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Oct 25 CAPHC Breakfast Symposium - Sponsored by the Nursing Network
- 1. Canadian Paediatric Nursing Standards: Standardizing High Quality Nursing Care for Children in Canada 2016 CAPHC Nursing Leadership Breakfast Session B. Fleming-Carroll, L. Rudden, F. So, K. Breen-Reid, M. McAllister, P. Hubley, M. Ballantyne
- 2. Objectives: • Explore children’s healthcare needs unique to Canada • Describe the development process of Canadian paediatric nursing standards • Share the Paediatric Nursing Standards • Building next steps for knowledge translation 2
- 4. 2016 UNICEF Report: Child Well-being https://youtu.be/CioMdBRF1RA 4
- 5. Key Health Concerns for Canadian Children • Mental health • Obesity • Poverty • Indigenous Health • New Immigrant Health • Childhood Disability & Complex Care • Chronic Health Conditions 5
- 6. A Call to Action 6
- 7. Harnessing our Strengths • Champion and advocate for children’s health issues • Care for children and their families as a unit • Focus on health promotion, illness prevention, curative & rehab. of the child • Working in many different settings • Many contacts with child & family members over time • Strength-based approach to care • Delivery of developmentally appropriate care • Focus on optimal functioning • Integrate scientific theory related to child health • Understanding of ethical, moral and legal problems unique to children • Breadth of knowledge related growth and development • Integration of Anticipatory guidance & health coaching • Frontline to vulnerable populations • Navigator/coordinator-understands the system • Collaborator with teams/sectors to provide best care 7
- 8. Why Standards? • Direction for professional paediatric nursing education and practice • Framework for the evaluation of this specialized practice. • Measurable standards define the nursing profession’s accountability to the public and the practice outcomes for which they are responsible. (Adapted from American Nursing Association [ANA]) “There will always be some interest more immediate than protecting the well-being of children. There will never be one more important.” - UNICEF REPORT CARD 2010 8
- 9. The Journey- “Just the beginning” • Develop a set of outcome oriented standards for paediatric nursing that will guide practice across the country and enable children and families to receive a consistent level of high quality care no matter where they are in Canada • To grow the value of specialty training for nurses who practice in paediatric settings • To grow the value paediatric nursing as a viable specialty area 9
- 10. What We Are Building Upon: • Children’s Rights – UN “Rights of the Child” – WHO • Paediatric Nursing Standards – US (2008) – UK (2013) – Australia (2006) • Canada • Canadian Nurses Association (CNA) • Canadian Association of Paediatric Nurses (CAPN) • Paediatric Intensive Care Nursing (CNA) • Provincial/Territorial standards 10
- 11. Development of the Canadian Paediatric Nursing Standards 11
- 12. Think Tank: October 2014 • Established interest and need • Developed core steering committee • Literature review and status report • Process map 12
- 13. Obtaining perspective: Delphi process Draft 1 Standards Developed 5 Paediatric Nursing Standards to reflect: - Setting/environment - Focus of nursing - Patient populations - Understanding of terms - Glossary E-Delphi Survey Round 1 Engaged >100 Canadian Nurses - Refinement - Understanding - Context - Refine Glossary E-Delphi Survey Round 2 Engaged >80 Nurses from all provinces/territories - Further refinement - Feedback concerning application, communication Review, Steering Committee Ratification Ensure agreement across standards Consistent language Reliability Validity 13
- 14. Summit – September 11-12, 2015 14
- 15. Vision • Paediatric Nurses are a powerful collective force that helps ensure that all children and families in Canada have equitable access to highest quality pediatric care regardless of their circumstances. • Paediatric Nursing Standards are leveraged to prepare the best paediatric nurses in the world and they are integrated into the practice of any nurse who works with children, youth and families in all settings and through key transitions. • Children, youth and families are healthier, safer and more able to reach their full potential as a result of our leadership in evidence based: policy development, advocacy, health promotion, early detection and family centred care. 15
- 16. Outcome Oriented Standards Exploration Proficiency / Competencies Always Events Desired Outcomes 16
- 17. Hybrid Delphi Process • Initial Round: Expert Consensus Summit • Round 1 & 2: e-Delphi Recruitment: 1) Snowball method 2) Direct contact 17
- 18. E-Questionnaire Development • Approved as a Quality Improvement project • Use of RedCAP© • Rated each component with a 4 point scale (5 domains, Always events, competencies) • Qualitative field to ask for clarifications & additions • Instruction package and glossary of terms 18
