Evaluation of an education programme for staff working with acutely

Evaluation of an education programme for staff working with acutely ill and injured children and young people (Core level) Final Report October 2009
Evaluation of an education programme for staff working with acutely ill and injured children and young people Contents Executive summary Page 3 Introduction Page 10 Aims of project Page 12 Stage 1 – Literature review Page 13 Stage 2 – National Survey Page 37 Stage 3 – Case studies Page 57 Conclusions and recommendations Page 84 References Page 87 Research team: C. English, Professor C. Clarke, A.Macfadyen, M. Cook, Professor S. Campbell, Dr G. Lawson, A. Garrow.
2 Evaluation of an education programme for staff working with acutely ill and injured children and young people Executive Summary The recognition of the need for a national and consistent approach in the care of acutely ill and injured children and young people in Scotland (SEHD 2006) led to a tiered approach to care and the development of a national education initiative commissioned by NHS Education for Scotland in 2007. The tiered approach identified a core level, intermediate and advanced level of care and the education programme reflected these tiers. This is a report of the evaluation of the core level education programme of study initially delivered by Robert Gordon University and supported by educational leads across Scotland. The programme relied upon on‐line study followed by attendance at clinical skills days where assessment of the students’ skills and knowledge took place. An alternative option which was later developed by the Clinical Education Lead Coordinator and the Clinical Education Leads, offered staff the opportunity to undertake the clinical skills days prior to undertaking the on‐line part of the programme. The evaluation comprises of three stages: Stage One – literature review. A literature search and analysis was conducted and reviewed throughout the course of the study. Stage Two ‐ a national survey was carried out to establish a baseline of the existing level of qualifications and skills amongst staff working with this patient group in Scotland. The survey also identified the levels of staff preparation and confidence in relation to specific areas of core knowledge and skills. This survey was also repeated one year later.
3 Evaluation of an education programme for staff working with acutely ill and injured children and young people Stage Three ‐ Interviews were undertaken at three case study sites (in Greater Glasgow and Clyde, Highlands and Islands and Grampian) which provided detailed information on how the programme had influenced the experiences of staff and recipients of services for acutely ill and injured children and young people. Literature Review In summary, it is clear that whilst recommendations suggest that children should be cared for by appropriately trained staff (Department of Health, 2004) the implementation of this gold standard is problematic. The issues have been debated in the literature for many years but the drive to ensure safe and effective care for children and young people has gained a new momentum. The need to deliver against the standards previously set has become a more pressing imperative. There are resource challenges which need to be overcome to ensure that the necessary training of staff takes place as well as the retention of experienced and competent staff. Survey Managers and staff from 124 sites across Scotland were surveyed in year one and year two of the evaluation. In year one questionnaires were sent out to 110 managers in 90 organisations with a response of 52 (47.2%). In year two 63 questionnaires were sent out to managers at sites where they or their staff had responded initially and the second year response rate was then 44 (69.8%).
4 Evaluation of an education programme for staff working with acutely ill and injured children and young people In year one, 1820 staff questionnaires were sent out and 248 staff returned completed questionnaires (13.6%) and in year 2, 1380 questionnaires were sent out and 171 returned (12.4%). In the survey, managers were asked about the service, staffing and training whilst staff were asked about their levels of preparation and confidence in all areas of practice covered by the core competencies and with different age categories. Examples of areas of practice were; assessment of children, prioritising interventions, recognition of urgent need and pain control. The age groups were; under 2s, 2‐11years, and 12‐16 years. The range of responses that staff could record were; extremely good, very good satisfactory or insufficient preparation. They also recorded whether they felt; extremely confident, very confident, confident, somewhere between confident and not confident or not confident. Areas where staff felt prepared and confident There were four areas of practice where the majority of staff (over 75%) identified feeling prepared, these were; assessment of children over 12 years of age, recognition of urgent need in all age groups, pain control in children over 2 years and prioritisation of interventions in children aged over 12. There were two areas of practice where the majority of staff (over 75%) identified feeling confident, these were; assessment of children over the age of 12 and the recognition of urgent need in children above the age of two.
5 Evaluation of an education programme for staff working with acutely ill and injured children and young people Areas where staff felt least prepared and confident Areas where the majority of staff (over 75%) felt least prepared included stabilisation, accompanying on transfer, administering medicines and red flag presentations. Staff felt least prepared and confident when dealing with the under 2s. Areas where the majority of staff (over 75%) felt least confident were in all aspects of care for under 2s and across all age groups with regard to; prioritisation of interventions, stabilisation, accompanying on transfer, red flag presentations, administering medicines, and pain control. Across all aspects of care staff confidence grew with the increasing age of the child. Case study site interviews Health care professionals provided details about the types of conditions with which children and young people presented at their services, and explained the ways in which they felt the programme had influenced their subsequent practice. Reported impact on professional practice included a more structured approach to assessment, better communication skills with the child, family and multi‐disciplinary team, an increased awareness of the need to have suitable environments and equipment , and an improvement in both their knowledge and confidence in dealing with this client group. Staff valued the skills days ‐ the content, organisation and particularly the delivery by credible practitioners. The “added value” of the clinical education leads’ role was evident with regard to advising and supporting staff to improve the environment and equipment available for children and young people.
6 Evaluation of an education programme for staff working with acutely ill and injured children and young people Conclusions and Recommendations In conclusion, overall the core level education programme for staff working with acutely ill and injured children and young people has evaluated very positively by staff. The utilisation of Clinical Education Leads to deliver education and training locally, in addition to the on‐ line learning, was well received by participants and resulted in some reported positive changes in staff behaviour, practice, environments and equipment. Content, organisation and delivery of training by credible practitioners in a realistic way was valued by staff. It is recommended that these successful elements of the programme be retained in future models. Participant’s experiences of anxiety regarding on‐line learning and the clinical assessments were evident and it is recommended that further introductory activities should be developed prior to online learning. This may help to improve the students’ early experience and engagement with this mode of learning. Completion of the on‐ line module option following the skills day may be enhanced if students received more specific information during or soon after the study days. Whilst some students requested more flexibility in the time frame for completion of the module it is recognised that there is a sound rationale for setting these limits. This was to ensure that the students’ knowledge and skills developed on the skills day were up to date when accessing the on‐line module. There is evidence from the survey data that there are particular areas of care of acutely ill and injured children in which staff do not feel fully prepared and confident. This data
7 Evaluation of an education programme for staff working with acutely ill and injured children and young people should prove helpful in ensuring that future programmes provide sufficient emphasis in these areas to increase staff’ levels of preparation and confidence. These areas include all aspects of care for the under 2s in addition to stabilisation and transfer, red flag presentations, prioritisation of interventions, administering medicines, and pain control across all age groups of children. A programme of regular updates is needed to support staff to maintain their skills, knowledge and confidence to safely care for children and young people who are acutely ill and injured. Contact and support from Clinical Education Leads with advice regarding care environments and equipment was effective in helping staff to consolidate new learning and in promoting safe care. It is recommended that:‐ · Key successful elements of the existing model should be retained ‐ o content, organisation and delivery of the programme o approachability and credibility of facilitators o the hands on nature of the skills days o the add‐ on value of the Clinical Education Leads e.g their expertise being used to improve equipment and environment at a local level. · For some students further introductory activities may assist in reducing anxiety and improving initial experiences with the on‐line mode of learning.
8 Evaluation of an education programme for staff working with acutely ill and injured children and young people · Further emphasis be placed on the education and training of staff in relation to care of the under 2s, stabilisation and transfer, red flag presentations , prioritisation of interventions,, administering medicines, and pain control across all ages. · Regular updates should be provided and supported with appropriate resources to enable staff to attend.
9 Evaluation of an education programme for staff working with acutely ill and injured children and young people Introduction For some years now there has been an acknowledged need for developments in services which care for acutely ill and injured children. A number of reports have recommended key changes to the ways in which assessment and treatment of such children is organised (Working Party of The Academy of Medical Royal Colleges, 2007; RCPCH, 2007; RCPCH 2008; RCPCH 2009; Department of Health, 2006; Scottish Executive, 2006; RCPCH, 2004; Department of Health, 2004). The need for a national and consistent approach in this area was identified in relation to clinical guidelines, service co‐ordination and education. In Scotland an action framework was created (SEHD 2006) which clarified the different levels of emergency care required and a tiered education programme was developed to ensure staff were trained at the appropriate level to deliver this care. The education programme consisted of core level, intermediate level and advanced level and was commissioned by NHS Education for Scotland. The core level programme commenced in 2007 and has been rolled out across Scotland. This is the final report on the work carried out by Northumbria University between April 2007 and September 2009 to evaluate this core level programme of study for healthcare professionals who work with acutely ill and injured children and young people in Scotland.
10 Evaluation of an education programme for staff working with acutely ill and injured children and young people An education package was developed by Robert Gordon’s University to deliver the programme for healthcare professionals who work with acutely ill and injured children and young people. The programme relied upon on‐line study followed by attendance at clinical skills days where assessment of the students’ skills and knowledge took place. The first cohort of students undertook the programme in 2007. An alternative option which was developed by the Clinical Education Lead Coordinator and the Clinical Education Leads, offered staff the opportunity to undertake the clinical skills days prior to undertaking the online part of the programme. This has been a popular option and has allowed many staff across Scotland to participate. These staff have the option of being awarded 5 SCQF (degree level) credits on successful completion of the 3 skills days (with an OSCE assessment) if they enrolled at the University. If they successfully undertook the online course work and assessment, they were credited with a further 10 credits. Some staff took up the option to enrol at the university, and they had up to a year to undertake the coursework and assessment. It would appear that some staff have worked through the course work, but did not undertake the assessment. A number of staff who undertook the clinical skills days have not yet enrolled at the university – so will not be credited for their participation and pass in the OSCE. An example of this was that for 194 staff who had completed the 3 days by September 2008, only 114 had registered at the University. This was despite the offer from NES that they would pay the fees for the complete module. Some staff undertook one or two of the skills days, but did not attend on the third, and so did not undertake the assessment.
11 Evaluation of an education programme for staff working with acutely ill and injured children and young people Aims of the evaluation project 1. To evaluate the NES tiered education programmes for all healthcare staff who deal with acutely ill and injured children and young people. 2. To evaluate the impact of the NES tiered education programme for the care of acutely ill and injured children and young people, on the individuals and teams who received the tiered education programme, as well as the service they provide. 3. To evaluate the impact of the NES tiered education programme for the care of acutely ill and injured children and young people on the patients themselves. In order to achieve these aims, the evaluation involved three stages : 1) A literature search and analysis was undertaken to determine key issues and developments in practice and policy in order to refine the overall framework for the study. The findings from the literature review informed the development of the survey questionnaire. 2) A mapping exercise of existing educational and clinical practice for acutely ill and injured children and young people. This involved undertaking a survey of national practice and service organisation to establish baseline data. This survey was repeated after 12 months, following implementation of the NES core level educational programme which had been rolled out across Scotland.
12 Evaluation of an education programme for staff working with acutely ill and injured children and young people 3) Three case study sites were chosen to provide detailed information on how the NES core educational programme has influenced the experiences of staff and recipients of services for acutely ill and injured children and young people. Stage 1 Literature review A primary review of the literature was conducted which was updated throughout the project. The project team members have a range of knowledge and expertise in the field which informed the individual search questions, selection of relevant search terms, identification of key authors, publications and journals as well as definition of the selection criteria, data analysis parameters and data synthesis frameworks. The search terms used were:‐ acutely ill and injured children; casualty; accident and emergency; initial treatment; trauma; trauma (care and treatment); accident (care and treatment); emergency (care and treatment); stabilisation; staff skills; staff competence; assessment; critically ill; urgent care. All search terms were used in conjunction with children and paediatrics. The review included literature published within the last ten years and which was published in English. The following database and website searches were carried out: Databases ‐ AMED (allied health), Social Care online, CINAHL (nursing), MEDLINE (medicine).
