is it that matters most in the practice of nursing children ?

“More than 40% of the South African population is younger than 14 years and yet only 1.3 % of all registered nurses hold a Paediatric/Child Nursing qualification (SANC, 1998).” Acknowledgement to colleagues for their eager participation in this action re­ search cycle and their honest commitment to nursing children : Jane Booth Herna Byrne; Lee-Ann Cooper; Fawzia Dessai; Hermina Dyeshana; Penny Gill and Trish McDonald.


Introduction
More than 40% of the South African population is younger than 14 years and yet only 1.3 % of all registered nurses hold a Paediatric/Child Nursing qualifi cation (SANC, 1998).The South African Nursing Council recognised Diploma in Child Nursing Science is currently of fered in only 5 centres in South Africa.Limited resources restrict intake of learn ers and completion of the course.In creased opportunity for the education of registered nurses in this priority area is imperative.In addition, adaptable cur ricu la are necessary to ensure that nurses emerge cognisant of their par ticular context and are suitably equipped to serve this country's children and their families into the next century.In these changing times, what are the priorities in this vital area of expertise?
Eight registered nurses, with varying lev els of experience, were invited to partici pate in a workshop to identify and ex plore these priorities.This was to con tribute to shaping the newly established post-registration, c h ild re n 's nursing pathway in the Bachelor of Nursing for R eg istere d n urse s [BN (R N )] p ro gramme planned at UCT. Participants included: • a manager and resource developer in primary care and clinic settings; • the designer and presenter of a cur rent post-basic Child nursing science course; • 3 unit managers: one managing an in-patient medical ward and another the outpatient and em ergency care unit, both in a government tertiary hospital, the third leading a general paediatric unit in a private hospital; • a paediatric psychiatric nurse special ist; • a clinical nurse specialist facilitating hom e care of ch ild re n w ho require chronic care; • A nurse lecturer and researcher (the author) w ho has designed and pre sented child related course work to un dergraduate students, subsequent to 8 years practice experience.The cum u la tive experience of these nurses was vast: almost 140 years in total!

Method
The participants convened and were in troduced to the proposed programme for RNs.The central concern of the work shop was: "What matters most in the practice of nursing children?"This ques tion enabled us to consider the issues more widely than simply asking: "What should be included in a post basic chil dren's nursing programme?"The work shop was designed to elicit, from the participants' experience, the central is sues in this field of nursing practice.
The principles of Action Learning (AL) were utilised in the design and accepted by the participants as appropriate not only for the purposes of the afternoon but also as guiding principles for the curriculum.According to Revans (1984) th e d e fin itio n of le a rn in g is: Revans asserts that programmed knowl edge (P) is the concern (and expecta tion) of traditional curricula.On the whole, however this in insufficient for ke e p in g a b re a st o f o u r c o n s ta n tly changing world with its current informa tion explosion.The most important task of learning is thus not only that Pro grammed knowledge must be expanded but also that it be supplem ented by Questioning insight (Q).Revans (1984) calls this the capacity to identify useful and fresh lines of inquiry.He defines action learning as the process whereby groups o f people (nurses, mangers or learners) work on real issues or p ro b lems, carrying real responsibility in real conditions.The solutions they formulate may require changes in the organisation and could pose challenges, but the ben efits are clear because people (the learn ers -in this case nurses) own the prob lems as well as their solutions.This defi nition of learning excited the workshop participants who could recognise the process in their own experience of learn ing.
It is recognised that by w orking and learning actively together, groups of peo ple can transform their organisations or program m es into " c ritic a l action re search system s" (Otrun Zuber-Skerrit, 1996).Thus research is not an esoteric activity confined to academics, but one which we all do, with varying degrees of rigour.
The process of action research was first conceptualised by Levin (1952) and fur ther developed by Kolb (1984), Schón (1983)