- 19. Data Analysis • Set limits for agreement – Greater than 80% for domains – Greater than 65% for sub-points • Small sub-group from steering committee reviewed the feedback and scoring 19
- 20. e-Delphi Scoring • Round 1 – Greater than 80% for domains – Greater than 70% for sub-points • Round 2 – Greater than 97.5% agreement for domains – Greater than 92% agreement for sub-points 20
- 21. Revisions • Terms/key words were stream-lined to ensure consistency in language • Repeated concepts were combined or eliminated • Additional sub-points were accepted based on participant consensus • Revisions & additions to glossary to ensure clarification 21
- 22. Who responded? Alberta British Columbia Manitoba New Brunswick Nfld & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Total 90 nurses 22
- 23. Who responded? Hospital Staff Development College/University Management Community/Home Care Clinic/medical office Rehabilitation Other Public Health Outpost Research Government 23
- 24. Results Roun ds # Agreed to Participate # Actual Participation # Completed Questionnaire in Full % Completed 1 128 84 78 61 2 135 85 77 57 STANDARDS • Over 97.5% endorsement ALWAYS EVENTS • Over 92% endorsement COMPETENCIES • Over 92% endorsement 24
- 25. 5 Domains of Paediatric Nursing Core Standards: Nursing Process Safety / Reliability Quality Ethics Research Education 2. Advocating for Equitable Access and the Rights of Children and their Family 1. Supporting and partnering with the child and their family 3. Delivering Developmentally Appropriate Care 4. Facilitating a child and family friendly environment 5. Enabling Successful Transitions 25
- 26. Standard I: Supporting and partnering with the child and their family Paediatric Nurses partner with the child and their family to achieve their optimal level of health and well-being leading to resilient families and healthy communities. The Paediatric Nurse ALWAYS: • Establishes an intentional therapeutic relationship with the child and family • Respects the child and family in goal setting and decision making • Collects and uses information from the child and family context to inform care • Communicates with child and family as partners in care • Advocates for optimal use of resources to support the child and family • Recognizes and fosters the parenting role to support child well-being 26
- 27. Standard II: Advocating for Equitable Access and the Rights of Children and their Family Paediatric Nurses demonstrate and mobilize their understanding of the social determinants and other systemic factors that impact child health. The Paediatric Nurse ALWAYS: • Completes a comprehensive assessment (beyond physical assessment) through an advocacy lens considering Social Determinants of Health and child well-being • Facilitates an appropriate environment to perform assessment and intervention considering privacy and confidentiality • Build capacity in the child and their family to self-advocate • Engages in a community of practice or network that focuses on paediatric nursing practice and knowledge and resources for children and families • Supports the child and family to navigate the health care system 27
- 28. Standard III: Delivering Developmentally Appropriate Care Paediatric Nurses perform assessment based on growth and development and deliver paediatric-specific care. The Paediatric Nurse ALWAYS: • Demonstrates knowledge of typical development and variation from typical • Demonstrates knowledge of safety risks relevant to developmental stage • Provides anticipatory guidance and coaching on typical development and safety related to the developmental stage of the child and family • Performs safety assessment at point of care to minimize risk and harm with developmental stage • Incorporates developmentally appropriate play and/or recreational activities into care • Performs age and developmentally appropriate bio-psychosocial assessment • Uses developmentally appropriate strategies when preparing for and performing interventions • Considers development that is influenced by ethnicity, spirituality and culture 28
- 29. Standard IV: Creating a Child & Family Friendly Environment Paediatric Nurses play an essential role in creating a child and family friendly environment that welcomes families and promotes hope and healing. It is understood that the environment changes as the child grows and is influenced by multiple factors including but not exclusive to psychological, spiritual, and social. The Paediatric Nurse ALWAYS: • Completes a child and family assessment • Demonstrates cultural competency and humility in all child and family interactions • Engages the child and family in all care decisions and plan of care in a respectful non- judgmental, culturally safe manner • Shares information relevant to plan of care and collaborates with and amongst circle of care providers • Recognizes and fosters family strengths and supports • Uses strategies to support and foster resiliency • Demonstrates caring and compassion to both child and family 29