13 Evaluation of an education programme for staff working with acutely ill and injured children and young people Key websites of professional organisations for relevant papers, reports and documents – Department of Health, Royal College of Paediatrics and Child Health, Royal College of General Practitioners, National Institute for Excellence, Royal College Of Nursing, Children in Scotland, Scottish Executive, Scotland’s health on the web, Scottish Intercollegiate Guidelines Network, Social Care Institute for Excellence (SCIE). In addition, other websites were searched for user perspectives in relation to the subject. These websites were; www.childrenfirst.nhs.uk; www.rights4me.org; www.unicef.org.youthvoice; www.dcm.org.uk; www.act.org.uk; www.whizz‐kidz.org.uk; www.direct.gov.uk/Parents/FamilyIssuesAndTheLaw/ChildrensRights Bibliographies of selected papers were hand searched for further relevant literature. Personal contact and email requests via professional email networks were made to further supplement and ensure an up‐to‐date body of literature was developed. This yielded useful information about emerging literature which has since been published and is included in the review.
14 Evaluation of an education programme for staff working with acutely ill and injured children and young people The references retrieved in the search were entered into endnote (reference manager software) and an initial literature “grid” was created for initial reporting which allowed the reader to view the literature in a format which identified the authors, date, source, country of origin and topic areas of the papers at a glance. The most recent two years of key journals were identified and searched. (Accident and Emergency Nursing, Emergency Nurse, Emergency Medicine Journal, Journal of Emergency Nursing (US), Journal of Accident and Emergency Medicine).
15 Evaluation of an education programme for staff working with acutely ill and injured children and young people Literature Review For some years now there has been an acknowledged need for developments in services which care for acutely ill and injured children. A number of reports have recommended key changes to the ways in which assessment and treatment of such children is organised (Working Party of The Academy of Medical Royal Colleges, 2007; RCPCH, 2007; RCPCH 2008; RCPCH 2009; Department of Health, 2006; Scottish Executive, 2006; RCPCH, 2004; Department of Health, 2004). These recommendations consider the geographical arrangement of services, and emphasise the need for a whole system approach, including medical, nursing, paramedic and social services (Cooke and Alberti 2007, RCPCH, 2007; Scottish Executive, 2006; DOH 2006; RCPCH, 2004). The Intercollegiate Committee for Services for Children in Emergency Departments’ report (RCPCH 1999) has been highly influential over the last decade in the improvement of care for children in the UK. This publication has guided developments and the updated version of this report (RCPCH, 2007) takes account of current service challenges.
16 Evaluation of an education programme for staff working with acutely ill and injured children and young people The need for such a comprehensive review of services is influenced by a number of factors, relating to staffing, the structure of health care delivery and changes in the acute illness and injury in children and young people. Although many emergency departments (EDs) were able to achieve many of the standards recommended in the “red book” ‐ as the 1999 guidance became widely known‐ other departments struggled (Salter and Maconochie 2005, Scottish Executive, 2006; RCPCH, 2004; Health Care Commission 2005, 2007). The main difficulties that departments encountered were in recruiting sufficient numbers of medical and nursing staff with paediatric training. The steady increase in children attending EDs and children admitted to hospital has further added to the pressures on the services. Factors that may have contributed to this changing picture include; decreased availability of General Practitioners (G.P.s) out–of –hours, use of NHS 24 and the rising expectations and demands of families. A range of factors have impacted on medical cover in recent years which have been influenced by the European Working Time Directive (Scottish Executive, 2006), changes in consultant and GP contracts and developments in medical career structures and education. At the same time there has been an increase in the number of children attending accident and emergency departments since changes were introduced in the out–of‐hours medical services (RCPCH, 2004) with some departments reporting a 20% increase in children’s attendances (RCPCH 2007). A high proportion of the workload of out of hours services is related to children – prior to the changes, one in six GP calls was identified as being to see a
17 Evaluation of an education programme for staff working with acutely ill and injured children and young people child with acute or life‐threatening condition, compared to one in 20 for adults (Working Party of The Academy of Medical Royal Colleges, 2007). The emergence of alternative methods of health care delivery (such as walk in centres, NHS Direct, NHS 24) has contributed to possible confusion as to what services are most appropriate to treat children. There is evidence that people will use the nearest available facility (Cooke and Alberti, 2007; RCPCH, 2004; Agnew, 2004), but limited evidence of the effects of reorganisation of services on the children and their families (Stewart et al, 2006; Agnew, 2004; RCPCH, 2007). There is the potential that improvements in telemedicine could contribute to care being delivered in different settings, as near as possible to the patient’s home (Scottish Executive, 2006). This development would be in line with the expectations of service users, who do not want to be passed between services (Department of Health, 2006). There have been changes noted in relation to injuries and deaths in children over the last two decades which need to be monitored when considering service provision. Some years ago Davies (2000) commented on the impact of a decrease in the number of traffic‐related accidents and sudden infant deaths, and an increase in the numbers of young people self‐ harming (Scottish Executive, 2006). It is generally accepted that injury is the major cause of death in childhood (Peden, 2002) with boys having a higher rate of injury and greater severity of injuries than girls (Unicef 2001). However, Pearson et al (2009) recently found
18 Evaluation of an education programme for staff working with acutely ill and injured children and young people that the gender difference in deaths from all causes of injuries in children aged 0‐14 years in Scotland has steadily declined over a twenty five year period to the point where the male excess may be non‐existent soon. Whilst the reasons for these changes are not clearly explained Pearson et al (2009) urge policy makers not to target preventative measures at boys without further review of the gender patterns of injury in their populations. Such epidemiological information is important and needs to be monitored and reviewed to develop appropriate and responsive services for children and young people. Guidance for commissioners regarding the provision of services is within the National Service Framework for Children and Young People (Standard 6) (Department of Health, 2004). However there is concern that previous recommendations have not been adequately implemented (Working Party of The Academy of Medical Royal Colleges, 2007; Healthcare commission review, 2005; Salter and Maconochie, 2005), and that some changes could lead to a variation on standard of care given – based on the geographical location, distance to major centres, preparation and support of health care professionals (RCPCH, 2007). In addition, the increasing diversity in the front line professional dealing with children in urgent care situations is also seen as a risk in terms of assuring standards of safe care (RCPCH, 2007). The need to meet the particular needs of dispersed, remote and rural populations has been highlighted (Working Party of The Academy of Medical Royal Colleges, 2007; Scottish Executive, 2006). The balance which needs to be reached between local,
19 Evaluation of an education programme for staff working with acutely ill and injured children and young people accessible care and the provision of expert help as early as possible in a child’s illness, in order to improve clinical outcome is well acknowledged (RCPCH 2007). It has been suggested that no single model of care delivery will be appropriate to every setting, but that the outcomes of urgent care should be similar (Working Party of The Academy of Medical Royal Colleges, 2007; Scottish Executive, 2006). In order to achieve these aims, the need for consideration of staff, equipment and policies has been identified (Scottish Executive, 2006; RCPCH, 2004). Configuration and location of services are to be determined locally by the needs and views of the population whilst ensuring the services are safe and of a high quality (NHS Institute for Innovation and Improvement 2008). There is recognition that it is not possible for every ED or hospital to offer full paediatric services including inpatient services or critical care. Equally it is acknowledged that the patient’s journey pre and post emergency visit is important and should be considered when determining best practices and services. The aim of providing expert help as early as possible in a child’s illness, in order to improve clinical outcome, has to be balanced by the apparently opposing aim of providing care as close as possible to home. The Scottish Executive has described a tiered model of emergency care for children and young people (Scottish Executive 2006) and a tiered education programme which has now rolled out across Scotland to address the education and training needs of staff working with children who are acutely ill or injured.
20 Evaluation of an education programme for staff working with acutely ill and injured children and young people Staff Education Adequate training of staff to ensure that they are competent to care for children is essential (Cooke and Alberti, 2007; RCPCH, 2007; Scottish Executive, 2006). Maconochie and Redhead (2005) recommend that timely, high‐quality assessment, diagnosis and treatment are particularly vital for children, as their health can deteriorate quickly. There is greater diversity in the front line workforce caring for children in urgent care nowadays which includes nurses with expanded skills, ( Emergency Nurse Practitioners (ENPs), Emergency Care Practitioners (ECPs)), and GPs employed on a shift basis to staff out‐ of‐hours centres. Ensuring competency for all front line staff in caring for acutely ill and injured children is problematic due in part to the range of access points available to families. It is, however, essential that all front‐line staff delivering urgent care to children are competent in the basic skills required for safe practice; in whichever setting they work (the home, the street, the UCC or the ED). The skills required for safe practice were identified in the document Emergency Care Framework for Children and Young People in Scotland (Scottish Executive, 2006) and since 2006 a national education programme has been rolled out across Scotland to address the skills gap for front line staff.
21 Evaluation of an education programme for staff working with acutely ill and injured children and young people In addition to the technical clinical skills required, skills in communicating with children and supporting their parents are also essential when caring for children who are acutely ill or injured (Department of Health, 2006; Salter and Stallard, 2004; Hurry et al, 2004). There are nationally recognised common core skills and knowledge for those working with children and young people (Department of Education and Skills, 2005), and these can be used as a basis for analysis of the training needs of all staff who might be involved (RCN, 2006). The RCPCH (2007) have also identified a basic skills set for professionals working with children which have been further added to in relation to children and young people requiring emergency care (NHS Institute for Innovation and Improvement, 2008). In Scotland a set of core competencies has been developed for all staff working with acutely ill and injured children and young people and these competencies reflect the tiered approach to emergency care outlined by the Scottish executive (2006). There is also recognition that issues such as morale and maintenance of skills after initial preparation should also be considered. (Working Party of the Academy of Medical Royal Colleges, 2007). The development of networks and the sharing of information between health care professionals is recommended (RCPCH, 2007; Scottish Executive, 2006; Maconochie and Redhead, 2005). The implementation of national standardised guidelines/algorithms has also been recommended (RCPCH, 2007; Scottish Executive, 2006).