Discussion
Four questions were designed prior to the workshop to guide the discussion and assist in exploring the issues as widely as possible.These were: 1.Is there anything you find particularly ch allen gin g, co nce rn ing or w orrying 82 Curationis September 2000 about current paediatric nurse practice?2. What has changed in the last 5-10 years? 3. What are the paediatric nurse's ar eas of responsibility, influence and rela tionship?4. What does she or he need to be, to know and be able to do in order to act skilfully and ethically in her or his nurs ing practice?
What concerns or challenges are there in current paediatric nurse practice?
Participants wrote their personal con cerns down and a lengthy discussion followed.The concerns raised are real and certainly similar in the various set tings of practice.The sense of shared concern rather than blaming amongst participants was encouraging.The con cerns, so clearly evident, are mentioned here to assist the reader in understand ing that these concerns about the prac tice of registered nurses working with children were significant.These have been categorised into four prevalent themes.
First is the general sense of lack of vi sion and direction amongst nurses.This seems to be characterised by a dispas sionate non-involvement and an unwill ingness to "sit it out" .We recognised this lack of vision and therefore lack of perseverance as pervasive in nursing and the health services at this time.This is also seen in an apparent inattention to the importance of taking responsibil ity for the registered nurse's own learn ing.
Secondly, a general know ledge and clinical skills deficit is apparent.A fun damental lack of prim ary care know l edge, sometimes as basic as the recog nition of com m on childhood ailments was identified.There seems to be some ignorance about differences between adult and paediatric indicators like car diovascular indicators and fluid and elec trolyte norms.In two settings it was con cerning to identify that nurses seem to be unable or unwilling to predict in a clini cal situation: they wait too long to speak up or intervene and therefore do not advance the care of the child.A discrep ancy between theory and practice was identified.It was generally believed that nurses in these settings may do some things the "easier" way as opposed to the "safer" way.Inadequate knowledge and cognisance of the child's particular developm ental stage brought about a lack of caring for a child's emotional well being.The apparent absence of rela tional skills to involve, reassure and teach parents was repeatedly mentioned as a concern.
Thirdly, it seemed that nurses in these settings were unable or possibly unwill ing to work together.This was seen in the context of working as part of a health team, especially when asking or offer ing input about a child's care.The lack of parental or family involvement in care decisions could, as mentioned before, be simply an inability to relate.There was also co nce rn that c h ild re n 's nurses seem unaware of the value of involving relevant others (e.g.teachers) in care.
Finally, there were issues of attitudes amongst nurses.Amongst those identi fied was the apparent lack of com m it ment and caring for children.The lack of warmth and nurturing of children was com pounded by staff who sometimes appear irritated with parents.The group felt that nurses in these settings may be struggling to "get to the level of the peo ple" -including the children and adults.This seems to be related to attitude and communicational skills, resulting in mis understandings of not hearing and not being heard.One participant said that children are not treated as you would treat your own children.(This does of course raise the issue of our expecta tions of care, which we did not discuss at length.It is included here for full re porting and probably warrants further indepth discussion).
A common theme attributed to attitudes, was that generally nurses seem to have little faith in their own ability.It seems as if they are not able or willing to bring their own life experience, own mothering or experience of being children to bear on their practice.It may be that the nursing com m unity and hospital culture have not welcomed this aspect of experience into settings of caring.Most nurses have traditionally been schooled to remain "professional" .Warned not to become "em otionally involved" , we may have taught one another that there is a differ ent set of interpersonal norms which apply.In this hierarchy of the strong and the subordinate, our confidence, our assertiveness and our being may not be expected to work in the same way as when we are "off duty" .Maybe it is there fore to be expected that there was also the concern that as children's nurses we are not su pp ortive of each other as caregivers.
These categories were summed up as the challenges facing the practice of nursing children at this time.This list could have been dem oralising, even paralysing to consider.This was not, however, the purpose.We realised if we did not start by describing the context as we were experiencing it, we could be making plans blinkered by our ideals.The challenges of the current context are significant to learning in these settings and therefore to learners and the curricu lum of the proposed programme.
The next question followed easily from the initial discussion as we had already recognised that there were specific as pects of current child nursing practice and health care p ro v is io n th a t had changed in the period of our experience.
What has changed in the last 5-10 years?
Participants of this group identified the following as the most important aspects of change in the past decade.
• Parents are doing more of the " nurs ing" or care of the ill child.
• There is more home based care.
• There is an increased focus on pri mary care.
• An increased turnover of children means a shorter hospital stay and sicker children in hospitals.
• III children have an increased lifespan.
-both the chronically ill and the critically ill child have a longer life expectancy.
• National and regional priorities for child health and paediatric care have been determined.
• The International Declaration of the Rights of the Child has been accepted and ratified by the South African govern ment.
• The care of the critically ill child is a recognised priority.
• The role of the professional nurse has changed to that of a more independent practitioner who carries more responsi bility.
• Resource management is becoming an expected competency of the regis tered nurse.
• There is an increased need for nurses to manage themselves.This last statement was emphasised by all the participants.It included the pro fessional nurse's responsibility to con sider her/his own career path, manage his/her financial situation, her time and personal resources and also to maintain her/his health.These factors can be described as the context in which the nursing care of children occurs.It is also the context in which learners must be able to learn and function as they work within our health care structures.
What are the child nurse*s areas of responsibility, influence and relationships?
The last point of the previous section led the discussion easily into this next ques tion, which was formulated from princi ples used by Stephen Covey of the Franklin Covey Institute (1989).He main tains that what matters most depends on how we respond to what we experience.We had explored what we were currently experiencing in our practice of nursing children and needed to identify our role in the care of children.Defining our re sponsibilities (ability to respond), areas of influence and key relationships was guided by this principle of how we re spond.
What are the key responsibilities of the registered child nurse practitioner?Care of the ill child is seen as the first re sp on sibility of the registered child nurse practitioner.This depends on a sound clinical knowledge base, astute assessment and management of the ill child, safety of the child and includes prevention of complications and recur rence of illness.Although this all seems to relate to the ill child, the practice must have a sound base in the Primary Health Care philosophy.Nursing practice al ways aimed at the child or children's best health and optimum development.Pre vention of harm and disease as the nurse acts as the clear advocate of children and parents, must remain a priority.The nurses' responsibility of sharing knowl edge requires a commitment to personal development, educating other nurses and sharing knowledge in appropriate ways with children and parents.
Re source management is a responsibility that has becom e im portant in recent years and is certainly not a task for which nurses have traditionally been equipped.The professional nurse's task now in cludes the cost effective planning, order ing and utilisation of equipment and sup plies, in recognition that profit is a shared responsibility.

