Children's nursing case studies

Find out about the different routes to working in this area, with advice for anyone who is thinking of making the move into children’s nursing.

Name: Adele Watkins

Job title: Mental Health Clinical Nurse Specialist for Women and Children

Speciality: Acute child health

Organisation: Children's Hospital for Wales, Cardiff

What is your current role?

I am the mental health clinical nurse specialist based within the Children's Hospital for Wales. I am employed by acute child health as a dual-qualified children’s and mental health nurse, which I feel has made a difference in improving the care of those children and young people admitted in mental health crisis. I firmly believe the quote that "there is no physical health without mental health" (World Health Organization) and this drives my motivation each day.

I had been seeking opportunities to provide more specialist mental health nursing in the hospital for some years ago and, when given the opportunity to explore this need further I found the demand and complexity of cases seen within acute child health were growing. With this in mind I achieved the role of Mental Health CNS in 2017 and since then have continued to strive to improve services for these vulnerable group of C&YP.

While my aim is to improve services for patients the need to end Stigma towards mental health is vital in achieving this. My ongoing support and education for staff has improved attitudes and understanding of staff caring for this group of C&YP on acute paediatrics wards. As I educate them, I also stress the need for supporting their own mental health, as we cannot provide the complex care for the C&YP without meeting the our own needs.

What was your route to this role?

My route into this role was my ongoing drive to bridge the gap between physical and mental health services for children admitted into acute child health in-crisis. I became a duel qualified children and mental health nurse to help achieve this.

What prompted you to do this role?

My ongoing passion to improve this service for these vulnerable group of children and young people.

What education/courses/modules have you undertaken to equip you for the role?

I am a qualified RSCN 2001 Project 2000 Registered Mental Health nurse 2005. Ongoing development courses to aid this role e.g. ASIST, brief suicide intervention training, mental health first aid, violence and aggression.

How do you see yourself developing your skills?

I continue to develop my skills and knowledge to improve patient care by bench marking the service with others. Attendance at both local and national conferences to update knowledge and practice. Attendance at study days and courses applicable to my development.

What is your long-term career plan?

• My long term career plan is to develop this role into a band 7 post
• Develop a team of training professionals within the acute child health setting who have to skills and knowledge to care for these C&YP
• In developing the role, I would also like to see a unit separate from acute medical wards to meet the specific age appropriate needs of the C&YP

What advice would you give someone thinking about moving to work in your area of practice?

It would be an excellent and often challenging opportunity to improve the care of this vulnerable group of young people.

What do you most enjoy about this area of care?

Being able to make even the smallest difference to the care that the young person receives in crisis, so that they move forward with a positive attitude toward seeking further help.

Name: Angela Wright

Job title: CNS for children with Intestinal Failure

Speciality: Paediatric Gastroenterology

Organisation: Barts Health, The Royal London Hospital

What is your current role?

I am currently the lead Clinical Nurse Specialist (CNS) for Children with Intestinal Failure requiring Home Parenteral Nutrition (HPN).

What was your route to this role?

I started my career as a junior staff nurse on a general paediatric ward with specialist gastroenterology. This was were my love and interest in paediatric gastroenterology began. I did however leave this ward to join a general medical paediatric ward in a hospital that had an A&E department in order to gain some more acute experience. I built on this experience and returned to the world of gastro on a surgical gastroenterology ward as a junior sister, during my time on this ward I acted up as a senior sister to cover a maternity leave post.

Following this experience I decided that clinical management rather that ward management was more suited to me and I took my first CNS role as a the Inflammatory Bowel Disease CNS. This was an amazing opportunity, I was part of a truly Multi Disciplinary Team setting up a service that included a young adult/transition component - it was a very exciting time. I held this role for 8 years, following my own Maternity leave I needed a part time role and therefore transferred to the role of CNS for children with Intestinal Failure.

What prompted you to do this role?

My career history had allowed me to experience both ward management and the management of a clinical case load. I have always enjoyed working within the gastroenterology speciality and saw an opening in an emerging speciality that has allowed me to develop my skills as an advanced nurse practitioner and promote the needs and welfare of children and families with complex long term conditions.

What education/courses/modules have you undertaken to equip you for the role?

I am an original Project 2000 qualified nurse; following this I obtained multiple degree level modules of interest. I was lucky enough to obtain funding for national and international conferences - allowing for my interest to really grow in the world of paediatric gastroenterology. During my early years as a CNS, I embarked on the Advanced Nursing MSC programme and obtained a Post Grad Diploma Cert.

I continue to attend conferences and speciality courses to ensure that my knowledge is up to date outside of my work base. I have joined advisory groups and belong to a NHS e-stakeholder group for HPN Home Care Commissioning.

How do you see yourself developing your skills?

I would like to develop my role as a non-medical prescriber.

What is your long-term career plan?

To continue promoting and advocating for the care needs of children and young adults with complex hidden health care needs. Supporting the family unit is crucial when they are undertaking such complex nursing care tasks within the home - I hope to work with national groups to enhance and continue this.

What advice would you give someone thinking about moving to work in your area of practice?

Find a speciality that really interests you, take your time and learn from others, gaining crucial experience along the way. Although as a CNS you look after a specialist care cohort, it is essential that you have a good understanding of general paediatrics to underpin your practice.

What do you most enjoy about this area of care?

Playing an integral part in helping children, young people and their families throughout the discharge process, teaching complex nursing skills to both parents/carers and young people and supporting children through education and into the world of transition and preparing for adult services.

Name: Christine Desmond

Job title: Advanced Nurse Practitioner - Paediatric Endocrinology

Speciality: Paediatric Endocrinology

Organisation: Royal Berkshire Hospital, Reading

What is your current role?

I am currently an Advanced Nurse Practitioner for paediatric endocrinology services at the Royal Berkshire Hospital.

