Building child health nurses' confidence and competence: a course aimed at boosting nurses' ability to competently care for children, has brought about noticeable improvements in practice and family-centred care at Christchurch Hospital.

Children admitted to hospital present with more complex conditions, tend to be sicker, stay less time and require more intense health care than ever before. (1)

Nursing children is fundamentally different from nursing adults. Having knowledge of their unique physiological and psychological needs is essential, yet the way in which registered nurses (RN) in New Zealand acquire this knowledge is often ad-hoc.

In Christchurch Hospital's child health cluster, three part-time clinical nurse educators (CNE) fill a 1.2 full-time equivalent position. Their rote is to ensure that knowledge fundamental to the care of children is well planned and accessible. This article describes the development of the Generic Orientation Programme, Child Health Nursing and its perceived impact on practice after ten months, through two simultaneous evaluation surveys, seeking the views of programme participants and their nurse managers.

'On-the-job' learning

Child health nursing requires orientation to a broad range of childhood illnesses and diseases, policies, procedures and specialised equipment. In New Zealand, the RN will acquire much of this knowledge "on the job", placing considerable demand on clinical preceptors. (2) This situation is compounded when children are cared for in "non-designated" children's areas. Christchurch Hospital is the largest tertiary teaching and research hospital in the South Island. Child health services include an acute assessment unit, two 20-bed wards, a seven-bed high dependency unit (HDU), a seven-bed ontology and haematology centre and the paediatric outpatient department.

For a variety of reasons and for varying lengths of time, children are also cared for in non-designated children's areas, such as the emergency department (ED), recovery and the day-surgery unit (DSU).

Our aim in establishing the programme was two-fold: firstly, to overcome the increasing demand on clinical preceptors in the child health cluster; and secondly, to address the learning needs of staff in non-designated children's areas. A private hospital also wanted a programme that would provide its nurses with adequate theoretical knowledge to competently care for children. Before implementation, advice was sought from the professional development unit co-ordinator and the postgraduate nursing education facilitator. The clinical nurse educators, in cooperation with the child health nursing director, clinical charge nurses, nurse specialist and ward/unit based preceptors, developed the programme.

Professional nursing care of children is reliant on RNs' knowledge of core aspects. These include basic anatomical and physiological differences; fluid and electrolyte management; safe administration of medication; pain management; recognition of the seriously ill child; and building partnerships with children and their families. The programme aims to equip the newly appointed RN in the child health cluster or the nurse working in a non-designated children's area with the knowledge and skills to safely care for children. It builds on the child health competencies of Canterbury District Health Board's nursing entry-to-practice programme and uses renowned nursing theorist Patricia Benner's seven domains of practice as its theoretical base. (3) Benner's work has been used as a framework to guide paediatric orientation programmes. (4)

The three-day programme is delivered in five modules over a two-month period. The five modules are: The diagnostic and patient monitoring function; Effective management of rapidly changing situations; Administering and monitoring therapeutic interventions and regimes; The helping role; and The teaching/ coaching function: monitoring and ensuring the quality of hearth care practices. Participants receive pre-reading material and a programme booklet two weeks before the programme starts. The first four modules are held over two consecutive days and module five one month later. In the final module each participant prepares a clinical presentation.

Teaching strategies

Teaching across the modules is primarily by the child health CNEs, with additional expertise from the clinical nurse specialist in the paediatric HDU, the clinical charge nurse and a senior staff nurse in the acute assessment unit, a senior paediatric registrar and paediatric clinical psychologist. Teaching strategies include clinical scenarios to foster critical thinking, audio-visual material, skill stations and role-plays.

The programme ran on three occasions between September 2004 and June 2005. Of the 41 participants, 19 were from child health wards and 22 from four non-designated children's areas. At the end of each module, formal evaluation forms were returned from 37 nurses, ie 90 percent. Each aspect of all five modules received mean scores of more than four, in a scale in which one was poor and five was excellent. An objective view of the programme's value was sought using the programme evaluation instrument (PEI). This evaluation toot is an effective measure of various programme components and across a diversity of programmes. (5) The 19-item scale consists of five sub-scales evaluating the programme objectives, learner objectives, teacher behaviours and programme satisfaction. Acquiring both quantitative and qualitative data is identified as important in assessing programme performance. (6,7)

In September 2005, two separate survey forms were malted to those who attended the programme between September 2004 and June 2005. Responses were anonymous and confidential Participants were asked for information about how long they had been nursing and their nursing qualifications (see Table 1), to complete the PEI, and to respond to three open-ended questions. Finally, they were invited to make any additional comments.

