An Evaluation of Training to Prepare Nurses in a Home-Based Service to Care for Children and Families
CATHERINE JONES cjon3519@uni.sydney.edu.au
Thesis submitted for the award of Masters of Philosophy
The University of Sydney Susan Wakil School of Nursing and Midwifery Faculty of Medicine and Health
June 2019 An Evaluation of Training to Prepare Nurses in a Home-Based Service to Care for Children and Families
Contents
ACKNOWLEDGEMENTS ...... 8 STATEMENT OF ORIGINALITY ...... 9 ABSTRACT ...... 10 GLOSSARY OF TERMS ...... 12 1. INTRODUCTION ...... 14 2. LITERATURE REVIEW ...... 21 2.1. Hospital in the Home ...... 21 2.2. Paediatric Nurse Training ...... 26 2.3. The Kirkpatrick Model ...... 33 3. RESEARCH DESIGN ...... 40 3.1. Framework ...... 40 3.1.1. Using the Kirkpatrick Model in Practice ...... 40 3.1.2. Research Questions ...... 42 3.1.3. Research Paradigm...... 43 3.1.4. Triangulation of the Data ...... 47 3.1.5. Methodology ...... 49 3.1.6. Methods...... 49 3.1.7. Quantitative Data Analysis ...... 50 3.1.8. Evaluation Method for Level 1 Reaction ...... 52 3.1.9. Evaluation Method for Level 2 Learning ...... 53 3.1.10. Evaluation Method for Level 3 Behaviour ...... 55 3.1.11. Interpretive Description ...... 57 3.1.12. Qualitative Data Analysis - Giorgi‟s Framework ...... 60 3.1.13. Evaluation Method for Level 4 Results ...... 62 3.2. Ethics...... 64 3.2.1. Human Research Ethics Application ...... 64 3.2.2. The Researcher...... 64 3.2.3. Participants ...... 66 3.2.3.1. Participant Inclusion Criteria ...... 68
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3.2.3.2. Participant Exclusion Criteria ...... 68 3.2.4. Participant Anonymity ...... 68 3.2.5. Participant Information Statement ...... 69 3.3. Data Collection ...... 70 3.3.1. Data Collection Period ...... 70 3.3.2. Participation Time ...... 70 3.3.3. Data Security ...... 70 4. RESULTS ...... 72 4.1. Results for Level 1 Reaction ...... 72 4.2. Results for Level 2 Learning ...... 75 4.3. Results for Level 3 Behaviour ...... 75 4.3.1. Phase 1 ...... 76 4.3.2. Phase 2 ...... 76 4.3.3. Phase 3 ...... 77 4.3.4. Phase 4 ...... 78 4.3.5. Phase 5 ...... 78 4.3.6. COREQ Checklist ...... 79 4.4. Results for Level 4 Results ...... 79 4.4.1. Part A - Family Satisfaction Survey ...... 79 4.4.2. Part B – Clinical Emergency Response Data ...... 84 5. DISCUSSION ...... 86 5.1. Discussion of Level 1 Reaction ...... 86 5.2. Discussion of Level 2 Learning ...... 88 5.3. Discussion of Level 3 Behaviour ...... 90 5.3.1. Theme 1 - Clinical Experts in Adult Community Nursing but not in Paediatric Nursing ...... 91 5.3.2. Theme 2 - Emerging Understanding of the Important Aspects of Paediatric Nursing Including Caring For the Family and Not Just the Child ...... 93 5.3.3. Theme 3 - Association between Confidence Communicating With Children and Competence in Paediatric Nursing ...... 97 5.3.4. Theme 4 - Emerging Competent Paediatric Nursing Practitioners ...... 101 5.4. Discussion of Level 4 Results ...... 103 5.5. Strengths & Limitations ...... 105
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6. CONCLUSIONS & RECOMMENDATIONS ...... 108 6.1. Conclusions ...... 108 6.2. Recommendations ...... 112 6.3. Recommendations for Future Research ...... 113 7. REFERENCES ...... 114 8. APPENDICES ...... 125 Appendix 1 - Publication: Jones C, Fraser J, Randall S (2018) ...... 125 Appendix 2 - Figure 2: APAC Community Nurses Identified Most Important Learning Needs Related to Paediatric Nursing ...... 134 Appendix 3 - Figures 3a and 3b: Age of Children Admitted to Paediatric Inpatient and Paediatric HITH Care ...... 135 Appendix 4 - Table 1: Summary of Proposed Research Plan ...... 136 Appendix 5 - Table 2: Frequently Used Evaluation Methods across the 4 Levels of Kirkpatrick Model ...... 137 Appendix 6 - Research Tool 1: Level 1 Reaction - Training Ratings Surveys...... 138 Appendix 7 - Table 3: Summary of the Aspects of the Paediatric Training for the APAC Community Nurses ...... 141 Appendix 8- Research Tool 2: Level 2 Learning – Knowledge Questionnaire ...... 142 Appendix 9 - Table 4: Application of the ACCYPN Standards to the Learning Phase of the Evaluation ...... 147 Appendix 10 - Research Tool 3: Level 3 Behaviour – Semi-Structured Interviews ...... 154 Appendix 11 - Figure 5: Analysis of the Interviews Based on Giorgi‟s Framework ...... 156 Appendix 12- Research Tool 4: Level 4 Reaction – Family Satisfaction Surveys ...... 157 Appendix 13 - LNR Ethics Approval Letter from NSLHD ...... 164 Appendix 14 - Participant Information Sheet (PIS) ...... 166 Appendix 15 - Data from the Reaction, Learning and Results Levels ...... 174 Appendix 16 – Example of Highlighting Meaning Units in the Transcripts ...... 180 Appendix 17 – Discrimination of Meaning Units and Themes from the Semi-Structured Interviews ...... 184 Appendix 18 – Transformation of Themes into Theme Categories ...... 198 Appendix 19 - COREQ Checklist ...... 199 Appendix 20 – A Snapshot of NSLHD...... 201 Appendix 21 - Novice to Expert Scale (Benner, 2000) ...... 204
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Figures & Tables
Figure 1: Diagrammatic Summary of the Conclusions 111
Figure 2: Perceived Learning Needs about Paediatric Nursing 134
Figure 3a: Age of Children Admitted to a Paediatric Inpatient Ward 135
Figure 3b: Age of Children Reported Receiving Paediatric HITH Care 135
Figure 4: Kirkpatrick Levels of Training Evaluation 133
Figure 5: Phenomenological Analysis of the Interviews Based on Giorgi‟s Framework 156
Figure 6: Between the Flags – Response to Patient Deterioration 62
Figure 7: Family Satisfaction Survey 176
Figure 8: Clinical Conditions 176
Figure 9: Treatment Received 177
Figure 10: Number of Days of School or Child Care Missed 177
Figure 11: Map of Northern Sydney Local Health District 201
Table 1: Summary of Proposed Research Plan 136
Table 2: Frequently Used Evaluation Methods across the 4 Levels of Kirkpatrick Model 137
Table 3: Summary of the Aspects of the Paediatric Training for the APAC Nurses 141
Table 4: Application of the ACCYPN Standards to the Learning phase of the Evaluation 147
Table 5: Reaction Ratings to the Paediatric Training 174
Table 6: Mean Reaction Ratings for Each Aspect of the Paediatric Training 73
Table 7: Mean Reaction Ratings for Comparable Questions 74
Table 8: Accuracy Ranking for the Knowledge Questions 175
Table 9: Family Ratings of Paediatric HITH Service 82
Table 10: Positive Aspects of Paediatric HITH 178
Table 11: Breakdown of „Other‟ Positive Aspects of Paediatric HITH 178
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Table 12: Negative Aspects of Paediatric HITH 178
Table 13: Breakdown of „Other‟ Negative Aspects of Paediatric HITH 179
Table 14: How We Can Improve HITH? 179
Table 15: Additional Comments from Families 179
Table 16: Length of Time Receiving HITH Care 179
Table 17: CERS Response Data for Paediatrics in NSLHD (2017) 84
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Dedicated to the paediatric and APAC community services in Northern Sydney Local Health District, and to the children and families of Northern Sydney
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ACKNOWLEDGEMENTS
I would like to acknowledge the traditional custodians upon whose ancestral lands the
University of Sydney campuses and Northern Sydney Local Health District stand and pay respects to Elders both past, present and emerging, and to the spirits of the land.
I would like to thank and acknowledge all those from Northern Sydney Local Health District involved in the paediatric hospital in the home (HITH) service. In particular to the APAC nurses and nurse managers, to the Paediatric Models of Care Committee, the paediatric HITH
Clinical Nurse Specialists as well as the Executive Support from NSLHD and the Clinical
Director for the Child, Youth & Family network.
I would like to thank the University of Sydney and in particular my supervisors, A/Prof
Jennifer Fraser and Dr Sue Randall for their support, gentle guidance and wisdom through my research journey. Thanks also to all those who offered advice, questioning and training during research weeks and progress reviews. It all contributed to the learning experience and ultimately this thesis.
Then last but by no means least, thank you to my husband, family and friends who have supported me through his journey.
Thank you
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STATEMENT OF ORIGINALITY
This is to certify that to the best of my knowledge, the content of this thesis is my own work.
This thesis has not been submitted for any degree or other purposes.
Signature:
Name: Catherine Helen Jones
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ABSTRACT
Background: A paediatric hospital-in-the-home (HITH) nursing service in Northern Sydney,
Australia, required an evaluation of the training to prepare community nurses to extend their portfolio to include the care of children and families. The paediatric HITH model of care was a collaboration between acute paediatric inpatient services and a community nursing service in Northern Sydney Local Health District (NSLHD). The community nursing service was providing HITH care for patients aged 14 years and over before introducing paediatric HITH.
The community nurses were challenged by the concept of adding the care of sick children and their families to their portfolio. Collectively the community nurses had little or no paediatric nursing experience. An education and training program about paediatric nursing was instrumental to the implementation of the paediatric HITH model. Existing paediatric and child health training programs were already available in the District. These included paediatric resuscitation, identification and care of the deteriorating child, normal child development, medication administration and child protection.
Aims: To evaluate the effectiveness of a paediatric nursing education and training program in preparing community nursing staff to adequately care for children and families in the home.
Methods: A multi-phased mixed methods study was conducted using the Kirkpatrick model
(KM) as a framework (Kirkpatrick & Kirkpatrick, 2016). Each of the four KM levels was evaluated; 1) Reaction (to the training); 2) Learning (knowledge acquired); 3) Behaviour
(practice change) and 4) Results (clinical outcomes).
Results: Overall the various aspects of the paediatric training provided basic knowledge and skills in the speciality. Nurses found the practical training most useful. A two-day Emergency
Nurse Paediatric Course was criticised by the participants as being too advanced when new to
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paediatrics. A survey completed by families who had received the service indicated a high level of satisfaction with all aspects of the service. Additionally, the rate of clinical emergency responses per 1,000 patients was significantly lower for paediatric HITH than for an affiliated paediatric inpatient unit.
Conclusions: The importance of and necessity for paediatric nursing training when caring for children was acknowledged by the community nurses. The training provided a sound knowledge base about paediatrics/child health as reflected in the knowledge questionnaire.
There were strong themes of needing to be confident interacting with children independent of them being sick, along with the need for increased exposure or opportunity to care for children and families. Families were very satisfied with the service suggesting that the current arrangement of support for community nurses from the paediatric nurse specialists was working well in favour of families wanting to care for sick children at home. The low incidence of clinical emergency responses holds promise for clinical safety associated with the model. The training program provided the knowledge and skills required to be a
„competent‟ (Benner, 2000) paediatric practitioner. However, further training and development is required before the community nurses can reach the levels of „proficient‟ or
„expert‟ in paediatric nursing cares and practice independently of the support from acute paediatrics services. The conclusions are summarised in Figure 1 (page 111).
Recommendations: The paediatric nursing education and training needs to be part of core business for the community nursing service. Alternative training options could be explored in order to meet the learning needs of the community nurses. These should include increased opportunities for the community nurses to work with children and families to improve their comfort and confidence interacting with children of all ages.
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GLOSSARY OF TERMS
Paediatrics is the branch of medicine that involves the care of Paediatrics infants, children, and adolescents from 0 to 16 years of age.
Provides acute, subacute and post-acute care to children residing
outside hospital, as a substitution or prevention of in-hospital
care. A child may receive their care at home or in an ambulatory Hospital in the Home setting that may include a hospital, community clinic setting, or
school. They are admitted to a virtual bed and if HITH is
unavailable then they would be admitted as an inpatient.
Kirkpatrick Model (KM) A framework for evaluating the effectiveness of workforce
training.
APAC Acute Post-Acute Care. A community nursing service in NSLHD
Short-term treatment for a severe injury or episode of illness in a Acute care hospital environment.
Subacute care is health care for people who are not severely ill
Sub-acute care but need: support to regain their ability to carry out activities of
daily life after an episode of illness
Short-term services and support for those who need extra help at Post-acute care home after a public hospital stay
Paediatric Acute Review Provides a non-admitted clinic care for children who are acutely
Clinic (PARC) unwell or have chronic and complex conditions that require
specialist care or for general paediatric conditions requiring
specialist paediatric assessment.
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Paediatric Outpatients Provides care for patient in a clinic or rooms for ongoing review
or management of non-acute or non-post-acute conditions for
children.
Paediatric Inpatients Provides care for children who require admission to stay in
hospital for observation or treatment for part or whole of their
recovery from injury or illness.
Emergency Nursing Emergency Nurses Association (ENA) two-day Emergency
Paediatric Course Nursing Paediatric Course (ENPC) run by the Australian College
(ENPC) of Emergency Nursing (ACEN)
Resus4Kids (R4K) A paediatric life support training program utilising a combination
of online learning and practical training.
DETECT Junior A course developed by the NSW Clinical Excellence Commission
on the recognition and management of the deteriorating child
The New South Wales Ministry of Health or NSW Health, a NSW Health department of the New South Wales Government,
Northern Sydney Local Health District. One of the local health
districts in NSW established as statutory corporations under the
NSLHD Health Services Act 1997, and is responsible for managing public
hospitals and health institutions and for providing health services
to defined geographical areas of the State.
Australian College of Children's and Young People's Nurses is a
ACCYPN national nursing professional organisation with children and
young people as its core focus.
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1. INTRODUCTION
A paediatric hospital-in-the-home (HITH) nursing service was established in the Northern
Sydney Local Health District (NSLHD), New South Wales, Australia in 2016. The model of care was established through collaboration between existing acute paediatric services and the community Acute Post-Acute Care (APAC) nursing service in NSLHD. Prior to the introduction of the paediatric HITH service, the nurses employed in the APAC community nursing service had provided care in the home for adults and children aged 14 years and over.
Younger children had to return to the hospital for treatment and follow up appointments.
Caring for sick children and their families in the community presented a new model of care for APAC. Collectively the community nurses had little or no paediatric nursing experience.
An education program was therefore a critical element of the implementation of the paediatric HITH model.
The training program utilised paediatric and child health training programs already available in the District. These included paediatric resuscitation, identification and care of the deteriorating child, normal child development, medication administration and child protection. This paediatric nursing training provided for the community APAC nurses required evaluation to determine if the education and training provided for nursing staff employed in the service was effective.
This study design was detailed in a publication in the Journal of Research in Nursing entitled;
The evaluation of a home-based paediatric nursing service: concept and design development using The Kirkpatrick Model (Jones, Fraser, & Randall, 2018) (Appendix 1). The Kirkpatrick model (KM) provides a framework for evaluating the effectiveness of workforce training for any industry including the healthcare industry (Kirkpatrick & Kirkpatrick, 2007). It has four
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levels of evaluation aimed to achieve a comprehensive evaluation of training provided. This thesis presents the way in which the Kirkpatrick model supported the design of the evaluation of a training program for registered nurses working in a community hospital in the home service for paediatric patients. It presents the outcomes and conclusions of the effectiveness of the training and recommendations for the future training for the paediatric hospital in the home service.
Keeping children out of hospital and providing effective health care as close to home as possible is a goal of the service within which the study took place (Northern Sydney Local
Health District, 2012; NSW Health, 2013a). Hospital in the home (HITH) provides an alternative to inpatient hospital care to facilitate this (NSW Health, 2013a). Models of home based or ambulatory care such as HITH have been developed in response to increasing demand for healthcare services, increasing numbers of patients with chronic diseases, response to consumer demand and improved health outcomes for patients who spend less time in hospital (Birch, Glasper, Aitken, Wiltshire, & Cogman, 2005; Boss, 2005; Hansson,
Hallstrom, Kjærgaard, Johansen, & Schmiegelow, 2011; Thompson, Martin, Abdul-Rahman,
Boddy, Whear, Collinson, Stein, & Logan, 2012). The model provides a substitution or prevention of in-hospital care (Birch et al., 2005; Maraqa & Rathore, 2010; NSW Health,
2013a; Thompson et al., 2012). Potential benefits of HITH include reduction of potential harm associated with hospitalisation, plus the psychological benefits of recovering at home, increasing family satisfaction through reduced impact of the hospitalisation of a child on their family and cost effectiveness (Bagust, Haycox, Sartain, Maxwell, & Todd, 2002; Hansson et al., 2011; Raisch, Holdsworth, Winter, Hutter, & Graham, 2003). The negative impact of hospitalisation on children and its effect on early childhood attachment was first investigated in the 1940s and 1950s (Bowlby, 1944; Bowlby, Robertson, & Rosenbluth, 1952).
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The paediatric HITH beds in NSLHD were established as virtual hospital beds providing patients with hospital level care and access to inpatient hospital services with the benefit of remaining in their own home. Paediatric HITH services have the potential to be less disruptive to other family members compared to traditional hospital inpatient care, allowing for continuity of education and promoting social and emotional development (Sender, 2011).
The HITH model in NSLHD admitted patients to the service via virtual inpatient beds. These were not physical beds in the hospital as the patient stayed at home but an admission electronically to the hospital inpatient system, referred to as virtual beds, via the same process as admitting a patient into a physical hospital bed. Patients admitted to virtual beds had the same access to hospital inpatient services as those in physical hospital beds including 24 hour medical cover. The use of 'virtual' inpatient beds by specialist nursing out-reach teams that provide care to patients at home has been shown to significantly improve patient care and reduce hospital admission (Lomas, 2009). The creation of virtual hospital beds enables hospitals to increase capacity without the capital costs of new hospitals buildings creating financial benefits for healthcare (Sawyer, 2011). The concept of virtual beds has been criticised as leading to poor estimation of hospital activity (Nocera, 2010), although in New
South Wales a State policy provides direction to staff to correctly categorise virtual wards and beds for reporting purposes (NSW Health, 2007).
NSLHD had already successfully provided a HITH service for adult patients through Acute
Post-Acute Care (APAC) for several years. The District established a paediatric HITH service through collaboration between existing hospital-based paediatric services including paediatric inpatients and paediatric ambulatory care services, and the community nursing service, APAC. This innovative model of collaboration thus acted to leverage the existing clinical expertise and service infrastructures. As such a comparable model of care was not
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evident in the literature, as paediatric home care models are commonly based or governed from specialist children‟s hospitals. NSLHD provides general paediatric care within mixed adult-paediatric healthcare facilities.
The community nurses in the APAC service were mainly general trained nurses with little or no previous experience caring for infants or children and their families. This was captured in the APAC Paediatric Training Needs Survey conducted prior to the introduction of the paediatric HITH service by the researcher as part of their role as project manager for paediatric HITH in NSLHD (Northern Sydney Local Health District, 2016). The survey was completed by 13 of the 70 APAC nurses invited to participate, resulting in a response rate of
18.6%. The survey was undertaken prior to the development of this Master‟s study but the limited data were utilised. The low response rate may have been reflective of the reluctance of some community nurses to care for paediatric patients. Despite sample size limitations, this data provided valuable insights into the training requirements and attitudes of the APAC nurses to the introduction of paediatric hospital in the home as part of their portfolio of care.
The provision of valid preliminary data has been demonstrated with small sample sizes due to the specificity of the participation group (Ranse, Yates, & Coyer, 2014).
The majority, over 60% had either no previous child health/paediatric nursing experience or only as a student nurse placement. A small proportion of the APAC nurses had a paediatric or child health qualification (7.7%). The same proportion (7.7%) had more than 2 years of experience in paediatrics or child health nursing and 23% had less than 2 years of experience.
The APAC nurses were only able to select one response option for this question although some may have had qualifications and experience in paediatrics/child health. It was assumed that those with a qualification would have experience as well in order to attain the qualification.
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The APAC Paediatric Training Needs Survey captured APAC nurses‟ initial reactions to the concept of the APAC service increasing its portfolio to include paediatrics. This showed that the majority of the APAC nurses, almost 77%, expressed a positive response either; „looking forward to learning about paediatrics‟ (46.2%), „excited‟ (7.7%) or „really excited‟ (23.1%).
There was a small group (23.2%) who expressed „being nervous‟ about their feelings related to starting to care for children and families. None of the respondents chose the „neutral‟,
„scared‟ or „don‟t want to look after children options‟ (Northern Sydney Local Health
District, 2016).
When asked to rate their comfort level with regard to caring for infants, children and adolescents, the APAC nurses expressed an increasing level of comfort with the increased age groups of the paediatric population (Northern Sydney Local Health District, 2016). The reasons for this were not explored in the survey but it could be hypothesised that potentially comfort increased as the paediatric patient becomes closer in age, appearance, communication, cognitive development and physiology to an adult patient and therefore closer to patients familiar to the APAC nurse.
An essential aspect to the provision of safe, high quality care for children and families in their homes in NSLHD was the education and training of the APAC nurses about paediatric nursing. A program of paediatric education was developed considering the outcomes of the
APAC Paediatric Training Needs Survey for the general trained registered nurses APAC nurses. The APAC Paediatric Training Needs Survey revealed that as a collective the APAC nurses had little or no previous paediatric nursing experience. They expressed decreasing levels of confidence interacting with children of decreasing age so were less anxious about caring for adolescents but increasingly anxious about children and especially infants. Based on the Summary Position Statement by the Royal College of Nursing (RCN) Children and
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Young People Field of Practice (Royal College of Nursing, 2003) the nurses were asked to identify their most important learning needs from the following aspects of care:
Paediatric life support Common childhood conditions
Child protection Health promotion
Communication Paediatric medications
Anatomy & physiology The deteriorating child
Normal growth & development Paediatric procedures
Child psychology Mental health
The results suggested that all of these aspects of training were important to the APAC nurses as all aspects rated highly ranging between 3.83 to 4.85 out of 5 with an average (mean) of
3.9 and a standard deviation of 0.39 (Figure 2, Appendix 2). Existing paediatric training resources utilised routinely by acute paediatric clinicians covered the aspects identified as important and were therefore deemed suitable for the APAC community nurses.
The existing training resources that made up the paediatric training program covered aspects of child growth and development, anatomy and physiology, paediatric life support, the deteriorating child, medication administration to children and child protection. The formal educational aspects of the program were complemented by the mentorship of the paediatric
HITH Clinical Nurse Specialists during home visits to families and the option of clinical experience on a children‟s ward in the District for up to five days.
Evaluating the paediatric nursing educational program for the predominantly adult care trained APAC nurses was an important aspect of the overall evaluation of the new paediatric
HITH service, with a suitable evaluation framework required to evaluate both the training and the impact of the training on the service delivery.
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The need for high quality research with models of care such as paediatric HITH to enable informed service changes in paediatrics has been identified in the literature. In particular, research concerning consumer satisfaction and identifying the preferences of children and families for such services (Birch et al., 2005; Hansson et al., 2011; Thompson et al., 2012).
The paediatric HITH service was established on the assumption it was a favourable and preferable option for families. Therefore this was an important aspect of the evaluation.
The Kirkpatrick Levels of Evaluation Model; Reaction, Learning, Behaviour and Results
(Kirkpatrick & Kirkpatrick, 2007; Kirkpatrick & Kirkpatrick, 2016) was chosen as the evaluation framework to provide the opportunity to develop a comprehensive evaluation of the paediatric nursing training. The Kirkpatrick model (KM) facilitated the inclusion of the perspectives of the nurses receiving the training, the mentors and the families as consumers of the paediatric HITH service, to facilitate the evaluation the impact of the training as well as the training per se for paediatric Hospital in the home (HITH) in NSLHD.
This thesis aimed to answer the overall research question;
Did the paediatric nursing training program for the APAC community nurses
prepare them to care for children at home?
The design and concept behind this research will be discussed and described in the methods chapter including research paradigm, methodologies, methods and research tools applied. The ethics approval application and participant information are detailed in this chapter along with the data collection process. Following this the results and discussions will look at each of the
Kirkpatrick Levels separately before drawing conclusions and recommendations. The next chapter will provide a critical review of the literature associated with the concept of hospital
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in the home care, the application of the Kirkpatrick model in healthcare and the evolution of paediatrics as a nursing speciality.
2. LITERATURE REVIEW
2.1. Hospital in the Home
Hospital in the home (HITH) is a model of care offering patients and their families‟ hospital level health care in their own home. It is a model of care suitable for both adult and paediatric patients. HITH models target clinically stable patients and their families with the option of staying at home to receive what is otherwise considered in-hospital care (Birch et al., 2005;
Maraqa & Rathore, 2010; NSW Health, 2013a, 2018a; Thompson et al., 2012). Recipients of
HITH may receive their care at home or in an ambulatory setting that may include a hospital, community clinic setting, school or workplace (Birch et al., 2005; Hansson et al., 2011;
Maraqa & Rathore, 2010; Nizar & Mobeen, 2010; NSW Health, 2013a, 2018a; Thompson et al., 2012).
HITH services bridge both acute and community health service and cannot be looked at in isolation of models of care such as ambulatory care, hospital-based home care, assessment units, outreach, outpatients and short stay as they are conceptually similar (Birch et al., 2005;
Boss, 2005; Hansson et al., 2011; Khangura, Wallace, Kissoon, & Kodeeswaran, 2007;
Thompson et al., 2012; Whiting, 2004) and the concept of caring for children as close to home as possible (Department of Health and Social Care, 2004; NSW Health, 2016a, 2018a;
Spiers, Gridley, Cusworth, Mukherjee, Parker, Heaton, Atkin, Birks, Lowson, & Wright,
2012). Providing quality care for children as close to home as possible was an objective of the NSW strategic health plan for children, young people and families 2014-24 (NSW Health,
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2016a). These innovations in care delivery have arguably been introduced, to reduce demand for acute inpatient care (NSW Health, 2018a; Ogilvie, 2005; Thompson et al., 2012).
Paediatric HITH models of care are based on common principles. Firstly that of providing acute, subacute and post-acute care to children and adults in the community (Birch et al.,
2005; Nizar & Mobeen, 2010; NSW Health, 2013a, 2018b; Thompson et al., 2012), and that patients stay in their home instead of in a hospital (Birch et al., 2005; Hansson et al., 2011;
Hansson, Kjaergaard, Schmiegelow, & Hallstrom, 2012; Nizar & Mobeen, 2010; NSW
Health, 2013a, 2018b). A person may receive their care at home or in an ambulatory setting that may include a hospital, community clinic setting, school or workplace (Birch et al., 2005;
Hansson et al., 2011; Hansson et al., 2012; NSW Health, 2013a, 2018b; Thompson et al.,
2012).
Nurses usually provide a lead role in the delivery of home care. In particular nurses provide care of vascular access devices, are responsible for evaluating the safety of the home environment, education for the patient or caregiver, prevention and management of infusion- related complications, collection and interpretation of laboratory results, monitoring patient adherence and assistance to the patient with waste management, but with the prescribing physician as ultimately responsible for the patient‟s care and outcome (Nizar & Rathore,
2010).
A systematic review compared the effectiveness of interventions aimed at reducing the rate of acute paediatric hospital admissions (Thompson et al., 2012). The difficulty in establishing the effectiveness of initiatives such as hospital in the home for children in the wider context of the healthcare system was noted. This was due to a lack of reported information about outcomes from the introduction of these initiatives and the evaluation of them, in particular
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the impact on paediatric hospital admissions (Thompson et al., 2012). A randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care similarly found that there were no clinically significant differences between the services including readmission rates suggesting no advantage in terms of parental coping.
Parent and child perceptions for home care have been suggested as stemming from a perception that children recover quicker in their home environment (Sartain, Maxwell, Todd,
Jones, Bagust, Haycox, & Bundred, 2002).
