented.
157
3. Leadership based on accepted beliefs and moral values works best as it treats people equally,
respects everyone in the team and seeks and welcomes new ideas, initiatives and innovations. It is
open, humble and has integrity.
4. Leaders need to be in training every day of their lives. They have constantly to adapt to the
crises and problems that arise around them, but they also need to train for a purpose.
5. Full engagement in leadership requires coping strategies that draw on physical, emotional, mental
and spiritual (this means being in touch with your values) energy. Each of these sources of energy
needs training and rituals. Like physical training, all of these sources require recovery time
before you can draw on them again, for example
Physical recovery time is rest
Emotional recovery time can be focussing on a happy thought/experience from outside
Mental recovery time can be sleep or meditation
Spiritual recovery time can be time alone to reflect on your values and beliefs
All great leaders and sportsmen have recovery rituals for these energies. We are creatures of
habit, so build rituals to sustain your sources of energy and to avoid compromising recovery do
not take emotional baggage into your recovery times.
6. If you wake in the middle of the night, never look at the clock but use the strategies that work for
you to shut out any fear, anxiety and stress.
158
Example of a health facility management team:
Team members
Finance
Manager
Responsible
for
Facilities
Manager
Responsible for
Human
Chief
Resources
Nurse
Manager
Responsible
Responsible
for
for
Manager of
all Clinical
Services
Responsible
for
Administration
Manager
Responsible for
Management and
control (team
leader)
Estate management
Personnel
Nursing
Clinical
departments
Secretariat
Accounting
Engineering
Human
Resources
Quality
assurance
Laboratory
services
Legal services
Paymaster
Building
Manpower
Patient
services
Imaging
(Radiology)
Administration
Budgeting
Transport
Planning
Catering
Therapists
Data management
Procurement
Utilities
(electricity,
sanitation and
water)
Occupational
health
Information
Laundry
Pharmacy
Others
Maintenance
Cleaning
Waste disposal
Capital planning
Training
Training
Training (lead
for continuing
professional
development)
Training
Training
Training
Each team member is responsible for the areas listed above and for representing and supporting
(providing leadership to) their health workers. The leader of this team can be elected by the team
members, although in many countries this is usually the director of the health facility.
It is especially important for the head nurse to be in a health facility management team and to provide
professional leadership as nurses are:
A health facilitys single largest human resource
Present 24 hours a day
See all the strengths and weaknesses of the organisation
Know what patients need
159
Unfortunately in many disadvantaged countries nurses have a low status, poor training (very basic, often
without any specialist training or very little), no professional organisations and are unable to contribute to
service planning and decision-making.
References
David Mencheon and Yi Mien Koh. Leadership and motivation. BMJ 2000 29 July Pages 2-3
160

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Child friendly healthcare

A manual for health workers

Email contacts: office@mcai.org.uk

How to use this book

Adversity and problem solving

Examples of the following are on the CFHI website:

Appendix: The CFH Toolkit

CHILD FRIENDLY HEALTHCARE INITIATIVE

HYGIENE is the principles and practices relating to cleanliness

The INTEGRATED MANAGEMENT of CHILDHOOD ILLNESS (IMCI) is a World Health

PSYCHO-MOTOR DEVELOPMENT is a combination of motor and psychological (mental,

Why is Child Friendly Healthcare important?

Needlessly dying, or becoming disabled, from treatable diseases and accidents

Care of critically ill

Survival (to life and healthcare),

In the middle of difficulty lies opportunity Albert

A reminder about the UNCRC

*What is child centred health care?

A day care unit in Pakistan for children with respiratory illness

3. Programs to prevent illness and injury (preventive services) that include:

STANDARD 2: Supporting and giving the best possible healthcare

Job aides in Pakistan showing

STANDARD 3: Giving healthcare safely in a secure, clean child friendly environment

A hand washing reminder, but the sink is unsafe as it has a taped

Gonad protectors of different sizes

Safety gates on the

No smoking sign on a childrens ward in Eastern

Reducing healthcare acquired infections

A bucket used to flush an adjacent nurses

What is needed to keep hands clean?

Soap on a string: An effective

The only facility for washing

An effective, clean, accessible

When there are no resources for buying

A method for drying hands properly

A water supply that is:

Secure (never runs out)

What else needs to be clean?

Unhygienic personal laundry facilities

A budget for cleaning is essential.

A method for using different coloured

Unnecessary over-crowding of babies in a

STANDARD 4: Giving child centred healthcare

Child Friendly hospital ward

Mother using her own mosquito net

Mother contributing to the special

Elements of partnership include:

Child Friendly laboratory corridor in

Child friendly play corner in a waiting area, UK

Child Friendly treatment room, UK

Mothers able to sleep opposite or next

Goldberg S. Attachment and Development. London: Arnold; 2000

Successful organizations are good at sharing

An example of a mission statement

Early morning meeting in Moldova for all

To share information effectively, it is necessary to have:

A system that keeps sensitive information confidential. Protecting confidentiality is vitally

Information for parents about

Having a second health worker present (a doctor/nurse combination works well)