- 30. Standard V: Enabling Successful Transitions Paediatric Nurses support the child and family through healthcare transitions to maximize their well-being. This may include, but is not limited to, hand-off between healthcare providers, admission and discharge, and facility transfer (such a from paediatric to adult care institutions) The Paediatric Nurse ALWAYS: • Uses effective communication strategies at all transitions in care • Engages in planning of health education and coaching at all transitions • Provides health education and information to optimize transition of the child and family • Assesses readiness and supports safe transition • Anticipates resources to support transitions in care • Plays an active role in facilitating effective transition 30
- 31. Small Group Work In table groups identify opportunities and activities that integrate the new standards within your assigned sector. 1. Paediatric Tertiary/Quaternary Hospitals 2. Community Hospitals 3. Community & Public Health Organizations 4. University & College nursing Programs 5. Research 6. Government & Professional Associations 31
- 32. Canadian Assocoation of Paediatric Nurses (CAPN) • Official membership with CNA • Obtained domain name paednurse.ca • Establish an Interim Executive for CAPN • First Executive meeting to be organized Nov. 2016 • Establish Roadmap including website development & membership, toolkits for standards implementation 32
- 33. Thank you to our supporters • Think Tank & Summit participants • Delphi responders • Financial supporters: 33
Editor's Notes
- I would like to start by thanking the CAPHC Nursing Session planning group for inviting us back this year to report on the development process for the Canadian Paediatric Nursing Standard. Not too long ago I organized a speaker to come to Sickkids to talk about our work as leaders. I remember distinctly, he talked about three different types of work that we do..our routine day to day work that needs to get done, our good work that energizes us in our roles and profession and lastly the ‘great’ work we do….game changing work that is transformational. Being involved in leading the development of the Standards is that ‘great’ work that has the potential to transform children’s health in Canada. Nurses are such a valuable resource within the Canadian health care system and we are well-positioned to further influence and advance the protection and promotion of the well-being of children no matter where they are and these standards will ultimately guide and ensure consistent and high quality nursing care for all Canadian children.
- The objectives of this presentation are to highlight the unique healthcare needs of children in Canada leading to the standards development. Karen is going to talk about the development process and the expected impact. Then we are hoping to spend a little time getting your thoughts and ideas about dissemination of the standards and how we can leverage this work to re-build a strong Canadian Network of Paediatric Nurses.
- We can see in this graph that even with an increase in immigration, the number of children in Canada is plateauing; while the number of elders is increasing. This creates a competition for resources and with anticipation that the elderly population will double in 25 years there is less and less healthcare dollars going to children’s care.
- I want to share a short video from Unicef. Every year unicef does a comparison report of the well-being of children in developed countries. The video talks about Canada’s position in the world related to the well being of children in Canada. So in fact what this video is describing is a widening of the equality gap for children. In 2013, Canada ranked 17/29 for Child Well-Being and is now 26th out of 35. This is not only Canada’s call to action but as paediatric nurses, this is our call to action.
- If we look at the literature, the key health concerns for Canadian children are mental health, obesity, poverty, aboriginal health, new immigrant health, childhood disability and complex care and also the growing number of paedatric chronic health conditions. We know from Maureen O’Donnell that we have some unique problems and we need to focus on both the health status of children and health services for children
- Social paediatrics refers to the health and well being of children, specifically those children who are marginalized and the recognition of the impact of the social determinants on health. This article highlights Canada’s struggle with addressing the issues related to social determinants of health. You might recognize some of the authors.
- So what can nurses do? Why are paediatric nurses positioned to make a difference in children’s health? I am not going to go through the whole list but we know paediatric nurses are champions and advocates for children’s health issues. They work in all different setting where children are seen and they are often the main contact with families over time. Paediatric Nurses have a strengths based approach and a breadth of knowledge related to growth and development and they are often the hub within a healthcare team being the navigator and coordinator within the system.