A review of literature related to hospital-based home care for children with cancer suggested that home based care was less disruptive for the children and their families than hospital based care. Moreover, families seemed to prefer home care to hospital care (Hansson et al.,
2011). They concluded that there was limited evidence about the effect of home care on children and families but that there are potential physical, emotional and psychosocial advantages. At the same time, a randomized study included in this review indicated that children may experience increased emotional distress when receiving home chemotherapy
(Hansson et al., 2011). The potentially negative effects of hospitalisation on children including social isolation from family and peers and emotional distress was documented in observational studies in the 1950s (Bowlby et al., 1952). In these studies the emotional distress and regressive behaviour demonstrated by children who were hospitalised and isolated from parents or carers was captured on film. Recent popularity and increased adoption of hospital in the home models of care for children has been influenced by a philosophical approach to improving paediatric care (Whiting, 2004). The emotional distress from hospitalisation on children and families has been well documented for some time (Bonn,
1994; Bowlby et al., 1952). The knowledge that illness and hospitalisation has the potential to
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negatively impact a child‟s motor, cognitive, emotional and social development is a now fundamental in paediatric nursing care (Fraser, Waters, Forster, & Brown, 2017).
Hospital acquired infections (HAI) are a major risk for inpatient care. In 2012 a survey
231,459 adults and paediatric patients from 947 hospitals across Europe was completed. The survey revealed that 6.0% patients had at least one hospital-acquired infection with infants under 1 year of age, at higher risk (6.4%), although general paediatrics had a HAI of 1.8% and Paediatric Intensive Care 15.7% (European Centre for Disease Prevention and Control,
2013). It would therefore follow that a model of care aimed at reducing the time a child spends hospitalised should result in a reduction in the potential negative outcomes associated with hospitalisation including emotional distress and the risk of hospital acquired infections.
The provision of home-based care for children has been enabled by technological developments and advances in clinical knowledge (Hansson et al., 2011). However, some concerns for home care models include specific aspects of these advances in clinical care such as the care of vascular access devices (Nizar & Mobeen, 2010). Administering intravenous medications has previously been the domain of nurses caring for the hospitalised patient. However, models of care such as HITH have enabled the practice to successfully evolve in the outpatient or community setting (Nizar & Rathore, 2010). The evolution of administering intravenous medications, traditionally the domain of hospitalised care, in the outpatient or community setting has been well documented in the literature (Balinsky &
Marie, 2001; Gouin, Chevalier, Gauthier, & Lamarre, 2008; Khangura et al., 2007; Nizar &
Mobeen, 2010). No adverse clinical outcomes from receiving home-based care instead of hospital-based care were reported (Balinsky & Marie, 2001; Khangura et al., 2007; Sartain et al., 2002; Spiers et al., 2012). Home based models of care have however, been criticised for
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poor communication and liaison between hospital and community services and the need for improved arrangements for medical responsibility (Jennings, 1994).
Efficiency and economic drivers such as the cost of hospital-based health care and the desire to reduce costs associated with healthcare provision cannot be ignored when understanding the introduction of home based models of care. Safe, economical and efficient are descriptors commonly used together for HITH models (Hansson et al., 2011; Nizar & Mobeen, 2010).
There are variations of the Paediatric HITH model concept, including home care and outreach services, as well as several comparable ambulatory care, short stay and day assessment services that exist. All of which aimed to minimise hospitalisation for children and provide care as close to home as possible. Both quantitative and qualitative methodologies have been used to evaluate such models (Balinsky, 1999; Balinsky & Marie, 2001; Gouin et al., 2008;
Thompson et al., 2012). Some evidence concluded that home based care for children is a viable or feasible alternative to hospitalisation (Gouin et al., 2008; Hansson et al., 2012), with potential for increased satisfaction with the medical care for children and families. A systematic review suggested there is some evidence that short stay units may reduce admission rates (Ogilvie, 2005; Thompson et al., 2012) and concluded that acute paediatric assessment services offer safe, efficient, and acceptable alternatives to inpatient admissions, although the evidence is limited in terms of both quantity and quality (Ogilvie, 2005).
Similarly a dedicated paediatric emergency assessment unit was described as being favourably received but provided no evidence for future service development (Birch et al.,
2005). Several authors identified a need for high quality research to enable informed service change in paediatrics (Birch et al., 2005; Hansson et al., 2011; Parab, Cooper, Woolfenden, &
Piper, 2013; Thompson et al., 2012; While & Dyson, 2000). The evidence for ambulatory and home based services for children as viable and efficient is limited but emerging.
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Family preference and satisfaction with home care services for children has been demonstrated (Sartain et al., 2002; Sartain, Maxwell, Todd, Haycox, & Bundred, 2001;
Spiers et al., 2012). Satisfaction surveys to evaluate the experience and preferences of children and families with home based care services, such as HITH, have been popular with researchers (Balinsky & Marie, 2001; Gouin et al., 2008; Hansson et al., 2011; Thompson et al., 2012). Clinical outcomes and demographic data related to specific conditions such as cellulitis and intravenous medications have been collated in some paediatric HITH evaluation studies (Gouin et al., 2008; Khangura et al., 2007). Patient satisfaction surveys provide a useful insight into the preferences of consumers. However, this is a one dimensional view and other dimensions need to be explored for a comprehensive evaluation.
Hospital in the home for children is regarded as a contemporary model of care. But the concept has been recommended since Charles West, the founder of Great Ormond Street
Children‟s Hospital in London in the 1850s. He expressed the view that children should be kept at home rather than in hospital if possible. This view of paediatric care in the 19th
Century was unfortunately influenced by economics and the income that hospitalisation brought to voluntary hospitals at the time (Clarke, 2017). West‟s vision for paediatric care is only now becoming a reality through paediatric hospital in the home.
2.2. Paediatric Nurse Training
The different physical, emotional and care needs of infants and children can be dated back to the 18th Century with child dispensaries and literature on the treatment of children (Clarke,
2017). Nursing specifically for children, infants and adolescents, often referred to as paediatric or children‟s nursing began to evolve in the 19th Century in Great Britain. Notes
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from Florence Nightingale, arguably the founder of modern nursing, highlighted differences between children and adults in particular that a child‟s condition can worsen rapidly;
“children: they are affected by the same things (as adults) but much more quickly and
seriously” page 152 (Nightingale, 2004)
Paediatric nursing in the United States of America (USA) has its origins in Philadelphia,
Pennsylvania in 1855 with the founding of The Children's Hospital, the first hospital in the
USA specifically for the care of children (Taylor, 2006). In the United Kingdom (UK) the origins of children‟s nursing lie in the founding of The Hospital for Sick Children, Great
Ormond Street in London in response the high death rate among children in the mid-19th
Century, and the eventual creation of the Registered Sick Children‟s Nurse (Clarke, 2017;
Glasper, 2002). History has acknowledged there are differences between adult and paediatric patients, and a need for specific nursing training to care for children. Catherine Jane Wood in
1888 first stated that;
„Sick Children require special nursing and sick children‟s nurses require special
training‟ cited in Glasper (2002) page 42
This history would suggest that the need for specific nursing skills to care for children seems to have long been noted. Events around the late 1980s and early 1990s in the UK had significant impact on paediatric care, Firstly, the Children‟s Act of 1989 in England and
Wales combined policies related to the care and welfare of children including those who care and work with children (UK Government, 2017). Additionally, the tragic deaths and grievous harm to hospitalised children in the sole care of nurse Beverley Allitt in UK in 1991 lead to a series of investigations and recommendations into the nursing of infants and children (Clarke,
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2017). This influenced major changes to nurse education in the UK, with a shift from hospital-based training to higher education institutes providing an increased theoretical based training for nursing, and the creation of the Registered Children‟s Nurse in the United
Kingdom. Similar pre and/or post registration paediatric nursing training is available in many countries (Clarke, 2017; Davies, Earles, Eaton, Luke, & Mills, 2001; Doyle, Murphy, Begley,
& King, 2008; Glasper, 2016). In these countries paediatrics is acknowledged as a distinct nursing speciality requiring extensive specialised training and skills. A paediatric training program for the APAC nurses to extend their role to include paediatric care in the home would therefore seem to be warranted.
The negative impacts of hospitalisation on children and the effects on early childhood attachment were first investigated by theorists such as John Bowlby (Bowlby et al., 1952).
The videos of children in hospital by James and Joyce Robertson (Robertson Films, 1952) supported this work and the culmination of their work ultimately lead to significant reforms and changes in practice related to the care of children and families in hospital to be inclusive of families instead of isolating children from their carers (Alsop-Shields & Mohay, 2018).
Home based care including HITH aim to reduce hospitalisation of children and consequently the negative impacts associated with it.
A literature review described paediatric nursing as;
“the practice of nursing with children, youth, and their families across the health
continuum, including health promotion, illness management, and health restoration”
page 128 (Taylor, 2006).
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But what specific training is required for paediatric nursing and in particular what paediatric training is required for the care of children in their home? A study of children‟s views on what makes a good children‟s nurse suggested some of the characteristics of good related to innate characteristics but also related to training (Randall, Brook, & Stammers, 2008).
Themes were identified in the literature associated with paediatrics as a speciality and paediatric nursing training requirements. The first of these themes is the notion that children are not simply „little adults‟ and should not be treated as miniature adult patients. This relates to anatomical, physiological, cognitive, communicative, social and emotional differences between adults and paediatrics (Children's Hospital and Medical Center Omaha, 2019; Clarke
& Davies, 2004; Fraser et al., 2017; Taylor, 2006). There are very few paediatric exceptions to this widely accepted and commonly heard „not little adults‟ concept (Washington, 2006).
Closely associated is the necessity to understand child development and the physiological and anatomical differences between children and adults (Australian College of Children's and
Young People's Nurses, 2016; Children's Hospital and Medical Center Omaha, 2019; Fraser et al., 2017; Taylor, 2006).
Assessing and recognising health problems and deterioration in children and young people is understandably a key requirement for paediatric nursing training, arguably fundamental to the care of sick children (Australian College of Children's and Young People's Nurses, 2016;
Royal College of Nursing, 2003). Associated with the need to recognise clinical deterioration is the need to manage and respond appropriately to clinical deterioration. Paediatric Life
Support and disaster scenarios training were therefore a characteristic of paediatric nursing training (Australian College of Children's and Young People's Nurses, 2016; Clarke &
Davies, 2004; Fraser et al., 2017; Royal College of Nursing, 2003) along with clinical practice skills through simulation training (Bultas, 2011; Clarke & Davies, 2004).
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Another theme was that care is to be provided in partnership with families (Australian
College of Children's and Young People's Nurses, 2016; Children's Hospital and Medical
Center Omaha, 2019; Fraser et al., 2017; Lee, 2007; Shields, Pratt, & Hunter, 2006; Taylor,
2006). Family centred care is widely accepted concept in paediatric and child health nursing as best practice in the delivery of care to children. It has been described as „a cornerstone of paediatric practice‟ (Shields et al., 2006), although without a clear definition and with its effectiveness unknown (Shields et al., 2006; Shields, Zhou, Pratt, Taylor, & Hunter, 2012).
The paediatric trained nurse plays an important role in communicating to parents to clarify their role in the care of their hospitalised child (Ygge, 2007).
Paediatrics includes the care of children from infancy to adolescence, during which time communication and language skills develop from basic non-verbal communication to proficient verbal communicators. It is not solely about communication skills with children of various ages but with their varied families as well. The need for paediatric nurses to develop specific communication skills with children and families is therefore a key training theme
(Australian College of Children's and Young People's Nurses, 2016; Children's Hospital and
Medical Center Omaha, 2019; Lee, 2007; Royal College of Nursing, 2003).
Children‟s Rights and Advocacy is a theme in paediatric nursing training (Australian College of Children's and Young People's Nurses, 2016; Clarke, 2017; Fraser et al., 2017; Royal
College of Nursing, 2003). It refers to the concept that infants, children and young people are a relatively powerless group in society with adults including parents, carers and professionals often making significant decisions on their behalf (Office of the Advocate for Children and
Young People, 2018).
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Nurses caring for children and families need to understand about advocacy and their role in its provision (Australian College of Children's and Young People's Nurses, 2016; Clarke,
2017; Fraser et al., 2017; Royal College of Nursing, 2003). The Office of the Advocate for
Children and Young People (ACYP) in NSW, Australia describes its role as advocating for and promoting the safety, welfare, wellbeing and voice of all children and young people aged
0-24 years in NSW, with a special focus on the vulnerable or disadvantaged (Office of the
Advocate for Children and Young People, 2018).
For paediatric nurses child protection is an important aspect of advocacy and protection as all
Australian healthcare professionals are legislated to report suspected cases of child abuse and neglect to government authorities (Australian Government, 2017). The rights of participation and provision of medical procedures and treatments are arguably as important as rights of protection (Reading, Bissell, Godhagen, Harwin, Masson, Moynihan, Parton, Pais, Thoburn,
& Webb, 2009). The Australian College of Children's and Young People's Nurses
(ACCYPN) Standards for Paediatric Practice encompasses these themes from the literature and as such provides a framework for identifying the skills and knowledge required for a nurse caring for children and young people in the hospital or home environment (Australian
College of Children's and Young People's Nurses, 2016).
The Australian College of Nursing Principles of Acute Paediatric Nursing course content includes an introduction to the concept of family centres care in paediatric but otherwise focuses on the physical assessment, pathophysiology and management of the body systems e.g. respiratory, metabolic. There is no inclusion of education related to child protection, communication skills or children‟s rights (Australian College of Nurses, 2017). However a publication about the principles of practice for paediatric nursing in Australia (Fraser et al.,
2017) identifies key subjects beyond physiology as core to paediatric nursing including
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children‟s rights, communication, mental health and psychosocial development. The concepts of patient advocacy, patient‟s rights and effective communication are well documented as fundamental and intrinsic to nursing generally not just to paediatrics through defined codes of conduct and nursing standards of practice (Nursing and Midwifery Board of Australia, 2018).
It would therefore logically follow that an education program about nursing a specific sector of the population, in this case children, would include these concepts as pertaining to that population group. The paediatric nursing training program for the APAC nurses incorporated all of these aspects and used the ACCYPN Standards for Paediatric Practice to define framework for the required program elements.
The Irish Children‟s Nurse Post-Registration Education Programme is a 12 month course in which the domains and requirements stipulate the need for children‟s nurses, a broader concept than acute paediatrics alone. The learning requirements for this programme needed; age-appropriate communication skills; advocacy for the child and family; understanding of sociology and psychology; child protection; mental health in addition to the physical assessment and management nursing skills for infants, children and adolescents (Nursing and
Midwifery Board of Ireland, 2018). Ireland and other countries with specific paediatric or children‟s nursing registration, such as USA and Britain (Doyle et al., 2008; Nursing and
Midwifery Board of Ireland, 2018; Royal College of Nursing, 2003) support the ACCYPN‟s perspective of paediatric (or children‟s) nursing being more than physiological differences and their education objectives reflect this. The training provided for the APAC nurses incorporated the same concepts as the specialist registration programs. However, speciality nursing registration and post-registration courses provide a greater depth of understanding and skill development than the time frame the APAC nurses could allow.
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2.3. The Kirkpatrick Model
Kirkpatrick describes learning as the extent to which participants change attitudes, improve knowledge, and/or increase skill as a result of attending a training program (Kirkpatrick &
Kirkpatrick, 2007). The Kirkpatrick model was created in the 1950s and is described as the worldwide standard for evaluating the effectiveness of training (Kirkpatrick Partners, 2018).
It was revised and updated as the „New World Kirkpatrick Model‟ (Kirkpatrick &
Kirkpatrick, 2016; Kirkpatrick & Kirkpatrick, 2015). It can be applied before, during and after training to both maximize and demonstrate the value of training to an organisation. It is comprised of 4 components of evaluation referred to in the model as levels; Level 1 Reaction,
Level 2 Learning, Level 3 Behaviour and Level 4 Results (Figure 4). Each level can be evaluated using qualitative or quantitative methods.
Figure 4: Kirkpatrick Levels of Training Evaluation
Results What was the patient outcome?
Behaviour How did it change their nursing practice?
Learning What did they learn?
Reaction What is the nurses' reaction to the training?
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The importance of standardised and consistent frameworks for the evaluation of education and training programs was also highlighted in the literature (Dubrowski & Morin, 2011;
Santos, Vicente, & Monteiro, 2012). Considerable international success has been experienced in applying KM to health services evaluation (Dubrowski & Morin, 2011; Lee, Weston, &
Hillier, 2013; Nestel, Regan, Vijayakumar, Sunderji, Haigh, Smith, & Wright, 2011; Weller,
Nestel, Marshall, Brooks, & Conn, 2012), management training (Omar, Gerein, Tarin,
Butcher, Pearson, & Heidari, 2009), and education programs (Anderson, 2009; Badu, 2013;
Sinclair, Kable, & Levett-Jones, 2015). The model has been used effectively in evaluating education programs in health related studies (Dubrowski & Morin, 2011; Lee et al., 2013;
Nestel et al., 2011; Sinclair et al., 2015) that aimed to improve knowledge and change culture.
Commonly only one evaluation method has been used in a study for training evaluation, although there are examples of studies that used more (Dubrowski & Morin, 2011). A criticism of the many outcome-based program evaluation models is that they can fail to demonstrate successful outcomes in terms of behavioural change. Behaviour change is one of the higher levels of the Kirkpatrick model along with the final level of Reaction to obtain a comprehensive evaluation of the impact training has on service delivery rather than simply an evaluation of the training itself.
Before providing a synthesis and critical analysis of the available literature, a summary of common evaluation methods used for each level of the Kirkpatrick model is provided.
Knowledge questionnaires (Anderson, 2009; Badu, 2013; Grzeskowiak, Thomas, To,
Phillips, & Reeve, 2015; Haller, Garnerin, Morales, Pfister,
Berner, Irion, Clergue, & Kern, 2008; Kar, Premarajan, L,
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Archana, Iswarya, & A, 2014; Matsuda, Negishi, Otani,
Arakida, & Higashi, 2016; Nestel et al., 2011; Omar et al.,
2009; Pickworth & Snyman, 2012; Santos et al., 2012; Sinclair
et al., 2015; Tennill, 2011)
Satisfaction Surveys (Anderson, 2009; Grzeskowiak et al., 2015; Haller et al., 2008;
Kar et al., 2014; Lee et al., 2013; Sinclair et al., 2015)
Rating Scales (Bylund, Brown, Bialer, Levin, Lubrano di Ciccone, &
Kissane, 2011; Haller et al., 2008; Matsuda et al., 2016; Nestel
et al., 2011)
Interviews/ Discussions (Nestel et al., 2011; Omar et al., 2009; Pickworth & Snyman,
2012; Tennill, 2011)
Observation (Anderson, 2009; Matsuda et al., 2016; Santos et al., 2012)
Forums (Patel, Fang, Harrison, Auerbach, & Kangelaris, 2016)
Reflective Journals (Anderson, 2009; Lee et al., 2013)
These methods of training evaluation have been endorsed by the authors of the model
(Kirkpatrick & Kirkpatrick, 2007).
Some studies describe their framework as a modification of the Kirkpatrick model, with the modification commonly being to omit levels 3 and 4 (Grzeskowiak et al., 2015; Matsuda et al., 2016). When applied to a health management environment an additional economic aspect was included in an evaluation, return of investment (Omar et al., 2009). Barr et al (2000) adapted the original model to be partially contextualized to healthcare with an additional level of benefits to patient/clients, further defined as „any improvement in the health and wellbeing of patients as a direct result of an educational program‟ (cited in (Nestel et al.,
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2011) page 2). These additional levels to modify the model for specific industries are arguably an extension of the Results level in Kirkpatrick. For example, the modification of one study to understand the return on investment for training was identified as part of the
Results level (Santos et al., 2012) .
Criticism of the evidence around KM is that both level 3 (Behaviour) and level 4 (Results) are not reported by many program evaluations (Grzeskowiak et al., 2015; Matsuda et al., 2016).
The reasons for this are unclear. But the omission of these two levels may be indicative of the model‟s limitations. For example, this gap in evaluations was identified in two systematic reviews of pain education programs (Dubrowski & Morin, 2011) and online based learning on clinical behaviour (Sinclair et al., 2015). In the review of pain education programs KM was identified as being useful in evaluating curricula. However, challenges in evaluating the impact on clinical practice in the final level of KM were noted (Dubrowski & Morin, 2011).
The review of online education for healthcare professionals highlighted that few studies have examined the effectiveness of it on clinical behaviour, level 3 of KM. Evaluations focused on knowledge, skill acquisition and satisfaction with the training but not on the transfer of these into clinical practice and identified a need for research into online education for healthcare professionals and its influence on sustained clinical practice changes (Sinclair et al., 2015). It is important for this evaluation to include the effect on clinical practice and completion of all four levels of KM is required to achieve this.
Dubrowski and Morin (2011) identify four main criticisms of outcome-based evaluations such as Kirkpatrick for pain education evaluations. These are 1) overemphasis on the training program itself; 2) focus on learning outcomes rather than learning occurred or not; 3) focus on learners and not the program objectives; and 4) emphasise progression to practice change without proper emphasis on integration of program content with the setting (Dubrowski &
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Morin, 2011). These are criticisms related to the choice of evaluation tool for pain education programs and the need to select the appropriate tool for different evaluations was discussed.
In this Master‟s thesis some of these points may not be applicable as the evaluation aims were focused on learners and learning outcomes as well as how practice changed as a result of the education.
Conversely, evaluations that have used all four levels of KM have achieved a more comprehensive evaluation and understanding of the impact of the training. In 2007 the
Kirkpatrick authors published a practical guide to implementing the four levels to accompany the original model. It focuses attention on what they describe as a much neglected level3
(Kirkpatrick & Kirkpatrick, 2007). The model‟s authors suggest that level 4 Results is sometimes omitted due to perceptions about the level being too difficult or too expensive.
These are notions shared by others (Nestel et al., 2011; Weller et al., 2012). The importance of level 3 Behaviour has been clarified in the new world revised Kirkpatrick model, and although training can lead to changes in behaviour or clinical practice other factors need to be acknowledged including cost, quality, efficiency and compliance (Campbell & Mather,
2018).
Programs that have successfully implemented all four levels have resulted in more comprehensive evaluations and more robust conclusions and recommendations for their training programs (Anderson, 2009; Bylund et al., 2011; Nestel et al., 2011; Omar et al.,
2009). The opposite can be said of those programs with higher levels omitted in their evaluation or utilising existing data, such as attendance. These studies were unable to demonstrate behaviour or reaction changes as effectively and impact of training results were often inconclusive (Badu, 2013; Grzeskowiak et al., 2015; Haller et al., 2008; Kar et al.,
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2014; Matsuda et al., 2016; Yu & Md, 2011), although high levels of participant satisfaction was described (Matsuda et al., 2016).
Studies that used levels 1-3 and omitted level 4 achieved evaluations focused on the individual trainee‟s satisfaction and knowledge attainment, without understanding of behavioural changes and organisational impacts of the training (Pickworth & Snyman, 2012;
Santos et al., 2012). The importance of levels 3 and 4 is underpinned by the assumption
Behaviour and Results are a direct result of the training. This potentially simplified view does not allow for the consideration of factors other than the training. These limitations have been highlighted in a critical analysis of KM (Bates, 2004). This does not undermine the validity of the application of the KM model simply a need for awareness of its limitations when analysing the data obtained. The limitations of Kirkpatrick may be associated with the absence of longer term evaluations of training.
The evaluation of nursing training programs and new nursing services needs to be comprehensive but can lack rigour (Lannan, 2017; Randall, Crawford, Currie, River, &
Betihavas, 2017). For example, a systematic review of the impact of community-based nurse- led clinics showed that while much literature has rationalised the introduction of the clinics in relation to access, few studies have evaluated whether they actually improve patient access to care (Randall et al., 2017). The Kirkpatrick model has been demonstrated to be an effective framework to evaluate a paediatric training program for predominantly adult-trained community nurses. A comprehensive evaluation calls for the use of the 4 levels of the model.
The literature reviewed has exposed the value of paediatric hospital in the home as a contemporary model of care. Moreover, the need for additional paediatric nursing training for the APAC community nurses was confirmed. A gap in the literature was identified that
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pertained to general trained nurses‟ confidence interacting and caring for infants and children, and the training required to overcome this for a specific nursing cohort. This highlighted an area for possible future research.
Research questions were developed from the review of literature and the study design was developed using the Kirkpatrick model. The next chapter details the research design and methods.
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3. RESEARCH DESIGN
The study design using the Kirkpatrick model (KM) was used as a framework to design a training evaluation study. This study design was detailed in a publication in the Journal of
Research in Nursing (Appendix 1) entitled; The evaluation of a home-based paediatric nursing service: concept and design development using The Kirkpatrick Model (Jones et al.,
2018).
3.1. Framework
3.1.1. Using the Kirkpatrick Model in Practice
Evaluation should be incorporated into the planning stages of any project. Kirkpatrick and
Kirkpatrick (2007) suggest that the outcomes and impact of training are often inadequately evaluated, despite their importance. In project management models the evaluation, results, or outcomes of a project are often described as part of the later or final stages of the process
(Duncan, 1993; Harvard Business Review Staff, 2016). However, if the planning stage in a project is about defining the solution to a problem and how this will be achieved then it would follow that the measurement of training should also be defined at this stage.
Therefore, the evaluation plan requires the identification of the evaluation framework from outset, in this case the Kirkpatrick model. It is an evaluation framework with four levels;
Reaction, Learning, Behaviour and Results (Figure 4, page 33 (Kirkpatrick & Kirkpatrick,
2016).
There are many reasons to evaluate health programs and there are many challenges associated with effective evaluation. Evaluation can determine achievement of objectives related to improved health status (Capwell, Butterfos, & Francisco, 2000; Torrance, 1997) as well as consumer satisfaction and consumer perspectives (Randall et al., 2017). It can assess program
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implementation (Capwell et al., 2000; Dooris, 2006; Fagen, Redman, Stacks, Barrett,
Thullen, Altenor, & Neiger, 2011); provide accountability to funding bodies, community, and others (Capwell et al., 2000); increase community support for initiatives (Akerman, 2002;
Capwell et al., 2000); contribute to the scientific base for community public health interventions (Capwell et al., 2000); inform policy decisions (Capwell et al., 2000; Dooris,
2006; Fernandes, Ribeiro, & Moreira, 2011); and finally, evaluate quality and cost- effectiveness (Russell, Wallace, & Ketley, 2011; Torrance, 1997).
Research questions require formulation prior to methodologies and methods being determined (Creswell & Plano-Clark, 2010). The Kirkpatrick model provided the framework for this and the methodologies/methods are detailed in a summary table of the research plan
(Table 1, Appendix 4). An evaluation plan for the paediatric nursing education and support program for general-trained APAC community nurses adopted a mixed methods approach, combining qualitative and quantitative data with the aim to achieving a greater depth of understanding.
Mixed methods research has been described as the third methodological movement or third research paradigm and is a relatively recent research methodological philosophy that challenges traditional beliefs that research should be wholly categorised as qualitative or quantitative (Creswell & Plano-Clark, 2010). The mixed methods approach includes at least one qualitative and one quantitative method, although the methods are not necessarily in equal proportions or priority but do have equal validity within research questions.
At the same time, the Kirkpatrick model is a training evaluation framework ideally suited to mixed qualitative and/or quantitative methodologies for each level; Reaction, Learning,
Behaviour and Results (Kirkpatrick & Kirkpatrick, 2016). Each level of evaluation requires
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the implementation of appropriate methodology which is complementary to but independent of the other levels. The overall research plan for this study was for a multi-phase design with multiple sampling strategies occurring both sequentially and consecutively (Creswell &
Plano-Clark, 2010). An alternative perspective is that the Kirkpatrick model facilitates a mixed methodology or a composite of four distinct sub-studies each with a single methodology. This thesis aimed to follow the KM framework‟s intentions and adopting differing but appropriate methodology for each of the levels creating a mixed methodology study, rather than a mixed methods study.
There are specific research methods more commonly used in conjunction with the
Kirkpatrick model than others, but there are no identified methods that are specific or exclusive to one of Kirkpatrick‟s levels. There are some methods more associated with a
Kirkpatrick level than other, for example, the Learning level with knowledge questionnaires, and the Reaction level with rating scales (Table 2, Appendix 5).
3.1.2. Research Questions
The overall research question for the study was; did the Paediatric Nursing Training
Program for Community Nurses prepare them to care for children at home? The Kirkpatrick model levels of the evaluation had research questions to determine the purpose of each level.
Level 1 What are the reactions of the general trained community nurses to the
Reaction training provided to expand their portfolio to include paediatrics?
Level 2 Have the community nurses learnt the relevant paediatric nursing
Learning knowledge, as defined by the Australian College of Children‟s and
Young People‟s Nurses (ACCYPN) Standards, as a result of the training?
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Level 3 Have the community nurses routinely and consistently applied their new
Behaviour knowledge and skills to their community nursing practice with children
and families?
Level 4 What are the consumers‟ (children and families) perceptions about the
Results paediatric hospital in the home care? Will the paediatric hospital in the
home (HITH) service be as safe as hospital care?
