Abstract
Paediatric nursing training has been reduced in scope, which has become a concern in nursing education. Little is known regarding students’ experiences and what they learn about children as patients during courses. For the students in this study, paediatric nursing training consists of a 1-day observation practice. The aim of the present study was to examine this observation practice in paediatric nursing and discuss the consequences of the reduction of practical training for the level of knowledge of student nurses after graduation. A descriptive and interpretative design with a hermeneutical approach was employed to examine students’ experience in hospitals. Individual interviews were conducted with 11 students, and the data analysis followed Brinkmann and Kvale's three levels of interpretation. The study was reported in accordance with the COREQ checklist. Three themes emerged: ‘preparing the child for a procedure or treatment’; ‘the importance of the care provided by parents’; and ‘the lack of hands-on paediatric nursing training for students’. This study has implications for nursing in terms of paediatric competence. The findings suggest that students receive insufficient practical training in paediatric nursing. A discussion is required regarding paediatric nursing in nursing education, as well as how to meet national and international requirements.
Keywords
Introduction
In the European Union (EU) and Norway, paediatric nursing training, including clinical training, is a legal requirement for a bachelor's degree in nursing.1,2 Indeed, student nurses in Norway must have paediatric nursing knowledge regarding the needs of patients aged younger than 18 years and the ability to treat and provide services to these patients, including providing care and treatment in cases with complex disease patterns. 2 However, exposure to paediatric nursing is reduced and often limited in bachelor's nursing degree programmes,3–5 resulting in insufficient paediatric nursing education internationally.1,3
The consequences of this reduction and limited exposure to paediatric nursing are that student nurses complete little practical training in this area and can graduate having had no contact with paediatric patients. Furthermore, previous studies have described student nurses’ practical experience in paediatric nursing as deficient, which contributes to the devaluation of paediatric nursing as a specialty.5–7 As a result, the academic content and clinical experience related to paediatric nursing are limited in nursing school curricula. 4 Furthermore, the failure to employ experts in paediatric nursing in nursing faculties at universities and university colleges 4 and the failure to ensure sufficient internships for students have led nursing education administrators to overlook paediatrics as a necessary competence in nursing, as well as the consequences a reduction in theoretical studies and paediatric placements may have for the future of nursing care for children.3,4 Theoretical studies before paediatric placements may include topics such as chronic medical conditions in children, pain management, medication safety,2,7 acute medical conditions, and child/adolescent growth and development.2,4 However, theoretical studies in paediatric nursing as a separate topic vary in undergraduate nursing programmes. The majority of nursing programmes have few or no lessons, while some have several hours. 4 In Norwegian nursing education, knowledge in paediatric nursing is also minimally emphasised. 8 The outcome of these variations and issues is a lack of paediatric competence among student nurses, despite this being an expected competence according to bachelor's programme curricula worldwide. 9
Research findings clearly emphasise the importance of learning through clinical practice in a hospital-based paediatric setting for student nurses.5,10,11 Indeed, through clinical practice over time, including participating in care, student nurses can learn about their role in informing patients’ parents and actively participate in planning and providing care for paediatric patients. 10 Students also learn to orient themselves to the paediatric unit, thus helping them to become familiar with common treatments and challenges encountered in paediatric care. 11
Furthermore, studies have found that paediatric nursing in Norway has shifted from not allowing parents to remain with their hospitalised child to parents playing a central role in the child's care. One consequence of this shift is that the responsibilities of parents for hospitalised children have become more extensive.12,13 Concurrently, nurses’ responsibilities in paediatrics have changed to include working in close collaboration with parents in addition to children. Therefore, when providing care, nurses must simultaneously relate to the parents and the children. This demanding collaboration highlights the complexity of paediatric nursing, with nurses and parents sharing responsibilities and tasks.12–14
Paediatric nursing competence is a complex issue and has an impact on the quality of care provided. In addition, this competence requires student nurses to meet children as patients during their bachelor's education. However, changes in nursing education, such as reduction in theoretical and practical studies, and limited exposure to paediatric nursing raise questions about the quality of nursing and clinical training. Little is known about students’ experiences and what they learn about children as patients during their courses, which, for the students in this study, is a 1-day observation practice.
Aim
The aim of the present study was to examine this observation practice in paediatric nursing and discuss the consequences of reduction of practical training for the level of knowledge of student nurses after graduation.