Similarly, the nurse managers' survey form was structured to elicit quantitative and qualitative data. Questions related to area of work, improvement in staff retention, nurses functioning more effectively when caring for children and their families, contribution of the programme to service improvement and perceived level of improvement in working relationships with children, families, other nursing colleagues, multi-disciplinary team members and nurse managers. They were also asked to identify three significant improvements to their service as a result of nurses' participation and any changes that could improve the programme. Finally, they were asked what three things encouraged them to continue supporting nurses to attend.

Response rate

There was a 40 percent response rate (N16) from programme participants. This tow rate may have been due to staff changing work areas and a time limit for responses. The majority of respondents (44 percent) had undertaken the programme in the past seven months; 62 percent worked in child health, and 60 percent had worked in this area for one to five years, with 40 percent in the area for less than a year. The remainder worked in recovery (13 percent), ED (six percent), day surgery recovery (six percent) and 13 percent at a private hospital Of those working in non-designated children's areas, 67 percent reported caring for children more often than weekly, and 33 percent reported caring for children weekly. The majority, 69 percent, worked part-time. Only 38 percent had undertaken previous child-related courses before the programme. Most reported favourably on the programme. Eighty-eight percent either strongly agreed or agreed that the instructors had applied the knowledge covered to the practice setting; with 38 percent strongly agreeing and 63 percent agreeing that the instructors encouraged the development of new viewpoints and appreciations. Just over half agreed their objectives for the programme were the same as the written course objectives and 56 percent also agreed their objectives for the programme were all met.

In response to the first open-ended question--"Do you believe you hove used the knowledge learned?" (please give on example)--almost without exception, participants reported feeling more confident when caring for children and that the programme had given them a basis to develop their skills: "Has given me more confidence in coring for children. I have made some quick reference charts for our ward for normal ranges of observations etc." [Nurse--non-designated children's area]

"I am more questioning of anaesthetists, as I feel more knowledgeable and confident. I feel more confident at rescuscitation of a baby as I found the scenario stations of great benefit." [Nurse--non-designated children's area]

Increased awareness

Others went on to describe this feeling of confidence in terms of an increased awareness of the anatomical and physiological differences in infants and children and implications for nursing care: "Yes the knowledge I was given on the first day on 'kids are different' and fluid end electrolyte imbalance was very beneficial, as it reminds me again that recovering children is different from an adult. So when I look after them now I am more focused and knowledgeable about my assessment and interventions re fluids after surgery and fasting." [Nurse--non-designated children's area]

In response to the second question--"What are you doing differently since completing the programme?"--many reported they were making more measurable assessments of children. "More measurable assessment of children, eg dehydration using measurable symptoms, pain scales. I was able to ask questions that I had previously been unsure about, eg "Why use D4S as maintenance fluid but NaCl 0.9% for replacement?, so this has given me knowledge to back current practice." [Nurse--child health area] Several felt their awareness of the importance of family care was heightened and their interactions with families had changed as a result: "I am much more aware of giving core to the family as well as the patient. Now, as well as including the patient in care, [I] also think of the wider family issues and talk to them more in recovery. Am now much more conscious of on-going impact of repeated surgery on children and how it affects the family and the child." [Nurse--non-designated children's area]

"I have become more aware of my interactions with families and how important it is to alert doctors to family situations where extra support is necessary." [Nurse--child health area] Most responses to the third question--Since undertaking the programme, do you feet it has lasting value to patient care?"--were positive:

"I am sure patient care will be improved by all nurses who attend the course." [Nurse--child health area]

"Yes, in that I am much more aware that paediatric care is different from an adult and now have specific skills which help me give more specialised care to children. They are not just mini adults but require specialised knowledge." [Nurse--non-designated children's area]

Nine surveys were sent to nurse managers and seven responses were returned. Of the respondents, 57 percent worked in child health, with the remainder in non-designated children's areas. There was a mixed response from the respondents in child health as to whether the programme had assisted in improving nurse retention. Half believed it had, with one commenting: "Staff feel valued, programme directed specifically to their needs."

All agreed they would recommend the programme to other managers if nurses' clinical work included caring for children: "It helps the words understand each other's workloads, acuity and resources. It also provides the basic knowledge that everyone working with children should have." Managing release time to enable attendance at in-service programmes can be a challenge for nurse managers and programme length may influence their decisions. The majority reported positively on the duration of the programme and agreed it caused the least possible disruption to staffing levels. All either strongly agreed (43 percent) or agreed (57 percent) that the programme had assisted the participants to function more effectively when caring for children and families.