3.1.3. Research Paradigm
Post-positivism is most commonly associated with quantitative research methods, where the researcher is unbiased and distant from participants through the use of tools such as online surveys (Creswell & Plano-Clark, 2010). Paradigmatic determinants for a post-positivism paradigm require certain characteristics; 1) Ontology (critical realism), 2) Epistemology
(modified dualist/objectivist) and 3) Methodology (modified experimental/manipulative)
(Guba & Lincoln, 1994). This study used the Kirkpatrick model as a framework to identify the appropriate methodologies to be applied to measure the reality where the ontology is based on the belief of a single entity, in this case the outcomes of a training program.
However, the relationship is flawed and is underlined by the concept that all research methods will result in errors. This is associated with the belief that we are all biased and therefore all of our interactions and observations as a researcher are affected by our personal experiences and beliefs. However post-positivism also emphasises the importance of multiple measures, observations and increased utilization of qualitative techniques (Guba & Lincoln,
1994).
The naturalistic inquiry encompasses qualitative research methods to incorporate observation and description of phenomena such as nursing practice. The researcher‟s own experiences
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can be drawn upon in the interpretation resulting in a richer, deeper understanding (Salkind,
2010). Lincoln and Guba (1985) have argued that inquiry, in particular qualitative inquiry is not and cannot be value free, and proposes that post-positivism is a part of new Naturalist
Inquiry paradigm encompassing the elements of post-positivism (Lincoln & Guba, 1985).
The qualitative aspect of this Master‟s thesis study however, used elements of constructivism as the researcher was familiar with and interacted with the participants in the interviews.
Thus bias in the data collection must be acknowledged. The pursuit of capturing the training experience and the impact on clinical behaviour from the perspective of the trainees was acknowledged as being associated with constructivism (Creswell & Plano-Clark, 2010). The naturalistic inquiry encompasses qualitative research methods to incorporate observation and description of phenomena such as nursing practice. The researcher‟s own experiences can be drawn upon in the interpretation resulting in a richer, deeper understanding (Salkind, 2010).
Lincoln and Guba (1985) have argued that inquiry; in particular qualitative inquiry is not and cannot be value free, and proposes that post-positivism is a part of new Naturalist Inquiry paradigm encompassing the elements of post-positivism (Lincoln & Guba, 1985).
Mixed paradigms may exist within research but can cause conflict that can give rise to contradictory outcomes (Creswell & Plano-Clark, 2010). It is therefore better suited to multi- phased research such as the study reported in this thesis. The different paradigms are applicable to specific levels within the KM framework avoiding paradigmatic conflict.
Mixed Methods (MM) research provided the overarching approach to be used for this study.
Recognized as the third major research approach or research paradigm, it is now respected along with qualitative research and quantitative research (Johnson, Onwuegbuzie, & Turner,
2007). In its simplest terms MM is research in which a mix of qualitative and quantitative
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methods are applied, and the researcher collects, analyses and draws conclusions from a mix of method for a single line of enquiry (Creswell & Plano-Clark, 2010). As the complexity of research questions has evolved so have the approaches to research. Mixed Methods has provided the means to combine data sources within a study to achieve more complex analysis of problems. The complexity of nursing research problems and the emic and etic nature of holistic nursing lends itself to mixed methods approaches (Creswell & Plano-Clark, 2010;
Johnson et al., 2007; Mukherjee, Wray, Commers, Hollins, & Curfs, 2013). Mixed Methods has evolved to become a research orientation in its own right. A literature review sought to define the MM approach and proposed a composite definition based on consensus from the literature (Johnson et al., 2007). Johnson et al (2007) provide a summative definition that acknowledged MM as the third paradigm with identified characteristics and its importance in the research to the provision of superior findings and outcomes in the right application.
There are variations in mixed methods based; a) what is being mixed; b) where in the process the mixing occurred; c) the scope of the mixing; d) the reason for mixing and e) the elements driving the research (Creswell & Plano-Clark, 2010; Johnson et al., 2007). In this Master‟s
Thesis study the mix occurs in the data collection methods and the data analysis. The qualitative and quantitative data were first analysed using statistical and thematic approaches before triangulation brought them together for cross-analysis. This is based on the MM premise that it provides greater depth of investigation through the combination of mixed data sources. There are disadvantages and challenges to the mixed methods approach. The researcher needs multiple skills for the multiple methodologies, for the research design, data collection and analysis. The collection of data from multiply sources can be time consuming
(Creswell & Plano-Clark, 2010).
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In this Master‟s thesis study the Kirkpatrick model provided the framework for mixed methodologies to be associated with each level. This framework aims to explore the different aspects of training evaluation; the reactions to the training; the learning acquired, changes to clinical practice and clinical outcomes. The KM levels follow a time progression as the impact of the training cannot be evaluated until the training is completed and the knowledge acquired. This progression lends itself to a multi phased approach. As each level has its own purpose and aims it would follow that methodology design for each level be specific for that level. Some levels are more naturally attuned to a methodology. For example, the first KM level, Reaction, is well suited to capturing individuals‟ reactions quantitatively on a numerical scale. The Behaviour changes in nurses as a result of training are not easily captured numerically but through qualitative methodologies such as observation and interviews.
With a mix of quantitative and qualitative methodology it is not possible to restrict the research paradigm to a single philosophical approach. This raises the question of whether the research paradigm here is regarded as having sub-paradigms for the qualitative and quantitative aspects, and as individual studies combined as part of a whole, or as a single study entity with distinct facets.
The research design for this Master‟s thesis study can therefore be seen as a multi-phased mixed methods research in its pursuit of a comprehensive evaluation of the effectiveness of training to adequately prepare nurses to care for children using the Kirkpatrick model as a framework. With the mix occurring in the philosophical approaches, the methodologies and in part the data analysis. This multiplism of methodology and analysis consequently requires triangulation to gain a better understanding of the reality (Johnson et al., 2007).
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3.1.4. Triangulation of the Data
Triangulation is a validity approach drawing data from several sources where the researcher can build evidence and triangulate findings to seek convergence and corroboration from the results of the different methods. Triangulation is closely associated with mixed methods research with the term first introduced in the 1960s (Johnson et al., 2007). It is often used by qualitative researchers to ensure a deeper understanding of an investigation and is based on the belief that a single method can never adequately explain a phenomenon (Pandey &
Patnaik, 2014). It is used in quantitative research to test the reliability and validity but can also be applied to test or maximize the validity and reliability of a qualitative study
(Golafshani, 2003). Multiple theories, data sources, methods or investigators within the study of a single phenomenon can be used. It was introduced originally into qualitative research to avoid potential biases arising from the use of a single methodology. It may be used to determine the completeness of data (Heale & Forbes, 2013).
Triangulation is generally regarded as a technique to facilitate more comprehensive or deeper understanding of a question. It can provide greater credibility if multiple data sources lead to the same conclusion (Creswell & Plano-Clark, 2010; Lincoln & Guba, 1985; Pandey &
Patnaik, 2014). However, triangulation assumes the two data sets from the different methods are comparable, and may or may not be of equal weight. Caution is advised that the convergence of two data sets does not always guarantee the reliability of the result, as both methods of data collection may be flawed (Heale & Forbes, 2013).
Guba and Lincoln (1994) indicate that the post-positivism paradigm and the multiple sources of data encourage triangulation. The triangulation of data aimed to strengthen the research and ultimately produce a quality research thesis as a result of additional sources of
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information providing more comprehensive collection of data and more insight into the overall evaluation of the training. It was hoped that any inadequacies in one data source could be minimised if data collected from each of Kirkpatrick‟s four evaluation levels confirm similar outcomes or highlighted inconsistencies.
Four types of triangulation have been identified (Pandey & Patnaik, 2014);
Methods triangulation checking out the consistency of findings from different
data collection methods
Triangulation of sources examining the consistency of different data sources from
the same method
Analyst Triangulation using multiple analysts/observers to review findings
Theory/perspective triangulation using multiple theoretical perspectives to interpret data
The methods triangulation and the triangulation of sources are most applicable to this mixed methods study. They combine qualitative and quantitative data sets to answer the same question. This can result in one of three outcomes (Heale & Forbes, 2013); 1) both data sources converge and lead to the same conclusion; 2) the results relate to different phenomena but complement one another or 3) the results contradict each other or are divergent. It is often the points where the two data results cross that are of greatest interest and provide the most insights to the researcher (Pandey & Patnaik, 2014).
The Kirkpatrick Levels of Training Evaluation provided a framework to comprehensively assess the effectiveness of workplace training, in this case paediatric nursing training. These levels of evaluation and the multiplism of qualitative and quantitative data collected
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facilitated triangulation and cross comparisons. For example, cross comparisons with the interviews as part of the Behaviour level are with both the APAC nurses and the paediatric clinical nurse specialist who supervised and supported them. This provides the opportunity to compare the perspectives of the student and the mentor, and their perception of the impact on clinical practice from the training. The four levels of KM provided multiple data sources to potentially verify or validate conclusions and outcomes as data and information is supported in multiple data sources and research methodologies through triangulation.
3.1.5. Methodology
The research methodologies for each stage were:
REACTION: Quantitative: survey research
LEARNING: Quantitative: descriptive research
BEHAVIOUR: Qualitative: interpretative description
RESULTS: Quantitative: survey research and correlational research
3.1.6. Methods
The data collection methods for each stage were:
REACTION a. Rating scales about the different aspects of the paediatric teaching
LEARNING a. Knowledge questionnaire
BEHAVIOUR a. Semi-structured interviews with the APAC community nurses about
their clinical practice with children and families
b. Semi-structured interviews with paediatric clinical nurse specialists
about the APAC nurses‟ clinical practice with children and families
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RESULTS a. Family satisfaction surveys (when community nurses supported by
paediatric nurses in the home and when support is no longer routine)
b. Incident data to ensure maintained safe service - compare number of
yellow and red incidents in paediatric HITH and a paediatric ward
over same time period
3.1.7. Quantitative Data Analysis
A descriptive statistical approach was adopted to describe quantitative data using simple statistical and graphical analysis. This provided the basis of the analysis of the quantitative data by summarising and organising the data into manageable and easily visualised forms. A current view is that „quantitative data analysis‟ rather than „statistical analysis‟ is preferred as it implies an understanding and analysis of data rather than just the statistical techniques behind them (Bryman & Cramer, 2005; Pallant, 2016).
The small sample size limited the statistical calculations that could be applied to the data. For the level 1 Reaction items measured with a Likert type scale, the arithmetic mean was calculated. If one or more of the data points had more weight or importance than others then they could have been weighted to provide the calculation of a weighted mean. Responses in this study carried equal weight and so weighted means were not reported. Weighted means can be influenced by outliers in data and were thus not used in this study.
With averages or mean it is important to establish the Standard Deviation as a measure of the amount of variation within the data values. For example, a small standard deviation of 1.01 to the Reaction question (Table 6, page 73) “The Resus4Kids course content was interesting” indicated small variation in responses with the majority providing similar responses. A higher
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Standard Deviation would have indicated a greater range of responses and reduced consistency of responses. It should be noted the Standard Deviation is influenced by the sample size. This was noted in the question Reaction (Table 5, Appendix 15) “The Children‟s
Ward placement was interesting” with a standard deviation of 2.16 with a sample size of only nine. The reliability of Standard Deviation increases with an increase in sample size.
Standard Deviation was calculated using Microsoft Excel Formula =STDEV() and selecting the range of values which contained the data. Tables were used to present the number of respondents (n), average or arithmetic mean and the standard deviation.
In the family satisfaction survey respondents were regularly asked a question such as “How do you normally travel to hospital?” with optional responses in this case; walk, private car, taxi, public transport or other. These data were presented as percentage of the total to demonstrate the prevalence of each option. Bar charts provided the most appropriate format for these percentage data.
The survey tools used for levels 1, 2 and 4 were developed by the researcher. The tools were not subject to pilot studies or tool validity studies. However, the researcher approached clinical and quality specialists for their review of the tools with regard to ease of understanding of the questions, time to undertake the surveys and expert comments related to the tools. All feedback was incorporated into the final version.
The quantitative data were analysed for each of the relevant KM levels. As it was a multi- method design each section was reported separately and then brought together in the discussion, along with the qualitative data.
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3.1.8. Evaluation Method for Level 1 Reaction
Level 1 Reaction aims to assess the degree to which participants find the training favourable, engaging and relevant to their jobs (page 39). The importance of this level being quick and simple is emphasised by Kirkpatrick. The authors suggest a blended evaluation approach is appropriate for level 1 Evaluation Tools, which allows you to ask questions about confidence and commitment to apply what is learned, and questions related to anticipated application and outcomes (Kirkpatrick & Kirkpatrick, 2016). This research is evaluating the reactions of the community nurses to the paediatric training and as such a learner-centred approach would be valid.
The rating scale Reaction evaluation of the training is based on a Likert Scale (Likert, 1932).
Rensis Likert developed a technique for the measurement of attitudes, based on the principle of asking people to respond to statements about a subject and indicating on a linear or continuum scale the extent to which they agree or disagree with them, therefore making the assumption that attitudes can be measured.
Likert-type scales typically have at least a five -point scale allowing the respondent to indicate their level of agreement or disagreement (Appendix 6 - Research Tool 1). The obvious question when developing the tool is what would be an appropriate number of points for a Likert Scale? The psychometric literature suggests that having more scale points is better but there is a diminishing return after around 11 points (Nunnally & Bernstein,
1994). Kirkpatrick provides examples of Likert Scales for evaluation using 5, 6, 7 and 10 point scales without expressing a preference for a particular numeric (Kirkpatrick &
Kirkpatrick, 2016).
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The literature suggest some preference to Likert rating scales with 5 points (Anderson, 2009;
Bylund et al., 2011; Grzeskowiak et al., 2015; Lee et al., 2013; Omar et al., 2009) for the evaluation of aspects of education and health training programs, with few examples of scales other than 5 points; 4 point (Badu, 2013; Haller et al., 2008) and 10-point (Kar et al., 2014).
The proposed rating scale for the Reaction evaluation is a learner-centred, blended evaluation, 5 point Likert Scale on a delayed basis once all aspects of the paediatric training have been completed. The paediatric training was composed of several distinct sub-courses and the evaluation aimed to gain insight into agreement or disagreement about each. A set of four questions were repeated for each of the elements of the training; Emergency Nurse
Paediatric Course (ENPC), Resus4Kids, DETECT Junior, child protection, medication administration to children and placement experience on a children‟s ward. The training elements are summarised in Table 3 (Appendix 7). These asked if the course was interesting, if the course provided the knowledge and skills needed to care for children and families at home, if the course was more confident about caring for children and families at home, and if the participants have successfully applied the knowledge to care of children at home.
These four questions are in themselves a reflection of the KM levels with each question seeking reactions to aspects of the training explored in the higher stages of evaluation. The first questions ask about how interesting the training was, which is the respondents initial
Reaction to the training. The second set of questions is related to Learning, third to
Behaviour through confidence and the fourth Results through application of knowledge.
3.1.9. Evaluation Method for Level 2 Learning
Kirkpatrick notes that like level 1, level 2 Learning is familiar to most training professionals as it aims to assess;
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“the degree to which participants acquire the intended knowledge, skills, attitude,
confidence, and commitment based on their participation in the training” page 42
(Kirkpatrick & Kirkpatrick, 2016) .
A form of knowledge test is identified by Kirkpatrick as a common formative method for this stage and its application can be found in the literature (Anderson, 2009; Badu, 2013;
Grzeskowiak et al., 2015; Haller et al., 2008; Kar et al., 2014; Matsuda et al., 2016; Nestel et al., 2011; Omar et al., 2009; Pickworth & Snyman, 2012; Santos et al., 2012; Sinclair et al.,
2015; Tennill, 2011).
The Learning evaluation used a descriptive quantitative research method that aimed to collect data about the knowledge and skills attained from the various aspects of the paediatric training program. The aspects of the paediatric training were a combination of existing educational resources and are summarised in Table 3 (Appendix 7).
The tool (Research Tool 2, Appendix 8) used for this Learning evaluation is knowledge questionnaire with 24 multi-choice questions designed around the ACCYPN Standards for
Paediatric Practice (Australian College of Children's and Young People's Nurses, 2016).
These Standards identify key elements for paediatric nursing training. For example ACCYPN
Standard 2 (Demonstrates ethical practice in nursing children and young people) has questions associated with it including;
“True or False? Children and young people have the right to participate in decision
making, and as appropriate to their capabilities, make decisions about their care‟ and
“Which of the following are recommended for Safe Sleep for Newborns to reduce the
risk of Sudden Unexpected Death in Infancy (SUDI)?”
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The questions were developed by the researcher and the information for each was sourced from material covered in the training program. A summary of the knowledge questionnaire and how each question related to the ACCYPN Standards and the information source on which each question was designed is detailed in Table 4 (Appendix 9).
3.1.10. Evaluation Method for Level 3 Behaviour
For the Behaviour level of this research a qualitative method was selected. Interpretive
Description (Thorne, Kirkhan, & MacDonald-Emes, 1997) was used as it enables analysis of the unique phenomena of the training and the impact on their nursing practice. It aims to assess;
“the degree to which participants apply what they learned during training when they
are back on the job” page 49 (Kirkpatrick & Kirkpatrick, 2016)
This level is identified by the Kirkpatrick authors as the most important of the four levels because training alone will not generate changes in practice or improved clinical outcomes.
They highlight that level 3 is also the most disruptive and challenging to traditional training evaluation process. The challenging nature of this level is supported by its absence in several studies claiming to use the Kirkpatrick levels of training evaluation model (Dubrowski &
Morin, 2011; Grzeskowiak et al., 2015; Matsuda et al., 2016; Sinclair et al., 2015).
Level 3 Behaviour is evaluating the combined effect of the learning and experiences of the individuals, and understanding how individuals synthesize this as reflected in their behaviour in the workplace. Kirkpatrick authors suggest it is probably the most significant of the levels of evaluation (Kirkpatrick & Kirkpatrick, 2016). In this Master‟s Thesis study, it is therefore an evaluation of the training from the participant‟s perspective that is sought for the
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paediatric nursing training and its effect on their clinical practice with children and families.
Initially a descriptive phenomenological methodology was explored for this study and incorporated into the published evaluation design (Appendix 1). On further reflection of the research approach an Interpretive Description methodology was adopted.
Capturing and analysing an experience from an individual perspective lends itself to an
Interpretive Descriptive method. Interpretive Description was developed as an alternate to and an evolution from traditional qualitative methods including phenomenology, to meet the unique demands of nurse researchers (Thorne, Kirkham, & O'Flynn-Magee, 2004; Thorne et al., 1997). A qualitative design with an Interpretive Description approach was chosen as the focus of this Behaviour evaluation level because the purpose was to describe how the community nurses would conceive, understand and conceptualise the paediatric nursing training and caring for children in the community (Hunt, 2009; Thorne et al., 2004; Thorne et al., 1997). The use of such an approach has been successfully adopted by nursing researchers aiming to understand experiences of nurses and patients including education (Nery, 2018).
Indeed the discipline of nursing is at the forefront of using both etic and emic approaches to research reflective of its holistic approach to health and healthcare.
Consideration was given to how the Behaviour of the APAC nurses in the clinical environment could be observed or their experiences relayed to a researcher. The community nursing environment is in the child‟s home, and the patient-nurse relationship is critical. In this model the home care was provided by the APAC who was supported by the paediatric clinical nurse specialist. There were therefore two clinicians in the family‟s home with often a child and a parent or carer. A third person observing Behaviour in a child‟s home was not deemed appropriate and was deemed potentially detrimental to good clinical relationships.
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The semi-structured interview method provided the ability to describe and analyse the
Behaviour of the APAC staff from their perspectives. The perspective of their mentors was also included and the interviews meant this could be done without impacting the clients, the nurse or the nurse-client relationship. The interview questions (Research Tool 3, Appendix
10) for the APAC nurses and the paediatric nurse specialists were aligned. For example,
APAC nurses are asked; “How comfortable do you feel communicating with children and families?” and at the same time the paediatric nurse specialists were asked “How comfortable do you feel the APAC nurses are communicating with children and families?”
Waters (2017) has provided guidelines for drafting interview questions that were noted in the development of the semi-structured interview questions. These were; a) starting with a brief introduction; b) questions should be clear, understandable, & inoffensive; c) asking follow-up or probing questions; d) not being too obvious; e), checking the order of the questions and f), keeping the interview brief and pre-testing interview questions (Waters, 2017).
The interviews were semi-structured providing the opportunity for the researcher to ask additional probing questions to follow up on information provided by the interviewee, to gain a deeper understanding of the key issues and themes.
3.1.11. Interpretive Description
Nursing research seeks knowledge that can be applied to clinical practice, and as such requires an approach that enables understanding of how the combined knowledge and experiences of nurses can be applied to individual patient care. The nature of nursing research therefore leans towards qualitative research methods. Qualitative nursing research exploring the experiences of nurses would have historically aligned with the established methodology of; phenomenological philosophy (Thorne et al., 1997). Phenomenology is a methodology of
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descriptive qualitative research which is concerned with the study of experience, or phenomenon from an individual‟s perspective (Giorgi, 1975, 2007, 2012). As a discipline that investigates people's experiences to understand their meaning and influence and as such is well suited to social sciences and nursing studies (Matua & Van Der Wal, 2015), and has been successfully applied to nursing and education research (Andersson, Willman, Sjostrom-
Strand, & Borglin, 2015; Endacott, Scholes, Buykx, Cooper, Kinsman, & McConnell-Henry,
2010; Han, Barnard, & Chapman, 2009; Imafuku, Saiki, Kawakami, & Suzuki, 2015;
Sjostrom & Dahlgren, 2002). However, the use of phenomenology in nursing research has been criticised. It is argued that nurse researchers largely misunderstand the concepts of phenomenology and as a result, their version of Husserl's philosophy bears little resemblance to the original (Paley, 1997). Variations in the application of this philosophy in nursing research was not encouraged and attempts to do so attracted criticism towards the end of the
20th Century (Thorne et al., 1997). Indeed after a few decades of its use in nursing research it became obvious that nurses had been developing new forms of phenomenological inquiry.
Interpretive description is thus a relatively new research methodology that aims to generate knowledge relevant for the clinical context of applied health disciplines (Hunt, 2009). The philosophical underpinnings of the interpretive description approach are described as; 1) an inductive process (describing the phenomenon being studied, and adding to knowledge and developing a conceptual and/or theoretical framework); 2) subjective (each person has his/her own perspective and each perspective counts) and recognising the subjectivity of the experience of the participant and the researcher; 3) designed to develop an understanding and describe phenomena (not to provide evidence for existing theoretical construction); 4) researcher is active in the research process (researcher becomes part of the phenomenon being studied as they talk directly to participants and/or observe their behaviours); 5) an emic
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stance (an insider view which takes the perspectives and words of research participants as its starting point) but is influenced by the researcher not only because of subjectivity but also when a degree of interpretation occurs.; 6) conducted in the natural setting (data collected in the natural setting of the participants who experience the phenomenon) (Bradshaw, Atkinson,
& Doody, 2017).
A theoretical-reflective study about the origin and the assumptions of Interpretive Description by Nery (2018) concluded that it is considered a feasible approach for the production of knowledge in applied sciences such as nursing. Interpretive Description in essence therefore developed from necessity for nursing researchers. It gave them a qualitative methodology to generate knowledge of the complexity of health (Nery, 2018).
The popularity of qualitative research approaches in nursing and the sometimes hesitancy to deviate from traditional methods such as phenomenology or grounded theory is acknowledged. The unique nature and complexity of nursing research is observed by several authors and the necessity for a qualitative research method to better service these (Hunt,
2009; Nery, 2018; Thorne et al., 2004). Thorne et al (1997) critique the application of traditional qualitative methods in the context of nursing research and attempt to answer questions around the health experiences or clinical practice using them. They describe critics of variations from traditional methodologies by nurse researchers referring to the nursing research demeaningly as „mixed methods‟ and „sloppy‟, and consequently leading to authors reporting almost apologetically to avoid accusations of bias or influence by the nurse researcher in a nursing research project (Thorne et al., 1997).
Thorne et al (1997) proposed a coherent set of strategies for conceptual orientation, sampling, data construction, analysis and reporting by which nurses can use interpretive description to
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generate knowledge relevant for the clinical context of applied health disciplines about health, nurses and experienced phenomena (Hunt, 2009; Nery, 2018; Thorne et al., 1997).
Qualitative research can assume that those who have lived an experience are the best source of knowledge about the experience. However individuals can interweave other experiences, interpretations and perceptions into the narrative related to the phenomena being studied.
Interpretive Description supports the use of data analysis frameworks such as Giorgi‟s framework (Giorgi, 1997). It also acknowledges the potential influence of the researcher but does not discredit the research because of it. This study followed the interpretive description approach aiming to analyse the training experiences of the nurses using Giorgi‟s framework
(Ebrahimi, Wilhelmson, Moore, & Jakobsson, 2012; Giorgi, 1997). This was performed in acknowledgment of the influence of the researcher in the interpretation of the phenomena.
3.1.12. Qualitative Data Analysis - Giorgi’s Framework
As mentioned, the thematic approach to the analysis of the semi-structured interviews with the community and paediatric nurses was undertaken using Giorgi‟s framework (Giorgi,
2012). This is an analytical technique recommended in Interpretive Description methodology
(Thorne et al., 1997).
There are two descriptive levels of the framework. Firstly, the interviews were transcribed to capture the raw data from the interviews. The transcripts were then edited to maintain anonymity of the interviewee and patient confidentiality through the removal of references to specific people or places.
In the second level the researcher applied the phases of Giorgi‟s Framework to describe the phenomena of the training based on reflective analysis and interpretation of the research
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participant's account through the identification of themes and theme categories. Other authors have described the implementation of Giorgi‟s framework in a greater number of steps or phases but the process remains the same (Ebrahimi et al., 2012). The key phases are set out in
Figure 5 (Appendix 11).
Each of the interview transcripts were read several times with the aim of attaining an overall sense of the outcomes of the interviews. This was followed by a period of scrutinising the transcripts line by line as part of the first phase of thematic analysis. During this phase, key words or phrases were highlighted to identify meaning units in the transcripts. An example of highlighted meaning units can be found in Appendix 16. Meaning units are different aspects or different descriptions of the phenomena from the interviewee‟s perspective. They are single words, phrases, sentences or anecdotes that captured aspects of the training experience.
The meaning units were then collated and reread. The next phase was to contextualise the meaning units into themes. Further scrutiny and reflection on the meaning units resulted in the emergence of sub-themes and eventually themes. All the sub-themes and associated themes identified in this phase are detailed in Appendix 17. These were further condensed into the final themes; a) Clinical experts in adult community nursing care but not in paediatric nursing; b) Emerging understanding of the import aspects of paediatric nursing including caring for the family and not just the child; c) Association between confidence communicating with children and competence in paediatric nursing; and d) Emerging competent paediatric nursing practitioner.
Continued analysis and synthesis resulted in the categorising of themes before the statements emerged capturing the essence of the experience of the community nurses, and eventually aiming to capture the essence of the training as a whole.
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3.1.13. Evaluation Method for Level 4 Results
The Results level is the raison d‟etre for training evaluation. Kirkpatrick and Kirkpatrick
(2016) posit that the degree to which targeted outcomes occur are a result of the training and the support and accountability package. Kirkpatrick identifies leading indicators to assist initiatives to stay on track, motivate training graduates and reassure stakeholders. These are quality, cost, volume/production, efficiency, compliance, employee satisfaction, safety, customer/market response and customer/consumer satisfaction.
This research focuses the Results of the training evaluation on consumer satisfaction and patient safety through survey and correlational research. A specific data set was collected for each. Firstly, a Family Satisfaction Survey (Research Tool 4, Appendix 12) was offered to all families admitted to paediatric hospital in the home in NSLHD. The survey incorporated different methods including Likert Scales, multiple choice and open text with the intention of a greater understanding of the Results from the consumer‟s perspective.
Figure 6: Between the Flags‟ Intervention on the „Slippery Slope‟ of Patient Deterioration
Source: Clinical Excellence Commission (2018)
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Secondly, the Between the Flags (BTF) program in NSW public health facilities (Clinical
Excellence Commission, 2018) is designed to assist staff identify deterioration in all patients, including children and young people, and respond appropriately (Figure 6). The system uses the analogy of Surf Life Saving Australia‟s lifeguards and lifesavers who keep swimmers safe by observing them and ensuring they don‟t venture into unsafe areas (Yellow Zone); and if they get into trouble, that rescue occurs rapidly (Red Zone) (NSW Health, 2013b). The yellow and red zone colours replicate the iconic yellow and red flags used by Australian Surf
Life Saving.