22 Evaluation of an education programme for staff working with acutely ill and injured children and young people Many of the issues outlined above are common for the care of acutely ill and injured children in developed countries – as is illustrated in the literature from the United States (Committee on Pediatric Emergency Medicine, 2007; Trainor, 2000; Smith et al, 1997; Simon and Sullivan, 1996), Canada (Forgeron and Martin‐Misener, 2005), Australia and New Zealand (Holland, 2005; Oakley et al, 2004). The need for adequate staff training and competence in caring for sick children has been highlighted in several reports (Cooke & Alberti 2007, RCPCH, 2007; Scottish Executive 2006; DOH 2006). The RCPCH (1999) review of A&E services for children identified that many staff lacked training in paediatrics. The National Service Framework (Department of Health, 2004) for children in hospital states that all areas providing care to children presenting with undifferentiated illness must be staffed by people who are competent and trained in paediatric assessment. The document recognises that currently this is not the case and that training is a keystone of the NSF (Maconochie & Redhead, 2005). The authors acknowledge that previous recommendations have not been implemented and this was demonstrated by a postal survey carried out in 2003/04 (Salter & Maconochie, 2004). The literature explored addresses the education of nurses in a variety of ways. Whilst recognising that nursing staff with a registered qualification in children’s nursing is desirable, this is not always feasible. This reality is generally accepted and more pragmatic approaches adopted including offering general Accident and Emergency staff skills in care
23 Evaluation of an education programme for staff working with acutely ill and injured children and young people of paediatric care (Hodson, 2000; Nixon, 2005) and recognising the value of work based learning (Swallow et al, 2000). Hodson (2000) describes an innovative project which promoted staff development utilising theoretical input and clinical teaching. This project evaluated extremely well with participants presenting an evidence base to inform future practice. Nixon (2005) adopts a similar approach delivering an inter‐professional module which incorporates mentorship in clinical practice by a children’s nurse. McGeary (2005) highlights the issues faced in practice when ensuring nurses are trained and competent to care for children in A&E, namely retention and competence. She argues that whilst the gold standard is for staff to hold a recognised qualification in the care of children, this does not necessarily provide the competence in assessing sick children. A three day course in Paediatric Advanced life support would provide such skills. However, it must be recognised that caring for children and their families incorporates a broader range of skills and knowledge, for example, Wood (1997) explores the knowledge and skills required for effective communication with a pre‐school child in A&E. Wood (1997) and Currie (2006) both identify the dual demands of A&E. On the one hand there is the need to assess and treat patients quickly and meet government targets and on the other recognition of the need to assess children in a calm environment using appropriate communication skills and distraction techniques, which usually takes time (a resource not always available in a busy A&E department).
24 Evaluation of an education programme for staff working with acutely ill and injured children and young people Whilst these authors approach the issue from a different perspective these are recurring issues. Cleaver (2003) identifies a loss of confidence when experienced paediatric nurses are appointed to A&E, even when caring for conditions in which they were confident in a ward environment. This loss of confidence is also acknowledged by Swallow et al (2000) who explored this issue for experienced A&E nurses being trained as nurse practitioners and therefore approaching care from a medical model rather than the familiar nursing one. It is apparent therefore that the context of practice is important and that staff need to feel supported in their new area of practice. As Cleaver (2003) concludes, expertise should be accompanied by a theoretical underpinning, which is then grounded in everyday practice. This approach along with active reflection and clinical supervision can lead to confidence in their practice. Auburn & Bethel (2007) also demonstrate the value of reflection in developing nursing practice. An example of good practice is cited by Currie (2006) who describes the introduction of a competence framework for treating paediatric patients as a nurse practitioner in Accident and Emergency. This document was devised when the minimum age for patients treated by the nurse practitioner in this department was reduced from thirteen years to five years. Currie (2006) acknowledges the importance of competence in contemporary nursing practice, both for patient care and for the individual practitioner’s professional development. The Royal College of Nursing (2006) has recently published a ‘Self assessment
25 Evaluation of an education programme for staff working with acutely ill and injured children and young people tool for Practice Nurses working with Children’. This document provides a comprehensive assessment tool of skills and knowledge desirable when working with children. Part one links to the ‘Common core of skills and knowledge for the children’s workforce’ (DfES, 2005) and part two highlights the key clinical skills and knowledge required to address the needs of children and young people presenting with acute illness and injury. One of the problems identified by Cleaver (2003) is the lack of appropriate courses and mentors or assessors of practice. Cleaver (2003) recommends that widening of participation should be considered and potentially paediatric Accident and Emergency staff could access courses aimed at general Accident and Emergency practitioners. Swallow et al (2000) reported on the strengths of a project to award academic recognition to work based learning, the participants acknowledging the value of peer support and the flexibility of the approach adopted. The need for coordination in the organisation of appropriate medical education and the development of paediatric medical training posts has been recognised (Cooke and Alberti, 2007; RCPCH, 2007). The need for increases in the establishment of medical training posts is acknowledged both in the UK and in the US (Committee on Pediatric Medicine, 2007). In relation to the development of medical confidence and competence when dealing with children in Accident and Emergency departments Langhan et al (2004) carried out a survey of medical staff’s feeling of ‘preparedness’ for dealing with paediatric trauma and
26 Evaluation of an education programme for staff working with acutely ill and injured children and young people emergencies. Simon & Sullivan (1996) also explored staff confidence and comfort when dealing with emergency care of paediatric patients. Trainor (2000) developed a training analysis for paediatric medical staff. The common theme which emerges from the findings is that each group of participants identified high levels of discomfort when dealing with paediatric emergencies and/or trauma resuscitation. As Simon and Sullivan (1996) conclude, this is not surprising as there is an infrequent need for these skills to be used in practice. Smith (1997) evaluated a six hour interactive programme targeted at emergency care providers in a rural setting. The training resulted in increased test scores, and confidence in paediatric airway management, and reduced anxiety levels when presented with a paediatric emergency. Care Interventions Specific care interventions were not the primary focus of the literature review but they do impact on an understanding of the skills and competencies required of staff. There were three key areas of intervention identified: · specific care · families · psychological.
27 Evaluation of an education programme for staff working with acutely ill and injured children and young people The specific care theme covers a range of topics including minor injury and illness (Hendry, 2005) e.g. hand injury (Auburn & Bethel, 2007), foot injuries (Eberl et al 2009), head injury (Tasker et al, 2006; McKinlay et al 2009), falls (van Hensbroek, et al 2009) epileptic seizures (Allen, et al 2007; Chin, et al 2008) corneal injuries (Aslam et al 2007), foreign bodies (Knight, 2006; Asif et al 2007; Purohit et al 2008; Gregori, et al 2009; Glynn et al 2008), emergency care interventions and preventative strategies (Wen and Chwo 2008), dental trauma (Addo, et al 2007), allergic reactions (Melville and Beattie 2008) respiratory distress including croup (Dykes, 2005), asthma (Wasilewski et al, 1996; Smeeton, Rona, Gregory et al 2007) and respiratory infection (Ajayi‐Obe, Coen and Handa 2008). Several studies relating to major injuries and illness have been published recently which include road traffic and cycling accidents (Malhotra et al 2008; Panzino, Oliveras, Alminana et al 2009; Mehan, Gardner, Smith et al 2009; Bevan, Babl, Bolt et al 2008; Wilson 2007; Collins, Smith, Comstock 2007) , head injuries (Maconochie and Ross 2007), brain CT reporting (Brandt, Andronikou and Wieselthaler et al 2007), emergency intubation ( Lecky, Bryden, Little et al 2009; Gerritse et al 2008), quality of life after major trauma (Janssen et al 2009), recognition of stroke (Srinivasan, et al 2009), ethanol intoxication (Marcos et al 2009), pesticide intoxication (Lira et al 2009), poisonings (McGregor et al 2009), injury prevention (Hirsh and Deross 2009; Rhodes and Iwashyna, 2007) and pelvic fractures (Bannerjee ,et al 2009). Paediatric specific issues have also been reported upon including
28 Evaluation of an education programme for staff working with acutely ill and injured children and young people pain management (British Association for Emergency Medicine, 2004), burn injury assessment (Malic, Karoo, Austin 2007), paediatric early warning score and triage (Bradman and Maconochie 2008) child protection (Bull, 2006, Joughin, 2003; Sanders & Cobley, 2005; McIntosh, Mok and Margerison 2007; Moss, Wassmer, Debelle et al 2009; ), injuries in the home and playground (Dotchin and Gordon 2007; Claudet, Toubal and Carnet et al 2007; Vollman, Witsaman, Comstock et al 2009, Tsoumakas, Dousin and Mavridi et al 2009; Mao, McKenzie, Xiang et al 2009) and self harm (Hurry et al, 2005). In addition, a number of papers have been published recently regarding major trauma and disaster planning (Lowe 2009; Gausche‐Hill 2009; Fruhwith and Zoraster 2009; Duffin 2008; Shirm, Liggin, Rassin et al 2007; Timm and Reeves 2007; Levy et al 2009; Balch 2008; Allen et al 2007; Raffoul and Berger 2007; Brandenburg and Arneson 2007; Freyburg, Arquilla, Fertel, Tunik et al 2008; Wattingney, Kaye and Orr 2007). Some have focussed upon violence from an accident and emergency perspective (Sivarajasingam et al 2009). Other authors have highlighted the need to improve and strengthen existing resources for trauma care for children on a global scale ( Mock , Abantanga , Goosen. et al 2009). Some literature referred to paediatric A&E concerns such as medication management and staff knowledge (Morrow‐Frost, 2006), medication errors (Marcin, Dharmar, Cho et al 2007), radiography reporting (Hardy et al. 2008), family centred care in A & E (Lee 2008), use of out of hours services (Dyher et al 2007; O’Keefe 2008), use of accident and emergency
29 Evaluation of an education programme for staff working with acutely ill and injured children and young people departments (Sinclair 2007; Bull 2007; Owens, Zodet, Berdahl et al 2008; Oterina de la Fuente. et al 2007; ter Riet. and Bindels, 2008), emergency transport (Kannikeswaran, Mahajan, Dunne et al 2007), waiting in A&E (Morton. and Bevan, 2008) and NHS Direct (Shah and Cook 2008), pre‐hospital care research priorities (2008) and telephone triage (Presho, 2002). The Scottish Intercollegiate Guidelines Network have produced a number of children’s guidelines relevant to practitioners working in emergency care e.g. CG 102 –management of invasive meningococcal disease in children and young people (SIGN, 2008) and CG – bronchioloitis in children (SIGN, 2006). Similarly the National Institute for Health and Clinical Excellence (NICE) have commissioned the National Collaborating Centre for Women and Children’s Health (NCC‐WCH) to produce a number of clinical guidelines relating to specific problems in children’s care. Recent guidelines that have been published which include ‐ feverish illness in children (NCC‐WCH, 2007); diarrhoea and vomiting in the under 5s ( NCC‐WCH, 2009); when to suspect child maltreatment (NCC‐WCH, 2009). The family theme included issues such as managing parental concern (Bentley, 2005) and parent’s intention to use nurse practitioners (Foregeron & Martin‐Misener, 2005). The psychological theme included articles on causes of distress (British Association of Emergency Medicine, 2006), mental health emergencies (Baren, Mace and Hendry 2008), staff attitudes towards suicide (Anderson and Standen 2007) and communicating with children (Cross &
30 Evaluation of an education programme for staff working with acutely ill and injured children and young people Gregory, 2002), children’s experiences of x‐rays (Chesson, 2002), play (Dugdale, 2002) and young people’s experiences of road traffic accidents (Salter & Stallard, 2004). In summary, it is clear that whilst recommendations suggest that children should be cared for by appropriately trained staff (Department of Health, 2004) the implementation of this gold standard is problematic. The issues have been debated in the literature for many years now but the drive to ensure safe and effective care for children and young people who are sick and injured seems to have gained a new momentum. There are resource issues which need to be overcome to ensure that the necessary training of staff takes place as well as the retention of experienced and competent staff. Stage 2 Ethical and governance approval Approval was gained from Northumbria University School Ethics Sub‐Committee in 2007. The identification of the appropriate external approvals for this study was problematic due to difficulties in obtaining clear guidance about the requirements. Although initial contact was made with the MREC administrator in July 2007 for advice and clarification of the approvals needed for this evaluation, the ethical clearance was not obtained for the national survey until December 2007 and for the interviews until May 2008. MRAD also
31 Evaluation of an education programme for staff working with acutely ill and injured children and young people reviewed the study and granted approval for the survey interviews. Full approval was also granted by the relevant Research and Development offices within the three case study sites – Highlands and Islands, Grampian and Greater Glasgow and Clyde. National Survey The project involved a survey of staff and managers working with acutely ill and injured children. The aim of the survey was to establish a baseline of the current situation with regard to the existing level of qualifications and skills amongst staff working with this patient group in Scotland. The accuracy of the information on the database was essential and was cross‐checked through web sites, information provided by NES and by telephone contact with key individuals in a range of organisations across Scotland. In addition to hospital settings, children present with injury and illness to GPs and health centres, so these sites across Scotland were also identified. Ambulance staff were targeted in the education provision for staff so the team set up a database of the ambulance centres serving Scotland. The evaluation team developed the questionnaire for national distribution to managers and staff. The managers’ questionnaire focused on the qualifications, training and experience of the unit’s staff, whilst the individual staff questionnaire aimed to collect information about the levels of confidence and competence of the staff in relation to key competency areas. The questionnaire reflected the core competencies detailed by NES and covered in the educational programme.