What was your route to this role?

I began my general nursing career at the Westminster hospital in 1991 consolidating my training on the paediatric ward at the Chelsea and Westminster hospital which I really enjoyed. In 1996, I began work at the Middlesex hospital where I completed a Diploma in Children's Nursing and Bsc in Professional Nursing. It was here that I first began working with patients with endocrine disorders. I was immediately drawn to the management of this complex group of patients and the variety of specialist care and dynamic testing they required. 

What prompted you to do this role?

It was whilst working at the Middlesex hospital in 1996, where I managed the Adolescent Daycare Unit organising various endocrine tests on a daily basis that my interest in endocrinology began. I loved the structure and fast pace of the dynamic function tests and was intrigued by the physiology and the diagnostic reasoning process used to identify a treatment plan for endocrine patients. I successfully began my career working with children and young people (CYP) with endocrine disorders as a clinical nurse specialist at St Georges Hospital, London. Throughout my nursing career, I continued working as a clinical nurse specialist in this area at Cork University Hospital, Ireland and now currently at the Royal Berkshire Hospital, Reading.

What education/courses/modules have you undertaken to equip you for the role?

• Registered General Nurse
• Diploma in Children's Nursing
• Bsc Professional Nursing
• Endocrine Module
• Non-Medical Prescribing Certificate
• History taking and Assessment 
• Leadership
• Diagnostic Reasoning
• Applied Research.

How do you see yourself developing your skills?

I am currently completing the final dissertation module of the Msc Advanced Clinical Practice. This qualification continues to support the advancement and development of my skills in the assessment and management of this complex group of patients. I am also an active member of the CYP specialist forum which has allowed me an opportunity to be involved in updating national guidelines and policies.

What is your long-term career plan?

I want to continue to support and be an advocate for CYP with endocrine disorders. On completion of my Msc, my plan is to set up a nurse led new patient clinic. I currently manage follow up patients both face to face and virtually but would like to advance this further by assessing new patients referred to the clinic.

What advice would you give someone thinking about moving to work in your area of practice?

It's really important to find a specialty that interests and challenges you, for me this was endocrinology. I have been very lucky to have gained a lot of clinical experience and knowledge throughout my career working alongside some very supportive and inspiring healthcare professionals which I feel was crucial to my success as a specialist nurse.

What do you most enjoy about this area of care?

There is always something new to learn within this specialty which I love. The challenges and learning opportunities the role offers, the remarkable children and young people I continue to meet along the way means I still enjoy my job even after 30 years of nursing.

Name: Claire Gillan

Job title: Clinical Educator & Liaison Nurse

Speciality: Children’s nursing

Organisation: Ulster Hospital, South Eastern Trust

What is your current role?

There are 2 parts to my role:

1. Clinical Educator, which involves providing education to staff nurse and healthcare assistants in the Children's Unit, being involved in the induction of new staff, and promoting development in existing staff.

2. Liaison. Facilitating and supporting the delivery of age appropriate care to children and young people in adult wards in the hospital, with particular emphasis on fluid management, administration of medicine, consent and safeguarding.

What was your route to this role?

I was Deputy Sister in Craig Ward for 3 years before taking this role. During this time I obtained BLS Instructor qualification and RQF Level 3 in Assessing Vocational Achievement. Before that I was a band 5 on Craig ward for 2 years and RBHSC ED for 7 years.

What prompted you to do this role?

I really enjoyed mentoring and teaching students, healthcare assistants and new staff and wanted to develop this side of my career further.

What education/courses/modules have you undertaken to equip you for the role?

I have recently completed the Effective Teaching in Practice Course and hope to start a PGCE soon. I am in the process of completing the RQF Internal Verifier Award. Learning from others has also been a great source of education!

How do you see yourself developing your skills?

This is a new role within the Children's Unit and Cohort Wards, so I am learning constantly. I am developing skills in teaching, negotiating and time management.

What is your long-term career plan?

I would like to stay in the area of Clinical Education. It is very rewarding to watch someone you have taught progress to greater things and fulfill their potential.

What advice would you give someone thinking about moving to work in your area of practice?

Go for it! Follow the dream. I came into nursing as a mature student. It is never too late!

What do you most enjoy about this area of care?

I enjoy making a difference to staff. By encouraging, supporting and providing education, they are empowered to progress.

Name: Coral Rees

Job title: Advanced Paediatric Nurse Practitoner

Speciality: General Paediatrics

Organisation: Children's Hospital for Wales, Cardiff

What is your current role?

Advanced Paediatric Nurse Practitioner - lead for General Paediatrics.

What was your route to this role?

I qualified with a diploma in children's nursing in 2000 at the University of Salford in Manchester. I worked within a variety of areas including critical care in different NHS trust in both England and Wales before securing a trainee ANP role in the children's hospital for Wales in 2005.

What prompted you to do this role?

During my first few years of being qualified it became very apparent that acute medical nursing was what i enjoyed and I began to develop an interest in the extended roles that nurses where beginning to develop. An aspiration to be a advanced nurse practitioner was beginning to develop.

What education/courses/modules have you undertaken to equip you for the role?

Bsc in Clinical Practice, Msc in Advanced Practice, PgCert Education for Health Professionals, APLS instructor -generic instructor course.

How do you see yourself developing your skills?

My skills have developed as the role has developed over the years. My skills are now best used training the ANPs of the future as we have led the way with this role with the General Paediatric field in Wales. I am still very fortunate to be clinical within my role and spend around 70% of my time with direct contact with children and their families.

What is your long-term career plan?

Consultant nurse role. 

What advice would you give someone thinking about moving to work in your area of practice?

Get as much experience as you can in different areas of acute care and include either critical care or emergency department experience as it will equip you will the skills you need to manage an acutely ill child.