What are the most important areas of influence of the registered child nurse practitioner?
In this position she/he can change be haviour, by example and design.She/ he is able to influence parents in their caring practices.This influence is wid ened by the specific knowledge base, especially if she/he takes the impact and importance of this specialised area of expertise seriously.In this area she also carries influence to raise the profile of nursing education, thus facilitating the recognition that it is equal in importance to medical student training, especially in the culture of undervaluing nursing prac tice.As the child nurse practitioner is able to facilitate formal learning, she fa cilita te s change.The wider areas of influence of this nurse practitioner include her/his role: • as a representative on lobby groups, e.g.Child rights • as a voice when public policy is being debated and made

• as a participant on Community health forums
• as a member of local religious organi sations and churches Invariably the child nurse practitioner also has influence in her/his own neigh bourhood as she is known and willing to assist.

What are the most important relationships of the registered child nurse practitioner?
This area was easy to distil from the dis cussion.Participants had referred to the devaluing of nurses on numerous occa sions and we immediately felt that prob ably the most important relationship was that of nurses with nurses.The next pri ority was relationship with children and their parents.In this context, relation sh ip w ith the w ho le fa m ily and the broader community was important.Relationships within the health team as well as with relevant others needed to be fostered at various times (e.g.School teachers, police, and the press).Other relationships are with management and employers.As the responsibility for for mal learning has been discussed, it fol lows that a relationship needs to be de veloped with students.
What is needed in order to act skilfully and ethically in child nursing practice?
In the discussion thus far, we had identi fied what we perceived as the challenges to learning and practice as well as the context where these occur.The con sideration of the role of the children's nurse practitioner in the light of this ena bled us to consider more fully the last question: What does she/he need to be, to know and be able to do, in order to act skilfully and ethically in her/his nursing practice?(The descriptors skil fully and ethically come from Benner's work, 1996.)Initially participants ques tioned the need to use ethically, but as one participant after another used sce narios from their experience to illustrate a point, we recognised the clearly ethi cal implications of our everyday work.We realised that this aspect was vital to consider as an integral part of the prac tice and therefore of learning to work with children.
What does she/he need to be?
Participants readily identified these as pects.The child nurse practitioner needs to be motivated, must want to nurse and must love and understand children.
What does she/he need to be able to do?
In answer to this question one participant said: " She needs to be able to help trou bled children." Another said that she must be able to assess well and to help.In discussion we expanded on this as pect of her skills and realised that to be able to listen and to assess the child's background -especially the social and cultural background -were very impor tant.Along with specific relational skills with children and parents, it seems of great value to understand and facilitate peer involvement, for both children and parents.
At this point it was interesting to note that there were no typical 'procedural skills" on the list.We realised that skills on our list may often be neglected as clinical skills, because in the traditional educa tion of nurses we had focussed on spe cific m easurable procedures, m aybe taken for granted that nurses are able to listen, to relate and understand..As we re-looked the list of procedural skills, we added three specifics to the accepted list of skills.The first two could be expected: proven resuscitation com petency and familiarity with the Essen tial Drug List Discussion ensued sur rounding the suggestion that registered Child nurses should be proficient in the inserting and management of an intraosseus infusion.Some participants were clearly surprised by this proposition and we were not all convinced.The debate will continue outside this forum and will only be seriously considered if a clear evidence base for implementation can be established.

