'We are pulled to the four corners': Qualitative role descriptions of advanced practice children's nurses in Malawi.

PURPOSE: This study investigated emerging roles among specialist child health nurses (CHNs) in Malawi. Advanced nursing role development is globally advocated. Nursing role descriptions provide an evidential basis for workforce planning. Rigorously developed role descriptions are scarce worldwide, especially for Africa. Advanced nursing roles were introduced in Malawi's child health system a decade ago. DESIGN AND METHODS: We followed guidance on generating nursing role descriptions to collect and analyse qualitative data from interviews and focus groups, using qualitative content analysis. We used COREQ reporting standards. RESULTS: More than half (41/80) of Malawi's child health nursing workforce participated. Richly descriptive accounts of roles elicited three themes: leading and developing new services and improving existing ones; holding rare knowledge which uplifts care quality; and responsibility for developing the role. These responsibilities are experienced as a privilege and a burden, often meaning CHNs are 'pulled to the four corners'. PRACTICE IMPLICATIONS: We found evidence of remarkable achievements by Malawi's CHNs but also suggestions that they are under heavy strain. Because multi-stakeholder agreement about role content is crucial to successfully implementing advanced nursing roles, we hope the approach taken by this study, and the information generated, could be useful as part of human resources for health strategy development in other lower-resourced countries globally.

Nursing stakeholder identification guidelines for human resources for health and health workforce development: A scoping review.

AIM: To investigate the existence of guidelines on the identification of nursing stakeholders as part of planning for human resources for health processes. BACKGROUND: Effective involvement of nursing stakeholders in planning and implementing human resources for health policies is strongly advocated by leading global bodies. Systematic identification of nursing stakeholders at an early stage is fundamentally important. Guidelines to support appropriate identification and inclusion of nursing stakeholders could support the active involvement of nurses and midwives in human resources for health planning processes at all levels. METHODS: We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We conducted a widely inclusive search for all types of records, including searches of bibliographic databases (PubMed, CINAHL, Scopus and Web of Science) and manual searches of selected websites and internet archives to identify grey literature, published in English since 2009. Search terms related to guidelines, stakeholder engagement and the health workforce. RESULTS: Of the 1058 potentially relevant sources identified, two studies met inclusion criteria. Both were guidelines produced by global bodies more than 12 years ago. Cochrane guidance on reporting 'near-empty' reviews was followed, and eight additional sources meeting most of the inclusion criteria were identified and critiqued. CONCLUSIONS: Guidelines regarding the process of nursing stakeholder identification specific to human resources for health planning processes are scarce and require updating. Critique of recent practices suggests considerable methodological variety and sub-optimal identification of nursing stakeholders. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nursing stakeholder engagement is an essential component of human resources for health planning processes, and the gap in literature points to a need for up-to-date guidance to ensure nurses' active involvement.

Development of a capability maturity model for the establishment of children's nursing training programmes in southern and eastern Africa.

Establishing sustainable training to strengthen human resources for health for children's nursing in Africa requires stakeholders to navigate complex pathways spanning multiple regulatory systems and sectors. Incomplete stakeholder insight threatens long-term sustainability of new training programmes. We drew on collective experiential knowledge of capacity building for children's nursing in southern and eastern Africa to articulate a Capability Maturity Model (CMM), using a six-stage process to: identify necessary supportive conditions; specify levels of process maturity; develop domains; characterise levels of capability; consult with stakeholders; and finalise the model. We articulated a comprehensive CMM describing five levels of process maturity in relation to education, clinical and regulatory systems, human resources for health systems, and requirements related to overall stakeholder collaboration. The model makes visible the range of regulatory and associated processes involved in developing a new educational programme for specialist nurses, including educational standards, quality assurance, scopes of practice, and systems for licensing and registering specialist children's nurses. Stakeholders can use the model as a map to identify where they are in the process, and establish the resources and actions needed to make further progress.

Engaging nurses in research awareness using a new style of hospital journal club - a descriptive evaluation.