What do you most enjoy about this area of care?

No day is ever the same when i am clinical! I can be on ward round seeing a child who has been admitted with pneumonia then have a crash call to an acutely unwell child in ED. I also enjoy training the new ANPs of the future as it is very rewarding to see them develop.

Name: Erica Thomas

Job title: ANP Paediatric Surgery

Speciality: Paediatric Surgery

Organisation: Noah's Ark Children's Hospital for Wales

What is your current role?

Currently I am employed as an Advanced Nurse Practitioner for Paediatric Surgery in a tertiary hospital in South Wales. For those interested in expanding their clinical skills to accommodate non- medical prescribing and radiology requisition in combination with clinical assessment and diagnostic skills this is the role for you.

Working alongside a team of surgeons caring for neonates, children and young people up to the age of 16 years. The role has evolved in line with changes in the legislation that govern the Advanced Practitioner role.

What was your route to this role?

This role evolved through my love of clinical contact with patients and particularly those with congenital bowel problem that have had contact with the surgical team from birth. The Welsh Assembly sponsored the MSc Advanced Practice which is a requirement for the role in Wales.

The role involves teaching of medical and nursing staff both at the bedside and in the classroom.

What prompted you to do this role?

Having been a ward sister on a paediatric surgical unit in London for 13 years, I had attended an ANP conference in the USA through my work with the RCN surgical nurses forum. I had become aware of the potential of such a career opportunity and applied when I saw the job being advertised.

What education/courses/modules have you undertaken to equip you for the role?

• BSc Nursing Practice
• MSc Advanced Practice
• Non-medical prescribing
• Basic surgical Skills course
• Non-medical radiology requester

How do you see yourself developing your skills?

Each day is a new learning experience and no two days are the same. By evaluating outcomes I can identify where my weakness can be built upon.

What is your long-term career plan?

To complete my 40 years within the NHS!

What advice would you give someone thinking about moving to work in your area of practice?

If you like patient contact, don't want to sit behind a desk and want to make a difference by developing yourself and those around you - go for it.

What do you most enjoy about this area of care?

Patient contact.

Name: Gillian Priday

Job title: Sister, Children’s nursing, Teenage Ward

Speciality: Teenage Haematology & Oncology

Organisation: The Christie NHS Foundation Trust

What is your current role?

I work as a Sister on the Teenage Haematology and Oncology ward at the Christie hospital in Manchester.  I love my job as I get to support junior staff and help develop their skills, I love working with and alongside teenagers and their families and trying to be a light in a dark situation.

What was your route to this role?

After qualifying I worked in Paediatric Intensive Care after two years I worked on paediatric and young adult ward haematology, oncology and bone marrow transplant ward.  From here I got my Sister's post at the Christie Hospital on the Teenage & Young Adult Haematology and Oncology Ward.

What prompted you to do this role?

I have always had an interest in haematology and oncology as a student nurse I had my final year management placement on a teenage cancer ward which I loved.

What education/courses/modules have you undertaken to equip you for the role?

I have completed my MSc in Teenage Oncology, I am passionate about research and turning evidence into action. From this research I have won first place in the country for the Royal College of Nursing research award.

How do you see yourself developing your skills?

I am on the CYP Specialist Care Forum Steering Committee, we provide a voice for our members and advocating for children and young people with specialist nursing care needs.  I have learnt a lot in this role and had the opportunity to present at conferences, update national guidelines and policies.

What is your long-term career plan?

I would like to be a Teenage Cancer Nurse Specialist and support the teenagers and their families both in and out of hospital and help them to live their life to the full. 

What advice would you give someone thinking about moving to work in your area of practice?

Attend conferences/RCN Congress to find more information about it and it also is a great opportunity to meet other Nurses who work in the area and talk to them about what it is like to work in the area. 

What do you most enjoy about this area of care?

I love that I get to be there for the teenagers and their families from the moment they’re diagnosed, all the way through their cancer journey. It’s about using my experience and knowledge to help navigate people through that journey. I love my job because I know I can make a difference.  

Name: Grace Edge

Job title: Head of Children's Nursing

Speciality: Acute and community paediatrics and neonataology

Organisation: Northern Health and Social Care Trust

What is your current role?

I am currently the Head of Children's Nursing within the NHSCT.

What was your route to this role?

I commenced my nursing career in 1988 by undertaking a 4 year combined RGN/RSCN qualification in what was then the Royal Group of Hospitals. Once I qualified in 1992 I worked within acute paediatrics as a Grade D staff nurse in RBHSC for 1 year before moving to England to take up a Grade E staff nurse post within orthopedics, plastic surgery and spinal injuries. Whilst working in England I was successfully appointed to a Grade F ward sister in 1994 and then promoted to a Grade G ward manager in 1996. I moved back to Northern Ireland in 2001 and worked as a Grade E staff nurse in paediatric orthopedics.

In 2003 I was then appointed as a Grade G Senior Nurse Practitioner within community children's nursing in Homefirst Community Trust. In 2007 under the review of public administration I was appointed as a Band 8a Paediatric Lead Nurse for the NHSCT. I acted up into a Band 8B Head of Children's Nursing within the NHSCT for a 6 month period in 2015 before being permanently promoted to my current role in September 2016.

What prompted you to do this role?

From a young age I was always interested in working with children. When I was still studying a school/college I undertook a number of volunteer roles within local community that related to children (Girl Guiding, hospital volunteer, church summer schemes). I have always sought to develop and seek alternative positions within paediatric nursing to enrich my nursing experiences and further my career.

What education/courses/modules have you undertaken to equip you for the role?