To ensure the results reflected a safe service for children and families‟ patient deterioration data were collected for 2017. In the ethos of Between the Flags (NSW Health, 2013) the deterioration events are classified as Red & Yellow responses, comparable to the Red (Rapid
Response) and Yellow (Clinical Review) responses familiar to public paediatric acute inpatient services in NSW. The paediatric HITH levels of deterioration of a child‟s clinical condition at home are defined in the NSLHD Clinical Emergency Response System (CERS) for paediatric hospital in the home as;
RED Need to call an ambulance from a child‟s home
YELLOW Need to call the hospital to be re-hospitalised
The red and yellow response of patient deterioration data can then be compared with the red and yellow response patient deterioration data from the children‟s wards. Paediatric HITH is based on the assumptions that it is an alternative to hospitalisation but the inclusion criteria are for children to be clinically stable. As alternative options for hospital level care, the response data from HITH and the children‟s ward can be compared. However the expectation
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would be for the HITH response data to be lower due to the clinical stability of the children required for admission to HITH.
3.2. Ethics
3.2.1. Human Research Ethics Application
The research proposal was identified as a Low and Negligible Risk (LNR) research project.
An application was submitted to the NSLHD Human Research Ethics Committee (HREC)
Executive Committee at the end of June 2017. Some minor modifications were requested and final approval was received in August 2017 (Appendix 13). Subsequently Site Specific
Authorisations (SSAs) were sought from the Royal North Shore Hospital, Mona Vale
Hospital, Hornsby Ku-Ring-Gai Hospital and the APAC Community Service in NSLHD.
These SSAs were approved in October 2017. Data collection commenced immediately once
SSA approvals received.
3.2.2. The Researcher
I was employed as a project manager for NSLHD. My role was to establish the paediatric hospital in the home service for the District. This section is a discussion of issues in relation to the relationship of me, the evaluation research lead and my role as project manager. Issues of bias, ethical concerns and a potential conflict of interest are discussed. These issues were addressed before an application was made to the human research ethics committee.
As the researcher and HITH project manager I had prior knowledge of both the positive and the negative aspects of implementation. For example, as a project manager I needed the project to succeed. At the same time I am a UK trained paediatric nurse. For me the outcomes for the patients are paramount and I held a belief that all children should be cared for by
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specialist paediatric trained nurses. I needed to manage personal tension between the project‟s success and my concern for the children and families. In other words, utilisation and service success through quality of care provided for children and families. There may be have been a perception of potential conflict of interest (COI) but there was no actual COI as I had no direct line management responsibilities, and did not provide any education or clinical supervision for Acute Post-Acute Care (APAC) or paediatric hospital in the home nursing staff in the LHD. In my role as project manager, I was not in a position of coercion through workplace hierarchy, but responsible for putting processes in place for the service delivery and for the training delivery.
This dual-sided perspective of the project I perceived as potentially neutralising any bias in the collection of the data and the analysis of it, however I was very cognisant of my personal perceptions influencing data collection during the interviews and data analysis. Conneeley
(2002) discusses her experience as both researcher and practitioner noting some of the challenges with this including trustworthiness and credibility. The qualitative aspect of this study uses an interpretative descriptive approach to explore the experience of both the APAC community nurses and the paediatric nurse specialists supporting them. The researcher as active in the research process is an identified aspect of the Interpretive Description methodology (Thorne et al., 1997). The potential for familiarity and assumed understanding during the interviews was experienced as interviewer. This is not necessarily a negative or a criticism of the research, and may be seen as an indication of trust between the interviewee and interviewer, and as such suggestive of a „good interview‟ (Conneeley, 2002). The need for self-awareness as researcher and practitioner and potential influence on both data collection and data analysis, for example when identifying themes in the interview data is discussed by Conneeley (2002).
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3.2.3. Participants
There were three groups of participants: a) Acute Post-Acute Care (APAC) Community
Nurses who have undergone paediatric training; b) Paediatric hospital in the home Clinical
Nurse Specialists (paediatric HITH CNS); and c) Families and children who had received paediatric HITH care. Each group was invited to participate in specific levels of the study.
The appropriate APAC nurses were invited to participate in the Reaction, Learning and
Behaviour levels of the evaluation. The paediatric HITH Clinical Nurse Specialists who supported them clinically on home visits were only invited to participate in the Behaviour level evaluation. The families of children who received HITH care were invited to participate in the Results level of the evaluation only.
The APAC nurses were known to their Nurse Unit Managers therefore email communication to the participants was via them. The paediatric HITH CNS was a specific role and the participants were identifiable through their position title. They were communicated with individually via email to be invited to participate in the interviews only as the supervisor of the APAC nurses during home visits. Email communication to both groups were either conducted as individual emails or as bcc (blind carbon copy) when providing group communication.
Only the APAC nurses who had received paediatric nursing training as part of the paediatric hospital in the home project were asked to participate in this research. This resulted in the potential number of participants from APAC being thirty nurses. There are only four paediatric clinical nurse specialists in NSLHD so the potential participant cohort was only four.. Other APAC and paediatric nurses were not included in the study. Each participant was interviewed by the researcher at a time and location convenient to them. All participants were
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supported by their line managers to be interviewed as part of this research. The interviews were undertaken in a clinical interview room or the nurse manager‟s office close to the participant‟s usual place of work. The interviews were carried out during normal working hours or at the end of the participant‟s rostered shift. No participant was interviewed outside of the work environment or outside of working hours.
Over the data collection period 1,428 families had been provided with paediatric hospital in the home care in NSLHD, all of which were provided with the opportunity to complete the family satisfaction survey. Families received their hospital level care through HITH whilst residing at home and either attending a HITH clinic daily, receiving nursing care in the home or a combination of the two. Only families of children who received this paediatric HITH home care were included in the study.
Submitting completed satisfaction surveys, questionnaires and ratings scales was considered as consenting to participate in the study. They could withdraw their responses any time before submitting the satisfaction surveys, questionnaires and ratings scales but once submitted responses could not be withdrawn because they are anonymous collated by an online survey program.
Participation in this research study was voluntary. Participants were free to withdraw at any time and free to stop the interviews at any time. They were also able to refuse to answer any questions that they did not wish to answer during the interview. Participants were not expected to receive any direct benefits from being in the study or to suffer any distress as a result in participation in this Master‟s thesis study. Contact details for participants who had any concerns about the study were provided in the Participant Information Statements (PIS)
(Appendix 14).
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3.2.3.1. Participant Inclusion Criteria
Participants for the first three levels of the evaluation were the nurses from the NSLHD
APAC community nursing service who had completed the following training; a) Emergency
Nurse Paediatric Course (ENPC); b) Resus4Kids - paediatric life support; c) DETECT Junior
- deteriorating child training; d) Child Protection training; e) Medication Administration to
Children; and f) the optional ward experience placement on a children‟s ward. Participants for Level 3 Behaviour evaluation only, were the paediatric hospital in the home Clinical
Nurse Specialists (in addition to the APAC community nurses). All families of children who had received HITH care were invited to participate in the fourth evaluation level.
3.2.3.2. Participant Exclusion Criteria
APAC nurses who had not undergone the paediatric nursing training for hospital in the home were not invited to participate in this Master‟s thesis study. The family satisfaction survey was only provided in English which may have excluded some parents from participating.
3.2.4. Participant Anonymity
The data collection has 4 distinct elements to it, each related to one of the Levels of KM. For levels 1,2 and 4 the data were survey results collected via an online survey collection tool familiar to NSLHD staff and as such collected anonymously from nursing staff and families.
Individual staff members or patients are not identifiable from their responses. The APAC nurses were asked to participate in the completion of ratings scale about the different aspects of the training and a knowledge questionnaire, that was available via an anonymous online survey tool, and that could be completed simultaneously.
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The data for the third level were recorded and transcribed verbatim from the one-on-one interviews with some of the APAC nurses and paediatric clinic nurse specialists. Individuals were not asked to identify themselves in the interview, and the transcribing de-identified them and their work location. All attempts were taken to de-identify individuals and data were analysed as a collective rather than individual interview analysis. However, 100% guarantee of anonymity could not be provided due to the small potential cohort of participants. This was reflected in the Participant Information Statements (PIS) and as part of the consent process prior to each interview undertaken (Appendix 14).
The APAC nurses and the paediatric clinical nurse specialists were invited to attend a semi structured interview with the investigator. The interviews were audio recorded for transcription purposes. Once an accurate transcript was obtained the audio recordings were deleted. Participants were offered the option to request to review the transcript of their interview as detailed in the Participant Information Statement but none requested to do so.
3.2.5. Participant Information Statement
The Participant Information Statements (PIS) were provide to the APAC nursing staff and the paediatric HITH clinical nurse specialist who were invited to participate in the study
(Appendix 14). It contained information pertaining to the study, the researcher, the consent process, data collection, anonymity and confidentiality.
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3.3. Data Collection
3.3.1. Data Collection Period
Data collection for the four levels of the evaluation model was collected concurrently for 19 months, commencing 3 October 2017 following the receipt of Site Specific Assessments
(SSA) from NSLHD and completed by 22 May 2018.
3.3.2. Participation Time
Completion of the ratings scale and questionnaire completed online was estimated to take about 15 minutes. It was estimated that the interview should take between 30-45 minutes. The online survey collection tool utilised indicated that the average completion times for the surveys were; Reaction Training Ratings Survey was 3 minutes; Learning Knowledge
Questionnaire Survey was 6 minutes. The Behaviour semi-structured interviews were ranged from 10:38 minutes to 30:23 minutes in length with a mean time of 19:10 minutes. The
Results Family Satisfaction Survey completion time average was not captured as some surveys were completed online and others submitted to staff as a hard-copy and results entered by staff to the online survey.
3.3.3. Data Security
All data collected for this study were gathered electronically and stored in a password secured laptop computer. Some study materials and notes were temporarily recorded as paper copies.
Once transferred to electronic format all paper files were shredded prior to disposal. Only the researcher and the supervisors, had access to the data. The data collected from the ratings scales and knowledge questionnaire were collected anonymously via an online survey collection tool. The online survey collection tool account was specific to the study and not
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available or accessible by anyone other than the investigator. The data and data analysis from an online survey collection tool were utilised and included in this Master‟s thesis. Collective data may be used and published in future journal publications related to the study but individual responses and respondents will not be identified.
The interview data were collated and analysed as a collective and not as an analysis of individual performances or appraisals. The purpose of the study was to evaluate the training as a whole and not as an evaluation of individual APAC nurses‟ practice. Any information obtained during this Master‟s study that suggested malpractice or unsafe clinical practice by nursing staff would have been discussed with the individual and referred to NSLHD management, as per section 2.4 of the NSW Health Code of Conduct (NSW Health, 2015).
Written consent was received from all participants in the interviews. Consent to the surveys and questionnaire was implied by their voluntary participation in anonymous online surveys.
The information collected for this study may be used in future projects. By providing their consent they agreed to allow us to use their information in future projects. Ethical approval will be sought before using the information in any future projects.
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4. RESULTS
This chapter details the qualitative and quantitative data collected and collated for each of the four evaluation levels of the Kirkpatrick model. The data for each level is presented separately in this chapter along with sample size information and survey response rates.
4.1. Results for Level 1 Reaction
The paediatric training was composed of distinct aspects from existing educational resources and short courses named; Emergency Nurse Paediatric Course (ENPC), Resus4Kids,
DETECT Junior, Child Protection, Medication administration to children, and a supernumerary placement experience on a children‟s ward. A set of four questions was repeated for each of the elements of the training;
Interesting The (insert name of course) was interesting
Knowledge and skills The (insert name of course) provided the knowledge and skills I
needed to care for children and families at home
Confidence After the (insert name of course) I was more confident about caring
for children and families at home
Applied knowledge After the (insert name of course) I have successfully applied the
knowledge to care of children at home
There were 16 individual respondents, out of a possible 30 APAC nurses invited to respond, but not all respondents completed all parts to survey as sections may not have been relevant or applicable to individuals. For example, there were only 9 individual respondents to the 4 questions related to placements on the children‟s ward as resources and rostering resulted in
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this being offered to a limited number of APAC nurses. Some gaps in the survey could not be explained but it could be speculated this was due to respondent error, accidental or intentional omission of the question in the survey. The mean number of respondents per question was
13.6 across all the questions and 14.5 when excluded those questions related to the ward experience placements.
Each question was rated on a 5 point Likert Scale (Likert, 1932) with 1 being the lowest score for Strongly Disagree and 5 the highest for Strongly Agree. The mean scores for each question are detailed in Table 5 (Appendix 15). The overall average mean for all of the questions was 3.5. The ENPC course had the lowest average score of 2.20 for the question related to application of knowledge. The highest average score was 4.0 associated with the
„interesting‟ and „knowledge/skills‟ questions related to the ward placement experience.
When one looks at the average scores across the 4 questions related to each aspect of the training, the ENPC scored the lowest, the ward experience scored the highest and the other aspects of the training had similar scores with their overall averages ranging from 3.54 to
3.58 (Table 6).
Table 6: Mean Reaction Ratings across the 4 Questions for Each Aspect of the Training
ENPC Resus4Kids DETECT Child Medication Placement Junior Protection administration experience to children Average number of 14.8 13.5 13.8 15.8 14.5 9.0 respondents (n) Average (Mean) Reaction Rating 2.91 3.58 3.54 3.57 3.56 3.86
Range (5 = highest) 1 to 5 1 to 5 1 to 5 1 to 5 1 to 5 1 to 5 Standard 1.24 1.11 1.12 1.17 1.06 2.06 Deviation
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The high Standard Deviation for the Placement Experience is possibly attributable to the low n value. The experiences of nurses on a paediatric ward were for a short period, often 1 or 2 shifts only. As such their experiences would be influenced by day-to-day variations in the ward environment including staffing and patient conditions resulting in differing learning opportunities.
The mean scores for the comparable questions are detailed in Table 7. Here the average score for the same questions related to each aspect of the training are collated. For example, all questions related to the (insert name of course) was interesting are collated for; Emergency
Nurse Paediatric Course (ENPC), Resus4Kids, DETECT Junior, Child Protection,
Medication administration to children and placement experience on a children‟s ward. The scores show a decrease as they progress with confidence and applied knowledge questions receiving the lowest scores. The applied knowledge questions average score was particularly influenced by the extremely low score for the application of knowledge from the ENPC course.
Table 7: Mean Reaction Ratings for comparable questions across all aspects of the paediatric nursing training
Question 1 Question 2 Question 3 Question 4 Interesting Provided Increased I have Content Knowledge and Confidence Applied Skills Needed After Training Knowledge Average number of 13.2 14.7 13.5 13.8 respondents (n) Average (Mean) 3.76 3.64 3.44 3.18 Reaction Rating
Range (5 = highest) 1 to 5 1 to 5 1 to 5 1 to 5
Standard Deviation 1.58 1.61 0.91 0.98
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4.2. Results for Level 2 Learning
There were 15 respondents to the knowledge questionnaire out of a possible 30 APAC nurses invited to respond giving a response rate of 50%. Out of the 25 questions the lowest score was 72% and the highest 100% with a mean score of 21/25 (82%) and a median of 80%. The expectation had been for a pass mark of 76%. There were 3 individual scores of 72% that missed the expected pass mark by 4% which is equivalent to one incorrect answer.
There were notable clusterings of correct and incorrect answers, with 13 questions being answered 100% correctly by all respondents, 5 questions were answered correctly 80-93% and 6 questions between 40-73% correctly. One question had an accuracy of only 13%. The question accuracy rankings and average scores are detailed in Table 8 (Appendix 15).
4.3. Results for Level 3 Behaviour
There were 9 semi-structured interviews undertaken; seven with APAC community nurses and two with paediatric clinical nurse specialists. The interviews were semi-structured enabling the researcher to pursue lines of enquiry through follow-up or probing questioning, for example (Appendix 16);
Because at the beginning you said that you were feeling more comfortable with
teenagers…but smaller children not so much? What particular aspects made you
nervous or potentially nervous?
Some of the probing questions were developed as part of the semi structured interview plan to be used if required, for example;
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Are you able to give me any examples of perhaps when communication has gone well
with children and families and when not so much?
4.3.1. Phase 1
Giorgi‟s Framework (Giorgi, 2012) was adopted for a thematic analysis of the semi structured interviews (Figure 5, Appendix 11). The first phase Sense of the Whole involved reading each of the interview transcripts to formulate initial thoughts about the overall experience of the nurses, to get a general sense of the whole. The opportunity to formulate first thoughts about meaning units was provided.
4.3.2. Phase 2
In Phase 2 Discrimination of Meaning Units the transcripts were read again to identify themes and commonality as discriminated meaning units and to relate them to each other, and summarised in Appendix 16. The meaning units were highlighted in the transcripts and consisted of single words, extracts, sentences and anecdotes such as;
that was really challenging because I‟m thinking this is something that‟s so easy for me
is now not easy, it‟s quite difficult, and I‟m thinking, “Am I recording it accurately”
and I know respiratory rates so important for children as well and I‟m thinking, “If I‟m
not counting it right because they‟re screaming or chatting away, then what
implications does that have?” So it sort of made me quite conscious about what I was
doing and how I was doing it. But that kind of worked well in the end, speaking to the
parents and kind of having just a normal conversation and calming the child down that
way. Because I think before I was trying to soothe the child but obviously I‟m a
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stranger to them, so that‟s not going to work at all. So, yeah, I suppose that was a
learning curve.
In Appendix 16 there are examples of extracts from the transcripts and highlighted meaning units along with notes made during this phase of analysis.
4.3.3. Phase 3
In Phase 3 Transformation of Themes into Theme Categories a modified Giorgi framework was used and the meaning unit reflected upon to create sub-themes and themes (Appendix
17) and then eventually the transformation of themes into theme categories (Appendix 18).
Some meaning units were associated with more than one theme. Examples of themes that emerged from the meaning units included; the participants emotions and feeling about caring for sick children and their families, a lack of previous experience, an awareness of what is required to be a paediatric nurse, differences between adults and children, communication challenges, more comfortable with older children and the influence of personal experiences with children on their comfort with paediatrics.
Further reflection on the themes to define the essence of experience for participants resulted in the theme categories. The theme categories identified (Appendix 18) were: a) Clinical experts in adult community nursing care but not in paediatric nursing; b) Emerging understanding of the import aspects of paediatric nursing including caring for the family and not just the child; c) Association between confidence communicating with children and competence in paediatric nursing; and d) Emerging competent paediatric nursing practitioner.
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4.3.4. Phase 4
In Phase 4 Synthesis a consistent statement about the experience of the paediatric training for each of the participants was developed as follows;
The APAC nurses are highly skilled clinicians in community nursing who have
embraced increasing their portfolio to include the care of children at home. The
paediatric training they have received has been adequate but lacks practical experience,
learning from skilled paediatric clinicians and exposure to children and families to
further develop their paediatric skills. Their competence and confidence is growing but
to progress the opportunities for them to put their learning into practice need to
increase. More practical learning opportunities such as the ward placement but also
through scenario or simulation training were their primary learning requirements, as
well as potential opportunities to interactive with well children to increase
communication confidence.
4.3.5. Phase 5
In Phase 5 Final Synthesis the experience of all the participants was synthesized into one statement to capture essence of the paediatric training as a whole as follows ;
The experienced community APAC nurses received adequate paediatric training but
require further opportunities to continue to develop their practical paediatric nursing
skills and to progress to becoming expert practitioners caring for children and families
in their homes.
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4.3.6. COREQ Checklist
The COREQ (Consolidated criteria for Reporting Qualitative research) checklist was utilised for the reporting of this qualitative research data. This 32-item checklist tool was developed to assist researchers to provide comprehensive reporting of qualitative studies including interviews (Tong, Sainsbury, & Craig, 2007). Details are summarised in Appendix 19.
4.4. Results for Level 4 Results
4.4.1. Part A - Family Satisfaction Survey
There were 138 responses from families to the Consumer Satisfaction Survey from 3 October
2016 to 30 April 2018 (19 months). Over the same time period there were 1,428 separations from NSLHD paediatric hospital in the home care in NSLHD (NSW Health, 2018b) resulting in a response rate of 9.6%. Of the 138 respondents not all responded to every question in the survey with an average of 88% questions completed per respondent. However the majority of questions were completed by all or almost all respondents. The last three questions related to identifying any negatives about the service or free text options were completed by significantly less respondents, between 32% to 54% (Figure 7, Appendix 15).
The first question was related to demographics and simply asked the age of the child who had received HITH care. The responses revealed a spread of ages similar to that of admissions to the paediatric inpatient unit at Royal North Shore Hospital (Figure 3a, Appendix 3) with around 50% under the age of 2 years, and a decrease in numbers as the age increased. This is suggestive of an equal distribution of inpatients who were receiving HITH care as an alternative and that the responses were a fair reflection of the HITH patient age ranges
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(Figure 3b, Appendix 3). Question 2 showed 42% of respondents‟ children were female and
58% male.
Families‟ responses to Question 3 showed 36% selected „other‟ when asked what condition their child received HITH treatment for. They were requested to detail what „other‟ meant.
When the „other‟ responses were broken down the dominance of infection as the clinical condition was clear at 68% (Figure 8, Appendix 15).
Question 4 asked „what type of treatment did your child receive from Paediatric HITH?‟
Bearing in mind the response to Question 3 and the dominance of infection as the condition associated with their HITH admission, the majority of children (52%) were receiving intravenous medications in particular antimicrobial medications through HITH. This correlates with the 68% of children having HITH care for infections (Figure 9, Appendix 15).
In question 5 respondents were asked “Where was your child referred to HITH from?” The main source of referral was the children‟s ward (72%) associated with their local hospital or from the local emergency department (18%) to paediatric HITH. Referrals from other sources including other wards, other hospitals, paediatric clinics, general practitioner or private paediatrician totalled 9%.
Paediatric hospital in the home has the options of daily treatment provided in the child‟s home, to attended hospital clinics daily in the children‟s ward or a combination of the two.
Question 6 showed 55% received in care in the clinics, 14% at home only and 31% through a combination. When asked how long they received HITH care for, the responses supported the average length of stay for Paediatric HITH in NSLHD (2016-2017) of 3.31 days (Table 16,
Appendix 15), but with the majority of children (79%) receiving HITH care for 1-3 days.
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Question 8 asked about „How long does it usually take you to travel from home to hospital?‟
This suggested the large majority of families were very local with 87% within 30 minutes of their local hospital (of which 39% were less than 15 minutes travel from their local hospital).
12% had 30-60 minutes travel from home to local hospital and only 1% had 1-2 hours travel.
No-one had over 2 hours travel. This may be influenced by the geographical size of the Local
Health District (Appendix 20). When asked in Question 9 „How do you normally travel to hospital?‟ 95% of respondents chose private car with walking, taxi and public transport making up the remaining 5%.
In Question 10 families were asked to rate their child's condition when they started care through HITH and when they were discharged from HITH. The averages were 5.1 at the time they were referred to HITH and 8.17 when discharged.
An aim of paediatric hospital in the home is to minimise the impact of hospitalisation on a child‟s life. School and child care are important aspects of normality in a child‟s life.
Question 11 asked about the amount of time a child missed of school or child care when receiving HITH care.
The survey indicated that 42% of children missed no days of school or childcare, and a further 35% missed on one or two days, only 5% missed a week and no one missed more than two weeks (Figure 10, Appendix 15). However, not all pre-school age children attend child care, some are too young to attend child care and some children were on school holidays at the time of their care. This question was therefore not relevant to some possibly resulting in a
0 days missed response or not responding by skipping the question as indicated in the free text.
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Question 12 asked families for their overall rating of the paediatric hospital in the home service. The average was 9.3 out of a possible 10. Question 13 then asked families to rate specific questions about their HITH care experience (Table 9).
Question 14 asked about the positive aspects of paediatric HITH from the families‟ perspective. Families were able to tick as many aspects that they believed to be applicable to them. This resulted in a ranking of positive aspects (Table 10, Appendix 15). Families who chose „other‟ were asked to specify and these were grouped as per Table 11 (Appendix 15).
The top ranked positive aspects of paediatric HITH were: 1) Staying at Home; 2) Support by nursing and medical staff; 3) Ability to care for the rest of the family and 4) Access to care for my child when needed.
Table 9: Family Satisfaction Ratings of Paediatric HITH service
Family Satisfaction Survey Questions n Range Rating Standard Average Deviation 10 = highest
Were you involved, as much as you wanted to be in 138 1 to 10 9.41 1.12 decisions about your care and treatment?
Do you feel you had access to clinical staff when 138 1 to 10 9.42 1.14 you needed?
Would you recommend the HITH service to other 137 1 to 10 9.62 0.86 families?
Would you use the HITH service again? 137 1 to 10 9.65 0.9
Did you feel supported by the visit(s) from the 116 1 to 10 9.69 0.86 nurse?
Were you satisfied with the treatment given by the 124 1 to 10 9.74 0.81 nurse?
Overall how would you rate the Paediatric HITH 138 1 to 10 9.24 1.12 service?
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The other positive aspects followed a similar vein with the top categories being; comfort/normality of home and access to same specialist medical/nursing staff, without waiting in Emergency Department again.
Families were then asked in Question 15 to identify the negative aspects of paediatric HITH.
Similar to question 14 families were asked to identify as many aspects as they believed were applicable to them. Only 32% of respondents responded to this question perhaps indicating that 68% could not identify any negative aspects of the survey (Table 12, Appendix 15). This degree of satisfaction was indicated in question 12 with a 9.3 out of 10 overall satisfaction rating. The breakdown of the „other‟ responses from the free text showed 43% of respondents expressing no negative aspects of their paediatric HITH experience (Table 13, Appendix 15).
The travel costs related to costs to attend the hospital if required for treatments unable to be provided in the home or routine medical reviews. The distance from the hospital was identified as a negative by some families and this again related to attendance at the hospital if required or access to hospital in the event of deterioration at home.
The last two questions were free text. Question 16 asked „What do you think we could improve?‟ These have been collated and grouped in Table 14 (Appendix 15). The highest ranked comment at 35% was „no comment‟ which included nothing else to add. 26% of comments were related to communication issues including issue between staff such as not expecting a child to present for HITH at the weekend, and information to families about
HITH and what to expect. Reduced waiting times, was a reference to waiting to see clinical staff when returning to a hospital clinic for their daily treatment, and was an area for improvement noted by 13% of respondents. Over 18% of respondents took the opportunity in the „how can we improve‟ free text to complement HITH on an excellent service (Table 14,
Appendix 15).
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In Question 17, families were asked an open question „Is there anything else you'd like to tell us?‟ The free text responses have been collated and grouped in Table 15 (Appendix 15). The breakdown process and grouping of the „other‟ responses in questions 16 and 17 was undertaken in the ethos of the Giorgi Framework (Giorgi, 1989) to identify themes in responses and then group then into common categories and themes. Almost 84% of the additional comments were positive and complementing the service and staff. A small percentage (5.5%) was either disappointed with the level of clinical support or had communication issues, similar to the negative aspects identified earlier in the survey.
4.4.2. Part B – Clinical Emergency Response Data
The „Between the Flags‟ (BTF) system (Figure 6, page 62) is designed to assist staff identify deterioration in all patients, including children and young people, and respond appropriately
(Clinical Excellence Commission, 2018).
Table 17: CERS Response Data for Paediatrics in NSLHD (2017) RNSH Paediatric Inpatients NSLHD Paediatric HITH (2017) (2017) YELLOW ZONE No. of Clinical Reviews No. admissions from Home to Ward RESPONSE n =524 calls n = 29 calls (65.4/1000 separations) (29.1/1000 separations)
RED ZONE No. of Rapid Responses No. of Ambulance Calls RESPONSE n = 92 n = 2 calls (12.3/1000 separations) (2.0/1000 separations)
Source: NSLHD Presentation at the NSW Hospital in the Home Forum (Jones, 2018)
The yellow and red zone expected clinical responses for the Paediatric Inpatient Ward at
Royal North Shore Hospital (RNSH) in NSLHD and the NSLHD Paediatric HITH service are
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defined within the departmental Clinical Emergency Response Systems (CERS) for NSLHD as required by NSW Health (NSW Health, 2013b). The CERS response data were provided by the NSLHD Clinical Governance Unit (NSLHD Clinical Governance Unit, 2018). The number of yellow zone and red zones responses for paediatric HITH were significantly lower than for the paediatric ward at RNSH (Table 17).
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5. DISCUSSION
The Kirkpatrick model (KM) provides a framework for evaluating the effectiveness of workforce training for any industry including the healthcare industry (Kirkpatrick &
Kirkpatrick, 2007). This chapter discusses the qualitative and quantitative data obtained for each of Kirkpatrick‟s training evaluation levels; Reaction, Learning, Behaviour and Results, and the relevance to nursing education.
5.1. Discussion of Level 1 Reaction
As Kirkpatrick (page 41) explains;
“Level 1 Reaction is the level most familiar to learning professionals, and one of the
simplest to evaluate” (Kirkpatrick & Kirkpatrick, 2016).