Method
This study adopted a descriptive and interpretative design with a hermeneutical approach. The research process was a continuous and dialogic process of eliciting hermeneutic interpretations in interview situations, analysing the students’ descriptions, and presenting the findings. Such interpretation is based on the notion of grasping the whole of students’ experiences in terms of the parts and the parts in terms of the whole through back and forth and circular motions.15–17 The reporting in the study was guided by the Consolidated Criteria for Reporting Qualitative Studies (COREQ). 18
Context and setting
In the programme, the nursing students’ exposure to paediatric nursing involves a 1-day observation practice in a hospital setting. Over time, the reduction has been from 120 h of clinical practice to 7.5 h of clinical observation practice. Observation practice is defined as a practice during which students observe professionals, such as nurses and doctors, providing care and treatment to patients. 19 The aim of observation practice is to provide an overview of and insight into a certain type of setting, in this case paediatric nursing. 2 The students in the study completed 1 day of clinical observation practice with paediatric patients in somatic hospitals during one of the two in-hospital 8–10-week clinical practice periods. Specifically, three of the students observed paediatric patients in a paediatric ward, one of the students observed paediatric patients in an adult surgical ward that also receives children, and seven of the students observed children as day patients in the ear, nose, and throat ward. The students each performed 1 day of observation practice in the fourth or fifth semester of their 3-year bachelor's programme.
Recruitment and sample
In total, 11 Norwegian student nurses (9 female, 2 male) agreed to participate. They were in the last semester of their bachelor's degree in nursing and had completed all required clinical practice periods. They were recruited from lists of internships at different departments to gain different experiences. Student nurses in this bachelor's programme have to complete five main clinical practice periods as part of their education, of which two occur in two somatic hospitals.
Data collection
Individual in-depth interviews 15 were conducted by the first author with the participating student nurses. The interviews focused on the students’ clinical experiences during their 1-day observation practice with paediatric patients in somatic hospitals. The main question in the interview guide was as follows: How did you experience the 1-day observation practice with children as patients?
Most of the interviews were conducted in an office in the University College, and some were conducted by phone due to the COVID-19 pandemic. The interviews lasted 40–90 min and were audio taped and transcribed verbatim. The first author was not involved in the observation practice and conducted the interviews after the students had finished their studies.
Data analysis
The analysis was performed by both authors, using Brinkmann and Kvale's three levels of interpretation: self-understanding; critical understanding based on common sense; and theoretical understanding. 15 The authors defined the first level, self-understanding, as a condensed form of what ‘the subjects themselves understand to be the meaning of their statements’, described as statements in the form of meaning units. Critical understanding based on common sense may include a wider frame of understanding, statements than that of the participants themselves. At the theoretical understanding level, theory and previous research were used to interpret the meaning of a statement. The interpretation on the third level exceeded the levels of self-understanding and common sense.
The researchers searched for patterns and variations in the students’ statements through moving from the one level to the next. First, the interview transcripts were repeatedly read holistically to capture an overview and their overall meaning. Meaning units were formulated and condensed. Examples of meaning units are as follows: ‘having the mother there provided security’ and ‘the parents have a great degree of influence on the child’. At the second level of interpretation, critical understanding based on common sense, the condensed meaning units were interpreted in a wider sense of understanding, namely in the form of statements. At this level, all statements that had something in common were collected, and themes and concepts were transformed into themes on a general level. The researchers discussed the statements and themes until consensus was achieved and three themes had been developed. On this level, it is possible to clarify and enrich the interpretation of the statements based on common sense and general knowledge regarding a statement's content. 15 The analysis gradually moved to the third level of interpretation, which is presented in the discussion section.
Ethical consideration
This study was reported to the Norwegian Centre for Research Data (reference 212484). The guidelines of the Declaration of Helsinki were followed. All students provided written informed consent, and they were fully informed of their rights, including regarding voluntary participation, the right to withdraw from the study, and the safeguarding of their confidentiality and anonymity during the presentation of the findings. 20 To safeguard the students’ anonymity, fictitious unisex names have been used in the presentation of the findings. The students had supervisors who followed up in relation to experiences from the 1-day observation practice.
Findings
Based on the results of the analysis, three themes emerged regarding the 1-day observation practice in paediatric nursing training. The three themes included the following: preparing the child for a procedure or treatment; the importance of the care provided by parents; and the lack of hands-on paediatric nursing training for students.
Preparing the child for a procedure or treatment
The student nurses discussed their experiences of observing nurses and doctors preparing children for a procedure during their single day of clinical observation practice in paediatric nursing. Specifically, the students observed how nurses and doctors communicated with, interacted with, and prepared children before they treated them or performed procedures to become acquainted with the child and gain the child's trust. They also observed that taking responsibility for paediatric patients is considerably different from being responsible for adult patients. Indeed, with adult patients, a care provider can simply explain what is going to happen, but with children, nurses and doctors must first gain the child's trust to avoid coercion. In addition, paediatric patients react differently to such interactions compared with adult patients. In this context, Luca reported the following: You really need to get to know the child, gain the child's trust to perform procedures. That is the priority. You can explain what is going to happen to an adult person. If you do not gain the child's trust first, you may have to use force to perform procedures. It's cruel.