• Combined training re Registered General Nurse and Registered Sick Children's Nurse
• ENB qualifications in teaching and assessing in practice, orthopaedic nursing and research & development 
• Diploma in Nursing (Staffordshire University)
• BSc (Hons) Community and Public Health Nursing 
• Post Graduate Diploma Health and Social Care management 
• RCN Leadership programme 
  

How do you see yourself developing your skills?

Every day is a learning day! I am currently enrolled on the HSC Leadership Centre Aspire programme. This is a programme for Senior Managers across the Health and Social Care System that helps to builds on existing leadership skills. It challenges participants to think about their personal resilience for change and what it takes to make confident decisions and engage effectively within and across organisational boundaries.

I also currently sit on the WellChild advisory panel as the Northern Ireland representative. 

What is your long-term career plan?

To continue to develop and promote acute and community paediatric nursing and neonatology both regionally and nationally.

What advice would you give someone thinking about moving to work in your area of practice?

As long as you are passionate about working with children and their families then a career in children's nursing is for you. Whilst Children's Nursing can be challenging and varied it is a hugely rewarding career pathway. There are a number of career opportunities available within paediatrics and neonatology e.g. advanced practice, service development, clinical education, governance, management of chronic long term conditions and complex health.

What do you most enjoy about this area of care?

No two days are the same!

Name: Helen Morris

Job title: Matron, Lead Nurse Southwest Paediatric Oncology

Specialty: Children’s nursing

Organisation: Bristol Royal Hospital for Children

Introduction

I led on the development of an Oncology/Haematology Telephone Triage Tool Kit for Children and Young People as a guideline for the provision of triage assessment and advice for staff answering telephone advice line calls from families who were at home with their children who were undergoing cancer treatment. Having researched a suitable tool, there was none that was available for paediatric oncology patients so decided to create one that could be used nationally.

Background

I recognised in my centre that there was little formal assessed training or guidance for nursing staff taking calls from families at home when undergoing cancer treatment and that documentation and communication about advice given was not always clear. When I raised this at a national meeting, other centres felt the same and so we decided to set up a development group to address this gap. We decided to adapt a validated tool that had been used in the adult setting developed by United Kingdom Oncology Nursing Society (UKONS).

How did you initiate the work? 

A development group was set up consisting of paediatric oncology nurses, UKONS adult nurses and representatives from the RCN. There is little published evidence regarding CYP oncology/haematology triage, though there was anecdotal evidence regarding the provision of 24-hour telephone advice line support for parents and carers in CYP Principal Treatment Centres (PTC) and CYP Paediatric Oncology Shared Care units(POSCU). The development group found following a national audit that the advice and support provided was reliant on the experience and knowledge of the nurse or doctor answering the call and that although there were local models of good practice they had not generally been validated.

There were no tested assessment or decision-making tools in use at the time. Furthermore documentation and record keeping differed from trust to trust. Despite this we wanted to develop a national tool that every centre would use and that families would recognise where ever they were in the country.

This Tool Kit would provide:

• Guidance and support to the practitioner at all stages of the triage and assessment process
• A simple but reliable assessment process
• Safe and understandable advice for the practitioner and the caller
• High quality communication and record keeping
• Competency-based training
• An audit tool

The first phase was to agree nationally the criteria that would be used and this was a challenge initially where different centres used slightly different guidance even based on national criteria. This required working corroboratively and ensuring the medical colleagues were also in board. We also had to think about how we could ensure that the toolkit would work in the many varied environments that paediatric oncology is given.

We then had to think about how we would finance the development of the toolkit and how it would be accessed by everyone. I decided to approach 2 charities and work with them as this toolkit would be very much about improving care and support for families, areas that I was aware both of these charities were very passionate about. CLIC Sargent agreed to help fund the development, printing and ongoing reviewing and auditing of the toolkit and Children Cancer Leukaemia Group (CCLG) agreed to host the toolkit and associated documentation on their open website so that it was easily accessible.

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?

The first phase of implementation was to pilot the tool and the RCN very kindly agreed to support this. The tool was subject to a pilot in 5 PTCs and 2 POSCUs, which resulted in a very positive evaluation from both staff and families. Following some minor alterations we then further developed the education and competencies around the tool and submitted the toolkit to the RCN to be assessed from a governance perspective as nurses needed to be clear they would be supported in its use. Having not undertaken this before, I did underestimate the time that this would take but the toolkit was passed in time for a national launch day supported by the RCN, CCLG and CLIC Sargent.

This day was crucial to get right to ensure that we met our aim of rolling this tool out across all 4 nations of the United Kingdom. We had attendance from nearly all PTC leads and all agreed to roll this tool out to their centres and review its future use in the POSCUs, which was incredible at the time. I believe that we have achieved this due to staff recognising a gap in their knowledge, the big impact that staff could see it would have for patient care, the support of the charities involved and the excellent national networks that we have in paediatric oncology.

Has the initiative or project made a difference to patients/service users and or staff? 

The pilot feedback was extremely positive with staff saying that they felt much more supported, especially the more junior staff, an improvement in documentation of advice given and positive feedback from families. Most PTCs have now rolled the tool out to their POSCUs as well and I was also approached by a team in Australia who wanted to use it. The tool was also commended in a coroners case that occurred. I presented the toolkit at an international paediatric oncology conference where it won best nursing poster. It is used on a daily basis around the country supporting staff and improving patient care.

What are the long-term aims for the work? 

I believe that we have met our aims of:

a) Improving patient safety and care by ensuring that they receive a robust, reliable assessment every time they or their carers contact a helpline for advice
b) Ensuring assessments are of a consistent quality and that advice is determined based on the use of an evidence based assessment tool
c) Providing management and advice appropriate to the patient’s level of risk. To ensure that those patients who require urgent assessment in an acute area are identified and that appropriate action is taken, but also to identify and reassure those patients who are at lower risk and may be safely managed by the primary care team or a planned clinical review and avoid unnecessary attendance
d) Forming the basis of triage training and competency assessment for practitioners
e) Helping to maintain accurate records of the assessment and decision-making process in order to monitor quality, safety and activity

The next step is to ensure this continues so CLIC Sargent and I are currently in the process of setting up a formal audit and review of the toolkit following 2 years of its use to back up the anecdotal feedback that we have. We will then publish this work. 

