Our care through our eyes: A service-user co-produced education programme for acute hospital nurses. The purpose of this project was to co-produce, with service-users and nurses, a digital education intervention for acute hospital registered children’s nurses to improve the care of children and young people that self-harm.
Within Europe the United Kingdom (UK) has one of the highest rates of self-harm, with a particularly high and increasing prevalence in children and young people (CYP). Each year in
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England, over 150,000 Emergency Department attendances are due to self-harm, resulting in over 25,000 annual hospital admissions. The majority of people who self-harm are aged between 11 and 25 years with this age group having more hospital presentations for self-harm than any other. Following presentation to the ED, an initial assessment by a health professional who is trained in using a CYP mental health triage system should be undertaken.
Following this initial assessment and management in the ED, all CYP under the age of 16 years should be, ‘admitted overnight to a paediatric ward and assessed fully the following day before discharge or further treatment and care is initiated’. CYP can spend significant time being cared for by nursing teams who work on paediatric wards who have no specialist training in relation to mental health. Nurses working in these settings are commonly the first health professionals encountered by CYP following a self-harm episode. However, staff within acute ward areas may be ill prepared to meet the unique, holistic needs of self-harming individuals. Nurses who lack vital knowledge and understanding are likely to operate on misconceptions about why people self-harm. Furthermore, a lack of confidence amongst staff in their ability to work with this client group nourishes negative attitudes.
The way in which professionals respond to CYP who self-harm will directly impact on the person’s engagement with support offered. It is crucial then that nurses have training to equip them with the knowledge, skills and confidence necessary to provide the highest quality holistic care. Furthermore, planning and delivery of such training should involve those who self-harm. Active training has been demonstrated to lead to consistent improvements in attitude and knowledge of health professionals caring for people who have self-harmed.
The purpose of this project was to co-produce, with service-users and nurses, a digital education intervention for acute hospital registered children’s nurses to improve the care of children and young people that self-harm. This project involved three distinct stages that included: Stage 1. Priority setting; Stage 2. Development; Stage 3. Evaluation.
The first stage of the project was the identification and consensus of topics that would be the focus of the educational intervention. This was achieved through conducting a face-to- face, priority-setting workshop with a cohort of registered children’s nurses.
The second stage involved educational intervention development using the Centre for Excellence in Teaching and Learning in Reusable Learning Objects (RLO-CETL) Agile Development Workflow. This involved workshops to co-produce the content and format of the educational programme with Child and Adolescent Mental Health Services (CAMHS) Tier 3 service users and registered children’s nurses. It also included the development of a high quality digital educational programme. The final phase involved a pre- and post- intervention evaluation of the digital educational programme implemented at Nottingham Children’s Hospital for all registered children’s nurses working in inpatient areas.
The digital innovation that has been co-produced with children, young people and registered children’s nurses can be accessed on: http://sonet.nottingham.ac.uk/rlos/mentalhealth/octoe/ Interim analysis of the post-intervention evaluation data indicates that overall registered children’s nurses feel more confident and have better attitudes following the completion of the digital education programme.
This digital innovation and wider study was funded by a grant from the Burdett Trust for Nursing- Young Minds Programme. Collectively, CAMHS service users, health professionals (Nottingham University Hospitals NHS Trust; Notts Healthcare NHS Trust), commissioners (NHS England), a youth theatre, and academics (University of Nottingham) from the Midlands collaborated to develop the digital innovation.
In addition to Dr Joseph Manning, Chief investigator and children’s nurse, the core study team consisted of: Dr Asam Latif, NIHR Clinical Lecturer / Pharmacist, School of Health Sciences, University of Nottingham; Dr Tim Carter, Assistant Professor in Mental Health, School of Health Sciences, University of Nottingham; Michael Taylor, Learning Technologist- Media Developer, School of Health Sciences, University of Nottingham; James Henderson, Learning Technologist, School of Health Sciences, University of Nottingham; Aaron Fecowycz, Learning Technologist, School of Health Sciences, University of Nottingham; Professor Heather Wharrad, Professor of E-learning and Health Informatics, School of Health Sciences, University of Nottingham
The study steering committee: Angela Horsley, Head of Clinical Network- Maternity and Children, East Midlands Clinical Networks & Senate; Marie Armstrong, Nurse Consultant (C&YP Self-harm team), Nottinghamshire Healthcare NHS Trust; Dr Joanne Cooper, Head of Nursing and Midwifery Research, Nottingham University Hospitals NHS Trust; Dr Damian Wood, Consultant Paediatrician, Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust; Jamie Crew, Deputy Head Nurse, Family Health Division, Nottingham University Hospitals NHS Trust; Professor Patrick Callaghan, Professor of Mental Health Nursing/ Head of School, School of Health Sciences, University of Nottingham
Digital innovation development and reviewers: Janine Smith, David Clark, Gemma Robbins, Leanne Harvey, Paula Dawson, Laura Holliday, Emma Popejoy, Rebecca Green, Miranda Witchell provided feedback during the development of the educational intervention. Members of Nottingham Youth Theatre (Alistair Conquer, Bronwen Pole and Theo Swan) and Staff Nurse Verity Bingham acted in the video scenes of the educational intervention, Nottingham Children’s Hospital (Nottingham University Hospitals NHS Trust) locations for filming.