BACKGROUND: Nurses, especially nurses in Africa, face barriers when trying to access and apply literature. These challenges include paywalls; complex academic language; and journal content which is hard to translate to local realities. OBJECTIVES: To investigate nurses' self-reported experiences of participating in a monthly hospital wide journal club at the Red Cross War Memorial Children's Hospital (RCWMCH). DESIGN: This descriptive study used a researcher-designed quantitative questionnaire design. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guideline were used. SETTING: Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa. PARTICIPANTS: All cadres of nurses working at the Red Cross War Memorial Children's Hospital (RCWMCH) who had attended six or more hospital journal club sessions at RCWMCH over the previous two years. METHODS: A descriptive study using a researcher-designed quantitative questionnaire. RESULTS: 155 participants completed the survey (96.87% response rate). Participants self-reported an improved knowledge of the main sections of a journal article (p < 0.001) and a significant increase in talking to colleagues about evidence-based nursing practice after attending journal club (p < 0.001). CONCLUSIONS: Attendance at a journal club appears to contribute to increased access to scientific literature, personal and organisational habits of reading, and collaborative exploration of clinical practice for nurses of all cadres. Innovative facilitation methods (including large-scale graphic facilitation) may contribute to efficacy and popularity of sessions.

A scoping review of mother-child separation in clinical paediatric settings.

There is increasing evidence to suggest that autonomic regulation of hospitalised infants is affected by separation from their mother. This review explored the extent of the evidence relating to the impact of separation on infants and children and aimed to identify suitable measures of the impact of mother-child separation. We conducted a scoping review of seven databases using the main search terms 'physiological', 'psychological', 'infant/child', 'maternal separation' and 'hospital'. Thirty-four articles containing data relevant to the effects of mother-child separation on either member of the pair were included. Findings highlight the central importance of the mother's presence in mediating the stressful effects of hospitalisation on her child. The majority of articles reported on psychological effects of separation on mothers of infants or on younger children. We identified no articles reporting on physiological effects on the older child or mothers of older children or psychological effects on mothers of older children. Only nine articles used validated tools to measure the effects of separation. There is a need for more evidence, based on validated measurement, about the psychological effects of separation on the child, particularly the older child, and on the physiological effects of separation on the mother-child pair during hospitalisation.

Developing children's nursing care outcome statements in Africa using World Café methods.

Nursing metrics use indicators to make the outcomes of nursing care visible through measurement. Metrics must be sensitive to the context-specific nature of nursing and should reflect the work that nurses really do. A workshop at the Building Children's Nursing conference (2019) was convened to develop statements of nursing care outcomes and actions specific to the work of children's nurses in African care settings, using the World Café method and the Nightingale Metrics approach. The process resulted in the development of statements as intended. Appropriate nursing metrics can guide data-driven practice improvements and decision-making about supporting the nursing workforce.

Distinctive nursing practices in working with mothers to care for hospitalised children at a district hospital in KwaZulu-Natal, South Africa: a descriptive observational study.

BACKGROUND: The presence of family members and their active involvement in caring for hospitalised children is an established practice in many African paediatric settings, with family members often regarded as a resource. This aspect of African paediatric nursing practice lacks formal expression or a clear conceptual basis, and difficulties arise when applying concepts of family involvement originating from the culturally distinct practice environments of higher resourced settings including Europe and America. The aim of this study was to articulate a nurse-led practice innovation intended to facilitate family involvement in the care of hospitalised children, observed in a paediatric inpatient ward in a district hospital in rural KwaZulu-Natal, South Africa. METHODS: A qualitative case study design was used. Data collection included visual research methods (graphic facilitation, sociograms and photo-elicitation) as well as a focus group, interviews and practice observation. Activities associated with 20 nurses and 22 mother-child dyads were observed. Data were subjected to content analysis, with Standards for Reporting Qualitative Research (SRQR) applied. RESULTS: Findings relate to six aspects of practice, categorised thematically as: preserving the mother-child pair; enabling continuous presence; psychological support and empathy; sharing knowledge; mothers as a resource; and belief and trust. CONCLUSION: The nursing practices and organisational policies observed in this setting relating to the facilitation of continuous maternal presence represent a distinctive nursing practice innovation. This deliberate practice contrasts with models of care provision which originate in higher resourced settings including Europe and America, such as Family Centred Care, and contrasts with informal practices in local African settings which tolerate the presence of mothers in other settings, as well as local institutional policies which limit mothers' presence to varying extents.