Name: Jackie O'Connell

Job title: Matron Children's Community Nursing Team

Speciality: Children’s nursing

Organisation: North Middlesex Hospital 

What is your current role? 

I am Matron for the Children's Community Nursing team and my team consists of specialist nurses and generic nurses.

What was your route to this role?

I started my adult nurse training in 1984 and worked in various areas which included Gynae A/E ITU. I worked in a holiday centre  in Jersey as the resident nurse.

What prompted you to do this role?

I always wanted to be a children's nurse and loved my placement during my nurse training. I applied for a job on the children's ward at Whittington in 1990 and worked there for eight years and was fortunate enough to undertake and pass my children's nurse training..

What education/courses/modules have you undertaken to equip you for the role?

I have a degree and I have also completed a paediatric cancer course.

How do you see yourself developing your skills?

I can support and develop my team. I can deliver a high standard of nursing care to my patients. I have managerial skills and have learnt over the years how to communicate with staff effectively.

What is your long-term career plan?

To continue to grow and develop my team.

What advice would you give someone thinking about moving to work in your area of practice?

Community nursing is so rewarding. It is a privilege to go into a patients home and deliver nursing care.  

Making your own clinical decisions and acting as an independent practitioner.

What do you most enjoy about this area of care?

Looking after children in their own homes. Children are able to relax and care can be delivered at the child's pace. 

Growing a team of generic and specialist nurses has been so rewarding.

Name: Lucinda Armstrong

Job title: Sister

Specialty: Children’s nursing

Organisation: University Hospitals Bristol NHS Foundation Trust

Introduction

Wheeze is a very common childhood presentation to Emergency Departments (ED) with a predictable clinical course. In our institution most are admitted to an observation unit to wean the frequency of inhaled medicines, a key step before discharge. Although nurses are allocated to this unit, medics and Emergency Nurse Practitioners (ENP) concurrently deliver care here and in the ED, which may create delays as children who are fit for discharge await their review.

Criteria Led Discharge (CLD) is a protocolised discharge process that empowers nurses to discharge pre-identified patients, and is identified as a method to support ED flow and reduces levels of crowding.

After implementing CLD for wheezy children we undertook serial evaluations to measure efficiency and safety using pre-defined time-related outcomes and safety measures. There was a significant reduction in the time to discharge, by over two hours per child, equivalent to a saving of 130 bed days per year; safety measures were stable pre and post-implementation.

Benefits have been sustained and amplified over three years, and expanded to include similar conditions; this has subsequently spread throughout our hospital and to other institutions.

Background

Childhood hospital admissions are rising annually, especially for breathing problems, with wheeze the most common diagnosis. Most admissions are short; in our institution these children are admitted to our observation unit.

On average, every bed in this unit is used for 2.5 patients per day, reflecting high efficiency. However when fully occupied, suitable patients are admitted to inpatient beds, and flow from the ED is impeded. Targeting efficiency improvement here speeds discharge, improves ED patient flow, and reduces inpatient admission, contributing to financial benefits and improved patient/family experience. Learning from (a) this unit can be translated rapidly to other departments in our institution and similar units nationally, and (b) from wheeze to other appropriate conditions.

Observation unit nurses autonomously wean medication and deliver family education, including inhaler technique and recognition of severe breathing problems. We therefore implemented CLD for wheezy children in this unit, with a planned evaluation to measure efficiency (time to discharge compared to existing practice) and safety (unplanned return rate, reflecting quality of education and safety of discharge decision).

How did you initiate the work? 

Prior to implementation, the CLD concept was supported by Senior ED Consultant, Nursing, and Management teams via our governance group. Input was sought from all nurses and medics during development of assessment proformas, checklists, communication and training materials, to encourage buy in. Families were not involved in CLD development, but are offered the opportunity to opt-out prior to discharge. Work is planned with families to explore whether any improvements can further enhance their experience.

When implementing CLD hospital-wide we engaged with general paediatric medics and nurses, management, and the hospital innovation team. CLD is covered in hospital induction and included in competency documents for all new doctors and nurses, with support and leadership from senior personnel. We anticipate this will safely improve efficiency hospital-wide, especially during seasonal illness outbreaks such as bronchiolitis, which place huge demands on resources nationally.

We share resources and experiences with paediatric departments and EDs who are keen to implement CLD; when doing so we strive to optimise successful implementation by discussing their infrastructure and common challenges.

Unsurprisingly many of the current issues and obstacles are identical; CLD appears to provide a deliverable solution to at least some of these.

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?

Nursing staff feel empowered and more valued in taking ownership for patients on CLD pathways. The medical team value the use of CLD and the efficiencies it has delivered, identifying that it is patient friendly, family friendly and promotes wider team engagement.

Has the initiative or project made a difference to patients/service users and or staff? 

CLD for wheeze was implemented in May 2016; serial evaluations demonstrate excellent adoption by staff.

2018 saw a 100% annual increase in use, with 32% of all patients discharged by CLD. We successfully expanded CLD to other conditions; comparing 2018 to 2017, the number of additional patients discharged by CLD equalled increases in admissions; despite an 18% annual increase in admission there was zero additional workload for medics.

For wheeze, evaluations consistently demonstrate CLD is efficient and safe. Compared to previously, time to discharge decreased by over 2 hours on average, from 140 to 15 minutes. This results in approximately 130 bed days saved per year. Generating this highly efficient turnaround improves ED flow and reduces inpatient admissions.