This simplicity makes the results easy to understand but limits any depth in evaluation of the training, as it is simply the participant‟s initial reaction to the training undertaken. It is the immediate reaction of participants to their level of satisfaction with training undertaken. The relationship between training satisfaction and learning has been explored by some authors
(Johnson, Aragon, & Shaik, 2000; Mansour, Nahi, & Leclerc, 2017). A positive relationship between training satisfaction and normative commitment, which has a positive effect on readiness to transfer learning was demonstrated (Mansour et al., 2017). However, the positive perceptions of participants about online or face-to-face training courses have been noted not to effect learning outcomes (Johnson et al., 2000).
The ENPC course attracted the lowest satisfaction ratings out of the various aspects of the training, but commentary from the ratings surveys and from the interviews in level 3 suggest
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that participants appreciated the importance of this training despite being possibly intimidated by the intensity of the course. For example;
“I think it unnerved a lot of nurses…It scared people about paediatrics…Very
necessary and fantastic course …Good course but stressed about doing exam at end of
the course” (Appendix 17)
Paediatric nursing placements for student nurses have been described as “the most stressful rotation” (Coetzee, 2004).
There was an acknowledgement of the extent of the knowledge associated with paediatric nursing as a speciality. This was further highlighted by individuals commenting that they should have done more of the preparation/pre-reading before undertaking the ENPC course, suggesting an underestimation of the volume of learning required. A study examining factors that affect participant‟s overall satisfaction with training in particular their immediate reaction to training demonstrated that the perceived usefulness of training had the strongest effect (Giangreco, Sebastino, & Peccei, 2009). The Kirkpatrick authors note that this first level can hold importance to the overall evaluation because positive reactions to training improve learning (Kirkpatrick & Kirkpatrick, 2016).
In the Reaction level a set of four questions was repeated in a ratings survey for each of the elements of the training. These four questions could be seen as a reflection of the Kirkpatrick model itself, with each question potentially correlating to one of the KM levels. As such by comparing the questions to the KM levels the APAC participants almost provided an initial insight into the levels of evaluation for the paediatric nursing training. For example, the rating question about how interesting was the training could be indicative of a Reaction evaluation.
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Similarly the knowledge and skills question and the Learning level evaluation; confidence about caring for children and families at home question and a Behaviour evaluation level; and the application of knowledge question and a Results evaluation level could be indicative of each other. The first two questions having the highest response rates and declining slightly as the questions progress, with the lowest associated with confidence caring for children and the application of knowledge to practice. This Reaction evaluation may have indicated an insight into the overall results of the study.
5.2. Discussion of Level 2 Learning
The expectation of the Knowledge Questionnaire had been for a pass mark of 76%. Out of the 15 respondents, 3 had individual scores of 72% missing the expected pass mark by 4% which is equivalent to one incorrect answer. This suggests that the training program provided the relevant knowledge required for paediatrics as defined by the ACCYPN Standards. It is important for the APAC nurses to want to learn about paediatrics and be enthusiastic about expanding their scope of practice to included children and their families. Poorer learning outcomes are known to result from a student not being motivated to learn (McMillan &
Forsyth, 1991; Wlodkowski & Ginsberg, 2017). As children are a small proportion of the
APAC caseload, then it would seem manageable to allocate paediatric patients to those
APAC nurses welcoming of providing nursing care at home to children and their families, and undertaking the paediatric nursing training.
In question number 9 it asks; „In the ABCDEFG acronym for paediatric assessment, what does the E stand for?‟ the correct answer was Exposure as it pertains to body temperature and the impact of environment on this (Clinical Excellence Commission, 2012; Corrales & Starr,
2010). The next answer option was Environment which is arguably a similar term and one
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was in other paediatric assessment acronyms. For example in the Trauma Primary Survey acronym E stands for Exposure or Environment (The Royal Children's Hospital Melbourne,
2018). It is therefore not inconceivable that some individuals may have learned the correct concept but confused terminology. The outcome of this knowledge question was considered a criticism of the survey design rather than necessarily a reflection of attained knowledge. If both Exposure and Environment were accepted as correct answers then 93% of respondents would have answered the question correctly.
Question 10 scored as the most difficult question with an average score of only 13%. The question was related to the age of consent for medical treatment. The correct answer was „any age if they are deemed competent to do so‟ as based on the Gillick Competence (Griffith,
2016). Gillick competence is a principle used to judge if a child has the capacity to consent to medical treatment based on the ability to fully understand the medical treatment being proposed and not solely on a person‟s age. Other answer options were 14 years, 15 years and
16 years of age. Of the incorrect answers 40% chose 14 years of age and 46.7% chose 16 years, with no-one choosing 15 years of age. Most people over the age of 16 years of age are assumed to be Gillick competent and commonly assumed that at 14 years of age children should have the option to consent for themselves. The fact that 40% chose 14 years of age raises questions about the delivery of the teaching material related to the subject of consent and if the issue of consent was presented as over 14 years and not as any age they are competent to do so. NSW Health Consent to Medical Treatment - Patient Information Policy
(NSW Health, 2005), section 25, page 20 discusses „minors‟ and the need that;
“A child aged 14 years and above may consent to their own treatment provided they
adequately understand and appreciate the nature and consequences of the operation
procedure or treatment”.
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It then provides additional explanations that;
“Generally, the age at which a young person is sufficiently mature to consent
independently to medical treatment depends not only on their age but also on the
seriousness of the treatment in question relative to their level of maturity. The health
practitioner must decide on a case-by case basis whether the young person has
sufficient understanding and intelligence to enable him or her to fully understand what
is proposed”.
When reviewing the phraseology of this knowledge question arguably none of the answers for question 10 are incorrect as a child can provide their own informed consent at 14 years old, 15 years old, 16 years old or any age if they are deemed competent to do so. This casts doubt as to not only whether there is only one correct answer to the knowledge questionnaire but the overall validity of this question in the survey.
For the Reaction and Learning levels there were small sample sizes. This was a consequence of a limited potential participation group due to the specific requirements of the participants invited. Small sample sizes can be a criticism of a study although this can be justified by the specific requirements of a survey (Ranse et al., 2014).
5.3. Discussion of Level 3 Behaviour
The themes from the interviews were further condensed into the theme categories (Appendix
18); a) Clinical Experts in adult community nursing care but not in paediatric nursing; b)
Emerging understanding of the import aspects of paediatric nursing including caring for the family and not just the child; c) Association between confidence communicating with
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children and competence in paediatric nursing; and d) Emerging competent paediatric nursing practitioners.
5.3.1. Theme 1 - Clinical Experts in Adult Community Nursing but not in
Paediatric Nursing
There was an overall sense that both the APAC and paediatric nurse specialists were extremely experienced in their own specialised field of nursing either paediatrics or adult community nursing. As experienced, expert practitioners were very aware of their learning needs to maintain a high standard of care for a new patient population. The concepts of paediatric nursing as a distinct speciality requiring a specifically trained nurse was highlighted by all of those interviewed in different forms.
“It‟s a completely different area of nursing, as far as I‟m concerned” (Transcript
11720_0007)
The collectively low level of paediatric experience, with most having previously never cared for children and some having some paediatric experience usually early in their career expressed in the interviews was similar to the results discussed in introductory chapter.
There was an overall positivity and sense of excitement from the APAC community nurses about extending their role to include children and families but with one nurse respectfully but clearly stating their desire not to do paediatrics having specifically chosen a career path to not do so. This was reflective of the APAC nurses‟ feelings about starting to care for children and families and the 77% who expressed a positive response and the small group who expressed a more negative „being nervous‟ response (Northern Sydney Local Health District,
2016). This general positivity can be seen as motivation through purposeful engagement, as
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described in the Heuristic Model of College Students‟ Motivation. This motivation can lead to improved learning outcomes because;
“if students believe they are able to satisfy the needs, then they will be motivated to
behave in ways that will meet the needs” (page 42) (McMillan & Forsyth, 1991).
One of the interviewees had no interest in children being part of their professional or personal life and was defensive about this point. This complete lack of interest in paediatric/child health nursing was not captured in the survey of APAC nurses prior to the establishment of paediatric HITH as discussed in the introduction. The paediatric training was believed to have been targeted at APAC nurses who had an interest in paediatrics or learning about paediatrics. The response of this individual did not completely reflect this.
I don‟t have children. I‟ve got no interest in children. I don‟t want children. I don‟t
like children. I don‟t think I can be any clearer. No interest in doing it at all.
(Transcript 11720_0007)
This interview was the shortest of the interviews requiring a lot of probing questions and the interviewee was apologetic that he or she was saying what the interviewer wanted to hear.
The result was a condensed but rich counter perspective compared with that of other community nurses interviewed.
The general positivity towards including paediatrics into their role was often expressed in terms related to professional development, and the notion of challenging or expanding their professional skills and knowledge. The excitement seemed almost egocentric, coming from their personal sense of satisfaction or rising to a challenge or as one nurse describes;
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“puts another feather in your cap” (Transcript 11720_0006)
The Interpretive Description philosophy acknowledges that the researcher is active in the research process. An example of this can be observed with a brief comment of “That‟s
Paediatrics” to encourage the interviewee to continue narrating their experiences caring for children demonstrating the researcher‟s understanding of paediatric nursing and the familiarity with the interviewees (Transcript 11720_0005).
There was no reference to children and families or of benefits to them as a result APAC nurses providing care in the home for them in the interviews. There was almost a sense of inevitability that APAC would expand to include paediatrics. That it was something that need to happen or a natural progression for the service. With one person even suggesting it would be a;
“travesty if children were not able to have care at home” (Transcript 11720_0009)
5.3.2. Theme 2 - Emerging Understanding of the Important Aspects of
Paediatric Nursing Including Caring For the Family and Not Just the
Child
Despite the paediatric training there remained a lack of comfort with the concept of caring for children and understanding of paediatric nursing. There were examples of learning about children being applied to practice but there remained unease amongst the APAC nurses and a lack of familiarity with children and paediatric nursing. In terms of Benner‟s Novice to
Expert Scale (Benner, 2000), the APAC nurses caring for children and families perhaps perceived themselves as having progressed only from novice to beginner. One of the APAC nurses when interviewed mirrored Benner‟s language to describe his or her self as;
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“as novices being introduced to (paediatrics)” (Transcript 117720_0006)
The minimum expectation for nurses in an area of autonomous clinical practice such as community nursing would be at a level of competent. As such they would be to be able to nurse children without supervision (Appendix 21). The APAC nurses were acknowledged by their peers, the paediatric nurse specialists, as well as self-identified as experts in community nursing but for most they started their journey into paediatric nursing as novices. The loss of role familiarity, in this case familiarity with a patient population and reverting to novice practitioners in the new nursing specialty has been identified in nurses‟ experiences related to transitioning from acute to community nursing (Ashley, Halcomb, & Brown, 2016; Godfrey,
2006; Zurmehly, 2007). For the APAC nurses the nursing environment had not changed but the client group had however the loss of familiarity and loss of expert status was comparable.
It is important to recognise that not being an expert in a new speciality of nursing such as paediatrics does not mean an individual is no longer competent as a nurse in that speciality.
The APAC nurses were experienced competent practitioners and coped with complex situations through deliberate analysis and planning by applying existing nursing knowledge and critical thinking in less familiar nursing scenarios.
The paediatric training courses undertaken as part of the paediatric nursing training program for the APAC nurses were perceived as important as grounding knowledge about the children and differences in paediatric and adult nursing. However, the community nurses needed increased opportunities to care for children and families to be able to apply this new knowledge and skills into clinical practice regularly. Similar challenges of training nurses to care for children and the limited opportunities to develop skills, and practice skills to build nursing confidence have been described, and the introduction simulation training specific to paediatrics as a response in particular to better prepare nursing students for paediatric clinical
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placements (Bultas, 2011; Clarke & Davies, 2004). Scenario and simulation training could assist with confidence through skills and knowledge acquisition but ultimately it is the limited experiences of interacting and communicating with children of all ages and their families that was preventing them from developing their competence and confidence in the delivery of expert paediatric nursing care.
A literature review exploring the experiences, requirements and challenges for nursing transitioning from acute to primary health care identified key themes. The three key themes were: (1) a conceptual understanding of transition, (2) role losses and gains, and (3) barriers and enablers (Ashley et al., 2016). The review concluded that there was a lack of research in this area. A similar lack of research was noted related to nurses transitioning from caring for adults to caring for children, although information related to transition programs in US hospitals was identified (Children's Hospital and Medical Center Omaha, 2019). No research was found specific to the transition of nurses from adult community to paediatric community nursing that would be directly comparable with this study.
Personal experiences were important to the APAC nurses‟ self-identified comfort levels with children. They attributed their comfort when communicating with children to having their own children or grandchildren or having done some paediatric nursing in the past. The reverse was expressed by those who were not comfortably communicating with children who attributed this to not having children or experience, personally or professionally, with children. Both sides sharing a common thought that having children of one‟s own was a benefit when expanding the APAC portfolio to include paediatrics. Establishing client relationships has been identified for nurses transitioning from one speciality area to another and the reestablishment as an expert nurse in new area of nursing (Ashley et al., 2016;
Godfrey, 2006).
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The 2-day Emergency Nurse Paediatric Course (ENPC) evoked a lot of discussion from the interviewees. A common phase associated with the course was that „it scared the APAC nurses‟ who attended about caring for children. It was also criticised for being too focused on emergency care of paediatrics and not necessarily relevant to the community setting. Despite this the ENPC course was still perceived as having a lot of value, interesting and necessary.
The course also surprised many who exceeded their own expectations in the assessment by achieving a pass mark for the course and receiving the certificate of successful completion.
When transitioning between specialist areas the literature suggests that nurses could have unrealistic expectations related to transferability of their skills from one specialist area to another (Ashley et al., 2016; Zurmehly, 2007).
The paediatric training overall was seen as relevant and interesting but the most valuable aspects were those associated with practical experience or training, in particular the placement experiences on a paediatric ward, undertaking home visits to children with the paediatric clinical nurse specialist (CNS), face-to-face training from the paediatric staff, and practical training such as paediatric life support, deterioration scenarios and child protection.
The least valued training aspects related to the online training including the medication administration course. Advances in technology has generated an increasing demand for online learning which has advantages of flexibility and is self-regulated but it is not without its challenges including academic rigour, although, research indicates that the advantages of online learning outweigh the challenges (Gilbert, 2015), and that well designed online education can be effective and appropriate for nursing education (Karaman, Kucuk, &
Aydemir, 2014).
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There were expressed preferences for practical teaching about paediatric medication calculations and administration techniques for children as a more beneficial alternative. There was a very strong, repetitive theme that the APAC nurses required more opportunities to put their training about paediatrics into practice, as well as opportunities to experience interacting with children, often described as needing increased exposure to children and families. The
APAC nurses perceived a strong correlation between increased exposure to children and caring for children, and their increased confidence communicating and interacting with children. A systematic literature review of the education of student nurses highlighted the wish of student nurses for more clinical practice (Jeppesen, Christiansen, & Frederiksen,
2017). This was supported by the participants in the paediatric ward placements who all identified this as the most valuable aspect of their paediatric training program. Those who did not have the opportunity usually due to staffing constraints, similarly saw this as the most valuable training they needed and would take the opportunity in the future if it arose.
Arguably the essence of Benner is that expert practice is achieved through experience
(Higham, 2013). Scenario based or simulation based training and the concept paediatric clinical skills acquisition in a laboratory setting as an appropriate training option to assist with the improvement paediatric nursing skills, knowledge and confidence could be explored
(Clarke & Davies, 2004; Jeppesen et al., 2017).
5.3.3. Theme 3 - Association between Confidence Communicating With
Children and Competence in Paediatric Nursing
The need for increasing exposure to children and experience in paediatrics were strong themes but so was the lack of opportunity for the APAC nurses to gain this exposure and experience. The numbers of children receiving paediatric HITH care in NSLHD has grown but the number receiving this as home care through APAC has remained a small percentage
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of the community nursing portfolio (NSW Health, 2018b). The challenge of limited opportunities for nursing students to gain experience caring for children in a hospital setting has been highlighted along with the notion of non-traditional children‟s nursing placements being explored, such as community and children with special needs, to broaden students‟ exposure to the expertise of parents and families (Coetzee, 2004).
The need for increasing exposure to paediatrics to increase confidence and competence with children was confirmed by the paediatric CNSs. They expressed similar sentiments that there were no inadequacies in the training but a need for more opportunities to put their learning into practice, and increase their skills and knowledge through increased paediatric experience. In terms of level of expertise the CNSs were confident the APAC nurses could competently care for teenagers and older children in the community, but not the younger children or babies. The association between exposure to children and confidence communicating with children was not specific to sick children and could therefore be achieved through alternative opportunities to be exposed to children including the well child in perhaps schools or childcare centres. Coetzee (2004) unveiled a similar theme in nursing education related to nursing comfort levels interacting with children and the importance of building interpersonal skills specific to children and families that;
“learning to care for children was about working out how to connect with them”
((Coetzee, 2004) page 642).
The RCN identifies „communicating with children and young people to understand their needs, involving them and their parents/carers in decision making and assisting children to care for themselves (page 4)‟ as one of the aspects of training and supervision required for
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practitioners without specific qualifications in paediatric nursing who are caring for children to ensure competence (Benner, 2000; Royal College of Nursing, 2003).
There were variations in levels of experience with paediatrics, enthusiasm for paediatrics and ultimately confidence and competence caring for children between individual nurses. As a collective the APAC nurses are extremely experienced experts in their field of community nursing, each bringing a different résumé of clinical expertise and experience to the role.
Several made particular note of their training or working experience in the UK as of particular relevance;
“my training in the UK certainly gave me a fairly good grounding but it was a long
time ago” (Transcript 171120_0003)
Similarly the UK nurse training system for Registered Children‟s Nurses was referred to;
“in the UK it‟s treated as two separate disciplines (adults and paediatrics)” (Transcript
171120_0008)
As community nurses now caring for children both the APAC nurses and the CNS would seem to agree that the APAC community nurses are not experts in paediatrics. They are, however, generally very willing to learn and take on what they see as the challenge of expanding their portfolio to include paediatrics, and have progressed in their learning and confidence with children. As one APAC nurse described;
“there are plenty of nurses that work for APAC now that wouldn‟t bat an eyelid going
out to see paediatrics” (Transcript 171120_0005)
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The APAC nurses are showing signs of putting the knowledge they have learned into practice but also have an awareness and acknowledgement of the gaps in their learning and expertise.
One of the nurses provided an anecdote related to very consciously applying knowledge from online training about communicating with children into practice;
This sounds quite forced but I did do one of the online learning packages about
communicating with toddlers and if you can show that their parent trusts you, then the
child will then, sort of, start to trust you as well. So when I realised that this kid just
didn‟t want anyone in a nurse‟s uniform to go near them, I went in and, sort of, didn‟t
ignore them but just was speaking to the parents and didn‟t really pay them too much
attention and they calmed down. You know, within about five minutes, they were quite
calm and then I was able to do what I wanted to do. And so initially I‟m thinking how –
like, this is so hard. (Transcript 171120_0005)
The paediatric care provided by the APAC nurses could be perceived as at best being achieved through deliberate analysis and planning but lacking in refinement, intuition or ease.
For example;
“differences that you have to look out for when doing observations, which is such a
basic nursing skill with adults that you don‟t really have to think about it” (Transcript
171120_0005)
“I‟m thinking this (doing observations) is something that‟s so easy for me is now not
easy (because it is on children)” (Transcript 171120_0003)
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5.3.4. Theme 4 - Emerging Competent Paediatric Nursing Practitioners
Applying Benner‟s „The Novice to Expert Scale‟ (Benner, 2000) the APAC nurses could be collectively be described as expert with regard to adult nursing care (Appendix 21). However as nurses providing care for children and families the APAC nurses self-identified as novices prior to the paediatric training. The evaluation provides evidence to suggest the APAC nurses as a group could be viewed as competent with regard to paediatric care, although individually some of the APAC nurses would be working towards or working beyond competent in paediatrics nursing care.
As a beginner practitioner in paediatrics a nurse would be described by Benner as having a working knowledge of key aspects of practice and able to complete straightforward tasks to an acceptable standard (Benner, 2000). As experts in adult nursing care they were able to apply existing knowledge and expertise to fulfil the requirements of a beginner in paediatrics.
Benner describes a competent practitioner as having the following traits; a) good working and background knowledge of area of practice; b) fit for purpose, though may lack refinement; c) able to achieve most tasks using own judgement; d) copes with complex situations through deliberate analysis and planning and e) sees actions at least partly in terms of longer goals
(Benner, 2000).
The evidence for the APAC nurses being competent in paediatric nursing includes the knowledge questionnaire results indicating good background knowledge of care for children and families. This is then supported by the interview responses highlighting examples of coping with situations but being conscious about what one was doing and how one was doing it. This behaviour of practice through conscious or deliberate planning albeit lacking in refinement has already been discussed;
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“adult nurses don‟t have that same continuity or flow with how to approach young
people and even families” (Transcript 171120_0004)
To be described as proficient the APAC nurses would need to have demonstrated a depth of understanding of paediatrics and paediatric practice and be confident in complex situations.
The evaluation outcome of requiring increased opportunities to care for children and build confidence in communicating with children of all ages does not support the status of proficient for the APAC nurses.
One area the APAC and CNS nurses did not agree on was the need for paediatric nursing qualifications. The CNS saw this as a minimum requirement to strive for, but the APAC nurses perception was that this should be considered for a small group of APAC nurses.
Several APAC nurses didn‟t feel they had the capacity to take on a post-graduate course at this point in their life.
When exploring paediatric nursing their perceptions seemed to revolve around two main aspects: parental involvement and the concept of caring for the whole family not just the child, and secondly the emotion of paediatrics both the sadness of seeing children sick and the joy of the affection from them to staff. Family centred care is a fundamental part of paediatric nursing, and important for APAC to have identified this. There was also evidence of the concepts of the importance of age appropriate explanations and the use of distraction therapy emerging in individuals through the examples and scenarios they described.
The paediatric clinical nurse specialists were highly regarded as experts in their field of paediatrics and provided a benchmark or standard to be reached for the APAC nurses for paediatrics. As result the APAC nurses seemed to measure themselves against their skills and
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knowledge to identify their learning deficits and requirements including the need for increased experience with children in order to become paediatric nursing experts.
5.4. Discussion of Level 4 Results
Patient or customer satisfaction, in the Master‟s thesis study the patient/customer being the family, and safety were identified as a „Leading Indicators‟ for this evaluation level
(Kirkpatrick & Kirkpatrick, 2016). Leading indicators can include internal measurements of undesirable situations such as the deteriorating patient in this scenario, as well as external indicators such as customer reactions. This study incorporated a combination of internal, family satisfaction survey, and external, incident data, leading indicators. The evaluation of clinical services through patient satisfaction is well documented in the literature. A systematic review identified that the majority of evaluations of the „Impact of community based nurse-led clinics‟ used patient satisfaction measures (Randall et al., 2017).
The Family Satisfaction Survey demonstrated a very high level of satisfaction among families who had received HITH care. The overall satisfaction rating of the survey had an average was
9.3 out of a possible 10 which was extremely high. Satisfaction ratings about specific aspects of the HITH service had an average between 9.4 and 9.7 out of 10. Other studies have described the high level of satisfaction from families with models of care such as HITH that facilitate families staying at home and avoiding hospitalisation (Angelhoff, Edell-Gustafsson,
& Morelius, 2015; Araujo da Silva, de Souza, Viana, Sargentelli, de Andrada Serpa, &
Gomes, 2012; Bagust et al., 2002; Campbell & Mather, 2018; Darbyshire, 2003; Edwardson,
1983; Elbers, 1995; Hansson et al., 2012; Parker, Spiers, Cusworth, Birks, Gridley, &
Mukherjee, 2012; Schrader, 1982; Sender, 2011; UK Government, 2015; While, 1991).
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Interestingly it was noted that even when families identified a negative aspect in the free text it was often accompanied with a positive comment. For example;
“was not as supported as initially thought would be, doctor discharged without seeing
patient and despite our concerns excellent option rather than staying in hospital”, and
“I think our child's treatment was not a standard one and it took some back and forth
arriving at a regular schedule for visits - this was very minor compared to the benefit of
HITH”.
It is important to note that these results related to families‟ satisfaction with the service were based on the service model, which included the paediatric clinical nurse specialists supporting the APAC nurses when providing care for a child at home. The satisfaction can therefore not be attributed to the expertise of the APAC nurses alone but to a combination of the APAC nurse supported by a specialist paediatric nurse. However, these high satisfaction ratings do indicate that the paediatric HITH model with APAC nurses supported by paediatric specialist nurses was successful in providing the care families required.
HITH is an alternative for hospital level care but only available to patients who met inclusion criteria including clinically stable (Northern Sydney Local Health District, 2017). The expectation would therefore be for less patient deterioration for HITH patients than those admitted to the paediatric ward. The call rate for Clinical Review (yellow zone) for paediatric
HITH was 29/1000 separations which is comfortably lower than the 65/1000 yellow zone call rate for the paediatric ward (Table 17). There is no defined acceptable range for the call rates as such. Instead an emphasis on trends and monitoring of trends to ensure rates do not have unexplainable spikes (Clinical Excellence Commission, 2018).
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Just as a rate too high would be concerning so a rate too low would be equally concerning.
No clinical deterioration would suggest that either the patients were too well and potentially not really requiring hospital level care at all or that deterioration was unidentified by nurses.
If unidentified as a yellow zone response then a high level of red zone response would be expected as unidentified deterioration continued to an obvious emergency situation. The red response rates for paediatric HITH were 2/1000. This was an expected low rate, and suggestive of an effective Clinical Emergency Response System (CERS) and appropriate referrals to the paediatric HITH service. There were no cardiac arrests or deaths of paediatric
HITH patients.
5.5. Strengths & Limitations
The key strength of this research is that the design of the research and the research undertaken incorporated all four levels of the Kirkpatrick model to aim for a comprehensive evaluation of the paediatric nursing training provided for the APAC community nurses.
Achieving all four levels of evaluation using Kirkpatrick was identified in the literature review as key to a comprehensive evaluation but not achieved by many studies.
The training had been provided between 1 July 2016 and 30 June 2017. Therefore data were not collected immediately after the training but potentially up to a year later for some aspects of the training. The Reaction survey results are therefore potentially more reflective as opposed to capturing the immediate, initial response to the training.
The potential participant cohort size was limited due to the nature of studying a specific group of nurses who had received specific training. The desire for high levels of engagement from the cohort was consequently heightened. With the aim of 70% participation from the
APAC nurses in the surveys related to levels 1 and 2 would require 21 out of the 30 APAC
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nurse potential cohort to participate. The support of the APAC Nurse Unit Mangers and
Nurse Manager was paramount to achieve this target or as close to as possible. There were 15 out of possible 30 responses (50% response rate) to the Knowledge Questionnaire and 16 out of possible 30 responses (53% response rate) to the Training Reaction Rating Scale.
The size of the cohort also influenced the fact that the data for levels 1, 2 and 3 had the high probability of being collected from the same individuals. This is itself is not a negative for the study as the aim is to evaluate the response and impact of those who received the training, not the response of some and the impact on others. The sample selection for this study was limited to the few individual nurses engaged in specific roles associated with the care of children in the home. This does not discount the suitability of Interpretive Description to the study but is a possible limitation.
The first level of the Kirkpatrick is Reaction to the training and aims to collect the participants‟ initial reactions to the training undertaken. Ideally this should have been collected immediately after training was completed. However this data could not be collected until after Ethics Approval had been received. Consequently the data for this level is not collected immediately after the training was undertaken but several weeks or months later.
The Reaction survey data related to the all of the aspects of training. These aspects were not undertaken by APAC nurses during one accession but over several occasions when opportunity and clinical rostering permitted.
The Learning level data through the Knowledge Questionnaire were based on training undertaken and therefore expected knowledge received. The questionnaire does not allow for applied knowledge from other aspects of nursing or personal experiences which could
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influence an individual‟s knowledge. With hindsight and the luxury of time a pre-training knowledge test could have been undertaken by APAC for comparison.
The family satisfaction Reaction survey results identified that almost 50% of respondents received HITH care either in the home exclusively or partially. A limitation of the family satisfaction survey was that the responses from the families who did receive their HITH care as home care cannot be separated from those who did not receive HITH care as home visits.
The research could have been strengthened by a comparison of the family satisfaction surveys for a period during paediatric specialist nurse support for the community nurses in the home and a period after when support is no longer routine. The practice of supported visits remains in place and therefore the opportunity to compare was not available.