The student nurses observed that the nurses and doctors made contact and built trust with paediatric patients before they performed procedures and distracted the children during the procedures or treatments. For example, the nurses and doctors would demonstrate a procedure to the parents, and the child would be allowed to play with the equipment before the procedure was performed. Isa explained that the nurses and doctors used an ‘approach with play and not using so many words’. The students also noted that procedures take a longer time with children, and sometimes challenges arise because a child does not want to undergo the procedure. Noa shared the following: I learned that it is important to take it easy, address the child, and explain—to explain that the child has received a patch with anaesthetic cream on the arm to receive a venous cannula; it does not hurt. The nurses were good at distracting the child while an anaesthesia nurse inserted a venous cannula… It is also important to make them familiar with the equipment and spend plenty of time, but it is not always possible. There were howls and screams on the way to the operating room. They were good at distraction. It was good to see. More time should have been spent to avoid discomfort for the child, although it is a simple procedure done in 5 minutes. It is easy to hurry up because you do not have time. You know it must be done for the child to recover. It is awful to see that the child is held tight.
The importance of the crucial care provided by parents
The student nurses described seeing paediatric patients whose parents remained close to them during the procedures. In particular, the students perceived the parents’ role as crucial in the practice of paediatric nursing, observing that the parents’ presence, care and responsibility were required to care for children exhibiting a range of reactions to medical care, including feeling safe, acting shy, experiencing pain, crying or protesting. For example, Sina described the case of one child, explaining that ‘he was a little shy, so it was a little difficult, but [his] mother was there’.
According to the students, the parents’ role in providing a sense of security to their children contributed positively to interactions between the children and the nurses and doctors in procedural situations. As Ariel explained, ‘having the mother there provided security’. Moreover, the parents acting calm and secure in a procedural setting often calmed the children, as Rayan described: ‘The parents have a great degree of influence on the child’. Alex similarly reflected, ‘If the parents stay calm, then the child stays calm’. Conversely, when the parents were not feeling calm, this could cause more stress for the child. Mika observed, ‘You saw it was difficult for the mother. The child was in pain and then exposed to the placement of a stomach tube.’
The students indicated that parents’ preparation of their children for the hospital stay and their presence in procedural settings were both important. The parents provided a safe base for the children, followed them into the operating room and were present during the introduction of anaesthesia. They were also there after the surgery when the children woke up.
A lack of hands-on paediatric nursing
The student nurses expressed a common desire to develop further knowledge about paediatric patients and perform nursing tasks to enhance their skills in paediatric nursing. Students described meeting children during their single day of observation practice and assisting nurses with nursing tasks and conversing with children and parents. However, several described their observation experience as unsatisfactory. This dissatisfaction was particularly true of the students who observed paediatric day patients in surgery. For example, Luca reported the following regarding meeting a child as patient: I was there when the child woke up after anaesthesia. It was nice that the child recognised me. I talked a bit with the child before the operation and afterwards. Then I took care of the father and took vital measurements of the child.
However, despite this, the students’ observations often involved remaining in the background and observing patient situations from a distance. These observations provided insight and an overview of the patients’ trajectories, from the arrival of the child on the ward to the preparation of the child for surgery and their awakening from surgery or the preparation of the child for various procedures and treatments. The students generally felt that it was necessary to remain in the background in order not to disturb the interaction, but they also frequently felt frustrated that they could not contribute. For example, Emily said that ‘it was not scheduled for me to participate, so I observed and followed these children’. Adel reported a similar feeling: We had no function in the situation and were standing in a way that we did not hinder the work because things happen fast. I remember it felt most natural to stay in the background.
Discussion
The observation practice examined in this study provides nursing students with insight into and an overview of paediatric nursing. Specifically, observation practice is defined as a form of practice where students learn through observation. The framework for discussing students’ learning through observation is Bandura's social learning theory, 21 which focuses on learning through observation based on model learning. To learn through observation, it is necessary to observe the model's behaviour in a situation and to create a memory of the behaviour through a retention process. 21 Specifically, the participating students gained experience by standing outside of situations and observing. The students remember key aspects of these situations, such as how nurses and doctors communicated and interacted with the patients. In addition, they paid attention and used a retention process to create memories of the behaviours of the nurses and doctors in the observed situations.