32 Evaluation of an education programme for staff working with acutely ill and injured children and young people Following the approval by MREC and MRAD to progress with the survey the questionnaires to staff and managers were distributed across Scotland. The questionnaires (see appendix) were sent out to lead clinicians/managers for distribution to staff. All questionnaires were accompanied by a covering letter, brief information sheet about the study (see appendix) and a pre‐paid envelope. The pre‐paid envelope enabled staff to respond directly to the team without having to hand their completed questionnaire back to the lead clinician/manager. 110 manager’s questionnaires and 1100 staff questionnaires were distributed to 90 organisations across Scotland. The managers were asked to distribute the staff questionnaires within their clinical area. After allowing a four week period of time to elapse, thank you and/or reminder letters were sent out along with a follow up pack of questionnaires for distribution. A number of enquiries arose from the second distribution of the questionnaires as several managers telephoned or emailed to say that they did not feel they were appropriate people to complete the questionnaire as they or their staff did not deal with children and young people or acutely ill or injured patients. Contacts were made with NHS 24 and the Scottish Ambulance service to ensure the staff from these service providers were given an opportunity to input into the evaluation. Twelve months later, a second survey was distributed. All manager questionnaires were sent out to named managers with a copy of their initial data to enable them to easily complete the second quest
33 Evaluation of an education programme for staff working with acutely ill and injured children and young people Strategies to increase the survey response rate It was anticipated that sending the questionnaires to named individuals recognised as the lead clinicians or managers in the units would increase the response rates for the survey. In addition to hospital settings, children will present with injury and illness to GPs and health centres so the numbers and sites of these facilities across Scotland also were identified. Ambulance staff were targeted in the education provision for staff so the team have also set up a database of the ambulance centres serving Scotland. A database of services including hospitals, health centres with minor injury units, NHS 24 and ambulance centres, where acutely ill and injured children may present, was developed and the accuracy of this has been cross‐checked through web sites, information provided by NES and by telephone contact with key individuals in a range of organisations across Scotland. The team have continued to establish and develop links with those involved in delivering the educational programme. In the first report an initial meeting with staff from Robert Gordon’s University was detailed which had allowed the team to gain useful information and insight into the development and proposed delivery of the course for the first student group. Since then two members of the research team have met with this first cohort of students whilst they were undertaking the core education programme. This took place at Inverness in November 2007 during the two day clinical skills days organised by the education providers. It was anticipated that such face‐to‐face contact with the researchers
34 Evaluation of an education programme for staff working with acutely ill and injured children and young people would assist in raising the students’ awareness of the evaluation study and the likelihood of their future participation. A further face‐to‐face meeting with the second student cohort took place in April 2008. Stage three Case studies In order to identify the three case study sites, demographic factors were taken into consideration, to ensure that the range of urban and remote and rural services were included. The sites selected were Greater Glasgow and Clyde, Highlands and Islands and Grampian. Students from all of these areas had undertaken the core level programme. These case sites also exemplified the different types of settings for emergency care for children and young people which exist across Scotland – out of hours service in Glasgow, District General Hospital in Oban, and a Community hospital in Grampian. Initial work took place to facilitate sample recruitment. There were two aspects of this: firstly, developing an acquaintance with the education provider; secondly, constructing a database of the sample population. Working with the education provider involved a member of the evaluation team visiting Robert Gordon University and meeting with the lecturers who facilitated the programme to discuss the content and delivery of the core programme. Expected cohort numbers, start
35 Evaluation of an education programme for staff working with acutely ill and injured children and young people dates and the sites from which these students were recruited was all helpful information in the planning of the further stages of the evaluation. This visit assisted in the development of a fuller understanding of the detail of the education provided and identified the potential dates that the research team could meet with the students to raise their awareness of the evaluation. Another visit to Inverness took place in November 2007 to meet the student cohort undergoing the education programme. The purpose of these visits was to raise awareness about the evaluation. Letters were sent out to recruit staff participation into the interview phase of the study. Contact addresses for students who had attended the education programme for staff working with acutely ill and injured children and young people was provided by the Programme Leader at Robert Gordon’s University. Clinical Education Leads and the manager of the staff invited to participate were contacted to inform them that interviews were to take place and to ask their advice on the practicalities of recruiting families. The first interviews with staff in Glasgow who had undertaken the programme (online and clinical skills days) took place between October and December 2008. After consultations with the manager, it was agreed that these staff would hand out information packs and an invitation to participate in the study to families whose children were cared for by the individual staff members. Interviews at this site were individual staff interviews carried out in the participant’s homes.
36 Evaluation of an education programme for staff working with acutely ill and injured children and young people Staff interviews in the Highlands case study site took place May 2009 at a District General Hospital. Interviews at this site were a mixture of both individual and focus group staff interviews. Staff interviews in the Grampian case study site were conducted in August 2009 and involved nursing staff working in the nurse‐led accident and emergency service.
37 Evaluation of an education programme for staff working with acutely ill and injured children and young people Findings Survey Managers’ questionnaire: In year one (2008) the questionnaire (see appendix) was sent to 110 managers in 90 organisations through recommendations by key personnel with a response of 52 (47.2%) completed questionnaires returned and of these 52, twelve managers reported that their service did not cater for children. In year two (2009) the research team repeated the survey and sent 63 questionnaires to managers in services that, either they or their staff had responded to year one survey, resulting in a response rate of 44 (69.8%). This figure contains data from six managers who responded to year two questionnaire which had not responded in year one. There was very little change between year one and two completed questionnaires apart from some slight variation between numbers of service users attending the services and minor fluctuation of staffing. The data reported below are from the managers completed questionnaires across both 2008 and 2009. Children’s attendance: Of the 40 services where children could attend the overall attendance figures ranged from 100 to 288,000 in which children attendance figures ranged from 40 to 75,000. The vast majority of the services (91%) reported no minimum age with the remainder stating that they had a minimum age; one service’s minimum age was over one month; another over one year of age, two stating over 2 years, one service children had to be aged 13 years and finally another where the minimum age was 18 years. 69% of services reported that they
38 Evaluation of an education programme for staff working with acutely ill and injured children and young people catered for people through their life span; the remaining services reported that their maximum age cut off ranged from 13‐18 years. Staffing: The numbers of whole time equivalent staff working in the services ranged from 1.8 to 477 staff. The staff work in services covering a large spectrum where at one end of the scale there are ambulance personnel who work alone or with another paramedic or technician; nurse‐led services with General Practitioner cover or where a Consultant can be accessed; NHS 24 which supplies an advisory service and at the other end of the scale large NHS Trusts with full children’s services. The doctor’s grades cover the full spectrum from junior doctors to Consultants and GPs with the majority of nurses in these services being Band 5 to Band 7. The services also report that the numbers of staff specifically children qualified and/or have formal training in the care of acutely ill and injured children ranged from 0 to 85. The most reported specific qualification was RSCN with RN and Paediatric Consultants joint second and the most reported formal training was that of paediatric life support. The managers reported that the numbers of staff with formal training range from zero to 300 with the following areas being the most reported areas covered in training: child protection, basic life support, assessment, recognition of a child who needs urgent attention, pain control, consent and advanced life support. The least frequent reported areas covered in training were accompanying transfer of a child, red flag presentations and legal issues. Other areas
39 Evaluation of an education programme for staff working with acutely ill and injured children and young people reported as being covered in training were the recognition of the sick child, specific condition related and domestic abuse. Explanatory comments by the managers were reflective of the natural geography of Scotland and the subsequent variety of sites at which acutely ill and injured children and young people present. The additional comments from managers fall into three distinct categories; differences in staffing levels, requirement to transfer children and levels of knowledge and training. Differences in staffing: The variety of sites resulted in comments ranging from at one end of the spectrum, indicated by comments such as ‘nurse‐led unit’ which may or may not have medical cover, ‘no‐one specifically trained in paediatrics’ and ‘ward nurses cover minor injury unit’. At the opposite end of the spectrum the comments indicates the difference in services, for example, ‘registered sick children nurse on duty 24/7’, ‘all staff at 2+ years of experience with children’ and specialist hospital for sick children’. Transfer of children: Once again the differences are quite stark, the comments range from ‘transport is a big problem’ and ‘the nearest District General Hospital is over 100 miles away’ with most reporting that ‘children are stabilised prior to transfer’ to ‘retrieval team transfer critically ill
40 Evaluation of an education programme for staff working with acutely ill and injured children and young people children’. Whilst other staff were working in large specialised children’s units that catered for almost all conditions. Knowledge/training: It was acknowledged that ‘levels of knowledge vary from basic to expert’ with most managers indicating that ‘staff are trained in child protection’ to an acknowledgement that ‘training by NES extremely successful, enjoyable and useful for the team’. It is perhaps not surprising that there are such wide variations given the geographical nature of Scotland, for example in urban areas there may be access to hospital services where medical and nursing staff have specialist training in the care of children whilst in remote and rural areas this may not be the case. Services can range from Emergency Departments staffed with nurses from 9am through to 10pm where all staff have undergone some paediatric training as part of the trauma training, to another area where it was reported that children present at nurse‐led units manned by the community hospital staff without registered paediatric training where staff access Doctors on an ‘as and when’ bases. In these services children are stabilised then transferred to specialised units.
41 Evaluation of an education programme for staff working with acutely ill and injured children and young people Staff Questionnaire In year one (2008) a total 1820 staff questionnaires were distributed via the managers with the resulting total of 248 (13.6%) completed. In year two (2009) 1380 questionnaires were Area of Scotland Number of sites Year 1: sent/returned/%response rate Year 2: sent/returned/%response rate Ayrshire & Arran 7 70/ 12/ 17% 40/ 10/ 25% Borders 7 70/ 16/ 22.8% 60/ 4/ 6.6% Dumfries & Galloway 7 70/ 16/ 22.8% 50/ 5/ 10% Fife 5 50/ 5/ 10% 20/ 4/ 20% Forth Valley 4 40/ 5/ 12.5% 20/ 5/ 25% Grampian 6 60/ 15/ 25% 60/ 23/ 38.3% Greater Glasgow 23 230/ 31/ 13.5% 170/ 20/ 11.8% Highlands 16 160/ 24/ 15% 60/ 14/ 23% Lanarkshire 11 110/ 19/ 17% 70/ 5/ 7.1% Lothian 12 120/ 18/ 15% 50/ 15/ 30% Orkney 2 20/ 1/ 5% 10/ 0/ 0% Shetland 2 20/ 6/ 30% 20/ 4/ 20% Tayside 11 110/ 21/ 19% 60/ 14/ 23.3% Western Isles 4 40/ 3/ 7.5% 40/ 8/ 20% Ambulance 6 450/ 42/ 9.3% 450/ 29/ 6.4% NHS 24 1 200/13/6.5% 200/ 11/ 5.5% 124 1820/ 248/ 13.6% 1380/ 171/ 12.4%
Totals 42 Evaluation of an education programme for staff working with acutely ill and injured children and young people sent resulting in completion of 171 (12.4%). Questionnaires were not sent to sites which had not responded in year one or where they had stated in year one that there were no children seen at their site. It should be noted that this method of distribution means that there is no guarantee that the same participants completing questionnaires in year one have been captured in year two. The previous table gives an overview of the sites of distribution, demonstrating the number of staff questionnaires sent, completed and the percentage response rate for both years. The completed questionnaires were received from all health care professional groups of qualified staff who were involved in the care of acutely ill and injured children. The pie charts below show the percentages of health care professionals that completed the questionnaire in year one and two.