The preparation for a cohort of community nurses to provide a niche service for children and families in their home study was comprehensively evaluated. The results support the philosophy of paediatrics as a nursing speciality, and the challenges of training nurses to transition their skills to become experts in the care of children and their families, in particular the development of communication and interaction skills for a population with a diverse communication spectrum. The results provide reassurance of the competency of the APAC community nurses developing paediatric skills and highlight training and experience needs for then to blossom into expert nurse caring for children in their home environment.
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6. CONCLUSIONS & RECOMMENDATIONS
6.1. Conclusions
The Kirkpatrick model was an appropriate framework for a mixed methods study to evaluate the paediatric nursing training program for the adult-trained APAC community nurses, and to answer the overall research question; did the paediatric nursing training program for the
APAC community nurses prepare them to care for children at home? For a comprehensive evaluation of the training and the impact on clinical practice, it was imperative to evaluate all the levels of Kirkpatrick.
The paediatric HITH service in NSLHD was rated highly by families in the Family
Satisfaction Survey which indicated that the collaborative model of care with the APAC nurses supported by paediatric clinical nurse specialists during home visits was successful and provided the care families desired. This level of support was envisaged to decrease over time and for the APAC community nurses to provide paediatric care more independently of them. The survey was not able to capture family satisfaction without the maintained levels of paediatric support.
There was a relationship perceived by the APAC nurses between the age of a child and their comfort level communicating and interacting with them. This was noted in the APAC
Paediatric Training Needs Analysis Survey (Northern Sydney Local Health District, 2016) discussed in the introduction, as well as a theme revealed in the semi-structure interviews for the Behaviour level. The older the child the more comfortable the APAC nurses were and the younger the child the less comfortable they were communicating and interacting with them.
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This was perhaps not unexpected as the older a child was the closer they were to the patient group the APAC community nurses were confident and competent practitioners in caring for.
Through the interviews the APAC nurses revealed that they believed that comfort communicating and interacting with children of all ages was directly proportional to the amount of exposure they had to children either in their personal or professional lives. Those nurses with their own children, grandchildren or other relatives perceived themselves and others as having an advantage in paediatrics as they were already familiar communicating and interacting with them. The concept of comfort interacting with children seemed to be a foundation stone on which to build confidence and competence caring for sick infants and children. The teenagers seem to be the least daunting and most APAC nurse expressed that they were reasonably comfortable caring for them in their homes. Babies and toddlers were the most daunting to the APAC community nurses initially.
The ENPC course seemed to do little to improve these comfort levels for the APAC community nurses with children and was criticised for being „too much‟ and „scaring‟ nurses about caring for children. The learning process that occurs with every interaction student has with a child has been conceptualised as „puzzling out a connection‟ and described as consisting of four sequential phases: anticipation, encounter, connection, and engaging the child and/or getting the task done (Coetzee, 2004). These phases were replicated by the
APAC community nurses learning to care for children and building confidence interacting with them. This was captured in the interviews with the nurses.
The APAC community nurses identified in the APAC Paediatric Education Needs Analysis
Survey they needed education in all aspects of paediatric and child health. The knowledge questionnaire suggested they had acquired a base knowledge about key aspects of paediatric
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nursing that related to the ACCYPN Standards of Practice for paediatrics and child health.
The mean score of 80% was above the expected pass score of 76%. The APAC nurses had no formal or post-graduate qualifications in paediatric or child health nursing but the importance of such education, and potential to undertake it in the future was identified by them.
No inadequacies were identified through the knowledge questionnaire. However, the interviews with the APAC community nurse and the paediatric clinical nurse specialists supporting them, showed a clear theme of the need for more opportunities to develop their practical paediatric skills. Those who were able to undertake a placement on a children‟s ward described it as the most valuable part of the paediatric training, and those who were unable to do so expressed a strong desire to do this in the future if the opportunity arose.
The opportunity to develop their skills and build practically on their theoretical knowledge about paediatrics was reduced by the relative small numbers of children attending APAC and the large cohort of nurses working for APAC. Some nurses clearly voiced their desire not to care for children through the surveys and the interviews. It would seem common sense to respect the preferences of those who do not wish to work with children for several reasons.
Nurses should always work within their scope of practice. It would facilitate increased opportunities to care for children for those who do want to develop their paediatric skills, and those who are motivated to learn will get the greatest benefit from ongoing training and clinical skills development in practice.
Children themselves have identified „how to make good children‟s nurses‟ suggesting some characteristics of good paediatric nurses are innate and some are learned skills. They identified the importance of being comfortable around them, as well as being able to have fun
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and play with them for a „good‟ children‟s (paediatric) nurse, along with patience and an advocate for children‟s rights (Randall et al., 2008).
Figure 1: Diagrammatic Summary of the Conclusions
Emerging paediatric clinicians
Foundation: Clinical experts in adult community nursing care but not experts in paediatric nursing
The conclusions are summarised diagrammatically in Figure 1. The foundation of the APAC community nurses is that they are clinical experts in adult community nursing care but not in paediatric nursing. They had expert foundational nursing skills and knowledge they could draw on to apply general nursing principles to paediatric care. This enabled them to safely navigate through clinical situations with children and families. However, they lacked the
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refinement and expertise in paediatrics that they were so familiar with when caring for adult patients at home. The paediatric nursing training they had received and the experience to date with children and families resulted in them emerging as paediatric nurses. With continued opportunities to interact and care for children they should be able to develop paediatric nursing knowledge, communication skills with children of all ages and increased confidence caring for children and families, assisting them to further grow as paediatric practitioners.
6.2. Recommendations
The evaluation of the paediatric nursing training provided for the APAC community nurses using the Kirkpatrick model resulted in several recommendations. Firstly, the continuation with the existing model of care for paediatric HITH whereby the APAC nurses are supported by specialist paediatric nurses during home visits until such time as the APAC nurses become proficient or expert in paediatric nursing care as defined by Benner (2000).
Consideration for further training to be facilitated within age groups for children e.g. to focus on school-aged children is recommended. The APAC nurses were generally comfortable interacting with adolescents, but training focusing on the unique nursing requirements and interaction techniques for toddlers and infants is recommended. A phased approach to skill building with younger children could be particularly relevant as there were limited opportunities to develop skills and may assist to develop confidence and competence in paediatric nursing.
Increased opportunities for practical skills development was a key deficit in the APAC nurses‟ learning needs about paediatrics. Opportunities for further ward placements in acute paediatric environments including children‟s wards should be explored. Additional practical skills develop options such as simulation training should be considered to complete the
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training program. Alternative options for practical training and experience with children outside of hospital wards or departments, for example, childcare centres, playgroups, schools, child & family health centres should be considered. These could provide further opportunities to build confidence through exposure to well children they could transfer over as increased communication confidence with sick children in their home.
New APAC nursing staff should be orientated to paediatrics and allowed the opportunity to build up a paediatric knowledge though the DETECT Junior, paediatric life support, child protection and medication administration before undertaking a more intensive learning experience such as the ENPC course. Alternative short courses to the ENPC that would better suit the learning needs of the APAC community nurses, or to develop a short course on paediatric community nursing in NSLHD should be explored. Encouraging the development of a core group of paediatric nursing expertise within APAC, and respecting the wishes of
APAC nurses who do not wish to care for children and families is also recommended.
6.3. Recommendations for Future Research
A follow-up study to explore the confidence and competence levels of the APAC nurses caring for children and families in a few years‟ time, including a comparative study of the outcomes from this study should be considered.
This study provided an opportunity to gain insight into the training requirements for nurses transitioning from adult community care to a portfolio that includes children and adults. The transition from speciality areas of nursing requires further research with larger scale studies.
With the increasing popularity and utilisation of home based services the demand for such research may increase.
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Schor, E. L., & American Academy of Pediatrics Task Force on the, F. (2003). Family pediatrics: report of the Task Force on the Family. Pediatrics, 111(6 Pt 2), 1541-1571. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/111/Supplement_2/1541.full.pdf. Schrader, E. S. (1982). Home care keeps children out of the hospital. AORN J, 35(4), 684-706. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/6917732. Sender, S. (2011). Pediatric home care: the best-kept secret. Home Healthcare Nurse, 29(2), 63. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21301269. doi:10.1097/NHH.0b013e31820cb0de Shields, L., Pratt, J., & Hunter, J. (2006). Family centred care: a review of qualitative studies. Journal of Clinical Nursing, 15(10). Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2006.01433.x. Shields, L., Zhou, H., Pratt, J., Taylor, M., & Hunter, K. (2012). Family‐centred care for hospitalised children aged 0‐12 years. Cochrane Database of Systematic Reviews. Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004811.pub3/abstract. Sinclair, P., Kable, A., & Levett-Jones, T. (2015). The effectiveness of internet-based e-learning on clinician behavior and patient outcomes: a systematic review protocol. JBI Database Of Systematic Reviews And Implementation Reports, 13(1), 52-64. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26447007. doi:10.11124/jbisrir-2015-1919 Sjostrom, B., & Dahlgren, L. O. (2002). Applying phenomenography in nursing research. J Adv Nurs, 40(3), 339-345. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12383185. Spiers, G., Gridley, K., Cusworth, L., Mukherjee, S., Parker, G., Heaton, J., . . . Wright, D. (2012). Understanding care closer to home for ill children and young people. Nurs Child Young People, 24(5), 29-34. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22774663. doi:10.7748/ncyp2012.06.24.5.29.c9143 Taylor, M. K. (2006). Mapping the literature of pediatric nursing. J Med Libr Assoc, 94(2 Suppl), E128- 136. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463034/pdf/i1536- 5050-094-02S-0128.pdf. Tennill, M. M. (2011). Five Year Follow-up Evaluation of a Faculty Development Program: A Qualitative Study. (Doctor of Philosophy in Education Dissertation), University of Missouri, ProQuest, USA. Retrieved from https://search.proquest.com/docview/1012121052 Available from EBSCOhost eric database. (UMI Number: 3505025) The Royal Children's Hospital Melbourne. (2018). The Primary Survey. Retrieved from https://www.rch.org.au/trauma-service/manual/primary-and-secondary-survey/ Thompson, C. J., Martin, A., Abdul-Rahman, A., Boddy, K., Whear, R., Collinson, A., . . . Logan, S. (2012). Interventions to reduce acute paediatric hospital admissions: a systematic review. Arch Dis Child, 97, 304-311. doi:doi:10.1136/archdischild-304 2011-301214 Thorne, S., Kirkham, S. R., & O'Flynn-Magee, K. (2004). The Analytic Challenge in Interpretive Description. International Journal of Qualitative Methods, 3(1), 1-11. Thorne, S., Kirkhan, S. R., & MacDonald-Emes, J. (1997). Interpretive Description: A Noncategorical Qualitatitve Alternative for Developing Nursing Knowledge. Research in Nursing & Health, 20, 169-177. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/17872937 doi:10.1093/intqhc/mzm042 Torrance, G. W. (1997). Preferences for health outcomes and cost-utility analysis. Am J Manag Care, 3 Suppl(S8-20), S8-20. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10180342. UK Government. (2015). Moving healthcare closer to home: Literature review of clinical impacts. (IRRES 03/15). London, UK Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/459268/Moving_healthcare_closer_to_home_clinical_review.pdf
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UK Government. (2017). Children Act 1989 United Kingdom: Legislation.gov.uk, Retrieved from https://www.legislation.gov.uk/ukpga/1989/41/contents (Accessed 1 June 2018) Washington, R. L. (2006). Children should not be treated as little adults… unless…. The Journal of Paediatrics, 149(3), A1. Retrieved from https://www.jpeds.com/article/S0022- 3476(06)00717-7/fulltext. Waters, J. (2017). Research Guidelines: Conducting and Analyzing Your Research. In: Capilano University. Weller, J. M., Nestel, D., Marshall, S. D., Brooks, P. M., & Conn, J. J. (2012). Simulation in clinical teaching and learning. Med J Aust, 196(9), 594. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22621154. doi:|| doi: 10.5694/mja10.11474 While, A. E. (1991). An evaluation of a paediatric home care scheme. J Adv Nurs, 16(12), 1413-1421. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/1791251. While, A. E., & Dyson, L. (2000). Characteristics of paediatric home care provision: the two dominant models in England. Child Care Health Dev, 26(4), 263-276. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10931067. Whiting, M. (2004). The future of community children’s nursing. Arch. Dis. Child, 89, 987-988. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1719715/pdf/v089p00987.pdf. Wlodkowski, R. J., & Ginsberg, M. B. (2017). Enhancing Adult Motivation to Learn: A Comprehensive Guide for Teaching All Adults (4th Edition). San Francisco, CA, USA: Jossey-Bass (A Wiley Brand). Ygge, B. M. (2007). Nurses' perceptions of parental involvement in hospital care. Paediatric Nursing, 19(5), 38-40. Retrieved from https://search.proquest.com/openview/a8526fc86391947e31354fc0fb873257/1?pq- origsite=gscholar&cbl=33983. Yu, T. C., & Md, A. G. (2011). Implementing an Institution-wide Resident-as-Teacher Program: Successes and Challenges. Journal of Graduate Medical Education, 3(3), 438-439. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22942983. doi:10.4300/JGME-03-03-29 Zurmehly, J. (2007). A Qualitative Case Study Review of Role Transition in Community Nursing. Nuring Forum, 42(4). Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-6198.2007.00083.x. doi:doi.org/10.1111/j.1744-6198.2007.00083.x
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8. APPENDICES
Appendix 1 - Publication: Jones C, Fraser J, Randall S (2018)
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Appendix 2 - Figure 2: APAC Community Nurses Identified Most Important Learning
Needs Related to Paediatric Nursing
5
4.5
4
3.5 Average13) (n = 3
2.5
2
1.5
1
Identified Paediatric Nursing Learning Need
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Appendix 3 - Figures 3a and 3b: Age of Children Admitted to Paediatric Inpatient and
Paediatric HITH Care
Figure 3a: Age of Children Admitted to a Paediatric Inpatient Ward at RNSH 2016-17
No. of admissions (n = 2,275)
Figure 3b: Age of Children Reported Receiving Paediatric HITH Care
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Appendix 4 - Table 1: Summary of Proposed Research Plan
Kirkpatrick Research Question Methodology Methods Analysis Expectation Level REACTION What are the reactions of the Quantitative Rating scales about attitudes related to the Numerical/ Greater than 70% overall different aspects of the paediatric teaching community nurses to expanding correlational rating
their portfolio and knowledge to (objective) include paediatrics?
LEARNING Have the community nurses learnt Quantitative: Knowledge questionnaire Numerical Over 75% correct answers the relevant paediatric nursing Descriptive (objective) knowledge, as defined by the Research ACCYPN standards, as a result of the training?
BEHAVIOUR Have the community nurses Qualitative: Semi-structured interviews with Emergent Competence & confidence to community nursing about their practice care for children and families. routinely and consistently applied Interpretive strategy their new knowledge and skills to Description with children and families (subjective) Potential ceiling to their their community nursing practice with children and families? comfort level with paediatrics. Semi-structured interviews with paediatric Emergent clinical nurse specialists about the strategy Paediatric nurses confidence community nurses’ practice (subjective) in skills of community nurses.
RESULTS What are the consumer‟s (families) Quantitative: Family satisfaction surveys (when Mixed More than 80% satisfaction perceptions about the paediatric Survey Research community nurses supported by paediatric strategies with service. nursing home care received by the nurse specialists in the home and when (subjective) community nurses? supported is no longer routine)
Will the paediatric HITH service be Quantitative: Incident data to ensure maintained safe Comparison Incident levels to be lower as safe as hospital care? Correlational service - compare no. yellow and red (objective) than paediatric inpatient ward Research incidents in paediatric HITH and a Paediatric Ward over same time period
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Appendix 5 - Table 2: Frequently Used Evaluation Methods across the 4 Levels of Kirkpatrick Model
Evaluation methods Literature
Knowledge questionnaires (Anderson, 2009; Badu, 2013; Grzeskowiak et al., 2015; Haller et al., 2008; Kar et al., 2014; Matsuda et al., 2016; Nestel et al., 2011; Omar et al., 2009; Pickworth & Snyman, 2012; Santos et al., 2012; Sinclair et al., 2015; Tennill, 2011)
Satisfaction Surveys (Anderson, 2009; Grzeskowiak et al., 2015; Haller et al., 2008; Kar et al., 2014; Lee et al., 2013; Sinclair et al., 2015)
Rating Scales (Bylund et al., 2011; Haller et al., 2008; Matsuda et al., 2016; Nestel et al., 2011)
Interviews/ Discussions (Nestel et al., 2011; Omar et al., 2009; Pickworth & Snyman, 2012; Tennill, 2011)
Observation (Anderson, 2009; Matsuda et al., 2016; Santos et al., 2012)
Forums (Patel et al., 2016)
Reflective Journals (Anderson, 2009; Lee et al., 2013)
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Appendix 6 - Research Tool 1: Level 1 Reaction - Training Ratings Surveys
1. The Paediatric Emergency Nurse Course content was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
2. The Paediatric Emergency Nurse Course provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
3. After the Paediatric Emergency Nurse Course I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
4. After the Paediatric Emergency Nurse Course I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
5. The Resus4Kids Course content was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
6. The Resus4Kids Course provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
7. After the Resus4Kids Course I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
8. After the Resus4Kids Course I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
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9. The DETECT Junior Course content was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
10. The DETECT Junior Course provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
11. After the DETECT Junior Course I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
12. After the DETECT Junior Course I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
13. The Child Protection Training Course content was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
14. The Child Protection Training Course provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
15. After the Child Protection Training Course I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
16. After the Child Protection Training Course I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
17. The Administration of Medications to Children Course content was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
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18. The Administration of Medications to Children Course provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
19. After the Administration of Medications to Children Course I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
20. After the Administration of Medications to Children Course I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
Complete this section if attended the additional Experience Placements on a Children’s ward
21. My experience placement on a Children’s ward was interesting Strongly Disagree Strongly Agree 1 2 3 4 5
22. My experience placement on a Children’s ward provided the knowledge and skills I needed to care for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
23. After my experience placement on a Children’s ward I was more confident about caring for children and families at home. Strongly Disagree Strongly Agree 1 2 3 4 5
24. After my experience placement on a Children’s ward I have successfully applied the knowledge to care of children at home. Strongly Disagree Strongly Agree 1 2 3 4 5
25. Any other comments you would like to make about the paediatric training (free text)
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Appendix 7 - Table 3: Summary of the Aspects of the Paediatric Training for the APAC
Community Nurses
Title Description
Paediatric Emergency Nursing Emergency Nurses Association (ENA) two-day Emergency Course (ENPC) Nursing Paediatric Course. Topics include epidemiology, assessment, triage, respiratory emergencies, respiratory failure, shock, paediatric trauma, child maltreatment, neonatal emergencies, medical emergencies, crisis intervention, environmental issues, toxicological issues, ethical and legal issues, stabilization and transport. Skills stations include airway/ventilation, position/securing, vascular access/medication administration, paediatric multiple trauma, paediatric resuscitation, and triage.
Resus4Kids Paediatric Life Support training for community nurses (theoretical and practical course)
DETECT Junior Recognition and management of the deteriorating child
Child Protection Training Recognition and reporting of child protection concerns
Administration of Medications An online course about the specific skills required for the administrating medications to children
Support and mentoring Support and mentoring from Paediatric HITH CNS for the APAC nurses during initial home visits until comfortable to provide home visits for children independently.
Experience placements A supernumerary placement on a Children‟s ward in NSLHD for up to 5 days to gain experience, knowledge and skills related to observed paediatric nursing care.
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Appendix 8- Research Tool 2: Level 2 Learning – Knowledge Questionnaire
Paediatric Nursing Care Questionnaire for APAC Nurses Please circle your answer. The questionnaire is based on the Australian College of Children‟s and Young People‟s Nurses published the Standards for Paediatric Practice (Australian College of Children's and Young People's Nurses, 2016) which identifies key elements for paediatric nursing training.
Standard 1 1) You are concerned about the welfare of child but not sure if you should report this as a child protection concern - which do you not do? a) Speak to your manager b) Wait until you are completely sure about concerns before doing anything c) Use the Mandatory Reporter Guide (MRG) d) Record your concerns in the Patient‟s Health Record
Standard 2 2) The Code of Ethics for Nursing Australia (Australian Nursing and Midwifery Council, Australian College of Nursing, & Australian Nursing Federation, 2008) is relevant to all: a) Registered and enrolled nurses b) Nurses working in clinical areas c) Nurses and nurse managers d) Nurses including those in clinical, management, education and research roles
3) True or False? Children and young people have the right to participate in decision making, and as appropriate to their capabilities, make decisions about their care. a) TRUE b) FALSE
4) Which of the following are recommended for Safe Sleep for Newborns to reduce the risk of Sudden Unexpected Death in Infancy (SUDI)? a) Sleep baby on the back from birth, not the tummy or side b) Keep baby smoke free before & after birth c) Sleep baby with head and face uncovered d) Breastfeed baby e) All of the above Standard 3 5) What is a key concept in paediatric nursing? a) Patient centred care b) Child centred care c) Family centred care d) Paediatric centred care
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6) Which of the following statements are true about immunisations? a) Mercury in vaccines can cause autism b) Vaccines cause or worsen asthma and allergies c) Diseases are virtually eliminated so vaccination is not needed d) One of the most effective interventions to prevent disease e) Flu vaccines cause the flu
7) What family factors will cause emotional distress leading to short-term or lasting poor outcomes for children? a) Financial or health problems b) Lack of social support c) Unhappiness at work d) Unfortunate life events e) All of the above f) none of the above
Standard 4 8) True or False? You only have to do Resus4Kids Paediatric Life Support Training once? a) TRUE b) FALSE Standard 5 9) In the ABCDEFG acronym for Paediatric Assessment, what does the E stand for? a) Environment b) Exposure c) Elimination d) Endocrine Standard 6 10) Question – what age can a child provide their own informed consent? a) Over 16 years old b) Over 15 years old c) Over 14 years old d) Any age if they are deemed competent to do so
Standard 7 11) What is the average age that children learn to walk? a) 6-15 months b) 8-18 months c) 12-28 months d) 6-24 months
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12) Which of the following is a concerning sign for a 4-5 year old? a) Has an imaginary friend b) Doesn‟t use sentences of more than three words c) Still has some temper tantrums d) Curious about their bodies including genitals e) Anxious about starting school
13) Which of the follow are appropriate distraction techniques for children undergoing a clinical procedure? a) Toys b) Blowing bubbles c) Reading or story-telling with visual imagery d) Using superhero or magical images e) All of the above
14) The following formula is used to calculate medications for children:
Dose Required (mg) Volume required (mL) = Strength of solution (mg) x Unit Volume (mL)
What is the volume of medication required for a child requiring 125 mg of 50 mg/5 mL preparation? a) 1.25 mL b) 2.5 mL c) 12.5 mL d) 25 mL Standard 8 15) Which one is a sign of severe work of breathing in a child? a) tracheal tug b) increased respiratory rate c) grunting d) intercostal recession e) decreased respiratory rate
16) How deep do you do chest compressions in paediatric life support? a) 1/4 depth of the chest b) 1/3 depth of chest c) 1/2 depth of chest d) 3/4 depth of chest e) 2/3 depth of chest
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17) What are the two most common arrhythmias in paediatric cardiac arrest? a) Bradycardia & Asystole b) Ventricular Tachycardia & Ventricular Fibrillation c) Supraventricular Tachycardia & Ventricular Tachycardia d) Bradycardia & Bigeminy e) Tachycardia & PEA
18) Which of the following is not a potential effect of hospitalisation of a child? a) Behavioural changes b) Separation anxiety c) Regression d) Character building e) Emotional distress
19) What two conditions are associated with allergies? a) Autism & Asthma b) Eczema & Autism c) Asthma & Eczema d) Eczema & ADHD e) ADHD & Autism
20) HEEADSS (Home, Education/Employment, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) is psychosocial assessment for young people. What age range are youth or young people defined as? a) 12 - 24 year olds b) 14 – 24 year olds c) 12 – 18 year olds d) 14 – 21 year olds e) 16 – 24 year olds
Standard 9 21) What services does Child & Family Health provide? a) Breastfeeding b) Coping with sleeping and crying c) Baby growth and development d) Immunisation e) All of the above
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Standard 10 22) When visiting a child and family at home, which of the following would require a Rapid Response to call an ambulance? a) Child having a seizure b) Child who is lethargic and not responsive to pain c) Child who has not passed urine for over 12 hours d) Child with a heart rate over 200 bpm at rest e) All of the above Standard 12 23) Which of the following statements is applicable to effective communication with children? a) Infants can‟t communicate their needs b) Child friendly explanations can be used for medical equipment and procedures c) Children become more stressed if you explain a treatment or procedure to them d) Communication should be directed at the parents/carers not the child e) You can‟t explain complicated medical procedures to children
24) Which of the following techniques are not be used in the non-pharmacological management of procedural pain in children (NSW Health, 2016b)? a) Clear and honest explanation of the procedure b) Age appropriate distraction techniques c) Ask the family to leave, hold down the child and do procedure as quick as possible d) Establishing a rapport with child before the procedure e) Comfort holding from family member Standard 15 25) True or False? The World Health Organisation (WHO) recommends that infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. a) TRUE b) FALSE
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Appendix 9 - Table 4: Application of the ACCYPN Standards to the Learning Phase of the Evaluation
ACCYPN Standard No. Question Information Source Knowledge Question (expected response in bold)
Standard 1 Question 1 based on 1) You are concerned about the welfare of child but not sure if you
Functions in accordance with responsibility of all nurses as a should report this as a child protection concern – which do you not legislation, common law, mandatory reporter. do? health standards and policies a. Speak to your manager pertinent to the practice of b. Wait until you are completely sure about concerns before nursing children and young doing anything people c. Use the Mandatory Reporter Guide (MRG)
b. Record your concerns in the Patient‟s Health Record
Standard 2 Question 2 based on The Code 2) The Code of Ethics for Nursing Australia (Council., Nursing., &
Demonstrates ethical of Ethics for Nursing Australia Federation., 2008) is relevant to all: practice in nursing children (Australian Nursing and a. Registered and enrolled nurses Midwifery Council et al., 2008) and young people b. Nurses working in clinical areas
c. Nurses and nurse managers
d. Nurses including those in clinical, management, education and research roles
Question 3 based on the Charter 3) True or False? Children and young people have the right to of Children‟s and Young participate in decision making, and as appropriate to their People‟s Rights in Healthcare capabilities, make decisions about their care.
Services in Australia a. TRUE (Children's Hospital Australasia b. FALSE & Association for the Wellbeing of Children in Healthcare, 2011)
Question 4 based on the NSW 4) Which of the following are recommended for Safe Sleep for Health Safe Sleep for Newborns Newborns to reduce the risk of Sudden Unexpected Death in Information sheet for Health Infancy (SUDI)?
professionals (NSW Health, a. Sleep baby on the back from birth, not the tummy or side 2016c) b. Keep baby smoke free before & after birth
c. Sleep baby with head and face uncovered
d. Breastfeed baby
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e. All of the above
Standard 3 Question 5 based on the concept 5) What is a key concept in paediatric nursing?
Respects the dignity and ‘that Family centred care has a. Patient centred care integrity of children, young become a cornerstone of b. Child centred care people and their families paediatric practice’ (Shields c. Family centred care including their values, et al., 2006) d. Paediatric centred care spiritual and cultural beliefs
Question 6 based on Immunise 6) Which of the following statements are true about Australia information for immunisations?
health professionals information a. Mercury in vaccines can cause autism to address some of the most b. Vaccines cause or worsen asthma and allergies commonly held myths about c. Diseases are virtually eliminated so vaccination is not immunisation (Commonwealth needed of Australia, 2013) d. One of the most effective interventions to prevent disease
e. Flu vaccines cause the flu
Question 7 based on literature 7) What family factors will cause emotional distress leading to review for Task Force on the short-term or lasting poor outcomes for children?
Family (Schor & American a. Financial or health problems Academy of Pediatrics Task b. Lack of social support Force on the, 2003) c. Unhappiness at work
d. Unfortunate life events
e. All of the above
f. none of the above
Standard 4 Question 8 based on 8) True or False? You only have to do Resus4Kids Paediatric Life
Demonstrates a Resus4Kids requires annual Support Training once? comprehensive knowledge of training. a. TRUE children and young people’s b. FALSE nursing and engages in ongoing professional development and education
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Standard 5 Question 9 based on NSW 9) In the ABCDEFG acronym for Paediatric Assessment, what
Utilises a reflective, critical Health „Recognition of a Sick does the E stand for? thinking and problem- Baby or Child in the Emergency a. Environment Department‟ Clinical Practice solving approach to the b. Exposure nursing care of children and Guideline (NSW Health, 2011) c. Elimination young people and the DETECT Junior Training Program (CEC) d. Endocrine
Standard 6 Question 10 based on Gillick 10) Question – what age can a child provide their own informed Supports and contributes to Competent consent? the advancement of the a. Over 16 years old health and wellbeing of b. Over 15 years old children and young people c. Over 14 years old through a commitment to d. Any age if they are deemed competent to do so research, evaluation and quality improvement activities
Standard 7 Question 11 based on Raising 11) What is the average age that children learn to walk?