Staff (registered children’s nurses) were involved in all phases of the development, implementation and evaluation of the digital innovation. Children and young people that had previously been admitted to acute paediatric inpatient care were involved in the co- production of the digital innovation. This followed the Centre for Excellence in Teaching and Learning in Reusable Learning Objects (RLO-CETL) Agile Development Workflow.
A stakeholder workshop was conducted. Participants were provided with priority areas that had been generated in stage 1 of the study. They were then asked to develop storyboards for each topic, using their experiences to inform the subsequent development of the educational resources. This information was collected on laminated storyboards, post-it notes, and flipcharts through text and drawings. From the workshops with CYP it was identified that the biographies of CYP who had experienced self-harm were present throughout the educational intervention. To ensure the fidelity of this information, it was agreed that the most appropriate and effective method of portraying it was through video excerpts. Therefore the team worked with actors from a local youth theatre group to develop this content.
Despite this digital innovation being meaningfully co-produced with children, young people and registered children’s nurses, low numbers attended the face-to-face workshops. This could be attributed to a range of factors that include: undertaking sensitive research with (perceived) vulnerable groups; CQC inspection at the same time as the project; not having the time to participate; fear of stigma. If we were to undertake the project again we would embrace technology to overcome some of these perceived barriers to engage stakeholders. One such platform could be a web forum to hold a virtual workshop.
It was anticipated that it might be difficult for staff to complete the digital educational programme due to time constraints and access to computers. Therefore the digital educational intervention was designed and tested to run on a number of devices (including PC, iPad, iPhone) to ensure it had full functionality across a range of platforms (including OSX and Windows). This as important as NUH NHS Trust had handheld devices (iPod touch) for all registered nurses to record electronic observations and this could be used for the digital intervention. Furthermore, relevance to the registered nurses was enhanced by in line with Nursing and Midwifery Council (UK) revalidation requirements, once each user had completed each RLO then they could print a certificate and undertake a reflective process of their learning. This could then be used as evidence towards their revalidation.
The NHS national learning strategy has identified e-learning as a central strategic delivery mechanism. As such, it was decided that the nurse educational programme should take the form of a series of reusable learning objects (RLOs). In practice, RLOs are typically small, ‘bite-sized’ chunks of e-learning focusing on a particular narrow topic. The digital innovation will be made freely available on-line ensuring it is openly accessible nationally and internationally. The team are currently in discussion with the Burdett Trust to formally launch this digital innovation.
All registered children’s nurses working in inpatient areas at Nottingham Children’s Hospital were invited to complete an online baseline questionnaire that included: -Confidence was measured using a number of Likert scales developed for this study, alongside an adapted version of the Self-efficacy Towards Helping (SETH) scale. -Behavioural intention was measured by the Continuing Professional Development Reaction Questionnaire.
-Attitudes and knowledge were measured using two separate scales previously used in paediatric settings. Following this period of baseline data collection, the educational intervention was made available to participants for 6 weeks, after which the post-intervention questionnaire was made available for 6 weeks. The post intervention questionnaire was only sent to nurses who completed the first questionnaire. Following completion of the post-intervention questionnaire, participants were invited to take part in a semi-structured interview. Interim analysis of the post-intervention evaluation data indicates that overall registered children’s nurses feel more confident and have better attitudes following the completion of the digital education programme.
Manning, J.C., Latif, A., Carter, T., Cooper, J., Horsley, A., Armstrong, M. & Wharrad, H. (2015) ‘Our Care through Our Eyes’: a mixed-methods, evaluative study of a service-user, co-produced education programme to improve inpatient care of children and young people admitted following self-harm. BMJ Open. 5(12):e009680.
Following completion of full analysis of the post-intervention data, this digital innovation will be launched nationally and be openly accessible. We will host a local event and invite all stakeholders including CYP involved in the development of the digital innovation to launch the intervention. Information pertaining to the development approach and findings, pre- and post- intervention evaluation is currently being written for publication in international peer reviewed journals.