43 Evaluation of an education programme for staff working with acutely ill and injured children and young people Respondents were employed in a range of settings, which illustrates the many access points for acutely ill and injured children in Scotland for example Accident and Emergency departments, minor injury units, tertiary referral centres, health centres, treatment rooms and paediatric wards. The following two pie charts show the diversity of settings where the respondents who completed the questionnaire in years one and two were employed. They highlight the complexity for ensuring standards of education and training for all staff to provide safe emergency care at these varied locations.
44 Evaluation of an education programme for staff working with acutely ill and injured children and young people The academic qualifications of the respondents in year one ranged from certificate to PhD with the highest proportion (32.25%) at degree level, 17.7% at diploma level, 14.5% at certificate and 10.9% at MD. Of the remaining respondents two have degrees at Masters Level and one had a PhD. Year two data revealed similar data in that respondents ranged from certificate to PhD with the highest proportion (32.3%) at degree level, 21.6% at certificate, 16.8% at diploma level and 16.2% at MD. Of the remaining respondents two have degrees at Masters Level and 20 failed to respond. When asked about recent training (within the last five years), 54.4% of respondents in year one reported that they had undertaken child protection training and 38.3% reported training in basic paediatric life support. These percentages appear on the low side especially when these are yearly mandatory training requirements for staff. A further 36.6% of respondents reported that they had undertaken some training in caring for children who are critically ill or in emergency situations and 20.1% undertook training in advanced paediatric life support. The remaining training recorded by small numbers of respondents included generic areas for example, minor illness, substance abuse, decision making, pain control,
45 Evaluation of an education programme for staff working with acutely ill and injured children and young people domestic violence, diabetes, consent and epilepsy with 6% reporting that they had no training at all in the past five years. Once again similar data was received in year two with 55.5% of respondents reported that they had undertaken child protection training and 36.2% reported training in basic paediatric life support. There was a slight rise of 1% in year two dataset of staff reporting that they had undertaken child protection training plus a slight decrease of 2.6% of staff undertaking paediatric basic life support training. Again, these percentages continue to be on the low side for a yearly mandatory training requirement for staff. Fewer staff reported (18.1%) that they had undertaken some training in caring for children who are critically ill or in emergency situations, in year two however, there was another slight increase in the numbers of staff (26.3%) undertaking training in advanced paediatric life support plus 12.8% reported undertaking the NES training. The remaining training recorded by small numbers of respondents included generic areas for example, minor illness, substance abuse, decision making, pain control, domestic violence, diabetes, consent and epilepsy with a small decline in the number of staff (3%) reporting that they had no training at all in the past five years. Year one respondents reported that the vast majority of training (80%) was conducted over the course of 3 days or less with the bulk (36.65%) taking place over the course of one day. Most training occurred in house (46.5%) with another 24% occurring within another NHS site and 10.2% taking place within universities. As with year one data the vast majority of training (81%) in year two data was conducted over the course of 3 days or less with the bulk (41%) taking place over the course of one day. Most training occurred in house (54.5%)
46 Evaluation of an education programme for staff working with acutely ill and injured children and young people with (15%) taking place in another NHS site and 6.5% taking place at a university, whilst a further 11% of respondents reported that they have undertaken the NES training. The following bar charts show the percentages of qualified health care professional staff reporting how prepared and confident they felt in carrying out a range of aspects of care, based on the core competencies set out in the Framework. The charts on the left are for year one and to the right, year two. Each chart conveys on the left of the chart the percentages of qualified health care professional staff who reported how prepared they felt in carrying out that aspect of care. If staff feel fully prepared, does this equate to the same percentage of them reporting confidence? On the right of the same bar chart are the reported percentages of qualified health care professional staff who stated that they feel confident in carrying out these core competencies.
47 Evaluation of an education programme for staff working with acutely ill and injured children and young people DONE TO HERE………
48 Evaluation of an education programme for staff working with acutely ill and injured children and young people 49
Evaluation of an education programme for staff working with acutely ill and injured children and young people There is an expectation from the public that qualified health care professionals are fully prepared to deal with all aspects of patient care. Year one charts above indicate that in certain areas such as recognising urgent need, assessment, prioritising interventions and controlling pain in children at least 70% of staff reported that they felt prepared regardless of the age of the child except for pain control in children under 2 years of age, where the feeling of being fully prepared falls to 67%. The remaining four areas of care, stabilisation, accompanying, administration of medicines and Red Flag presentations in children, reported feelings of preparation levels fall below 70% and in some cases, i.e. accompanying and Red Flag presentrations in the under 2s fell below 50% of staff feeling fully prepared to deal with this aspect of care. If staff feel under prepared how does this translate into their confidence in dealing with aspects of care? Year two charts suggests that there is a general trend towards staff feeling more prepared across all aspects of care across all age groups with the range of increase of staff feeling prepared of between 4 – 17%. However as stated ealier caution is needed when making comparisions between datasets as the year one and year two respondents are not guaranteed to be the same individuals. Whilst the increase is across all ages in every core aspect of care staff continue to feel least prepared to deal with the under twos. Areas in which there was the greatest improvement were assessment, recognising urgent need, prioritising interventions, stabilisation, administration of medicines and pain control with some reaching over 90% especially with children over the age of two years. The remaining two areas accompanying children and Red
50 Evaluation of an education programme for staff working with acutely ill and injured children and young people Flag presentations in children, whilst continuing the upward trend did not achieve a high percentage of staff who reported feeling prepared. Not surprisingly their reported preparation reflected in their confidence levels with key aspects of care. These levels of confidence also appeared to indicate that they were more confident the older the child. Year one charts show that the percentages of staff reporting feelings of confidence ranged beween 80 ‐50% across all aspects of care with children aged 12 – 16 years, the percentage range of staff reporting feeling confident with children aged between 2 and 11 years fell to 75 – 47% and with children under 2 years the precentage fall continued to 69 – 44% of staff feeling confident across all aspects with some aspects causing less confidence than others. The aspects of care where staff reported feeling least confident especially with the under 2s were accompanying the child, Red Flag presentation and administration of medicines to children. In regard to the reported feelings of lack of confidence with accompanying children this maybe due to the employment of ‘dedicated retrieval services’ to transfer patients in some areas of Scotland or an infrequent need to transport ill children cared for in major units, thus staff lack experience in this area reflecting in their responses. In the case of Red Flag presentations there were a number of staff who reported that they either did not know what this referred to or felt that it was not applicable to their area of practice, which could explain why they felt neither prepared or confident. Administering medicines to children could be perceived as a routine occurence for health care professionals however 40% did not feel prepared and 45% did not feel confident in giving the under 2s medication.
51 Evaluation of an education programme for staff working with acutely ill and injured children and young people Both feeling prepared and confident rises with the child’s age however 30% of staff were not confident administering medication to children aged 12 ‐16 years old. In year one the highest percentage of staff feeling prepared for any aspect of care was 81.1% and 80.6% reported confidence in the same aspect, that of recognising urgent need in children aged 12 to 16 years. These results indicate that at least 20% of staff felt neither prepared nor confident with core competencies. Some competencies, for example, accompanying children, showed a higher percentage of staff feeling neither prepared nor confident, i.e. 51% did not feel prepared and 55.4% did not feel confident accompanying children under 2 years of age. An indication that these feelings of lack of preparation and confidence continued through the age ranges especially with this particular competence is shown by 43% of staff reporting that they did not feel prepared or confident accompanying older children aged 12 – 16 years. Other competencies where staff reported feeling under prepared and thus lacking confidence were stabilisation of children, administering medicines and red flag presentations. It is interesting to note in year two that despite a general increase in the levels of preparation indicated above this is not wholly reflected in the reported levels of staff confidence. There is a mixed picture with an increase in confidence levels in some areas for example assessment , prioritising interventions, accompanying children, Red Flag presentations and pain control. The remaining three areas showed a difference in confidence levels depending upon the age of the child:
52 Evaluation of an education programme for staff working with acutely ill and injured children and young people (1) Recognising urgent need; the confidence level remained unchanged with older children but decline slightly with children aged 2 ‐11 and further decline with the under 2s. (2) Stabilisation shows that whilst there is an increase in confidence with the older child aged over 2, again there was a decline in confidence with the under 2s. (3) Administration of medicines; once again with older children there was an increase in confidence levels but their confidence declined the younger the child. The charts below show the reported level of preparation and confidence in relation to specific aspects of practice for year one and two. Year one chart shows that the reported confidence levels are lower than the levels of reported preparation in the different areas of practice. Legal issues are identified as being the area in which almost half (49.4%) of respondents felt they lacked confidence and
53 Evaluation of an education programme for staff working with acutely ill and injured children and young people similarly dealing with children suffering from non‐accidental injury was an area in which 43.9% of respondents lacked confidence. Over 30% of respondents also reported a lack of confidence in communicating with their fellow professional colleagues and/or with the child and their family. Once again, year two chart shows that there appears to be a general trend towards the staff feeling more prepared across all specific areas of practice with the increase in the percentage of staff feeling prepared being between 5 ‐8%. This increase is also reflected in their reported levels of confidence of between 1 – 7%. Over 40% of staff continued to lack confidence with recognition of the signs of non‐accidental injury and legal issues. Similarly 35% of respondents also reported a lack of confidence in communicating with their fellow professional colleagues. The reported training needs of the year one respondents were ranked thus; 63% wanted training in legal issues; 55% in red flag presentations; 48% in advanced life support; 45% in accompanying children; 44.5% wanted training in child protection despite this being a yearly mandatory training requirement; 42% in consent; 40% in assessment; 38.5% in both recognising the child needing urgent attention and pain assessment and finally 21% in basic life support, again a mandatory training requirement. There was little reported differences between year one and year two, with the training needs of the year two respondents ranked thus; 63.2% wanted training in legal issues; 55.9% in red flag presentations; 48% in accompanying children; 46.8% in child protection; 44.4% in advanced life support; 40.4% in consent; 38.6% in pain assessment; 36.8% in assessment; 32.7% in recognising the child
54 Evaluation of an education programme for staff working with acutely ill and injured children and young people needing urgent attention and finally 18.1% in basic life support. There were very small changes to the percentages of staff reporting the need for further training in most areas but it still remains that 50% of staff wish to have further training in child protection which is a yearly mandatory training requirement. In year one the majority (55.6%) reported that they were in the presence of qualified nurses when assessing children and young people with 40% reporting that there were junior doctors within the clinical areas for support. 39.5% and 31.8% reported that there was assistance from registrars and consultants respectively within the clinical area to assist as and when necessary. 21.4% reported that General Practitioners (GPs) were present when assessing children and young people. 13.7% reported that they were alone at times of assessing children. There was little difference between year one and year two datasets with the majority of year two respondents (55%) reporting that they were in the presence of qualified nurses when assessing children and young people and 44% reporting that there were junior doctors within the clinical areas for support. 38% and 17.5% reported that there was assistance from registrars and consultants respectively within the clinical area to assist as and when necessary. 12% reported that General Practitioners (GPs) were present when assessing children and young people. 9.3% were in the presence if their ambulance colleague and 8% reported that they were alone at times of assessing children. The majority of respondents in year one reported that they would turn to the medical staff if they were worried about a child’s condition, whether this was the junior doctor through to the consultant in hospital and/or the GP in community settings. Staff working in NHS 24
55 Evaluation of an education programme for staff working with acutely ill and injured children and young people would refer to their team leader and ambulance personnel would contact either their local GP or the local A&E department for advice if they were worried about a child’s condition. Once again there was little change to year two data with 83.6% of respondents reporting that they would turn to the medical staff if they were worried about a child’s condition, whether this was the junior doctor through to the consultant in hospital and/or the GP in community settings. Staff working in NHS 24 would refer to their team leader and ambulance personnel would contact either their local GP or the local A&E department for advice if they were worried about a child’s condition. Respondents in year one stated that contact would be made for further support via the telephone system with a small proportion (7%) stating that they would just verbally call for assistance as their colleagues worked close by. The time for assistance to arrive ranged between immediately to over two hours. The majority (38.5%) reporting that assistance would be immediate; however 35.6% reported that the time for assistance to arrive would vary between minutes to hours depending upon the medics location and work priority. There were two respondents who reported that assistance could take over two hours to arrive. The transfer journey for the children could take from a minimum of 2 minutes to a maximum of ten hours. The majority (77.2%) falling into the categories 2 minutes to one hour range with another 16.4% ranging from one to two hours transfer; however just below 10% of transfers took between three to ten hours. 10% may be a relative small number of transfers taking up to ten hours however it could be argued that it is these areas where staff are required to be fully prepared and confident in dealing with all aspects of caring for children especially the very young as the children are in their care for longer periods. Once
56 Evaluation of an education programme for staff working with acutely ill and injured children and young people again there was little difference between year one and year two dataset with year two respondents reporting that the most common mode of calling for assistance was via the telephone system however 30% of respondents reported that assistance was close at hand and would only require a verbal call. The time for assistance to arrive ranged between immediately to hours depending upon factors including where the child was (at home/clinic/hospital) and where the assistance was based. The majority (54%) reported that assistance was close at hand and would be at the child’s side in 15 minutes or less however 32% claimed that assistance could take anything from 20 minutes to hours to arrive, once again depended upon the location of the child and/or health care professional and their work load priority. In most cases the senior medical personnel i.e. consultants and registrars would make the decision to transfer the child but in some cases this decision was taken by ambulance personnel, nurses or in NHS 24‐ team leaders. Reported transfer journey time ranged from 2 minutes if the child was in an appropriate hospital to a maximum of 24 hours if special arrangements for example in winter conditions where an air ambulance was required but weather conditions were unsuitable. The majority (66%) of transfers took place in one hour or less with 6.4% taking anything from three to 24 hours to transfer a child. Once again this reflects the geography of Scotland ranging from remote areas to highly populated cities both presenting different and sometimes challenging transfer arrangements.