The children's nursing workforce in Kenya, Malawi, Uganda, South Africa and Zambia: generating an initial indication of the extent of the workforce and training activity.

BACKGROUND: This study sought to identify, as far as possible, the extent of the specialist children's nursing workforce in five selected African countries. Strengthening children's nursing training has been recommended as a primary strategy to reduce the under-five mortality rate in African nations. However, information about the extent of the specialist children's nursing workforce in this region is not routinely available. Developing an accurate depiction of the specialist children's nursing workforce is a necessary step towards optimising children's health service delivery. METHODS: This study used a convergent parallel mixed methods design, incorporating quantitative (surveys) and qualitative (questionnaire and interview) components, to generate data addressing three related questions: how many children's nurses are believed to be in practice nationally, how many such nurses are recorded on the national nursing register and how many children's nurses are being produced through training annually. RESULTS: Data provide insights into reported children's nursing workforce capacity, training activity and national training output in the five countries. Findings suggest there are approximately 3728 children's nurses across the five countries in this study, with the majority in South Africa. A total of 16 educational programmes leading to a qualification in paediatric nursing or child health nursing are offered by 10 institutions across the countries in this study, with Kenya, Malawi and Zambia having one institution each and South Africa hosting seven. Data suggest that existing human resources for health information systems do not currently produce adequate information regarding the children's nursing workforce. Analysis of qualitative data elicited two themes: the role of children's nurses and their position within health systems, and the capacity of HRH information systems to accurately reflect the specialist children's nursing workforce. CONCLUSION: The data generated provide an initial indication of the size of the children's nursing workforce in these five countries, as well as an overview of associated training activity. We hope that they can start to inform discussion about what would represent a viable and sustainable regional children's nursing workforce for the future.

Graphic facilitation as a novel approach to practice development.

The active participation of staff from the outset of any health service or practice improvement process ensures they are more likely to become engaged in the implementation phases that follow initial service analyses. Graphic facilitation is a way of getting participants to develop an understanding of complex systems and articulate solutions from within them. This article describes how a graphic facilitation process enabled the members of a multidisciplinary team at a specialist paediatric neurosurgery hospital in Uganda to understand how their system worked. The large graphic representation the team created helped each team member to visualise their day-to-day practice, understand each person's contribution, celebrate their triumphs and highlight opportunities for service improvement. The process highlighted three features of their practice: an authentic interdisciplinary team approach to care, admission of the primary carer with the child, and previously unrecognised delays in patient flow through the outpatients department. The team's active participation and ownership of the process resulted in sustainable improvements to clinical practice.

Pediatric Critical Care Nursing Research Priorities-Initiating International Dialogue.

OBJECTIVE: To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. DESIGN: One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. SETTING: Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. PARTICIPANTS: Pediatric critical care nurses and nurse scientists attending the open consensus meeting. INTERVENTIONS: Systematic review, gap analysis, and interactive multivoting. MEASUREMENTS AND MAIN RESULTS: The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. CONCLUSIONS: The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.

Developing family-friendly signage in a South African paediatric healthcare setting.