Provides age and Kids Child Development page a. 6-15 months information. developmentally appropriate b. 8-18 months nursing care that promotes c. 12-28 months safety, security and optimal d. 6-24 months health
Question 12 based on Raising 12) Which of the following is a concerning sign for a 4-5 year old?
Kids Child Development 4 to 5 a. Has an imaginary friend years page information. b. Doesn’t use sentences of more than three words
c. Still has some temper tantrums
d. Curious about their bodies including genitals
e. Anxious about starting school
Question 13 based on 13) Which of the follow are appropriate distraction techniques for distraction techniques children undergoing a clinical procedure?
information in Infants and a. Toys Children: Management of Acute b. Blowing bubbles and Procedural Pain in the c. Reading or story-telling with visual imagery Emergency Department guideline (NSW Health, 2016b) d. Using superhero or magical images e. All of the above
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Question 14 based on formula 14) The following formula is used to calculate medications for in NSLHD Medication children:
Administration For Infants, Dose Required (mg)/Volume required (mL) = Strength of solution Children And Adolescents (mg) x Unit Volume (mL) (Northern Sydney Local Health What is the volume of medication required for a child requiring District, 2010) 125mg of 50mg/5mL preparation?
a. 1.25 mL
b. 2.5 mL
c. 12.5 mL
d. 25 mL
Standard 8 Question 15 based on NSW 15) Which one is a sign of severe work of breathing in a child?
Effectively coordinates and Health „Recognition of a Sick a. tracheal tug Baby or Child in the Emergency manages the nursing care of b. increased respiratory rate children and young people Department‟ Clinical Practice c. grunting Guideline (NSW Health, 2011)
and the DETECT Junior d. intercostal recession Training Program (CEC) e. decreased respiratory rate
Question 16 based on 16) How deep do you do chest compressions in paediatric life Resus4Kids support?
a. 1/4 depth of the chest
b. 1/3 depth of chest
c. 1/2 depth of chest
d. 3/4 depth of chest
e. 2/3 depth of chest
Question 17 based on 17) What are the two most common arrhythmias in paediatric Resus4Kids cardiac arrest?
a. Bradycardia & Asystole
b. Ventricular Tachycardia & Ventricular Fibrillation
c. Supraventricular Tachycardia & Ventricular Tachycardia
d. Bradycardia & Bigeminy
e. Tachycardia & PEA
Question 18 based on research 18) Which of the following is not a potential effect of about Effects of Hospitalisation hospitalisation of a child?
on Children (Bonn, 1994) a. Behavioural changes
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b. Separation anxiety
c. Regression
d. Character building
e. Emotional distress
Question 19 based on eczema, 19) What two conditions are associated with allergies?
asthma and allergy clinical a. Autism & Asthma links: ACCAI, Asthma b. Eczema & Autism Australia. c. Asthma & Eczema
d. Eczema & ADHD
e. ADHD & Autism
Question 20 based on 20) HEEADSS (Home, Education/Employment, Eating, Activities, HEEADDSS (Home, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) is Education/Employment, Eating, psychosocial assessment for young people. What age range are Activities, Drugs and Alcohol, youth or young people defined as?
Sexuality, Suicide and a. 12 - 24 year olds Depression, Safety) youth b. 14 – 24 year olds psychosocial assessment tool. c. 12 – 18 year olds
d. 14 – 21 year olds
e. 16 – 24 year olds
Standard 9 Question 21 based on NSW 21) What services does Child & Family Health provide?
Demonstrates knowledge of Health Child and Family Health a. Breastfeeding FAQs page information. primary health care, health b. Coping with sleeping and crying promotion and continuity of c. Baby growth and development care, and incorporates this d. Immunisation approach into practice to improve the health and well- e. All of the above being of children and young people.
Standard 10 Question 22 based on CERS 22) When visiting a child and family at home, which of the
Effectively utilises and procedure and on NSW Health following would require a Rapid Response to call an ambulance? advocates for adequate ‘Recognition of a Sick Baby a. Child having a seizure resources to provide safe and or Child in the Emergency b. Child who is lethargic and not responsive to pain effective care for the child Department’ Clinical Practice c. Child who has not passed urine for over 12 hours and young person Guideline (NSW Health, 2011). d. Child with a heart rate over 200 bpm at rest
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e. All of the above
Standard 11 Consider in Level 3
Establishes peer networks in the speciality area of Children and Young People’s Nursing
Standard 12 Question 23 based on RCH 23) Which of the following statements is applicable to effective
Communicates effectively Communicating Procedures to communication with children? with children, young people Families Clinical Guide a. Infants can‟t communicate their needs and their families b. Child friendly explanations can be used for medical equipment and procedures
c. Children become more stressed if you explain a treatment or procedure to them
d. Communication should be directed at the parents/carers not the child
e. You can‟t explain complicated medical procedures to children
Question 24 based on the NSW 24) Which of the following techniques are not be used in the non- Health Acute and Procedural pharmacological management of procedural pain in children?
Pain in the Emergency a. Clear and honest explanation of the procedure Department Guideline (NSW b. Age appropriate distraction techniques Health, 2016b) c. Ask the family to leave, hold down the child and do procedure as quick as possible
d. Establishing a rapport with child before the procedure
e. Comfort holding from family member
Standard 13 Consider in Level 3
Advocates for children and young people in health care through a negotiated partnership approach
Standard 14 Consider in Level 3
Demonstrates effective participation in interdisciplinary teams
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combining skills to support children, young people and their caregivers
Standard 15 Question 25 based on WHO 25) True or False? The World Health Organisation recommends
Demonstrates a knowledge recommendations regarding that infants should be exclusively breastfed for the first six months of, and skill in, health infant feeding. of life to achieve optimal growth, development and health. education and therapeutic a. TRUE relationships b. FALSE
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Appendix 10 - Research Tool 3: Level 3 Behaviour – Semi-Structured Interviews
INTRODUCTION
Welcome and thank you for agreeing to be interviewed today, it should take about 20-30 minutes of you time. As you know APAC recently expanded its portfolio to include the care of children and families.
The purpose of the interview it to seek your perspective about APAC nurses caring for children in the home and the paediatric training and support received.
The interviewed will be recorded for transcript purposes, and be used as part of my Masters research thesis with the University of Sydney. The information you provide in the interview will be treated confidentially and the transcribing recorded anonymously.
The interview can be stopped at any point and you don‟t have to answer any questions if you don‟t want to. There will be no consequences for you and your position from the answers you provide me.
Are you happy to proceed with the interview?
INTERVIEW A – APAC NURSING STAFF 1. How did you feel about extending your role to caring for children and families at home? Probing question: Has this changed over time? 2. Describe your previous paediatric nursing experience?
3. How comfortable do you feel communicating with children and families? Probing question: Could you give an example of successful communication with a child? 4. Tell me about the aspect of the training you find the most relevant?
5. What do you think are the most important aspects of paediatric nursing?
6. How adequately trained do you feel to care for paediatric patients in the home? Probing question: Describe an example of when you used your paediatric skills on a home visit?
7. What do you think is missing from the training or you would like to undertake? Probing question: Would you be interested in further training such as undertaking a paediatric nursing course?
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INTERVIEW B – PAEDIATRIC CLINICAL NURSE SPECIALISTS 1. How did you feel about APAC extending their role to care for children and families at home? Probing question: Has this changed over time? 2. What was you experience/observation of the adult trained nurses caring for children at home?
3. How comfortable do you feel the APAC nurses are communicating with children and families? Probing question: Could you give an example of successful communication with a child?
4. What training do you believe that nurses should have to care for children and families?
5. Do you believe the APAC nurses were adequately educated and supported to care for children?
Probing question: Describe an example of when you observed their paediatric skills on a home visit?
6. What do you think are the most important aspects of paediatric nursing?
7. What do you think is missing from the training for APAC nurses?
Probing question: Should further training be offered /encouraged for APAC nurses such as undertaking a paediatric nursing course?
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Appendix 11 - Figure 5: Analysis of the Interviews Based on Giorgi’s Framework
• Sense of the Whole • Reading the interview transcripts to get a general sense of the whole Phase 1
• Discrimination of Meaning Units • Read again to indentify themes and commonality as discriminated meaning Phase 2 units and relate them to each other
• Transformation of Themes into Theme Categories • Reflects on the meaning units to come up with the essence of experience Phase 3 for participants
• Synthesis • Develop a consistent statement about the experience of the paediatric Phase 4 training for each of the participants
• Final Synthesis • Synthesize all the participants experience into one statement to capture Phase 5 essence of the paediatric training as a whole
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Appendix 12- Research Tool 4: Level 4 Reaction – Family Satisfaction Surveys
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Appendix 13 - LNR Ethics Approval Letter from NSLHD
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Appendix 14 - Participant Information Sheet (PIS)
What is this study about?
You are invited to take part in a research study evaluating the paediatric nursing training received by the general community Acute Post-Acute Care (APAC) nurses in Northern
Sydney Local Health District (NSLHD). The study will use the Kirkpatrick Training
Evaluation Framework to explore four different aspects of the training; reaction to the training, learning from the training, behaviour changes as a result of the training and the results in practice from the training. To explore each of these levels different research and data collection techniques are used i.e. ratings scale, questionnaire, interview and family satisfaction survey.
The study aims to evaluate the different aspects of the paediatric training provided to the
NSLHD APAC nurses. To determine if the training provide the skills and knowledge the
APAC nurses required to expand their portfolio from adult patients only to include children and families. As well as identify any gaps in the paediatric training.
You have been invited to participate in the Master‟s thesis study because you are an APAC nurse in NSLHD who received the paediatric nursing training as part of the Paediatric
Hospital in the Home project. This Participant Information Statement tells you about the research study. Knowing what is involved will help you decide if you want to take part in the research. Please read this sheet carefully and ask questions about anything that you don’t understand or want to know more about.
Participation in this research study is voluntary. By giving your consent to take part in the
Master‟s thesis study you are telling us that you:
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Understand what you have read.
Agree to take part in the research study as outlined below.
Agree to the use of your personal information as described.
You will be given a copy of this Participant Information Statement to keep.
Who is running the study?
The study is being carried out by the following researchers:
Catherine Jones, RN, BA (Hons) Paediatric Nursing
Catherine Jones is conducting this study as the basis for the degree of Masters of Philosophy at The University of Sydney. This will take place under the supervision of Jennifer Fraser,
Associate Professor, School of Nursing, University of Sydney and Dr Sue Randall, Senior
Lecturer in Primary Health Care, University of Sydney.
Catherine Jones is also the Project Manager for the Paediatric Hospital in the Home project in
Northern Sydney Local Health District.
What will the study involve for me?
The study will evaluate the following paediatric training components as aspects of a whole training program, so data collection is not repeated for each aspect:
Resus4Kids
DETECT Junior
Administration of Medications to Children
Child Protection
Practice supervision in the children‟s ward or during home visits to children &
families
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You will be asked to participate in the completion of ratings scale about the different aspects of the training and a knowledge questionnaire. These will be available via an anonymous online survey program, and can be completed simultaneously.
You will be asked to attend a semi structured interview with the investigator, Catherine Jones only, and asked about your experience when providing clinical supervision and the practice behaviour of the APAC nurses observed during home visits to children. The interviews will be audio recorded for transcription purposes. Once an accurate transcript is obtained the audio recordings will be deleted.
If you wish to review the transcript of your interview, you may request to do so via Catherine
Jones. The data collected during the interview is anonymous and all attempts to ensure you cannot be identified will be taken.
How much of my time will the study take?
Completion of the ratings scale and questionnaire completed online should take about 15 minutes. It is estimated that the interview should take between 30-45 minutes. It will be conducted at a time and location negotiated with you to minimise any inconvenience to you.
Who can take part in the study?
The study is related to training received by a specific group of nurses working within APAC in NSLHD. Only APAC nurses who have received all aspects of the paediatric training as part of the Paediatric Hospital in the Home program will be evaluated. APAC nurses who did not receive the paediatric training are excluded from the study.
The Paediatric HITH Clinical Nurse Specialists provided the home visit supervision and are therefore included in the study. Other paediatric nurses are not included in the study.
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Families whose child received hospital in the home care were asked to complete a family satisfaction survey. Only families who received this care are included in the study.
Do I have to be in the study? Can I withdraw from the study once I've started?
Being in the Master‟s thesis study is completely voluntary and you do not have to take part.
Your decision whether to participate will not affect your current or future relationship with the researchers or anyone else at the University of Sydney or Northern Sydney Local Health
District.
If you decide to take part in the study and then change your mind later, you are free to withdraw at any time. You can do this by requesting this in writing to Catherine Jones, at [email protected]
You are free to stop the interview at any time. Unless you say that you want us to keep them, any recordings will be erased and the information you have provided will not be included in the study results. You may also refuse to answer any questions that you do not wish to answer during the interview.
Submitting your completed questionnaire and ratings scale is an indication of your consent to participate in the study. You can withdraw your responses any time before you have submitted the questionnaire. Once you have submitted it, your responses cannot be withdrawn because they are anonymous and therefore we will not be able to tell which one is yours.
If you decide to withdraw from the study, we will not collect any more information from you.
Any information that we have already collected, however, will be kept in our study records and may be included in the study results.
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Are there any risks or costs associated with being in the study?
Aside from giving up your time, we do not expect that there will be any risks or costs associated with taking part in the Master‟s thesis study.
If you suffer any distress as a result in participation in the Master‟s thesis study, please contact the research team who will assist you in arranging appropriate support. Information about the Employee Assistance Program was made available on the PIS.
Are there any benefits associated with being in the study?
We cannot guarantee that you will receive any direct benefits from being in the study.
What will happen to information about me that is collected during the study?
The data collected from the Ratings Scales and Questionnaire are collected anonymously via on online survey program. The online survey account will be specific to the study and not available or accessible by anyone other than the investigator. The data and data analysis from the online survey will be utilised and included in the thesis submitted by the investigator.
Collective data may be used and published in journal publications related to the study but individual responses and respondents will not be identified.
The information obtained from the interviews with be analysed alongside data collected from interviews with the APAC nurses to verify or question responses from each other. The information will be collated and analysed as a collective and not as an analysis of individual performances or appraisals. The purpose of the study is to evaluate the training and if it meets the needs of the APAC nurses. It is not an evaluation of individual APAC nurses practice.
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The interviews will be audio recorded for transcription purposes. Both the audio recordings and the transcripts will be stored securely for 5 years.
If you wish to review the transcript of your interview, you may request to do so via Catherine
Jones. The data collected during the interview is anonymous and all attempts to ensure you cannot be identified will be taken however, due to the small number of Paediatric HITH nurses the ability to not identify you or your role cannot be guaranteed.
The transcripts and the analysis of them will be stored securely by the investigator. Part or your entire interview transcript may be included in the final thesis submitted for the Master‟s degree. Any journal publications based on this study may reference information provided during your interview and the subsequent analysis but will not publish your identity or the transcript in part or in its entirety.
By providing your consent, you are agreeing to us collecting personal information about you for the purposes of this research study. Your information will only be used for the purposes outlined in this Participant Information Statement, unless you consent otherwise.
Your information will be stored securely and your identity/information will be kept strictly confidential, except as required by law. Study findings may be published. Although every effort will be made to protect your identity, there is a small risk that you might be identifiable in publications due to the small cohort of Paediatric HITH nurses in NSLHD.
We will keep the information we collect for this study, and we may use it in future projects.
By providing your consent you are allowing us to use your information in future projects. We don‟t know at this stage what these other projects will involve. We will seek ethical approval before using the information in these future projects.
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Any information obtain during the study that suggests malpractice or unsafe clinical practice by nursing staff will be discussed with the individual and will be referred to NSLHD management, as per section 2.4 of the NSW Health Code of Conduct (PD2015_049).
Can I tell other people about the study?
Yes, you are welcome to tell other people about the study.
What if I would like further information about the study?
When you have read this information, Catherine Jones will be available to discuss it with you further and answer any questions you may have. If you would like to know more at any stage during the study, please feel free to contact Catherine Jones, at [email protected].
Will I be told the results of the study?
You have a right to receive feedback about the overall results of this study. You can tell us that you wish to receive feedback by contacting Catherine Jones [email protected]
This feedback will be in the form of a one page lay summary. You will receive this feedback after the study is finished.
What if I have a complaint or any concerns about the study?
Research involving humans in Australia is reviewed by an independent group of people called a Human Research Ethics Committee (HREC). The ethical aspects of this study have been approved by the Northern Sydney Local Health District HREC (LNR/17/HAWKE/251).
As part of this process, we have agreed to carry out the study according to the National
Statement on Ethical Conduct in Human Research (2007). This statement has been developed to protect people who agree to take part in research studies.
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If you are concerned about the way this study is being conducted or you wish to make a complaint to someone independent from the study, please contact the university using the details outlined below. Please quote the study title and protocol number.
The Manager, Ethics Administration, Northern Sydney Local Health District:
Telephone: +61 2 9926 4590
Email: [email protected]
If you are distressed by the questions in surveys or during the interviews, support can be accessed via NSLHD Employee Assistance Program (EAP) at these numbers:
Royal North Shore Hospital: 02 9462 9299
Hornsby Hospital: 02 9477 9301
Mona Vale Hospital: 02 9998 0908
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Appendix 15 - Data from the Reaction, Learning and Results Levels
Table 5: Reaction Rating Scores to Questions about the Paediatric Nursing Training
Average Standard Reaction Rating Question n Rating Range 5 = highest Deviation (mean) The Paediatric Emergency Nurse Course content was interesting 15 3.67 1 to 5 1.23
The Paediatric Emergency Nurse Course provided the knowledge and 15 3.00 1 to 5 1.07 skills I needed to care for children and families at home. After the Paediatric Emergency Nurse Course I was more confident 14 2.79 1 to 5 1.19 about caring for children and families at home. After the Paediatric Emergency Nurse Course I have successfully 15 2.20 1 to 5 1.08 applied the knowledge to care of children at home.
The Resus4Kids Course content was interesting 13 3.77 1 to 5 1.01 The Resus4Kids Course provided the knowledge and skills I needed to 13 3.77 1 to 5 1.09 care for children and families at home. After the Resus4Kids Course I was more confident about caring for 14 3.50 1 to 5 1.09 children and families at home. After the Resus4Kids Course I have successfully applied the knowledge 14 3.29 1 to 5 1.27 to care of children at home.
The DETECT Junior Course content was interesting 14 3.71 1 to 5 1.20 The DETECT Junior Course provided the knowledge and skills I needed 14 3.64 1 to 5 1.08 to care for children and families at home. After the DETECT Junior Course I was more confident about caring for 13 3.46 1 to 5 0.97 children and families at home. After the DETECT Junior Course I have successfully applied the 14 3.36 1 to 5 1.28 knowledge to care of children at home.
The Child Protection Training Course content was interesting 15 3.73 1 to 5 1.22 The Child Protection Training Course provided the knowledge and skills 16 3.81 1 to 5 1.11 I needed to care for children and families at home. After the Child Protection Training Course I was more confident about 16 3.56 1 to 5 1.03 caring for children and families at home. After the Child Protection Training Course I have successfully applied 16 3.19 1 to 5 1.33 the knowledge to care of children at home
Administration of Medications to Children Course content was 13 3.69 1 to 5 1.03 interesting Administration of Medications to Children Course provided the 15 3.60 1 to 5 1.06 knowledge and skills I needed to care for children and families at home After Administration of Medications to Children Course I was more 15 3.53 1 to 5 1.06 confident about caring for children and families at home After Administration of Medications to Children Course I have 15 3.40 1 to 5 1.18 successfully applied the knowledge to care of children at home My experience placement on a Children‟s ward was interesting 9 4.00 1 to 5 2.16 My experience placement on a Children‟s ward provided the knowledge 9 4.00 1 to 5 2.16 and skills I needed to care for children and families at home After my experience placement on a Children‟s ward I was more 9 3.78 1 to 5 2.09 confident about caring for children and families at home. After my experience placement on a Children‟s ward I have successfully 9 3.67 1 to 5 2.04 applied the knowledge to care of children at home Overall 13.6 3.5 1 to 5 1.2
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Table 8: Accuracy Ranking for the Knowledge Questionnaire Questions
Questions (n=25) Accuracy Correct Ranking Responses
Q3 - True or False? Children and young people have the right to participate in decision making, and as 1 100% appropriate to their capabilities, make decisions about their care.
Q4 - Which of the following are recommended for Safe Sleep for Newborns to reduce the risk of 1 100% Sudden Unexpected Death in Infancy (SUDI)?
Q6 - Which of the following statements are true about immunisations? 1 100%
Q8 - True or False? You only have to do Resus4Kids Paediatric Life Support Training once? 1 100%
Q12 - Which of the following is a concerning sign for a 4-5 year old? 1 100%
Q13 - Which of the follow are appropriate distraction techniques for children undergoing a clinical 1 100% procedure?
Q16 - How deep do you do chest compressions in paediatric life support? 1 100%
Q18 - Which of the following is not a potential effect of hospitalisation of a child? 1 100%
Q19 - What two conditions are associated with allergies? 1 100%
Q21 - What services does Child & Family Health provide? 1 100%
Q22 - When visiting a child and family at home, which of the following would require a Rapid 1 100% Response to call an ambulance?
Q23 - Which of the following statements is applicable to effective communication with children? 1 100%
Q24 - Which of the following techniques are not be used in the non-pharmacological management of 1 100% procedural pain in children (NSW Health, 2016)?
Q7 - What family factors will cause emotional distress leading to short-term or lasting poor outcomes 2 93% for children?
Q14 - The following formula is used to calculate medications for children: Volume required (mL) = 2 93% Dose Required (mg)/ Strength of solution (mg) x Unit Volume (mL) What is the volume of medication required for a child requiring 125mg of 50mg/5mL preparation?
Q5 - What is a key concept in paediatric nursing? 3 87%
Q11 - What is the average age that children learn to walk? 4 80%
Q25 - True or False? The World Health Organisation (WHO) recommends that infants should be 4 80% exclusively breastfed for the first six months of life to achieve optimal growth, development and health.
Q2 - The Code of Ethics for Nursing Australia (Council., Nursing., & Federation., 2008) is relevant to 5 73% all:
Q1 - You are concerned about the welfare of child but not sure if you should report this as a child 6 60% protection concern – which do you not do?
Q15 - Which one is a sign of severe work of breathing in a child? 7 53%
Q17 - What are the two most common arrhythmias in paediatric cardiac arrest? 7 53%
Q20 - HEEADSS (Home, Education/Employment, Eating, Activities, Drugs and Alcohol, Sexuality, 8 47% Suicide and Depression, Safety) is a psychosocial assessment for young people. What age range are youth or young people defined as?
Q9 - In the ABCDEFG acronym for Paediatric Assessment, what does the E stand for? 9 40%
Q10 - What age can a child provide their own informed consent? 10 13%
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Figure 7: Family Satisfaction Survey Response Rate per Question
100% 90% 80%
70%
60% 50% 40%
Response Rate Rate Response 30% 20% 10% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Survey Question Number
Figure 8: Clinical Conditions of Children in HITH
Other - Not Walking Other - Haemolytic Anaemia Other - Hypoglycaemia Other ‐ Seizure/Febrile… Other - Headaches/Head Injury
Other - Dehydration Allergy Burns Cardiac Oncology
Sleeping problems HITH Clinical Clinical Conditions HITH Post-surgery Skin condition Feeding Infection Gastro (stomach/bowels) Breathing
0% 10% 20% 30% 40% 50% 60% 70% 80% % of Respondents (n = 136)
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Figure 9: Treatment Received by Children in HITH
Other - Investigations/Tests
Other - Monitoring/Observation
Other - Hydration
Other - Follow-up
Wet dressings for Eczema HITH Clinical Clinical Received Treatnenst HITH Education about your child's condition or care
Wound care
Intravenous medications
0% 10% 20% 30% 40% 50% 60% % of respondents (n = 132)
Figure 10: Number of Days of School or Child Care Missed whilst Receiving HITH Care
45%
40% = 128) =
35% n
30%
25%
20% % ( % respondentsof 15%
10%
5%
0% 0 days 1 day 2 days 3 days 4 days 5 days 6 days 1 week 2 weeks 3 weeks 4 weeks more Number of days school/child care missed than 4 weeks
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Table 10: Positive Aspects of Paediatric HITH Rank Positive Aspect of Paediatric HITH % Respondents (n = 137) 1 Staying at home 86.9% 2 Support by nursing staff 70.1% 3 Support by medical staff 65.0% 4 Ability to care for the rest of the family 61.3% 5 Access to care for my child when needed 56.9% 6 Involved in care as much as I wanted to be 43.8% 7 Receiving daily treatments at the hospital 26.3% 8 Receiving daily treatments at home 19.7% 9 Less time off work 19.0% 10 Other (please specify) *(see table 13) 16.8% 11 Less travel costs 13.1%
Table 11: Breakdown of Other Positive Aspects of Paediatric HITH Identified
Rank Positive Aspect of Paediatric HITH % Respondents (n = 23) 1 Comfort / normality of home 6.6% 2 Access to same specialist medical/nursing staff (without 3.6% waiting in Emergency Department again) 3 Not staying in hospital 2.2%
4 Flexibility 1.5% 5 Free up hospital bed for other children 1.5%
6 Reduced exposure to hospital infections 0.7%
Table 12: Negative Aspects of Paediatric HITH
Rank Negative Aspect of Paediatric HITH % Respondents (n = 44)
1 Other (please specify) *(see table 15) 65.9% 2 Waiting for treatment in hospital 36.4% 3 Time off work 25.0% 4 Isolated 25.0% 5 Difficulty in caring for the rest of family 15.9% 6 Waiting for treatment at home 13.6% 7 Travel costs 11.4% 8 Staying at home 2.3%
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Table 13: Breakdown of „Other‟ Negative Aspects of Paediatric HITH Identified
Rank Negative Aspect of Paediatric HITH % Respondents (n = 29) 1 No negative aspects experienced 43.2% 2 Delay seeing /contacting doctors in the hospital 4.5% 3 Cost of parking 2.3% 4 Distance from hospital 2.3% 5 Assessing and monitoring child at home 2.3%
Table 14: How We Can Improve HITH?
Rank Comment %. Respondents (n = 54) 1 No comment 35.2% 2 Improve communication between staff and with families 25.9% 3 Excellent service/care 18.5% 4 Reduce waiting times 13.0% 5 Helpful & supportive 3.7% 6 Minor issues compared to benefit of HITH 3.7% 7 Option of care in home 1.9%
Table 15: Additional Comments from Families about HITH
Rank Comment %. Respondents (n = 74) 1 Excellent Service/Experience 36.5% 2 Thank you 17.6% 3 Amazing Staff 14.9% 4 Great option/idea 14.9% 5 No comment 12.2% 6 Disappointed with clinical support 4.1% 7 Communication issues 1.4%
Table 16: Length of Time Receiving HITH Care
Length of Time 1-3 days 4-6 days 1-2 weeks 3-4 weeks 5-6 weeks more than 6 weeks No. respondents (n) 107 12 12 2 1 1
% respondents 79% 9% 9% 1% 1% 1%
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Appendix 16 – Example of Highlighting Meaning Units in the Transcripts
Transcript (Extract from Interview Transcript 171120_0005) Notes
How did you feel about extending your role to care for children and families Range of emotions. at home? Term ‘foreign’ I was excited about the idea; I thought it was great to be able to learn something again later in new in an area that I wouldn‟t otherwise be given an opportunity. However, interview quite nervous about children, especially the babies, because it‟s just so foreign in terms of the type of nursing care.
If you take yourself back to, you know, 18 months ago, have your feelings Increasing changed between then and now? confidence related Yeah, I think I’m much more confident, especially with teenagers; that‟s fine to age of child – and I’m not nervous about that at all. I haven‟t had a huge amount of supports APAC experience looking after young children or toddlers in the community, although I survey (Table A) have had the experience on the ward. I did the two days on the paediatric ward and that was really great, that was really – yeah, it was really good and gave me a little bit more confidence in terms of handling babies and things like that.
What sort of things on the ward? Can you give me an example? Focus on basic Basic things like checking their obs and the differences that you have to look out nursing skills in paediatrics e.g. for when doing observations, which is such a basic nursing skill with adults that observations & you don‟t really have to think about it beyond your first year or nursing training, medications. and the tips and tricks in terms of their breathing and distractions and things like Again ‘foreign‟ – that so you can get accurate results. So I think small things like that made me suggesting it is very realise the gap in my knowledge but at the same time, sort of, helped part way to different/unfamiliar. fill it. The medications and how serious they are about dosing and weight and Appreciated making sure that they‟re accurate, which is a little bit more foreign in adult training but nursing as well because we .., just a standard dose unless someone‟s grossly practical experience overweight or underweight. So that kind of particular thing was really eye is key – supports opening. So I think that all of the training I received, including the online Reaction Level courses, I think that the best for me was the two days on the paediatric ward results because I think everything into practice and made it a little bit more relevant and real.