57 Evaluation of an education programme for staff working with acutely ill and injured children and young people Findings Case study site interviews Process Analysis of the staff interviews from the three case study sites are provided in this section of the report. The three case study sites were Greater Glasgow and Clyde, Highland and Grampian. For each site a different approach was taken in interviewing staff who had undertaken the course, following discussion with the local managers and clinical education leads. In the Greater Glasgow and Clyde site (GG&C), letters were sent to the home address of staff who had undertaken the 12 week online programme. Four participants were interviewed individually in their own homes. In the Highland (H) case study, letters were distributed by the local clinical education lead, who also arranged for staff who were willing to participate, to be available at the local hospital on one particular day. These staff were then interviewed individually or with one other participant. This included both staff who had undertaken the 12 week online programme and some who had undertaken the two or three day skills course. Discussion with the clinical education lead in the Grampian (G) area resulted in contact with the service manager in a community hospital, where several of the staff had undertaken the 2 days skills programme, and where some had signed up for the online programme. These five staff were interviewed individually or in pairs within their work environment. The impact on the service was assessed both by the staff themselves, and service users. The strategy used to recruit children and families in the different areas was agreed following
58 Evaluation of an education programme for staff working with acutely ill and injured children and young people negotiations with local service managers. In Greater Glasgow and Clyde, invitation and information packs were given to those staff who agreed to participate, who all agreed to hand these out to children and families who they cared. All of the staff interviewed worked in the out‐of‐hours service. The majority of them worked in the out of hours service as a second job, and the sporadic nature of their work may account for the apparent poor response from families recruited from these sources. One child, her mother and Grandmother were interviewed. Their responses are presented in the section ‘Change in communication skills and family involvement’ below. In the Highland region, the invitation and information packs were sent to the local clinical education lead, who distributed them to the departments where the staff who had undertaken the 12 week online programme or the two day course were working. The invitation was an open invitation, with families invited to send an ‘expression of interest’ form to the research team in Newcastle. No responses were received. Following discussion with the national steering group and the clinical education lead, in Grampian region, the invitation and response packs were sent to the local service manager, and were distributed by staff to families who attended their department. These families were invited to be interviewed at the local hospital or in their own homes on a specified day. No responses were received. The different case study sites were illustrative of some of the different settings where staff will see children who are acutely ill or injured. In Greater Glasgow and Clyde, the participants worked in different out‐of‐hours services throughout a city, and they reported
59 Evaluation of an education programme for staff working with acutely ill and injured children and young people that the service catered for all ages of babies, children and young people. Whilst many patients presented with minor illness there were occasions where patients were more seriously ill at presentation. In these situations the child would be referred to the nearest casualty department or specialist children’s hospital in that city. In the Highland site, staff worked in a variety of areas – in the surgical ward, day surgery unit, in theatres, in accident and emergency and in the community. They saw children of all ages and had cared for both acutely ill and injured children. If a child needed to be seen out of hours, the GP from the out of hours service would see them. If the child needed admission (other than for planned surgery) they would be transferred to a district general hospital 90 miles away (a drive of over two hours), or the specialist children’s hospital (over 100 miles away). The staff from Grampian were based in a community hospital which offered both accident and emergency and out of hours services. The staff saw children in their unit every day, from small babies to adolescents and young adults. The range of conditions covered acute medical conditions, minor conditions and a wide range of accidental injury. The number of patients a year was about 16,000 a year, with just under a quarter of these being children. The out of hours service was nurse led, with telemedicine and telephone links to a district general hospital and telephone links to a specialist children’s hospital. In the case of children needing specialist treatment, they would be air lifted to the Children’s Hospital which was 40 miles away, in less urgent cases, the children could be taken to the District General Hospital by their parents by car (20 minute journey).
60 Evaluation of an education programme for staff working with acutely ill and injured children and young people Analysis of interviews There were a number of common themes which emerged from the interviews. These are the comments about the programme of education which they had undertaken, the impact of the course on various aspects of their practice, level of knowledge and skill and confidence and their awareness of the importance of a care environment which was designed and equipped for children of different ages. The quotations below are attributed to the site, and participant number. The course The comments refer both to the 12 week online programme and the 2/3 day skills course. The staff in the Greater Glasgow and Clyde site had all undergone the 12 week online programme which culminated in the skills days. Some of the Highland staff had undertaken the 12 week on line programme (with the skills days at the end) and some had undertaken only the skills days. In the Grampian area, all of the staff had undertaken the 2 days skills course at a local venue (an hours drive away), and some had signed up for (but not completed) the online course. Comments for each type of course delivery are presented here: Course delivery – online learning
61 Evaluation of an education programme for staff working with acutely ill and injured children and young people The experience of on‐line learning was a steep learning curve, which for some, not only involved purchasing a computer but also learning how to use it. Younger relatives and friends more familiar with IT were utilised for support. . “I got a laptop just before I started the course. There’s lots to learn. But my nephew helps”. (GG&Cp1) “I spent a lot of time just playing about. You know, trying to get into this and into that”. (GG&C p3) One person described feeling “lonely” as an on‐line student “I felt a bit yes, lost like that. And a little bit lonely at home.” (GG&C p4) But others found this method of study suited them “…I had never really used a computer before. I wasn’t really computer literate apart from just knowing the basics at work. But I found it a great experience, you know. And I really enjoyed doing it online because you could do it in your own time.”(GG&Cp1) A number of comments were made that an opportunity for face‐to‐face contact or classroom teaching, particularly in relation to familiarisation with IT, could have been beneficial at the beginning of the course. On‐going facilitated peer support may also have been helpful to some students who either utilised colleagues and family members to help them through the course.