BACKGROUND: Multiple renovations and changing flow in a tertiary children's hospital in Cape Town resulted in numerous signs being posted in the corridors and units, making wayfinding extremely complex. A request from nursing management prompted the formation of a learning collaborative of nurses from all departments to improve wayfinding signage. OBJECTIVES: The project aimed to contribute to a family-friendly environment by reviewing the current situation and developing signage to improve wayfinding and convey essential information to parents, caregivers and patients. METHODS: A participative action research method followed a four-stage process to facilitate the development of family-friendly signage. Nurse participants reviewed existing signage and collaboratively developed new signage templates and posted signs. The signage was then evaluated using a rapid appraisal questionnaire involving 50 parents and nurse respondents. At each stage of data collection, thematic content analysis was used to analyse data gathered in process meetings and the reflections of participating nurses. RESULTS: A design template and then 44 new signs were developed and used to replace old signage. Respondents reported that the new signs were noticeable, looked attractive and were easily understandable. CONCLUSION: Intentional and active participation of nurses in clinical paediatric settings ensured collaborative data gathering and analysis. An inclusive research design allowed for insights into the words and tone of posted signs that nurse participants had not noticed previously. The participative redesign of signage resulted in a sense of ownership of the signs.The support and involvement of hospital management throughout ensured that the resulting signage received wide acceptance.

Re-envisioning paediatric nurse training in a re-engineered health care system.

BACKGROUND: South African's infant and child mortality rates remain high and at the current rate of decline will not meet the Millennium Development Goals of a two thirds decrease by 2015. At the latest available count, there were fewer than 1500 qualified paediatric nurses on the National South African Nursing Council register, with only about 100 nurses graduating with this qualification from South African nursing schools annually. It is not clear, however, if current paediatric nurse training programmes adequately equip nurses to make a real impact on reducing the under-5 mortality rate. In their 2011 interim report, the Ministerial Committee on Morbidity and Mortality in Children under 5 years recommended strengthening paediatric nurses' training as a strategy to reduce the under-5 mortality rate. METHOD: In response to the Committee on Morbidity and Mortality in Children recommendation, a colloquium was convened as a national forum for schools of nursing, departments of health, health care facilities, clinicians and regulatory bodies to advance children's nursing in South Africa. OBJECTIVES: The goals of the colloquium were to thoroughly investigate the situation in South Africa's paediatric nurse training, plot ways to strengthen and expand postgraduate paediatric programmes to meet priority child health needs, and to build relationships between the various schools and stakeholders. RESULTS: Outcomes included the clarification and strengthening of a 'stakeholder grid' in nurse training, recognition of the need for more active teaching and learning strategies in curricula linked to national child health priorities, as well as the need to develop and support clinical nursing practice in facilities.

Journal club: Integrating research awareness into postgraduate nurse training.

BACKGROUND: Evidence-based nursing requires nurses to maintain an awareness of recently published research findings to integrate into their clinical practice. In the South African setting keeping up with recent literature has additional challenges, including the diversity of nurses' home language, geographically foreign origins of published work, and limited economic resources. Students enrolled in a postgraduate programme came from various paediatric settings and displayed limited awareness of nursing literature as an evidence base for practice. OBJECTIVES: The study aimed to design and introduce a journal club as an educational strategy into the postgraduate programmes in children's nursing at the University of Cape Town (UCT), and then to refine the way it is used to best serve programme outcomes and facilitate student learning whilst still being an enjoyable activity. METHOD: An action research methodology using successive cycles of 'assess-plan-act-observe' was used to design, implement and refine the structure of a journal club within the postgraduate diploma programme over four academic years. Six educators actively tracked and reflected on journal club sessions, and then analysed findings during and after each annual cycle to plan improvement and increasing programme alignment. RESULTS: Considerable refinement of the intervention included changing how it was structured, the preparation required by both students and educators, the article selection process and the intervention's alignment with other learning activities in the programme. CONCLUSION: Journal club facilitated an increase in student awareness and reading of nursing literature, offering the opportunity to consider application of published research to current nursing practice. Another benefit was enabling students to become familiar with the specialised and technical language of research, children's nursing and the critical care of children and neonates, by speaking about these in peer settings.

Improving the quality of nursing documentation: An action research project.