Safety measures included completion of an education checklist, a written wheeze plan, protocolised primary care communication, proportion removed from CLD pathways, and unplanned reattendance rates.

Completion of checklist, wheeze plan, and primary care communication are 100%; removal from CLD pathways occurs appropriately in 10% due to needing oxygen.

Unplanned reattendance rates remained stable before and after CLD at 1%.

What are the long-term aims for the work? 

Dissemination has enabled spread in three main domains: (i) our observation unit, (ii) our hospital inpatient wards, and (iii) other similar institutions. Our dissemination strategy included peer-reviewed journal publication (Archives of Disease in Childhood Education & Practice, widely accessed by relevant healthcare staff), presentation at local, regional and national conferences, and social media.

In each forum we shared the results, implementation strategy, and assessment proforma, to enable easy uptake. We are engaging with our Academic Health Science Network to spread this more formally.

In our observation unit we expanded CLD to other conditions including procedural sedation recovery, bronchiolitis, head injury, accidental ingestion and gastroenteritis. In our hospital we worked with the General Paediatricians to support hospital-wide CLD implementation for wheeze and other conditions. This was implemented in late 2018, and is currently undergoing its first round of evaluation; the early signal is optimistic, with increasing numbers of children discharged safely on CLD through the first two months.

We have also trained and supported other paediatric teams, both regionally and nationally, resulting in CLD implementation for wheeze in their observation and paediatric assessment units. Whilst none of these have yet been formally evaluated, initial feedback is uniformly positive.

Name: Martyn Wood

Job title: Paediatric Disability Clinical Specialist

Specialty: Children’s nursing

Organisation: University Hospitals Bristol NHS Foundation Trust

Introduction

I have set up a pre-admission screening system for children with disabilities to try to meet their needs coming in to hospital for elective admissions. This involves searching the electronic patient record for children with alerts for Learning Disability, Hearing Impairment, Visual Impairment & the Bristol Children's Hospital Passport and contacting the child's parent/carers approximately one week before admission to identify their specific needs based on the hospital environment, communication preferences, play and distraction, and the anaesthetic and recovery process.

This is backed up with video resources that can be accessed from home and offers of play support and desensitisation techniques (e.g. sending an anaesthetic mask home for children to play with, wash, decorate and then bring back in for use).

Background

All patient information letters about admission to Bristol Royal Hospital for Children have the contact details of the Paediatric Disability Team on the reverse. Most phone calls that were made were 1-2 days before admission and in discussion with a range of parent/carers it was apparent that human factors meant that parent/carers typically read the front of the letter on receipt (the date and time of admission) and the reverse closer to the date...leaving little time to make changes.

The Equality Act (2010) states that service providers "take 'reasonable steps‘ and to make ‘simple modifications’ legally known as ‘reasonable adjustments’ to anticipate the needs of disabled people, not just to react as these arise.” It therefore seemed logical to make a proactive effort to contact families of children with identified disabilities in advance to anticipate needs with time to make reasonable adjustments.

Children where a disability has not been identified to the hospital and therefore no alert has been created can still access the Paediatric Disability Team the way they would but would be offered the use of an electronic alert for future admissions.

How did you initiate the work? 

University Hospitals Bristol uses the Medway electronic medical record system and this has been utilised to add alerts to patient records for a number of clinical and social reasons, including learning, physical and sensory disabilities. Admission lists were already available and the Medway team created 10 day admissions lists for me for four wards with potentially complicated admissions. Information is shared with the ward, play and theatre teams in time to implement the requested reasonable adjustments.

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention?

The main challenge to implementing this change has been time. the Paediatric Disability Team is 25 hours per week Band 7 (myself) and 15 hours per week Band 4 support worker. The number and complexity of patients identified can vary each week and only I am doing this work. This means that it has to sit alongside my other responsibilities and other parent/carers contacting directly.

Has the initiative or project made a difference to patients/service users and or staff? 

There has been positive feedback from parent/carers, children and young people and from the whole multi-professional team saying that the pre-admission disability assessment makes the care of children with disabilities and complex needs easier with better patient and family experience. Reasonable adjustments have included the use of play for preparation and distraction, information sent out in a child-friendly format, allocation of side rooms, sourcing special beds and supporting parents and carers.

So far data has been collected for three consecutive quarters showing that a total of 181 patient attendances have been pre-assessed by the Paediatric Disability Team. The majority of these are attending the day case unit as this is the preferred location for children with disabilities to support a quick return to the home environment and avoid a complicated discharge following a longer stay. The largest specialty group is orthopedic surgery.

What are the long-term aims for the work? 

At present the work is continuing as part of my role along side my existing responsibilities. There is work being developed to create more materials for children such as boxes to carry favourite items from the ward to recovery. Ultimately this work could be developed to either a stand-alone role or devolved to each ward area to take responsibilty for their own complex patients.

Name: Pauline Nelson

Job title: Primary Mental Health Practitioner

Speciality: Specialist Child & Adolescent Mental Health Nurse

Organisation: Southern Health and Social Care Trust

What is your current role?

I currently work in Step 2 Child and Adolescent Mental Health Service where my role is early intervention and prevention. I undertake assessment of individuals and families and provide appropriate therapeutic approach and interventions. The preventative aspect is carried out through a community development approach focused on awareness of emotional and mental health through parent psycho education in community groups like parent & toddler groups and for children & young people through programmes such as Active for Life and school sessions.

I also provide training programmes to Step 1 professionals for example, Health Visitors, Community Paediatric Nurses, School Nurses and teachers. Also included is provision of consultations to Step 1 professionals such as Paediatricians, Nurses, Social workers .

What was your route to this role?