- So why standards and in particular Canadian Paediatric Nursing standards. Canada has a number of unique aspects, our health care system is different than in other places, our demographics are diverse, our geography is vast and we aren’t doing well overall in child well-being particularly in vulnerable populations. The standards will provide direction for professional paediatric nursing education and practice and a framework for the evaluation of this specialized practice. Written in measurable terms, standards define the nursing profession’s accountability to the public and the practice outcomes for which they are responsible. Overall , the national standards and potential certification process would strengthen the paediatric nursing profession in Canada resulting in role clarity, credibility and accountability of paediatric nurses leading ultimately to improved child health. I’m going to stop here and hand over to Karen to talk about the development process.
- Reviews in literature, online resources and historically in Canada indicate that many countries and children’s advocacy organizations have created or attempted standards of care for children generally and in health care. In 2004 Canadian Nurses attempted a process of creating standards adapted from the Pediatric Nursing Standards in the US We have a new group of nursing leaders interested in revitalizing this work with the support of CAPHC and people like you.
- A Delphi process was used to obtain agreement with the standards outside the original design group at the summit. We applied to SickKids for a Quality Improvement project since many of the investigators were from this hospital and it was one of the supporters of the project. Delphi technique is a series of sequential questionnaires or “rounds” to obtain controlled feedback seeking to gain the most reliable consensus of opinion of a group of experts (Powell, 2003). We used an online survey tool (Redcap) which is easy to use, can allow for either anonymous or named feedback and provides some ability to collate data for analysis. A 4 point Likert scale was used (Strongly agree to Strongly disagree) as well as free test type in fields for comment. For each round we obtained demographic data as well so that we could be assured we were obtaining consensus from a broad range of perspectives. During each round, the current version of the standards, always events and competencies were shared with those who volunteered to be part of the survey through an online survey. Descriptors and a glossary were available to assist with consistency in interpretation. After Round 1, all the feedback was reviewed and analyzed by the survey group (4 nurses) and refinement of the statements, explanations, and glossary were completed. Any item that did not receive at least 80% consensus was either modified based on feedback or deleted. It was assuring to the survey group that the standards received over 80% consensus from the beginning with only minor wording changes. The most refinement over the 2 Delphi rounds, occurred at the Always event, competency and glossary levels.
- Over 30 nurses from 9 provinces and 3 territories met to develop the first draft of standards. They worked over two days to create the first draft of the standards. We considered the first stage of the Delphi process
- Summit members identifying others Direct contact at conferences and professional organizations
- Wanted to make sure that we captured the unique practice core of the pediatric nurse and worked to eliminate general foundational practice components that all nurses would exhibit.
- We were committed to ensuring all provinces and territories were represented at each stage. At the Summit in September, all had at least one representative, except Manitoba. However, as you can see here, by the end of the process, there was input from every province and territory and fairly well defined based on population size of each. Sent to 132 then 135 nurses Overall, 90 different nurses responded to at least summit participation or at least one round of the Delphi process.
- Needed to ensure relevance to pediatric nurses in all sectors working with all different patient populations. We also wanted to be sure we addressed all the possible points of care for children and families. There was broad representation of roles and sites within the group. Many respondents held multiple roles and indicated that on their surveys. The only area where there was not representation was any nurse at a government level; federally or provincial/territory.
- During the Delphi process we set a target of at least 80% consensus with any statement (strongly agree or agree) with the 5 Standards and at least 75% agreement with the Always events and Competencies. As you can see we exceeded our targets for all and were often at 100% for many items. Response rate for both rounds was over 57% of those approached
- In the development of paediatric specific nursing standards, it is assumed that each province and territory has its own regulatory body for nursing. The regulatory body sets practice standards and guidelines that apply broadly to all nurses. Practice standards outline the expectations for nurses that contribute to the public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. The core standards apply to nurses regardless of the role, job description or area of practice. The Paediatric Nursing Standards are meant to build on this foundation.