BACKGROUND: Documentation is an important function of professional nursing practise. In spite of numerous improvement efforts globally, inadequate documentation continues to be reported as nurse authors investigate barriers and challenges. OBJECTIVES: The project aimed to improve nurses' documentation of their patient assessments at the CURE Children's Hospital of Uganda in order to enhance the quality of nursing practise. METHOD: An action research methodology, using repeated cycles of planning, intervention, reflection and modification, was used to establish best practise approaches in this context for improving nurses' efficacy in documenting assessments in the patient record. The researchers gathered data from chart audits, literature reviews and key informant interviews. Through analysis and critical reflection, these data informed three cycles of systems and practise modifications to improve the quality of documentation. RESULTS: The initial cycle revealed that staff training alone was insufficient to achieve the project goal. To achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, and continuous leadership support. CONCLUSION: Improving nursing documentation involved complex challenges in this setting and demanded multiple approaches. Evidence-based practise was the foundation of changes in systems required to produce visible improvement in practise. The involved role of leadership in these efforts was very important.

Community health workers and professional nurses: defining the roles and understanding the relationships.

The use of community health workers (CHWs) has been advocated in both developed and developing countries for many years. This article reports the findings of a descriptive research study that explored the relationship between CHWs and nurses working in resource-poor settings in South Africa. The findings of the study highlight dimensions of complex interactions occurring between these two main providers of care at the district level. Understanding the primary interaction of CHWs with nurses offers further understanding of the broader role of CHWs within the district health system. It is evident that CHWs are ideally suited to play a pivotal role in supporting the public health services. However, their role and functions are not formalized and the effectiveness of programs is often not rigorously evaluated. This article discusses some of the issues related to this cadre of health worker and their role in public health care structures.

Finding the voice of clinical experience: participatory action research with registered nurses in developing a child critical care nursing curriculum.

The voice of clinical nurses is important to find and hear in the design of curricula. A participative action research project proposed to add this voice to the design of a new Critical Care Child Nursing programme at the University of Cape Town (UCT). Nurses' experiences of nursing critically ill children and their perceived learning needs in this context, were the central focus of the study. Participants were registered nurses working in the paediatric intensive care unit at the Red Cross Children's Hospital (a specialist hospital), which offers secondary and tertiary care in the Cape Town region and beyond. Data were gathered in five focussed group discussions. Findings indicate that the Critical Care Child Nurse needs not only a specialised knowledge base and acutely developed assessment skills, but also astute interpersonal skills. The nurse's professional identity and integration into the multidisciplinary team need exploring. Together with the development of interpersonal skills, the nurse needs to engage the child and family.

Learning to nurse children: towards a model for nursing students.

BACKGROUND: As undergraduate nursing students approach their paediatric placement, their anticipation ranges from keen expectation to anxious avoidance. This placement has been described as the most stressful in nursing programmes. While various nurse scholars have attempted to describe the practice and the theory of nursing, it has been the challenge of nurse teachers to weave the theory and practice of nursing together for their students. The nature of this learning is, however, still being explored. AIM: This paper reports a study whose aim was to describe, and propose a theoretical understanding of, how nursing students learn to care for children. METHOD: In this grounded theory study, participants were drawn from four consecutive student groups in their third year of a Bachelor of Nursing programme. Data included participant observation, focus groups and student descriptions, from both personal reflective journals and narratives. The qualitative research paradigm and the interlaced, often simultaneous, roles of researcher and teacher defined the design and implementation of the study. FINDINGS: Data analysis confirmed the complex nature of students' learning to care. The relationships that they established with children and others (families, peers, clinical nurses and lecturers) whom they encountered emerged as key in their learning. The social process that was central to student learning was working out how to connect with a child in their care: puzzling out a connection. Each connection with a child contributed to the next and thus to the student's learning. Each connection also contributed to the student's resources, knowledge and experience base, adding to learning by further equipping the student for the next encounter with a child. CONCLUSION: The resulting theory contributes towards understanding the complexity of learning to care for children. The relational nature of learning shown in this work can guide the structuring and evaluation of learning environments in child nursing programmes. The context of interpersonal relationships of students when learning to care for children provides evidence for re-examining how nurse teachers facilitate and evaluate student learning in child nursing programmes.