I think that my route began with my interest in people and I completed my Degree in Psychology . I researched many careers and each was eliminated, not fitting with the person that I was until I was impressed by the compassion and enthusiasm when I asked nurses about their career Having completed general and mental health nursing I worked in Southern Trust NI and Riverside Trust, London.

At this time, AIDS was a new illness so I sought further understanding so that I could be better at providing care and completed EMB specialist AIDS Nursing and provided care in GI Surgery. Throughout this I reflected on how many illnesses were preventable & researched prevention in nursing and was drawn to Health Visiting & completed this diploma. 

What prompted you to do this role?

In the course of working with a wide range of families in the community and with an age range from birth to end of life I became more acutely attuned to the need to develop emotional and mental health I felt that people were frequently aware of the importance of the latter but I was struggling to support their efforts to make changes in their attitudes or interactions to develop emotional literacy in the family. I sought help and found it in a foundation course in family therapy which changed my way of having conversations with families and supported them to consider how they can promote emotional and mental health from birth.

I found myself spending increasing time on this aspect of health in the new born and child as the need was uncovered. The need was such that it was necessary to establish a specific clinic which we called 'The Behaviour Support Clinic' and came to be provided by a number of Health visitors and was additional to our role. We had to acknowledge that we had insufficient time within working hours to provide this service. I counted the number of hours in direct clinic provision and suggested making a business plan to request extra Health Visiting hours in order to provide the service, outlining the need, the aims and the outcomes.

We were initially declined but in the course of a year a new report was launched outlining the need for this type of service. The report was 'Together We Stand' 1995. My excitement was uncontainable and the business plan was re submitted with supportive references from this report. The outcome was positive. We had requested an additional 8 hours of Health visiting time but we were granted 37.5 hours (1 WTE) in the first instance with potential to be increased and this was the birth of Step 2 CAMHS SHSCT.

What education/courses/modules have you undertaken to equip you for the role?

The post was advertised and one of my health visiting colleagues and I were successful in obtaining it as a shared post as we were both already part time balancing work and family. I completed the Specialist Practice in Child And Adolescent Mental Health. In addition I pursued family therapy to the next level and completed the intermediate family therapy qualifying as a systemic practitioner.

How do you see yourself developing your skills?

I use an eclectic mix of skills in communicating with families and children and young people individually. I use the skills of establishing therapeutic engagement through the language that I use the type of questioning and curiosity that creates therapeutic conversations through neutrality. This supports the capacity for change, paving the way for incorporating additional interventions such as solution focused therapy, psychological therapies, cognitive-behavioural therapy or social learning theories.

What is your long-term career plan?

I have to be honest in saying that I have never planned my career but I realize that my career developed as a result of continuous reflective practice. 

'The best place to succeed is where you are with what you have' C.M. Schwab.

What advice would you give someone thinking about moving to work in your area of practice?

I would advise all nurses to be true to themselves in following what commands them to pay attention and to respond to need in service users and seek to address that need through the use of their skills and if necessary seek information and education to give the best to those who come to us. Be inspired to reach wider horizons of thought and action. I would say that if they wish to work to make a difference to the emotional and mental health of children, young people and their families then this is one care service in which to do that. I would add that therapist neutrality is essential.

'The things that constitute real success is not in learning as much as you can but in performing as well as you can something that you consider worthwhile, whether it is healing the sick, giving hope to the hopeless or adding beauty to the world' - W. Raspberry.

What do you most enjoy about this area of care?

To return to my inspiration for nursing - I love working with people! What I find most enjoyable is that every individual is unique and so also the family. I become part of that system for a period in supporting the challenge of change, peeling back the layers of struggles experienced. I like the element of surprise when they come to realize that they are the experts of their own selves or family and together we can discover how they can make things different and have emotional and mental health through healthy interaction and relationships.

Also the sense of achievement in an individual child/young person in developing skills to manage emotional and mental health challenges. The greatest job satisfaction that I feel is that I have made a difference in the lives of families.

Name: Sarah Kvedaras

Job title: Paediatric Neurosurgical Clinical Nurse Specialist

Speciality: Children’s nursing

Organisation: Noah's Ark Children's Hospital for Wales, Cardiff and Vale University Health Board

What is your current role?

I am currently the clinical nurse specialist for paediatric neurosurgery for inpatients in Cardiff. All children referred from south, mid and west Wales are all transferred into Cardiff as the tertiary centre for paediatric neurosurgery in Wales. 

What was your route to this role?

Since qualifying from Cardiff University in 2013, I undertook a role as a staff nurse in a DGH in England. I then returned back to Cardiff and Vale UHB in 2014. I undertook a rotation around the Children's hospital within medicine, surgery and paediatric critical care. I began the role part-time for 8 months before going full-time. 

What prompted you to do this role?

Working on the paediatric surgical ward I cared for many children with neurosurgical conditions including head injuries, bleeds and tumours. My experience in critical care also gave me a much deeper insight into the care of a child facing a significant head trauma. My colleague then encouraged me to apply for the role part-time as I had an interest in paediatric neurosurgery and wished to advance my clinical role from a ward staff nurse.

What education/courses/modules have you undertaken to equip you for the role?

There is no set welsh education course to take on this role and a lot of support and teaching has been undertaken by the neurosurgical registrar team and my consultants, such as the administration of intrathecal antibiotics . I attended a 'Fundamentals of Paediatric Neuroscience Nursing Course' offered by GOSH in 2018. I have also completed venapuncture training within my local hospital. 
I have also been completing my nursing masters course part-time over the last four years which I hope to complete this Autumn. This is an MSc in Advanced Practice offered by Cardiff University where I have completed modules in research, leadership and education alongside a paediatric specific module. I have completed this masters in my own time to further my education and development as a nurse. 

How do you see yourself developing your skills?