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You said, you know, there was some nervousness about going in to doing Example of probe paediatrics. What particular aspects made you nervous or potentially and follow-up nervous? questioning Identifying I suppose it‟s just the unknown. I mean, you know, I‟ve done paediatric basic differences between life support training all through my career, so that‟s never – that‟s not foreign adult and paediatric and I think if anything happened very seriously I wouldn‟t hesitate in giving, you patients. know, CPR but I suppose it‟s the – it‟s the other things, like, there‟s different
– parameters for observations and I think with adults you have you can use your Unfamiliar with clinical reasoning a little bit better because you know – you‟ve had experience in communication and different medical conditions, you know the medications and what effect they children. It is an have on adults and the adults can communicate a lot easier or you‟re much more unknown area. better equipped to pick up body language cues and nuances in conversation with adults, so you can sort of read between the lines, whereas with children it‟s a lot Recognise harder and you don‟t often get the right answer or the direct answer to the importance of body question. You know, “Have you got pain?” “Oh, it hurts. It hurts. It hurts,” language you know, that type of thing, and you can‟t decipher it easily. So I think it‟s those types of things made me nervous.
Because at the beginning you said that you were feeling more comfortable This supports with teenagers…but smaller children not so much. results of the APAC Yeah, and I think that‟s probably a communication thing because with teenagers survey I find it fine to speak to them on their level and get the information and cues I need out of them, whereas with toddlers it‟s a lot harder.
Do you have any examples of communication with children that perhaps Recognising that didn’t go so well but it was a great learning? even basic nursing Yeah. So when I was on the paediatric ward, I think that the navy blue uniforms skills are different – there was an 18 month old child and I just had to do a set of observations. I for children than adults had to do a blood pressure and try and get them to sit still for, you know, 30 seconds and I think that they were scared. They obviously had recognised that the people in the blue uniforms were a little bit scary and wanted to poke and Putting learned knowledge into prod, and the child would just scream when you walked into the room and you practice. weren‟t able to actually, you know, stop and take a pulse or take a respiratory rate or anything like that …, Proud of This sounds quite forced but I did do one of the online learning packages about
Masters of Philosophy – Catherine Jones ([email protected]) Page 181 of 204 An Evaluation of Training to Prepare Nurses in a Home-Based Service to Care for Children and Families communicating with toddlers and if you can show that their parent trusts you, achievement in then the child will then, sort of, start to trust you as well. So when I realised that communication. this kid just didn‟t want anyone in a nurse‟s uniform to go near them, I went in and, sort of, didn‟t ignore them but just was speaking to the parents and didn‟t really pay them too much attention and they calmed down. You know, within about five minutes, they were quite calm and then I was able to do what I wanted to do. And so initially I‟m thinking how – like, this is so hard. With adults you just – you know, you can whiz around and do everyone‟s observations in about 10 minutes, and I‟m thinking, “It‟s taken me half an hour to do an obs(ervation) round. This is not – I‟m not doing something right here.”
That’s paediatrics. Used to being Yeah, and so that was – that was really challenging because I‟m thinking this is experts in adult something that‟s so easy for me is now not easy, it‟s quite difficult, and I‟m community nursing and now being thinking, “Am I recording it accurately?” and I know respiratory rate‟s so challenged. important for children as well and I‟m thinking, “If I‟m not counting it right Aware of where skill because they‟re screaming or chatting away, then what implications does that levels need to be. ” have? So it sort of made me quite conscious about what I was doing and how Paediatric skills are I was doing it. But that kind of worked well in the end, speaking to the parents very conscious – and kind of having just a normal conversation and calming the child down that moving towards way. Because I think before I was trying to soothe the child but obviously I‟m a competent stranger to them, so that‟s not going to work at all. So, yeah, I suppose that was practitioner a learning curve. (Benner, 2000)
Transcript (Extract from Interview Transcript 171120_0003) Notes
How did you feel about extending your role to care for children and families at home?
Exciting but nervous. I think there was – my training in the UK certainly gave Range of emotions. me a fairly good grounding but it was a long time ago and I wasn‟t particularly Associated good at it. I found it quite emotional. You know, I was probably worse than the paediatrics with parents. They cry and I‟m crying, you think, oh, just, you know, my kids were high emotions. little when I was doing paediatrics as well because I sort of did my training and Draw on own … I worked on paediatrics for a while because I thought that it would fit but it family experience wasn‟t for me. So for me I was a bit anxious. and kids
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Has this changed over time, your feelings about extending the role? Probing question Yeah. Yeah, definitely.
So how are your feelings now compared to----- Refer to skills as competent…never I think we‟re far more competent than we think. I think we‟ve had some really refer to selves as good support when we‟ve gone out there to see patients. Definitely. So I think experts – almost that was the anxiety thinking, you know, … we‟ve had the support and the acknowledging the backing to get us to feel confident and I know there are plenty of nurses that work difference for APAC now that wouldn‟t bat an eyelid going out to see paediatrics.
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Appendix 17 – Discrimination of Meaning Units and Themes from the Semi-Structured Interviews
Meaning Units Sub-Themes Themes excited Personal emotions Emotions and feeling about caring quite nervous about children, especially the babies, because it‟s just so foreign in terms of the type of nursing care. for sick children Excited about the idea but quite nervous of children/ Excited but nervous and their families If I had wanted to paeds I would have done it from the start!
It‟s just the unknown
Foreign
Brilliant. Exciting
Quite emotional (when dealing with families)… They cry and I‟m crying
Had chosen earlier in career not to do paediatrics and now find themselves having paediatrics in community portfolio
I was bit anxious
Feeling about paediatrics have changed over time since paediatric HITH
Not interested in children, don‟t have children , don‟t want children
Not comfortable/don‟t have the knowledge about children
Find paediatrics quite emotional an opportunity …(to) learn something new Professional development Puts another feather in your cap opportunity
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Learn something new
Expanding own personal skills
Nice challenge to increase your skillset
Such scope for paediatrics and APAC The right thing to do for APAC and HITH I think it is necessary for HITH to grow.
Travesty if we didn‟t offer HITH to paediatrics
Yeah, definitely. Feelings about caring for children there are plenty of nurses that work for APAC now that wouldn‟t bat an eyelid going out to see paediatrics changed over time
A lot of community nursing experience Many years of Skills and nursing experience knowledge of the Training in UK gave me good grounding adult community Varied clinical Twenty years nursing experience nurses backgrounds District Nurse in London for 5 years
Lots of experience in many aspects of nursing and nursing management inc. surgical, medical, palliative, flight nursing, private companies, ICU, ED, mental health
In UK paediatrics is a separate disciple so bit disturbed to do paeds as an adult nurse
Love the autonomy of community nursing
Lack of experience for APAC community nurses caring for children Little or no paediatric Lack of previous experience experience caring Paediatrics is a new thing for me for children Welcoming of
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opportunity Did a bit of paeds – twenty years ago
Something I‟ve been interested in
I did 18 months working in paediatrics
I think it‟s great and I‟m happy
Brief foray into paediatrics but didn‟t really like it
Did enjoy paediatrics as a student nurse but no enough to want to do paediatrics
Staff are gaining confidence with exposure to paediatrics and doing visits with CNS but still have a way to go Improving skills in paediatrics We are novices being introduced to paediatrics
I think we are more competent than we think (with paediatrics)
Comfort with teenagers as they have always provided service for 15 or 16 year olds Community nursing is working in isolation so need to be very confident and competent in your own nursing skills, I am at the opposite end of spectrum with children
Paediatrics is quite a specialised area Paediatrics as a Awareness of what speciality is required to be a (paediatrics ) is foreign in terms of the type of nursing paediatric nurse Got to think 10 times harder (than working with adults)
Acknowledge there is a large amount of knowledge associated with paediatrics
Don‟t see enough paediatrics at home to become confident/comfortable
As soon as CNS walked into a home they were assessing the child, they were streets ahead of where (an APAC) was with assessment. As they walked up to a child they had already checked off 20 things in their own minds
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APAC compare themselves to the CNSs and …have a lot still to learn to get to their level of competence and confidence with children
There‟s different parameters for observations Basic paediatric nursing skills How serious they are about dosing and weight (medications)
Tips and tricks in terms of breathing and distraction differences that you have to look out for when doing observations
It‟s taken me half an hour to do an obs(ervation) round
Need to take different adrenalin doses with them for different weights of children
Important to get treatment right
It‟s a lot harder calming the child down
Importance of comfort and sense of safety
Most important is to make sure children are comfortable (pain management)
Trying to convince (a child) to stay still so can give them a needle…..is very different conversation than just playing a game or chatting to them
Learnt importance of explanations & distractions/things to do/occupy them
I know respiratory rate is so important in paediatrics but lack confidence to do this and question if got it right Clinical deterioration in children Importance of differences in observations/parameters & signs of deterioration
Lack of verbal warnings from children that you get from adults e.g. I feel dizzy in adults
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Remember a paediatric patient giving them the biggest hug when they saw them Emotions
Lot of experience with communicating with families in general and stress situations e.g. dying/ grieving families The importance of caring for the family Import to build rapport with child and family and not just the child Different as need to deal with stressed families as well the child
Not had to deal with screaming child in home yet
Remembered paediatrics was a lot about looking after the parents
I can see why families would like HITH and why it is good for them
I firmly believe HITH offers incredible advantages for families inc. quality & safety
Nurses‟ relationship with parents is just as important as relationship with child
Easier to build rapport/working relationship with parents than with children
Not surprised that families love paediatric hospital in the home, and very complementary of APAC service and its dedicated staff
Parents do amazing things at home, often by themselves for long periods of time without breaks or nursing support like you get on a ward
Parents have emotional guilt and emotional attachment to the situation,
They‟re exhausted are really to be praised because they go above and beyond
Need to really support families as nurses but also be able to identify/advocate when a clinical situation is no longer appropriate for home and need to go back to hospital
Different as need to deal with stressed families as well the child
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use your clinical reasoning a little bit better because you know – you‟ve had experience in different medical conditions Awareness of their expertise in adults adults can communicate a lot easier much more better equipped to pick up body language cues and nuance…with children it‟s a lot harder
Signs of increasing confidence communicating with children
Quite challenging at times but also really rewarding because adults don‟t tend to hug you as much as kids Differences between adults and children They obviously had recognised that the people in the blue uniforms were a little bit scary
Children are just so…moody. They‟re up and down but they‟re so innocent, so forgiving and so thankful in the space of 5 minutes. Whereas adults if there in a mood they‟re in a mood for the whole time you are there.
Realised through training that things you look for in children are completely different to those in adult patients
Foreign
Greater sensitivity of my trip switch to deterioration in children
Can drop off the Richter scale as don‟t have resilience of an adult
Like a two-stroke engine that works really hard then stops compared to adult as four-stroke that digs in and keeps going
Children don‟t tell stories (don‟t lie about things)
More comfortable with older children especially the teenagers More comfortable with older children Increased anxiety about caring for babies/younger children than babies/toddlers Most uncomfortable/scared of the babies/toddlers
Become more confident especially with teenagers
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Gave me more confidence in terms of handling babies
Looking after a newborn who is very ill with anxious parents would be difficult
I understand the 14 year old better because they are mini human
Comfort with older children associated with communication with teenagers I find it fine to speak to them on their level …with toddlers it‟s a lot harder.
Not comfortable with babies
Saw teenagers at home without support of paediatric CNS but not little ones
Easy. Love it. Never had any problems. I‟m a mother so I guess that helps Influence of personal I have my own children/grandchildren experiences with Not interested in children, don‟t have children , don‟t want children children on their comfort with paediatrics
Comfort with older children associated with communication Challenges identified with Adults can communicate a lot easier…with children it‟s harder communicating with You don‟t often get the right or direct answer to a question (from children) children It‟s fine to speak to (teenagers) on their level…whereas with toddlers it‟s a lot harder
Trying to convince (a child) to stay still so can give them a needle…..is very different with teenagers I find it fine to speak to them on their level …with toddlers it‟s a lot harder. conversation than just playing a game or chatting to them
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Examples of planning communication with families/children and reflecting on it e.g. talking to teenager not just the mother; talking to parent to gain trust of the toddler who was observing you.
Putting learning into practice
Signs of increasing confidence communicating with children
It‟s a beautiful feeling (when get communication right with a child)
If you build rapport with child and family you can probably do anything or be able to do anything, to some degree
If you get off on bad foot you‟re never going to be able to treat a child
Absolutely fabulous except it was for emergency situations and really high-care kids Mixed feelings and The importance of controversy about the basic paediatric First aid and all that was brilliant 2-day paediatric nursing skills and Too much/ too advanced emergency nursing knowledge I enjoyed but it was way above my head and what we needed in community. It was really perhaps for emergency course
Good course but stressed about doing exam at end of the course
Probably of more value if done after they started seeing children and had some experience to draw on when doing the course
It was emergency based and too intense for community nursing
Nice to have the certificate but not sure how they passed
I think it unnerved a lot of nurses
It scared people about paediatrics
Very necessary and fantastic course for emergency nurses involved in paediatrics
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Acknowledge there is a large amount of knowledge associated with paediatrics and should have done more of the preparation/pre-reading before the course
Not sure how much knowledge retained as little opportunity to put into practice
Surprise myself by getting 80% in the assessment
Very important with adult and child nursing The importance of child protection I am comfortable on how to report things that I see as possible (child protection) problems training I have had experience of dealing with a child abuse case
Excellent. Better than I thought it was going to be.
Really good feedback from staff
Certainly have confidence to report, and investigate or have investigated
I think this prepared me because that‟s basic nursing as need to detect deterioration no matter how old the patient is Training about the deteriorating sick Probably worthwhile child (DETECT Realised through training that things you look for in children are completely different to those in adult patients Junior)
Great. One of most important aspects of the training Paediatric life support (Resus4Kids) training I‟ve done paediatric basic life support training all through my career as fundamental skills
Great. Can just learn on a computer – need to put into practice Learning about medications Probably worthwhile administration to Would have been better to spend some time on a paediatric ward instead children needs to be
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more practical than theory
Importance of checking medications, dosing and weight and putting this into practice as use CIAP or MIMS or Evidence of therapeutic guidelines to check medications applying learning about paediatrics Examples of learned communication techniques with children into practice This sounds quite forced but I did do one of the online learning packages about communicating with toddlers and if you can show that their parent trusts you, then the child will then, sort of, start to trust you as well. So when I realised that this kid just didn‟t want anyone in a nurse‟s uniform to go near them, I went in and, sort of, didn‟t ignore them but just was speaking to the parents and didn‟t really pay them too much attention and they calmed down. You know, within about five minutes, they were quite calm and then I was able to do what I wanted to do
Brilliant. Helped build confidence The importance of the support of the APAC were the primary nurse on home visits but CNS interjected if needed paediatric clinical We‟ve had the backing and support to get us to feel confident nurse specialists The paediatric nurses we went out with are exceptional and fantastic at what they do.
I admire them.
APAC compare themselves to the CNSs and see they have a lot still to learn to get to their level of competence and confidence with children
As soon as CNS walked into a home they were assessing the child, they were streets ahead of where (an APAC) was with assessment. As they walked up to a child they had already checked off 20 things in their own minds
Feedback and reflection on the visits with the CNS was really valuable
Need ongoing support from paediatric CNS/ doing home visits with CNS was a great learning experience about all
Masters of Philosophy – Catherine Jones ([email protected]) Page 193 of 204 An Evaluation of Training to Prepare Nurses in a Home-Based Service to Care for Children and Families aspects of paediatrics including how to approach a situation with a child and their reactions to you
Saw teenagers at home without support of paediatric CNS but not little ones
Best aspects were …going out with the paediatric CNS on home visits
Need more than 3 or 4 nurses in APAC who are confident with children For a core group of APAC nurses to If APAC is serious about paediatric should identify nurses interested in paediatrics and support them to do a diploma develop more in paediatric nursing like a graduate certificate course advanced paediatric Important that identify the nurses who are interested in paediatrics in APAC and target training to them nursing skills
Not enough exposure to paediatrics in APAC to be able to build confidence Need increased Need for further exposure to working practical training or Need more face-to-face/ more exposure to paediatrics/children. It is that simple with children experience 2 day experience on the ward gave me more confidence in terms of handling babies opportunities I don‟t think we see enough paediatrics to remain confident
Saw teenagers at home without support of paediatric CNS but not little ones
Need to increase exposure to children to increase confidence
Need to put training into practice or relate to observed practice
Time will tell how many children we will see, it is definitely increasing in numbers
Needing to see children in different clinical situations and with different conditions
Numbers of children in APAC are small and therefore not enough opportunity to care for children so confidence and skills can develop
Need APAC educators to be up skilled to support others do the online courses to get more out of the online learning Identified ongoing/training/supp
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ort requirements Need to facilitate staff being able to attend the paediatric training i.e. workloads
Important to have relationship with paeds ward so comfortable to call & ask questions
Need constant reminders and exposure through practice or courses
Interesting but need to maintain knowledge base continually
Limited value from the formal training but acknowledgement that it is necessary as base knowledge and needs to be ongoing
Scenario/simulation training could help with confidence through training Needs for scenario/ simulation/ hands-on Face-to-face training from paediatrics was excellent training Hands on experience is what is missing
No not adequate just doing HETI (online training) on a computer – need to put into practice, have opportunity for actual exposure with children and different dynamics
Great. Can just learn on a computer – need to put into practice
Like to have an intense week of working on a paediatric ward Need for further opportunities to work Doesn‟t have to be 5 days in a row but can be over time say 5 days with paeds CNS on a paediatric ward Need to consolidate training and put into practice
Increasing time and exposure on paediatric ward is what is missing from training
2 day experience on the ward gave me more confidence in terms of handling babies
Would have been better to spend some time on a paediatric ward instead Would like more time on the paediatric ward – like to have a whole week on ward
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Ward placement was best learning experience
Didn‟t get the opportunity but would have like to
If there were opportunities again to go to paediatric ward would absolutely want to go
This was the most valuable part of the training as identified by all who attended and the others all wanted to or would definitely want to in the future if opportunity arose
Staffing/rostering challenges prevented some APAC nurses being able to go on ward placements
Would like more time on the paediatric ward – like to have a whole week on ward
Ward placement was best learning experience
Scenario/simulation training could help with confidence through training Association between Association between confidence with confidence with Not enough exposure to paediatrics in APAC to be able to build confidence children and children and Need constant reminders and exposure through practice or courses competence in competence in Saw teenagers at home without support of paediatric CNS but not little ones paediatric nursing paediatric nursing, and confidence and Need to increase exposure to children to increase confidence communication with Increasing time and exposure on paediatric ward is what is missing from training children have a lot still to learn to get to their level of competence and confidence with children
See personal exposure to children/grandchildren as a positive to being confident communicating with children Not comfortable with babies
More comfortable with older children especially the teenagers
Increased anxiety about caring for babies/younger children
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Most uncomfortable/scared of the babies/toddlers
Become more confident especially with teenagers
Gave me more confidence in terms of handling babies
Looking after a newborn who is very ill with anxious parents would be difficult
I understand the 14 year old better because they are mini human Association between confidence and Comfort with older children associated with communication communication with with teenagers I find it fine to speak to them on their level …with toddlers it‟s a lot harder. children Saw teenagers at home without support of paediatric CNS but not little ones
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Appendix 18 – Transformation of Themes into Theme Categories
Themes Theme Categories
Awareness of their expertise in adults Clinical Experts in adult community nursing Skills and knowledge of the adult community nurses care but not in paediatric nursing Feelings about caring for children changed over time How the APAC nurses assess their own skills in paediatrics Emotions and feeling about caring for sick children and their families Lack of previous experience caring for children
The importance of caring for the family and not just the Emerging understanding of the import aspects child of paediatric nursing including caring for the Awareness of what is required to be a paediatric nurse family and not just the child Differences between adults and children Challenges identified with communicating with children Emotions and feeling about caring for sick children and their families The importance of the support of the paediatric clinical nurse specialists
Lack of previous experience caring for children Association between confidence communicating More comfortable with older children than babies/toddlers with children and competence in paediatric Influence of personal experiences with children on their nursing comfort with paediatrics Challenges identified with communicating with children
Improving skills in paediatrics Emerging competent paediatric nursing Awareness of what is required to be a paediatric nurse practitioners Evidence of applying learning about paediatrics into practice The importance of basic paediatric nursing skills and knowledge Importance of the support of the paediatric nurse specialists For a core group of APAC nurses to develop more advanced paediatric nursing skills Need for further practical training or experience opportunities
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Appendix 19 - COREQ Checklist
COREQ (COnsolidated criteria for REporting Qualitative research) Checklist (Tong et al., 2007)
Item Topic Guide Questions/Description Reported in No. Domain 1: Research team and reflexivity Personal characteristics
Interviewer/facilitator 1 Which author/s conducted the interview or focus group? Appendix 14 Credentials 2 What were the researcher's credentials? E.g. PhD, MD Appendix 14 Occupation 3 What was their occupation at the time of the study? Appendix 14 Gender 4 Was the researcher male or female? Appendix 14 Experience and training 5 What experience or training did the researcher have? Appendix 14 Relationship with Participants Relationship established 6 Was a relationship established prior to study 3.2.2 commencement? Participant knowledge of the 7 What did the participants know about the researcher? e.g. 3.2.2 interviewer personal goals, reasons for doing the research Interviewer characteristics 8 What characteristics were reported about the inter 3.2.2 viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic Domain 2: Study design Theoretical framework Methodological orientation and 9 What methodological orientation was stated to underpin 3.1.3 Theory the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis Participant selection Sampling 10 How were participants selected? e.g. purposive, 3.2.3 convenience, consecutive, snowball Method of approach 11 How were participants approached? e.g. face-to-face, 3.2.3 telephone, mail, email Sample size 12 How many participants were in the study? 3.2.3 Non-participation 13 How many people refused to participate or dropped out? 4. Results Reasons? Setting Setting of data collection 14 Where was the data collected? e.g. home, clinic, 3.3 workplace Presence of non- participants 15 Was anyone else present besides the participants and 3.2.3 researchers? Description of sample 16 What are the important characteristics of the sample? e.g. 3.2.3 demographic data, date Data collection Interview guide 17 Were questions, prompts, guides provided by the authors? Appendix 10 Was it pilot tested?
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Repeat interviews 18 Were repeat interviews carried out? If yes, how many? -
Audio/visual recording 19 Did the research use audio or visual recording to collect 3.2.4 the data?
Field notes 20 Were field notes made during and/or after the interview or - focus group? Duration 21 What was the duration of the inter views or focus group? 3.3.2 Data saturation 22 Was data saturation discussed? - Transcripts returned 23 Were transcripts returned to participants for comment - and/or correction? Domain 3: analysis and findings
Data analysis
Number of data coders 24 How many data coders coded the data? 3.2.4
Description of the coding tree 25 Did authors provide a description of the coding tree? -
Derivation of themes 26 Were themes identified in advance or derived from the 4.3 data? Software 27 What software, if applicable, was used to manage the data? 3.2.3
Participant checking 28 Did participants provide feedback on the findings? -
Reporting
Quotations presented 29 Were participant quotations presented to illustrate the Appendix 16 themes/findings? Was each quotation identified? e.g. & 17 participant number
Data and findings consistent 30 Was there consistency between the data presented and the Sections 4 & findings? 5 Clarity of major themes 31 Were major themes clearly presented in the findings? 4.3 Clarity of minor themes 32 Is there a description of diverse cases or discussion of 4.3 minor themes?
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Appendix 20 – A Snapshot of NSLHD
Northern Sydney Local Health District (NSLHD) is one of 15 geographic Local Health
Districts in NSW. The District covers an area of around 900 square kilometres ranging south from the Hawkesbury River to the northern shore of Sydney harbour and west from the eastern seaboard to the Old Northern Road. Population density gradually increases from the agricultural areas just south of the Hawkesbury River to the highly populated areas of North
Sydney (Northern Sydney Local Health District, 2015).
Figure 11: Map of Northern Sydney Local Health District
Northern Beaches
NSLHD is divided into three health services with five acute hospitals:
Hornsby Ku-ring-gai: Hornsby Ku-ring-gai Hospital Northern Beaches: Manly and Mona Vale Hospitals (now amalgamated into the new Northern Beaches Hospital) North Shore Ryde: Royal North Shore and Ryde Hospitals
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Current Population
The 2011 Census indicates the NSLHD estimated resident population was 853,162 which is 11.8% of the NSW population. The place of usual residence for NSLHD was reported at 808,642 which is lower than the estimated resident population but is used as the basis for more detailed demographic comparison particularly of cultural and linguistic diversity. Between 2015 and 2025, the total population is expected to grow by 13.6% to 1,018,022. North Shore Ryde will grow by 15.6%, Hornsby Ku-ring-gai by 13.1% and Northern Beaches by 11.6%.
Demography
The fertility rate for NSLHD of 1.62 is lower than the NSW average of 1.80 (2005 – 2007). Single parent families with children aged less than 15 years make up about 11.8% of all families with children aged less than 15 years in the NSLHD population, and jobless families with children aged less than 15 years make up 5.3%. These are both lower than the NSW average of 21.3% and 13.3%. For young people aged 15 to 19 years 89.4% were learning or earning in 2011, compared to 81.4% for NSW.
The prevalence of single person households increases with age, peaking in the 85 years and older age group where just over one in three people live alone, compared to the average for all ages of less than 10%. North Shore Ryde health service has a higher proportion of people living alone (11%) compared to the NSW average (8.7%). Hornsby Ku-ring-gai health service has a lower proportion of people living alone (5.7%) compared to the NSW average.
NSLHD is the least disadvantaged Local Health District in NSW. However there are pockets even in relatively affluent areas that may be classified as „disadvantaged‟. NSLHD has lower proportion of its population who are unemployed (3.5%) and higher proportion of the population who participate in the labour force (69.1%) than the NSW averages of 5.2% for unemployment and 63.9% for labour force participation. Public housing rates are substantially lower in NSLHD (1.6%) than across NSW (4.4%). Within NSLHD the rate is highest in Hunters Hill (6.4%) followed by Ryde (3.8%).
NSLHD has the highest rate of health insurance in NSW with 71% of the population having private health insurance. This has increased from 2001 when only 63% of the NSLHD population had health insurance.
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Health Profile
Current smoking levels among NSLHD adult residents (13.2%) are significantly lower than for the NSW average. Hornsby Ku-ring-gai residents have the lowest rate of 10% and Northern Beaches residents the highest at 15% compared to 20% for the NSW average. Exercise rates are similar to the state average of 53% in Northern Beaches or slightly below in Hornsby Ku-ring-gai at 50%.
Risk-drinking behaviours among residents of NSLHD are above the NSW average for Northern Beaches residents, but lower for Hornsby Ku-ring-gai and North Shore Ryde residents (although these differences are not statistically significant). Estimates of chronic disease for NSLHD residents are lower than the NSW average. In general NSLHD had fewer adults who had at least one of the four risk factors of smoking, harmful use of alcohol, inactivity and obesity and fewer adults with a combination of a risk factor plus a chronic disease.
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Appendix 21 - Novice to Expert Scale (Benner, 2000)
Knowledge Standard of Work Autonomy Coping with Perception of context Complexity
1. Novice Minimal or „textbook‟ Unlikely to be Needs close supervision Little or no conception of Tends to see actions in knowledge without satisfactory unless or instruction dealing with complexity isolation connecting it to practice closely supervised
2. Beginner Working knowledge of Straightforward tasks Able to achieve some Appreciates complex Sees actions as a series of key aspects of practice likely to be completed to steps to using own situations but only able steps an acceptable standard judgement, but to achieve partial supervision needed for resolution overall task
3. Competent Good working and Fit for purpose, though Able to achieve most Copes with complex Sees actions at least background knowledge may lack refinement tasks using own situations through partly in terms of longer of area of practice judgement deliberate analysis and goals planning
4. Proficient Depth of understanding Fully acceptable standard Able to take full Deals with complex Sees overall „picture‟ and of discipline and area of achieved routinely responsibility for own situations holistically; how individual actions fit practice work (and that of others decision making more within it were applicable) confident
5. Expert Authoritative knowledge Excellence achieved with Able to take Holistic grasp of Sees overall „picture‟ and of discipline and deep relative ease responsibility for going complex situations, alternative approaches; tacit understanding beyond existing moves between intuitive vision of what may be across area of practice standards and creating and analytical possible own interpretations approaches with ease
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