62 Evaluation of an education programme for staff working with acutely ill and injured children and young people “… it would have been very helpful at the start of the course if we’d had a day to all meet and for the course to be explained face to face as opposed to online. You know. I would say that that would have been nice.” (GG&C p3) The boost in confidence following the online programme was mentioned by several participants “It’s quite mind boggling. You know, really doing it online, I think, when you're not used to, you know... But I would do another course online.”(GG&Cp1) “I came back to work more motivated. You know, because sometimes you just hop along, don’t you?” (GG&C p3) For the staff in the Highland site who had undertaken the online learning, working and communicating online was also a new experience “we didn’t really know what they were looking for…“It’s just you’re frightened to type it.” ( Hp5) “you’re speaking to people online, you don’t know who they are. And you just feel stupid. … The first time they asked me to send something, I sent it through the post as well. Because I didn’t know if it would get there.” (H p4) The opportunity to undertake a video conference with other participants enabled them to feel more comfortable to communicate
63 Evaluation of an education programme for staff working with acutely ill and injured children and young people “I think once we got used to using the chat room and things it was fine, you know.”(Hp5) Being able to actually see who they were talking to seemed to be very important. So although video conferencing was initially a frightening and embarrassing event it was also acknowledged as helpful ultimately. To explain how nerve wracking such an experience was for her, one participant said “I hate even talking into an answer machine…It’s a nightmare (Hp7)”. The thought of being seen and heard on the video conferencing was clearly difficult for participants. “…you’re so self conscious. But it was actually very helpful.” (Hp5) Those staff who signed up for the online course following the locally delivered skills days commented that they would have found more guidance helpful “And I thought, “Well, I might as well do that paediatric thing.” So that’s what I did – I downloaded it and I said I would do it. We’ll see… I've only done topic 1 – topic 2 stumped me and I don’t know what they want, so… I’m not really sure. Because I haven’t had any guidelines apart from what I’ve downloaded”. (G p 5) More than one of the staff in this situation commented that they had signed up for the course, but hadn’t realised that there was a set time for the work to be undertaken
64 Evaluation of an education programme for staff working with acutely ill and injured children and young people “I think probably because it was so long after – that (skills days) was the summer‐time and it (online course) didn’t start until January. By that time you’d totally forgotten about it. And although you get the thing in the door – the Robert Gordons… Oh, it’s not Robert Gordons… That’s bad, isn’t it? And I’ll look at it after. But you didn’t because you get caught up with other things and you just forget. It’s not an intentional thing – you just forget about it. And then you get a little letter out saying, “You didn’t submit.” “Did I not?” Oh dear… “(G p 1) One participant commented that it would have been better to have a longer time to undertake the online component of the programme “It being open. You know, there not being a time limit. That for me, personally, would have been fine. Because eventually I would get round to it. Which sounds terrible, but you know, eventually I would have fitted it in. But it was quite prescriptive in that, you know, I had missed that submission date, and the next submission date was, I think it was like 4 weeks away. “(G p 4) Although none of the staff from the Highland site had signed up for the online course, their comments indicated that they would not be unwilling to do this in the future “But yeah, I think I’ll do it at a later date. I’ve just got that much other courses and things on just now. …I’m definitely interested in doing it though..” (H p2) “I want to have a wee break because I need to consolidate what I’ve learned.” (Hp1)
65 Evaluation of an education programme for staff working with acutely ill and injured children and young people Some participants commented that more detail of what the on‐line course involved may have encouraged them to continue with it straight after the skill days. Course delivery – practical skills days The content of the clinical skills days was similar, whether they were delivered at the end of the 12 week online programme, or as stand alone days (after which participants could sign up for the online programme). Staff were very positive about the content and delivery of the days. “But yeah, it definitely gives you more confidence and competence, because they let us try it as much as we liked, and practised as much as we like, and asked any questions” (Hp9) “I liked the way that they approached as we did lots of short sessions, so it wasn’t like a long day that you were listening to somebody. We did lots of different – like the child protection session, the A, B, C, D, E. You know, lots of different little bits that we went into different groups and did…it was all hands on and a lot of scenario based things which you can relate to your work.” (G p 3)
66 Evaluation of an education programme for staff working with acutely ill and injured children and young people Support for study When asked about the level of support offered by their employers to enable them to complete the course in terms of study leave and expenses the responses were variable. Participants appeared to be accepting of whatever study leave they were granted by their line manager which ranged from study leave for the skills day with travel and accommodation expenses paid to no paid study leave or expenses. “But we had to pay for, like, our taxis. and had to pay for our lunches. So it was quite costly.” (GG&C p3) “Well I didn't get time off because it wasn’t for my main place of employment. So I took annual leave. But all the expenses were paid.”(GG&C p1) The skills days in the Highland and Grampian sites were delivered locally – at the local hospital or in a venue an hours drive away. Staff in the Grampian site were particularly positive about the venue and catering for their skills days, which had been delivered in a church hall. “You went up in the morning and you just got your coffee and a biscuit. Which I thought would continue for the day. But no, no. At you mid‐morning break you got homemade
67 Evaluation of an education programme for staff working with acutely ill and injured children and young people scones, some days. You got pies, cakes. And it was all homemade. And the ladies of the church served you and then your dinner was like… I think there was three different types of homemade soup and sandwiches and crisps. It was lovely… and then in the afternoon – I just thought it would be a biscuit again. No, no. We got cakes. Homemade sponges and… What’s coming next? So after your first day you’re raring to go for the second one, it’s lovely.” (Grampian p5) Comments on the teaching staff Overall, very positive remarks were made about the tutors from Robert Gordon’s University as students had found them to be very helpful and accommodating. “they were very, very accommodating. And explained that if, indeed, I did have problems with accessing computers, at times, then obviously to get in touch with them. And they were very, very accommodating. Because there were some things that it was difficult for me to copy from... Well, to download from them. And what they did was they supplied me with photocopies of some things and they gave me hard copies and posted them down to me. I was very, very, very grateful for that. 2 or 3 articles that they did that with”. (GG&Cp1 ) Positive comments were also made about the clinical education leads who were involved in the clinical skills days, both at the end of the online programme and as the locally delivered stand alone days
68 Evaluation of an education programme for staff working with acutely ill and injured children and young people “The people who presented it were excellent. They were easy to relate to and they seemed to put across their information in a very easily understood way.” (Gp4) Course content All the participants were very positive about the courses they had undertaken, both the online and the skills days. “I thought the training was very good. It was very realistic.” (Hp3) “I’m trying to think. I think everything… I think everything was covered because the lectures were good, you know, as well as the practical. So I don’t think so. I can’t think of anything that stood out that I thought could have been improved or, you know… I think it was good doing a mixture of the lectures and the practical.” (Hp2) “It was very good and I learnt a lot from it”(GG&Cp4) When asked how it had impacted on their work since, they articulated changes in the way in which they assessed children, communicated with children and families, and they commented on how their confidence in caring for children had increased. The OSCEs (Observed Structured Clinical Examination) were a new and for some a “terrifying” experience but all participants acknowledged that once the assessment was over they felt fine and also felt a sense of achievement. “Because, you know, there was a sense of achievement when I completed the course. I’d never, kind of, done... I hadn’t participated in observed practice before, either. And the
69 Evaluation of an education programme for staff working with acutely ill and injured children and young people OSCE. And although it was very, very nerve wracking, I actually quite enjoyed that towards the end of it, anyway” (G&C p3) Assessment of children The most significant change in assessment were that participants recognised that they were using a more detailed, structured and holistic approach to assessing children, since completing the course. “I think it’s certainly given me far more of a structured approach to the way I approach assessing people and treating people as well. So it’s not just about the initial assessment, it’s about kind of, reassessing people as well, all the time. It’s not about just, kind of, saying, “Oh well, I’ve looked at that person and I’ve done my baseline observations and therefore it’s now somebody else’s responsibility.” (GG&Cp2) “A child with a high temperature or something you just ask Mum “Is there a rash?” or… But now we tend to look ourselves, now, rather than just saying to Mum, “Is there a rash?” So, because on that course it was strip your child, look. (G p 2)” “Yeah, I would say… Just, you’re more clearer. It’s always knowing to just start from your ABCs all the time. Because I think people just get into a bit of a tizzy at first and, you know,
70 Evaluation of an education programme for staff working with acutely ill and injured children and young people flap about a bit. But it’s just going in there and just starting from the start like you would with an adult. Just going through your ABCs and it just makes everything clearer, and makes you remember everything a lot easier. And then just go back to the beginning again, and keep going over it, you know, in case you have missed something.” (Hp5) “And even when you think the child might be okay, but when you talk to the parents and you find out just what has been going on you realise that the child is sicker than you first realised.”(GG&Cp4) There was also an acknowledgement of the need to first look for urgent signs when assessing patients and act accordingly. Pulse oximeters were now being used by one nurse but only with older children as the unit she worked in did not provide paediatric oximeters. “… I look at the child even before they get into the room... (GG&Cp1) “You know, before you’re doing your child and you were worried, you know… And because their blood pressure and things are different. You know, and I now don’t worry. I say, “Oh, don’t worry about the blood pressure. You know, I don’t need to worry about that. I do this and this.” (Hp1) Similar improvements in their observational skills have been noted specifically around respiratory assessment e.g. listening and looking carefully rather than making a quick judgement based on respiratory rate alone.
71 Evaluation of an education programme for staff working with acutely ill and injured children and young people “the other thing that I do very differently now – if a child is coming in with breathing problems I concentrate very much on the breathing – and I never used to ask to look at the stomach to get the breathing. I would just have a quick check ‐ rapid, not rapid.”(GG&Cp4) “I would think about it more, probably. You know? Whereas before I probably just went on my instinct, you know? But I would probably go through all the A, B, C, D...” (GG&Cp3) Staff reported that following the programme pulse oximeters were now being used more frequently in two of the areas. Change in confidence A positive impact on confidence levels has been reported with participants remarking that they were more assertive in situations where they feel a patient needs to be seen more quickly by the medical staff. Recognition of how to communicate this more effectively was also mentioned by one participant. “ I’m a bit more assertive about patients who I think really need to be seen quickly rather than just sit in the queue ...” (GG&C p4) “the language to be able to describe what’s going on with somebody. Rather than just saying, “I think this individual’s very unwell....It gave me more clinical confidence, I think, in being able to deliver my care. It gave me more of a background in the language to be able to express myself to my colleagues as well.” (GG&C p1)
72 Evaluation of an education programme for staff working with acutely ill and injured children and young people Several staff commented that they had, in the past, found caring for children quite daunting, but their confidence had improved following the course “I would have got someone else to do it (assess a child) , before… You know, prior to the course. Whereas now I would be happy to start the assessment, or make an initial judgement and then go and have it verified by somebody else. Whereas before I would have just gone and got someone else, you know. Come with me while I do this. Whereas now I will do it and then go and say this is what I’ve done, you know, is that okay?” (Gp 4) “Well, you know, say you get a baby or a very small child in cardiac arrest or respiratory distress and things like that – you know how to treat them. What to do with them. Who to contact in the first instance. ” (Hp10) “it was good to have information regarding child abuse issues. Things like that. Although we don't get many ‐ in my experience in Out of Hours, I’ve not come across any. But I must say I am more aware, you know. I think I feel that I would be better able, you know, to spot somebody that’s been abused. But I wouldn't... I don't feel that I would be as scared, you know, of that situation” (Hp 9) Change in communication skills and family involvement Changes in the ways in which they communicate with children and families was mentioned by many participants.
73 Evaluation of an education programme for staff working with acutely ill and injured children and young people “You know, before you talked to the parents, which is probably what I did. And now I would probably include the child more. And talk more to the child. And try and, you know… Come down to their level and chat away to them. And then, sort of, ask questions to the parent. But you’re looking up at them, because you’re down at child‐level. Which I probably didn’t do before. I probably just sat and talked to the adults” (Hp 3) “my whole demeanour has probably changed towards children. I’m much more likely to offer them pain relief before I do anything. You know, give the pain relief time to work. I was aware of it before, just it seems more important. To make sure that they’re comfortable to make sure that they have a good experience, because it colours their judgement for a long time to come.” (Gp4) Perhaps more importantly the children’s and families positive responses to these changes were noticeable and rewarding for the staff. “They just engage with you better. And you just… It’s just going down to their level, really, isn’t it? Making it less threatening for them and I suppose I maybe, at the end of the day, they can only be more compliant with you if they feel easier.” (Gp 3) “I did find when I went back to work after it that I got a better rapport with most of the children even the very young children, I would explain what I was going to do and why I was doing it.”(GG&Cp4)
74 Evaluation of an education programme for staff working with acutely ill and injured children and young people Recognition of the need to involve and communicate with other family members came across in several interviews. “.. a big part of communicating is with the parents as well as the child. And reassuring the parent, you know” (GG&Cp3) “Maybe with the rapport with the children and the parents. You know, this time... They are much more... You know, “Thanks for your advice, nurse.” And always when they go out – before they just used to say, sort of, “Bye‐bye.” (GG&Cp1) The ability of the staff to interact with the child was very much appreciated by the child and family interviewed for the study. One child, her mother and grandmother were interviewed, and this was the aspect of care (carried out by a staff nurse who had undertaken the 12 week online course) which most impressed them. “The nurse was funny and explained what he was going to do. Put a ‘stapler’ [saturation monitor] on my finger, and I had oxygen through an oxygen mask, then I went home and went to sleep. The steroids tasted very salty – I don’t like them.” (GG&C C1) “He was a good nurse – I understood what he was telling me. He talked to me. Mummy didn’t come till half way through – she was at work. She ran out of the room ‘cos she was scared – she gets dead panicky.” (GG&CC1) “And I thought he was absolutely brilliant with her. I thought he was great. He like... He was telling her everything he was doing as he was doing it, why he was doing it. He really
75 Evaluation of an education programme for staff working with acutely ill and injured children and young people explained. And it was all about what he needed for her. You know, it was... And I thought he was really good. Aye, I did.” (GG&CG1) “he was great with her. You know, and I actually came out thinking that. I thought, “Oh God.” Because, you know, sometimes... I mean, I work with people with learning disabilities and sometimes you take them to doctors and they’re speaking you and this person is sitting here and can’t understand what they’re talking about. So it’s – “Talk to him.” And it’s maybe just similar to kids, you know. But he didn’t. He spoke to (name withheld) the whole time. … I thought the guy was brilliant. I really did. I thought he was really, really good.”(GG&CG1) The nurse who had cared for them had commented on the change in his communication skills since undertaking the course “I think I’m probably a little less directive with young people. I think before I was probably a little more directive and a little more, kind of... I didn't really give them the space and opportunity to, kind of, talk first. And I probably now step back an awful lot more and allow them the space to, kind of, to do that. ... But I think it’s about giving people the opportunity to do that. Yeah, I think I probably do reassure them that, you know, now. Which maybe I didn't beforehand. That, you know, it’s about them. You know, it’s not about me processing their illness, if you like. You know, it’s much more about them as an individual, yeah? And recognising that they’ve got, you know, their own rights.”