Moreover, the students experienced paediatric nursing as being different from general nursing. The importance of paediatric nurses maintaining effective interaction and communication with paediatric patients has been emphasised in other studies. 22 The participating students in the present study described how these interactions enabled doctors and nurses to effectively provide treatments and perform procedures with paediatric patients. However, the students in this study did not clearly express observations of the close collaboration between parents and nurses regarding the care of paediatric patients. Indeed, the study participants were less likely to describe collaboration between nurses, parents and children than participants in previous studies.12–14
However, according to Bandura, 21 learning through observation from outside a situation is not sufficient; one must also perform the tasks in order to learn. In line with this suggestion, the students in the present study were able to observe situations with paediatric patients, but they described a need for further experience, such as performing tasks, to achieve the required knowledge of paediatric nursing. Further experiences require long periods of paediatric placements where they would be able to be hands-on. Carey 10 found that student nurses need to actively participate in planning and providing care for paediatric patients and thereby learn their own role by performing paediatric nursing tasks.
The desire of the students in the present study to engage in hands-on training in order to achieve the required knowledge of paediatric nursing is supported by previous findings.5,11 Being familiar with common treatments and encountering challenges in paediatric care seems important.5,11 According to Bandura, 21 individuals transform their knowledge when they observe others performing tasks, and then they need to perform the tasks they have seen based on imitation and model learning. Students must reproduce the behaviours to learn from the model's behaviour, memorise the order of events and remember the details of the events they observed. By reproducing a behaviour through imitation, an individual develops a deeper understanding of the behaviour they are imitating. However, in the present study, the period was too short for the students to engage in hands-on nursing and, thus, did not have the opportunity to reproduce the behaviours they observed.
The last sub-process of social learning is motivation. Indeed, motivation and reinforcement enable students to translate knowledge into action. Motivation may be derived from the consequences of students’ own behaviour or their desire to achieve their goals. According to Bandura, 21 the steps for student nurses’ learning should include reproducing the behaviours of nurses and doctors, followed by a motivational reinforcement process to enable students to transfer their knowledge into action. However, the last two steps in learning – reproduction and motivation – did not occur. Observing others and lack of hands-on nursing did not provide good learning conditions for reproduction and motivation. Indeed, the students described observing others rather than performing tasks, a lack of close contact with children and a desire to perform nursing tasks. This lack of sufficient training is due to limited opportunities for clinical training in paediatric nursing for student nurses.23
Strengths and weaknesses of the study
A descriptive and interpretative design with a hermeneutical approach 16 and in-depth interviews with students’ experiences from different context has given in-depth insight on a limited topic.15,17 To achieve breadth, depth and variety in the data, there was an emphasis on recruiting participants who had experienced different wards in two hospitals where children are patients, and students of both sexes were included.15,17 The context and setting of the study are well described so that the findings can be as transferable as possible. An introductory open-ended interview question at the start of the interviews can be regarded as a strength of the data collection process, as the follow-up questions followed spontaneously in the situation based on the students’ descriptions. In this context, the researcher's experience with qualitative studies had a positive impact.15,17 The analysis was conducted with the use of the COREQ checklist to improve the transferability of the findings. 18 The fact that two researchers analysed and agreed on the findings is another strength of this study, as this approach enhanced the credibility of the findings. A limitation of this study is that the in-depth interviews with the student nurses were not combined with observation, which would have provided in-depth insight into the students’ experiences and learning processes.15,17 Furthermore, it is an advantage that the first author has taught paediatric nursing for several years and has supervised many students in project-based learning in paediatric nursing in nursing education.
Conclusion
This study adds to the knowledge of paediatric nursing training during bachelor's degree education for student nurses. The lack of competence in paediatric nursing after graduation requires further attention. The preparation of a child for a procedure or treatment and the importance of the crucial care provided by parents were experienced as important in the care of a child. However, observing others and a lack of hands-on nursing do not provide good learning conditions for reproduction and motivation. Rather than just observing, student nurses should have opportunities to reproduce the behaviours they observe. Having students solely observe from outside the situation does not meet national and international guidelines and requirements for the provision of nursing care for children and young people. This study recommends reflecting on paediatric nursing in bachelor's degree education and healthcare settings to equip nurses with adequate competence in paediatric nursing after graduation. Further research on paediatric nursing in bachelor's degree education for student nurses in a national and international context is recommended.
Footnotes
Acknowledgements
The authors would like to thank the participants for their support in making this study possible.
Author contributions
HS and JA designed the study. HS collected the data. HS and JA conducted the analysis. HS wrote the draft. HS and JA contributed to manuscript revisions, critically reviewed the article, provided final approval of the version to be published, agreed on the journal to which the article was submitted, and agreed to be accountable for all aspects of the work.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