I hope to further develop my clinical skills within neurosurgery to undertake reservoir/shunt taps. I also hope to undertake a cannulation course in the next year. I would also like to become a nurse prescriber in the future if I had such an opportunity.

What is your long-term career plan?

I would really like to further my skills to become an advanced nurse practitioner. Once my masters is completed I can then top this up with an 18 months clinical course. However, this would be a new job role within Wales and is not yet within the scope of practice for the paediatric neurosurgical service. 

What advice would you give someone thinking about moving to work in your area of practice?

I would advise others to undertake any and every opportunity to advance their knowledge and clinical skills. Whether that may be rotating to a new area or undertaking a study day. Further learning can offer so much insight across your scope of practice for the care of children you give. I would also advise not to be afraid of doing something new or working in an area you don't have too much prior knowledge of, you will always learn and be supported within a new role. 

What do you most enjoy about this area of care?

I really enjoy the autonomy this role brings as a children's nurse. As a clinical nurse specialist I can offer support and advice for my client group when parents contact me. I always have the backing of my colleagues and can contact members of my registrar/consultant team for advice. As part of my role I also educate the children's nurses within the hospital which I really enjoy. To support the learning of others is a privilege to offer education about neurosurgical management.  

Name: Tendai Nzirawa

Job title: Quality Improvement Manager 

Speciality: Children’s nursing

Organisation: NHS England and NHS Improvement - East of England. Maternity Clinical Network

What is the initiative or project you are involved in?

Paediatric Pan London Oxygen Group (PPLOG) Discharge Bundle has been shared through study days and workshops in order to make the transition from hospital to home of every child on oxygen therapy seamless.

Since July 2018, a total of three study days that include workshops have been run in London (Whittington, St Thomas and Mile End Hospitals). The study days have been well attended. On record about 160 health professionals so far and about 100 health professionals participating either by group/one to one workshops within their clinical area facilitated by a PPLOG member. Prior to the study days, a survey was conducted in 2017/2018 and highlighted that there were various practices in each area on how parents and staff are taught about home oxygen. Furthermore, the results found some areas had guidelines that were either out of date or not evidence based.

What prompted you to do this work?

The Paediatric Pan London Oxygen Group (PPLOG) was founded in 2016 with the aim to bring knowledge and experience of Respiratory Nurses, Community Children's Nurses and Community Neonatal Nurses together, and set standard guidelines that will ensure the management of children on oxygen therapy is safe and uniform within the London region.

The PPLOG members include: Emilie Maughan (Co-Chair), Rebecca Smith (Co-Chair), Abigail Beddow (Secretary), Tendai Nzirawa (Treasurer), Caroline Lock (Air Liquide), Alison Camden, Sook Lin Yap, Nichola Starkowitz, Ceara Turner, Samantha Ahern, Tamsyn Hernandez and Billie Coverly.

The PPLOG discharge bundle contains seven separate documents to aid the safe and timely discharge of a child requiring home oxygen across Greater London. The BTS guidelines for home oxygen in children have been used however the limitation is that there were published 10 years ago therefore slightly out of date based on the current practices. 

How did you initiate the work?

PPLOG came together after a Respiratory Clinical Nurse Advisor set a forum to share concerns and find solutions to make the baby's or child's journey from hospital to home as safe as possible however using evidence based practice.

The barriers were trying to find a location to run the quarterly meetings and setting a meeting date that was convenient for every member. However, this was overcome by routinizing the venues and ensuring as long 70% of members attended the meeting would be held. PPLOG has been run for the past three years with no grants from any organisation, only occasional sponsorship during study days. PPLOG has been peer reviewed and endorsed by WellChild the national charity for sick children, London Neonatal Operational Delivery Network, London Clinical Oxygen Network and Respiratory Futures. 

What have the challenges to implementing the service/intervention been? And what has enabled the implementation of the service/intervention? 

The challenges of implementing PPLOG have been lack of support from some organisations to implement change that would be beneficial for the staff and families. However, through the support of NHS London, London Clinical Oxygen Network, Contract Management Board and Clinical Commissioners Groups, there has been a lot of collaborative working and changes.

Has the initiative or project made a difference to patients/service users and or staff? 

There has been written feedback from post-study days surveys that indicates that staff found the PPLOG discharge bundle and the study days usefully to implement positive change within their organisation. The plan would be to conduct a larger feedback survey prior to the PPLOG discharge bundle review in 2020. 

Achievements:

• Finalist (Respiratory Nursing) Nursing Times Awards 2018 
• Finalist (Primary Care Innovation) Health Care Transformation Award 2018 NHS England
• Various poster presentations.

Each study has been attended by 50-55 health professionals involved in the discharge process of children requiring home oxygen daily and includes medical, nursing and educational representation from community, tertiary hospital, neonatal intensive care and commissioned oxygen provider settings. There is now a demand for PPLOG to be shared outside London. There are three study days set for November 2019.

Follow up conclusions and next steps: - What are the long-term aims for the work?

The aims and objectives of PPLOG would be:

1. To review the PPLOG discharge bundle in 2020 and make changes based on survey and peer feedback
2. To establish standard guidelines for home oxygen weaning within tertiary and community settings
3. To streamline the discharge process for children on home oxygen therapy
4. To continue facilitating educational programmes for hospital staff preparing to discharge a child on home oxygen therapy
5. To support the families with evidence-based information on how to care for their child on home oxygen therapy
6. To set a platform and create a Pan London Oxygen protocol for education and management of all children on oxygen therapy within tertiary and community settings
7. The PPLOG to audit every setting using the guidelines/pathways annually through staff, parents and children satisfaction feedback
8. Guidelines and pathways to be reviewed every three years or earlier if advised of new evidence-based practices.

Please let us know if you have any photographs or slides which will help show the work

See: Paediatric Pan London Oxygen Group (PPLOG) Discharge Bundle