76 Evaluation of an education programme for staff working with acutely ill and injured children and young people Change in knowledge Changes in the level of the nurses’ knowledge have been noted even relating to common situations which they had previously had experience e.g. pyrexial children, and asthmatic children. “And also, has anything changed? You know, guidelines change all the time with things, you know. You used a tepid sponge, and now you don’t and all these things. So, that sort of thing – it makes sure you’re using the correct procedures and it’s updated information. I think we did do it all before, but in a kind of haphazard way, really. So, and at least if we’ve all done the course, then we’re all doing the same thing and there’s nobody fighting over what should be done this way or that way, so…” (Hp8) “Dealing with, like, an asthmatic child. We’ve got a lot of asthmatics coming into GEMS. Fevers. Because that was something that I learned the hot... If a child has got a fever, but he’s hot and happy – the happy hot child, you know, you don't tepid sponge them. And you don't need to give them Calpol” (GG&C p2) Awareness of environment/equipment
77 Evaluation of an education programme for staff working with acutely ill and injured children and young people Comments were made within the interviews about the need for a child friendly environment in which to care for children. On course completion students had attempted to improve or adapt the environments or equipment that was available to create a more child friendly setting. There was a realisation of the importance of distraction and preparation in not only improving the child’s experience but also enabling easier completion of nursing assessments. Some staff had bought toys themselves for this purpose but had to discard many of them due to infection risks. “I think the thing that they could improve in the out of hours in relation to the course would be the setting for the child. You know, it’s not really child‐friendly. The rooms are just stark. You know, there’s not nice visual things for the children to look at...because it’s dead easy to carry a thing of bubbles in your pocket, isn't it? Or a wee pen with the wee face at the top. Just wee things like that that are good at distracting them.”(GG&C p3) “And we try and make it child friendly because we’re not child friendly up there. And you try that wee bit extra – you’ll get the telly and the video in. But you’re that wee bit more confident with a child.”(Hp6) An awareness of appropriate equipment for the use of children of all ages was recognised by staff following the programme, and they were appreciative of advice from the clinical education lead in updating this.
78 Evaluation of an education programme for staff working with acutely ill and injured children and young people “…new stuff now that we’ve got in since, we’ve updated our bag. And the Clinical Education lead has been very helpful with that too… Just making sure that we’ve got everything up to date. So that’s helped. And that in itself – updating all our equipment. We had done most of it, but there were things that we didn’t quite have right. And that’s really helped as well. So it’s all these wee things that make a big difference.” (Hp5) Need for updates All participants commented on how valuable the course had been, “I came back to our Lead Nurse and said everybody has got to go on it.” (Gp 3) and several identified the need for future updates, although they recognised the resource implication in this. “It’s not just enough just to give people the training and say, “Well, that’s it, we’ve given you the training.” I think you’ve always got to go back and reassess and re‐evaluate people and give them the opportunity to develop their skills even further, I think. Because what we should be looking for here is to give the best standard of care we possibly can. And I think training is very, very, very important – not only because it improves people’s knowledge base but because it makes people feel better about what they’re doing. You know, they feel better. They feel more professional in what they’re doing. And then, yeah, I think it’s important to keep up with the training. Not just to give people training once off and then kind of say, “That’s it; we’ve discharged our responsibility, as far as that goes.” I think you’ve always got to keep updating these things” (GG&Cp2)
79 Evaluation of an education programme for staff working with acutely ill and injured children and young people “And some hospitals have got even more mandatory training than here. Some of them have a huge list of stuff that’s mandatory. And also, you know, for the course, who’s going to pay. So, even a wee online update might be quite nice.” (Hp3)
80 Evaluation of an education programme for staff working with acutely ill and injured children and young people Discussion Survey The survey data collected in year one and two of the study demonstrated that the majority of staff across all professional groups felt least confident in dealing with children under the age of two in relation to all aspects of assessment and treatment. It was interesting to note that confidence levels gradually rose with the increasing age of the child. Other areas where staff particularly lacked confidence were in the stabilisation of the child and the accompanying of a child on transfer to other centres. Areas of lack of confidence The lowest levels of confidence reported were in the under 2s across all care and treatment situations. This finding is perhaps not surprising in itself as in this age group manifestation of illness may be difficult to assess and diagnose. Coupled with the rapid deterioration that can occur in young children it is understandable that these patients are anxiety provoking for practitioners. The sheer size of the child and perhaps the emotional aspect of seeing a young baby or toddler so unwell can be frightening for staff especially if this is an infrequent experience. The words used to communicate staff concerns in relation to babies and children were strong – terrifying, scared, worried. Having the knowledge and skills to act in a situation and being allowed to rehearse those skills in a safe environment such as was provided in the clinical skills days appeared to be beneficial. Following a systematic approach to assessment and knowing the actions to be taken when faced with very ill babies and children helped staff to manage their emotions in the situation.
81 Evaluation of an education programme for staff working with acutely ill and injured children and young people There were several examples in the survey and in the interviews where staff identified that they found communicating with the families or within the multi‐disciplinary team challenging. Following the education programme there was evidence that staff had gained knowledge and confidence in communicating in different ways. For some staff this was about feeling more confident to be assertive with professionals e.g. limiting the number of doctors entering a room to talk to a child through having more understanding of the experience from a child’s point of view. For some nurses their increased knowledge and confidence allowed them to articulate more clearly their assessment of a child to a doctor. In other situations staff had become more aware of the need to speak directly to the child and develop a rapport with them first. Stabilisation and transfer The acutely ill and injured children who require stabilisation or transfer to a more specialist centre were of the greatest concern to staff. Clearly these patients would be the most ill patients and the staff’s lack of confidence in dealing with these children perhaps reflects the lack of regular exposure to these situations. Again, the language used by the staff to describe their feelings about looking after such patients included “frightening” and “scary”. Whilst it might be unrealistic to expect to completely eliminate such feelings, through education and skills training staff have been able to improve their confidence levels. The benefits of being taught to use a systematic approach in such situations and practising their
82 Evaluation of an education programme for staff working with acutely ill and injured children and young people responses in a safe and supportive environment were recognised by the staff. Knowing “what to do” and “why” promoted their confidence. The responsibility for the patient during the journey, the potential for untoward incidents during transfer and the relative infrequent opportunity to experience transfers of patients may all contribute to the lack of confidence expressed by staff who responded to the survey. In areas where patients are transferred by a retrieval team there are limited opportunities for other staff to gain the knowledge, skills and experience. In this situation it may be unnecessary for staff to develop their skills and confidence as they will not be required to perform these duties. On the other hand, if on occasion they will be called upon to transfer patients then efforts should be made to skill up staff perhaps through shadowing the retrieval team etc. It was noticeable that levels of staff confidence were generally lower than the reported levels of preparedness across all professional groups and across all areas of competencies. Medical staff reported a higher level of preparation than other groups of staff generally but children’s nurses reported the highest levels of competency and confidence across all areas of competency in caring for children and young people. This is perhaps not surprising as the children’s nurse has followed a specific programme of learning to achieve registration within this specialised field of practice.
83 Evaluation of an education programme for staff working with acutely ill and injured children and young people Interviews Modes of Learning Content, organisation and delivery of the programme of learning were well received by staff. There appeared to be a strong preference for a practical and “realistic” approach to be taken in training. The need to rehearse actions through scenarios and simulations is a well recognised strategy in preparing individuals for stressful situations and staff valued this type of training. The credibility of the facilitator and their ability to recall situations where they had dealt with acutely ill and injured children was also a notable feature in the interviews. The learning style of the staff may affect their preference for the mode of teaching (Felder and Spurlin, 2005). The nurses interviewed appeared to prefer a more active style and whilst they acknowledged that some learning could take place on‐line or through lectures they believed that other skills could only be gained by a “hands on” approach. The issues with the comfort of staff in using the on‐line learning mode have been discussed elsewhere in this report but may need to be taken on board if on‐line learning is to feature in future programmes.
84 Evaluation of an education programme for staff working with acutely ill and injured children and young people Updating The need for regular updating was thought important by participants but they also reported the difficulties with this from a resources point of view. The current amount of mandatory training, the logistics of staff attending such updates and the finance to resource such training and back fill to allow staff to attend were all cited as barriers to future training and updates. Add‐ on value A positive side effect of the training days and the clinical education leads input was that staff developed a rapport with these approachable and knowledgeable staff who they could then request advice from – one education lead helped with the updating of the resuscitation equipment in a GP practice. It seemed that the relationship and contact with the education leads and other staff on the skills day strengthened networks of support.
85 Evaluation of an education programme for staff working with acutely ill and injured children and young people Conclusions and Recommendations In conclusion, overall the core level education programme for staff working with acutely ill and injured children and young people has evaluated very positively by staff. The utilisation of clinical education leads delivering education and training locally in addition to the on‐line learning was well received by participants and resulted in some reported positive changes in staff behaviour, practice, environments and equipment. Content, organisation and delivery of training by credible practitioners in a realistic way was valued by staff and are successful elements of the programme which it is recommended should be retained in future models. Some participant’s experiences of anxiety regarding on‐line learning and the clinical assessments were evident. It is possible that further introductory activities prior to online learning could be beneficial for some students and may help to improve the student’s early experience and engagement with this mode of learning. Completion of the on‐ line module option following the skills day could be enhanced for some students if they received more specific information during or soon after the study days. Whilst some students requested more flexibility in the time frame for completion of the module it is recognised that there is a sound rationale for setting these limits. This was to ensure that the students’ knowledge and skills developed on the skills day were up to date when accessing the on‐line module. There is evidence from the survey data that there are particular areas of care of acutely ill and injured children in which staff do not feel fully prepared and confident. This data should prove helpful in ensuring that future programmes provide sufficient emphasis in
86 Evaluation of an education programme for staff working with acutely ill and injured children and young people these areas to further increase staff’ levels of preparation and confidence. These areas include all aspects of care for under 2s in addition to stabilisation and transfer, red flag presentations, prioritisation of interventions, administering medicines, and pain control across all age groups. A programme of regular updates is needed to support staff to maintain their skills, knowledge and confidence to safely care for children and young people who are acutely ill and injured. Contact and support from clinical education leads with advice regarding care environments and equipment was effective in helping staff to consolidate new learning and in promoting safe care. It is recommended that:‐ · Key successful elements of the existing model should be retained ‐ o content, organisation and delivery of the programme o approachability and credibility of facilitators o the hands on nature of the skills days o the add‐ on value of the clinical education leads e.g their expertise being used to improve equipment and environment at a local level. · For some students further introductory activities may assist in reducing anxiety and improving initial experiences with the on‐line mode of learning. · Further emphasis be placed on the education and training of staff in relation to care of the under 2s, stabilisation and transfer, red flag presentations ,
87 Evaluation of an education programme for staff working with acutely ill and injured children and young people prioritisation of interventions,, administering medicines, and pain control across all ages. · Regular updates should be provided and supported with appropriate resources to enable staff to attend.
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