Seventy-one percent agreed the programme had contributed to improvements in a number of areas--clinical nursing assessment of children, recognising the seriously ill child, medication safety and professional development. Furthermore, 86 percent agreed there had been an improvement in promoting and practising family-centred care among nurses who had attended the programme. Half either strongly agreed or agreed that programme participation had improved working relationships between the participants and children, families, nursing colleagues and the functioning of the multi-disciplinary team. There were indeterminate responses as to whether relationships with nurse managers had improved.

Finally, respondents were asked three open-ended questions on the implications of the programme and suggestions for improvement. Most described significant improvements to their service as a result of nurses' attendance. A heightened awareness of family involvement in care and increased confidence with care delivery were identified by a number of respondents. Others observed that nurses' clinical knowledge and skills had improved, citing examples of greater awareness of potential problems, and confidence with emergency procedures. Most were satisfied with the current programme.

Suggestions for improvements, particularly from respondents in child health, included opening up some or all of the sessions to current staff and eventually having all staff attend. Finally they commented on important aspects of the programme, including the increased confidence of those who had completed it, specific content, such as anatomical and physiological differences, and family-centred care.

The aim of the programme was to equip nurses working in child health and in non-designated children's areas with the requisite knowledge for nursing children in acute care. The majority of nurse respondents believed they had gained new knowledge and described how they were incorporating it into everyday practice. Similarly, several nurse managers observed that nurses' clinical knowledge and skills had improved since attending the programme. In particular, responses from those working in nondesignated children's areas suggested the programme had provided them with greater insight into the care of children.

Group discussion and role play focusing on the practical application of family-centred care into everyday practice appeared to have positively influenced nurses' attitudes towards caring for families. This was reflected in their responses and subsequent examples of changes in their practice. Similarly, most nurse managers believed nurses who had attended the programme had a better understanding of family-centred care and were actively promoting it in practice.

Incorporating knowledge into practice

The majority of those who participated in the survey reported high levels of satisfaction with the programme and provided tangible evidence of how they were incorporating the knowledge gained into their daily practice. Correspondingly, nurse mangers observed improvements in the nursing assessment of children, recognising the seriously ill child, and the practice and promotion of family-centred care.

The programme, which runs three times a year, has been a successful response to addressing the learning needs of child health nurses and nurses working in non-designated children's areas. Since June 2005, 88 more nurses--25 from child health and 63 from non-designated children's areas--have completed the programme, and there is usually a waiting list. Nurses from intensive care and transit care are also participating in the programme.

The programme is widely regarded as beneficial, enjoyable and provides a valuable insight into the delivery of quality nursing care to children and their families. It has been instrumental in developing strong links with nurses and nurse managers in non-designated children's areas and fostering knowledge sharing between areas.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in October 2006.

References

(1) Casey, V. (2002) Child Health Strategy Report. Christchurch: Canterbury District Health Board.

(2) Maiden, V. & Hewitt-Taylor, J. (2005) Linking theory and practice in children's nursing: lessons from abroad. Paediatric Nursing; 17: 5, 24-28.

(3) Benner, P. From Novice to Expert. Menlo Park, California: Addison-Wesley Publishing Company:

(4) Waddell, J., Durrant, M., & Avery, S. (1999) The integration of research by nurse educators: advancing practice through professional development programmes. The Journal of Continuing Education; 30: 6, 267-271.

(5) Henker, R. & Hinshaw, A.B. (1990) A programme evaluation instrument. Journal of Nursing Staff Development, 12-16.

(6) Metheny, W.P., Espey, E.L., Bienstock, J., et al. (2005) To the point: medical education reviews evaluation in context: assessing learners, teachers, and training programmes. American Journal of Obstetrics and Gynaecology; 192, 34-37.

(7) Johnson, J.H. & Olesinski, N. (1995) Programme evaluation key to success. Journal of Nursing Administration; 25: 1, 53-60.

* I would like to acknowledge the generous assistance of Canterbury DHB's nursing education facilitator Nanette Ainge in the preparation of this article.

Kim Chenery, RN, MA (Appld), is a nurse educator in the child health cluster at Christchurch Hospital.

PARTICIPANT CHARACTERISTICS

Experience as RN   First Nursing               Post-registration
                   Qualification                 Qualification

> 15 yrs   50%     Hospital trained         Level 700 or Masters   31%
                     RN               44%
6-15 yrs   12%     Bachelor of
                     Nursing          25%
 1-5 yrs   38%     Diploma of
                     Nursing          19%
                   Enrolled Nurse     12%