What does she/he need to know?
This part of the discussion was broad and resulted in the following list: • HIV/AIDS This list does not obviously include the initial com m itm ent to practise skilfully and ethically, but these aspects seemed to be the language of the discussion rather than the results.The challenge of this will be worked out with the learn ers as they engage with the new course.
The steps of enquiry proposed for ac tion research cycles will be completed and the process of data collection will continue as this programme at UCT gets underway.Learners will become partici pants as we endeavour to track and max imise their learning opportunities.Expert practitioners in the field will also be ap proached to participate as we evaluate and refine the curriculum and its meth ods.

Conclusion
So what is it that matters most in the practice of children's nurses?In this dis cussion the expectations of nursing care were certainly relational, with an empha sis on the child and family and their cul ture.Children's nurses should be com mitted to helping troubled children, able to engage people -b o th children and others, able to think about and take re sponsibility for their actions.The encour aging feature of this discussion was the active involvement of the expert practi tioners who participated.It was clear that participants started to consider their own practice and were bringing to the discus sion what they had learned there, rather than in previous formal educational set tings.
In the current climate of dramatic change challenging our health services, it seems that we no longer have the time or op portunity for extended study leave or s a d ly even m e n to rin g of n e o p h yte nurses.Nurses are required to step into positions of unit management and lead ership soon after or even before com pletion of post-basic qualifications.As we consider this challenge, the informa tion gathered at this workshop correlates with the findings of Benner et al (1996) in their recently published research.This extensive research describes the acqui sition of clinical expertise and examines the clinical knowledge, clinical enquiry, and judgem ent and ethical conduct of expert nurses.One of their significant conclusions is that the expert nurse's central concern is her involvement with the family.In their discussion of clinical judgement they draw two very significant conclusions: Firstly, that the clinical judgement of ex perienced nurses resembles much more the engaged, practical reasoning first described by Aristotle, than the disen gaged, scientific, or theoretical reason ing promoted by cognitive theorists and represented in the nursing process.
Unfortunately many current curricula, in South Africa and elsewhere, are struc tured using the latter principles S econdly, th a t e xperienced nurses reach an understanding of an ill person's experience and response to an illness, not through abstract labelling such as nursing diagnosis, but rather through knowing the particular patient.This in cludes knowing his typical pattern of re sponses, his story and the way in which illness has constituted his story.This u n d e rs ta n d in g is e n h an ced by a d vanced clinical know ledge, w hich is gleaned from experience with many per sons in similar situations.
In South Africa we may argue that in our current situation of limited resources and overwhelming demand for health serv ices we cannot afford the time or luxury of this kind of "knowing of patients" .Yet the p le th o ra of sh ort content-based courses we design and offer does not seem to have significantly increased the num ber of expert nurses with clinical judgement in our services.This may be related to a combination of the above two research findings.
The challenge is therefore to enable or at least facilitate nurses to begin this learning in their formal educational set tings and places of work.The emerging theory base of Action Learning and Ac tion Research are certainly tools which we can use to achieve this goal of in volved relational learning.

Recommendations
Even though this article describes the first cycle of an Action research process, there are some clear recommendations which can be distilled from this initial process.It is evident that what matters most in the practice of nursing children is not what we find or have learned in traditional curricula.
The first recommendation would be that we make a commitment to recognis ing the life experience of nurses who care for children.More than this that we celebrate it and give voice to this as pect of their expertise, both in educa tional programmes and in clinical prac tice.
Secondly, that we actively encourage a culture of questioning to increase the p ra ctica l reasoning skills am ongst nurses.This would contribute to prac tice as well as the knowledge develop ment of the discipline of nursing children.
Lastly, and probably of most significance at this time is a real commitment, by educators and hospital administration, to active participation of nurses.This means welcome participation in decision making about care giving, policy and curriculum developm ent.This is no longer an ideological prerequisite or a luxury we cannot afford.A culture of in volvement, listening and care is likely to be the most important gear that will shift out current deadlock of apathy, disillu sionment and dropping standards.
The Chinese way of writing the word cri sis is by using two characters, one mean ing "danger " and the other "opportu nity" .At this time of crisis in nursing edu cation and practice this concept seems to hold very appropriate challenge for us as child nurse practitioners and educa tors.Let us risk looking at things a little differently and recognise the opportuni ties these times bring.
issues surrounding child abuse as well as the registered nurses' responsibilities and resources in intervening• childhood accident prevention • care of the critically ill child • a good knowledge base of the aetiol ogy, pathophysiology, assessment and care of the nationally defined paediatric priorities in SA.: