Article
An exploration of children’s nursing graduates’ ability to assess children’s emotional health and well-being
Journal of Child Health Care 2015, Vol. 19(3) 370–380 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513509032 chc.sagepub.com
Moira Catherine Little Edge Hill University, UK
Abstract This exploratory, qualitative study was designed to be the first stage of an action research project to investigate whether graduates from BSc children’s nursing programmes are sufficiently prepared to assess children’s emotional health. Early identification of children’s and young people’s emotional problems is important for timely interventions to be initiated. Data were gathered from a focus group and a series of semi-structured interviews and interpreted using thematic analysis approaches. The findings indicated those interviewed can recognise when a child was emotionally unwell, reporting that assessments were brief, subjective and completed without the use of age-appropriate assessment tools. It is concluded that assessment of a child’s emotional health appears to take low priority in comparison to its physical counterpart. Keywords Child and adolescent mental health, emotional health assessment, nursing curriculum, preregistration children’s
Background Growing evidence shows an increased incidence of children experiencing mental health problems (World Federation for Mental Health, 2003). In the United Kingdom (UK), 1 in 10 children, between the age of 1 and 15 years, experience mental health disorders, with the incidence increasing in adolescents (Office for National Statistics [ONS], 2005). For example, among the 5- to 10-year age group, 10% of boys and 6% of girls are affected by depression. This figure increases to 13% of boys and 10% of girls aged 11–13 years (Mental Health Foundation,
Corresponding author: Moira Catherine Little, Senior Lecturer, Edge Hill University, St Helen’s Road, Ormskirk, Lancashire, L39 4QP, UK. Email: [email protected]
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2009). Figures also show the prevalence of self-harm and suicide is increasing in young people (ONS, 2005). Some groups of young people are at particular risk of mental health problems. These include children with physical disabilities, learning difficulties and those in adverse family circumstances. Children experiencing serious or chronic illness are twice as likely to develop an emotional disorder (Immelt, 2006). In addition, a number of other groups seem especially vulnerable, such as looked-after children, homeless young people and young offenders (Sutton, 2006). Poor child mental health can be related to unsatisfactory educational achievement, dysfunctional family life, antisocial behaviour and consequent involvement with the criminal justice system (Stevenson and Goodman, 2001). It has been suggested that the preservation of the mental health of children is the means to prevention of mental disorder throughout the lifespan (Department for Children, Schools and Families [DfCSF]/Department of Health [DH], 2009). Scott et al. (2001) consider that mental health problems in childhood mark the early stages of difficulties that often continue into adult life. With one in six adults in the UK reported to have a mental health problem and the wider costs of mental health problems in the UK reaching as high as £77b, this appears to be a major concern of our society (Centre for Economic Performance’s Mental Health Policy Group, 2006). Emotional well-being is increasingly becoming a feature of government strategies for people of all ages, for example, within ‘No Health without Mental Health’ (DH, 2011). Other recent policies also stress the importance of this area of health promotion for children within the Healthy Child Programmes (DH, 2009a, 2009b). Furthermore, the ‘Child and Adolescent Mental Health Service Review’ (DH, 2008) recommends that all bodies responsible for the initial training and continuous professional development of the children’s workforce should provide basic training in child development, mental health and psychological well-being. The Royal College of Nursing (RCN) contributed to this review and suggests that nurses caring for children in both acute and community settings appear to be ill-equipped to assess emotional and psychological needs. This could result in an overemphasis on physical needs and a subsequent incomplete assessment of the child. The government’s response within ‘Healthy lives, brighter futures: The strategy for children and young people’s health’ (DCSF/DH, 2009) also emphasises the need for core skills and competencies relating to psychological well-being and mental health, together with the need for confidence of those in universal services being able to recognise more serious problems and know how to work with them or refer on to specialist services. This brief review of the literature and the policy backdrop demonstrates the importance of assessment of children’s emotional needs in conjunction with their physical needs. However, there is evidence that nurses caring for children are not skilled to carry out this holistic assessment, which gave impetus for the study undertaken.
Aim The aim was to investigate graduating children’s nurses’ perceptions of their abilities to assess children’s emotional health. It was intended that the information gained would be used to inform curriculum development.
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Methods Design The study was designed to be the first stage of an action research project. As a work-based venture ultimately aimed at curriculum development, the use of action research methods was thought to be the most appropriate. Assumptions underlying action research methodology are that it is a cyclical process, where the results of the last stage inform the first stage of the next cycle (Ritchie and Lewis, 2006). The exploratory, qualitative study undertaken was therefore used as the first stage of an action research project. That is, the baseline data gained would be used to inform curriculum development. Qualitative approaches were used, with an initial focus group undertaken to help formulate and refine questions for a subsequent one-to-one interview study.
Participants Non-probability sampling methods were used. Cohen et al. (2005) suggested that this method, where participants are chosen because of their typicality, is well suited to small-scale, indepth studies. Recruitment strategies for the sample involved sending letters and information sheets to 42 graduating children’s nurses inviting them to participate in the study. They had all commenced the course at the same time and were at the point of completion, awaiting final results. Seventeen graduating children’s nurses agreed to participate (response rate of 38%). They were randomly allocated to take part in either the focus group or the interview study. In total, 6 nurses were selected to take part in a focus group and 11 to take part in the semistructured interviews.
Ethical considerations Ethical approval for the study was given by the University Ethics Committee. Voluntary participation was stressed, so the participants did not feel under pressure to take part. However, as the participants were graduating nurses, it was felt that the potential ethical problems of studies using student samples may apply. Clark and McCann (2005) reflect on the ethics of lecturers conducting research on their students and identify the chief impediment to informed consent is the unequal power relationship between students and lecturers. In the present study, whilst the participants had completed their theoretical studies, they could still fear adverse employment references if they refused to take part. Therefore, everyone approached to take part in the study was assured that their refusal or withdrawal would not lead to any form of penalty or discrimination and decisions whether or not to participate would not affect their relationship with the researcher. The researcher’s dual position as lecturer and researcher could be viewed, in the positivist tradition, as a limitation to this study. The researcher needs to remain detached, carefully exploring all the data gathered, regardless of any personal need to develop the curriculum. Anti-positivists, such as Bowling (1998), would argue that it is difficult to be a detached, objective observer. Therefore, rather than deny the situation, the researcher tried to recognise this, affirming the role of the interviewer as human and inherent in the nature of interviewing. Robson (2007) claims the effect the presence of the researcher has on the situation is vital to action research, rather than a methodological problem.
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Data collection Data collection in this study took the form of a focus group of six students. The remaining 11 students were interviewed in order to legitimise findings and add to the overall rigour of the study. Trochim (2006) suggests such multiple measures help achieve a better view of what is happening in reality. Both the focus group and the semi-structured one-to-one interviews took place in a quiet, private area within the university. The focus group proved quite informal and the spontaneous discourse generated greatly assisted in shaping the interview schedule and resulted in the formulation of interview questions. These highlighted a number of issues concerning assessment of children’s emotional health. Included were questions about skills the interviewee required to assess children’s emotional health, if they felt equipped to contribute to such an assessment, if they had observed the use of any emotional assessment tools within the practice settings and their knowledge or experience of Child and Adolescent Mental Health Services (CAMHS). The interviews and the focus group were recorded with the participants’ consent. The aim was to collect insightful data of the phenomena under investigation. Such data collection methods provide a good opportunity for recounting and detailed understanding of personal perspectives. Seidman (2006) suggests that as a method of inquiry, interviewing and focus group studies are most consistent with people’s ability to make meaning through language. Both the interviews and the focus group were most appropriate because it allowed the participants to speak with ‘richness and spontaneity’ (Oppenheim, 2003: 81). Whilst the interview schedule was alluded to, the intention was to be as flexible as possible. With reduced adherence to the interview schedule, the interviews became increasingly free flowing as they progressed. This natural approach can help put the interviewee at ease and afford more informative answers (Walliman, 2005). Wellington (2003) suggests these experiences are not usually heard outside of formal arrangements for student evaluation. Therefore, many opportunities for clarification and detailed understanding arose.
Data analysis The focus group and semi-structured interview data were transcribed verbatim. Miles and Huberman’s (1994) thematic content analysis was used to analyse the rich data, thus ensuring relevance and accuracy. The process involved reading, then rereading through data, whilst listening to the interviews, obtaining a general sense of information and getting a first impression from the tone and ideas portrayed. By identifying recurring patterns of responses, this led to a more detailed analysis with a coding process, organizing material into themes and sub themes for further analysis. Miles and Huberman (1994: 10) indicate the features of qualitative data that contribute to its strength are that it focuses on naturally occurring ordinary events in everyday settings to get a handle on what ‘real life’ is ‘like’. Whilst becoming immersed in the data gathered, in an attempt to de-contextualise interview material and make sense of it, the researcher has an ethical duty to analyse and draw conclusions from it (Macnee and McCabe, 2008). Emerging themes identified by the author were verified by a senior nurse academic and a clinical psychologist in order to ensure accuracy and credibility in the findings (Polit and Beck, 2010). Each of these individuals examined and discussed the final version of analysis, so
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Table 1. Participant characteristics (n ¼ 17). Characteristic Age
Sex Marital status
Placement experience Parents
Focus group
Interviews
4 1 1 0 6 3 2 1 0 3 3 4 2
10 1 0 0 11 9 2 0 0 8 3 10 1
21–30 years 31–40 years Over 41 years Male Female Single Married Divorced Widowed CAMHS placement experiencea No CAMHS placement experience No children One or more children
a
Children and Adolescent Mental Health Services (CAMHS)
as to ensure the concluding interpretations and data patterns were consistent and coherent. Such analytical strategies involving investigator triangulation (Denzin and Lincoln, 1998) encompass the use of different people to check the integrity of inferences drawn from the data. Miles and Huberman (1994) highlight the debate that exists about whether the value of triangulation is to validate qualitative evidence, or lies in extending understanding, through the use of multiple perspectives. It is, however, important these principles remain at the centre of data gathering, analysis and the writing of projects (Koshy, 2010).
Findings All participants were female and a substantial number in this study were under 30 years old (Table 1). Interestingly, the interviewees’ age in this study had little relationship with their confidence and appeared to relate more to their own emotional intelligence. The findings challenge the work of Shepherd (2008) who highlights concerns of younger students, when caring for patients of a similar age. This had a marked bearing on the ability to recognise emotional issues for the child and adds credence to Hurley’s (2008) suggestions around helping provide nurses with skills to develop thoughts and understanding of their own emotions in order to become emotionally intelligent nurses. The data gathered around the students’ own life experience, for example, the diabetic student who recognised the diabetic teenager’s reluctance to take insulin (Table 2), helped influence their understanding of fragile behaviour in children and young people. Having younger siblings or being a parent themselves also influenced their beliefs and understanding of children’s emotional health. Overall eight themes were identified in the analysis, which subsequently highlighted issues for both theory and practice development of the curriculum (Table 2). The interviewees felt that physical assessment was overemphasised by lecturers, and the majority felt unprepared to manage children admitted to general wards with complex emotional issues. This reveals a need for more emphasis on the emotional components of assessment with greater theoretical consideration of age-appropriate emotional assessment tools.
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Table 2. Data themes, examples of data motifs and curriculum development issues. Data theme
Examples of interview/focus group quotes
Recognition/awareness of ‘I know that children should be asked more emotional health about how they are feeling, for instance when they are not taking their insulin, because they just want to be like the other kids’ ‘You get a perspective of how scared they are before an operation and how emotionally unstable they may be’ Over emphasis on physical ‘It’s mostly around physical assessment. I health assessment know how to physically assess very, very well but mentally maybe not too much’ ‘I don’t think emotional health is really considered unless a problem comes up’ ‘We had a child who’d overdosed. I think Confidence when you need to know the right things to say undertaking assessment because you could put your foot in it and of a child’s emotional make it ten times worse’ health. ‘If I knew a bit more they’d probably feel a bit more confident in me as well, and I’d have more confidence in myself to speak to them’ Theoretical preparation ‘Learn skills to do with children’s cognitive development. Emotional developmental age . . . if they are meeting their standards’ ‘Something that I think is an issue CAMHS might not . . . what information would they want to know?’ CAMHS ‘It needs to be made a bit more memorable, talked about earlier and revisited a little later on’ ‘I know it’s for children that need that sort of intervention, but I’m not sure where exactly’ ‘A couple of nurses on the ward didn’t have a clue what it even meant, what CAMHS stood for their role fits in to be honest’ Referral to other services/ ‘I’m nearly qualified. I should know who to expert practitioners liaise with. And I think it would be good to know the way you go around it as well’ ‘I had to tell the CAMHS team everything she told me. I didn’t hear anything about it after’
Curriculum development issues Encourage recognition of fragile behaviour in children and young people and their families.
Consideration of emotional components during all assessments
Need to include more clinical skills/ role play opportunities
Inclusion of emotional assessment as a recurrent theme. Cross field teaching to capture expertise.
Need to include series of sessions from practitioners working in CAMHS. Explore the use of emotional assessment tools.
Need for more collaborative working with CAMHS
(continued)
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Table 2. (continued) Data theme Practice placement experience
Role of mentors/qualified nurses
Examples of interview/focus group quotes
Curriculum development issues
‘Children come onto the ward with mental Better preparation in practice by involving students in all aspects of health problems. I feel we are kept away assessment. from them. I think they should try and expose students a bit more to these types of patients, because I am going to qualify in a few weeks and don’t feel that I have had any exposure to them really’ ‘I’ve heard of mental health assessments, but I’ve never seen them or anything’ ‘You can’t do that with emotions can you?’ ‘I think it’s the parents who pick up on it Partnership working with Mentors around their skills and knowledge. more than the staff do. They could slip through the net. They’d never get the help that they could potentially need’ ‘When you report back to people it just kind of gets dismissed. I feel that sometimes the assessments aren’t looked at in depth like they should be’
The inclusion of emotional assessment, alongside the physical assessment as a recurrent theme throughout the course, was deemed to be necessary. The nurse’s lack of exposure to more detailed assessment in practice, together with a lack of confidence, appeared to reinforce the assertion that it is not a part of their role. There was a general sense of the emotional assessment being someone else’s domain. It was felt that developing clinical skills and role play opportunities for the students in theory could enhance confidence in practice. Stronger partnership working between the university, mentors and CAMHS practitioners was considered necessary to strengthen collaborative working and support better preparation for practice. The interviewee’s perceived lack of inclusion by their mentors, in any complex emotional health assessment in practice, left some feeling ill prepared. This could be addressed within a future action research study with mentors and may assist in determining their knowledge and skills around assessment of emotional health.
Discussion The findings show there is broad agreement among interviewees around the need for further theoretical and practical preparation for assessing children’s emotional health. This echoes the concerns of the Nursing Midwifery Council (NMC, 2008), calling for children’s nurse education to have a greater emphasis on mental health. Generally, the nurses felt they had some skills necessary to assess emotional health including observation, listening and communication. However, their clinical observations gave the impression that commonly nurses’ emotional assessment appears to be subjective and lacking in depth.
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Early findings from an exploratory survey into preregistration nursing curricula by Hooton (1999) found the inclusion of child mental health issues to be weak. Jones (2003) also highlights inadequate curriculum content of child and adolescent mental health, which Richardson et al. (2006) suggest could be the consequence of an overstretched curriculum, resulting in cursory visits to some subject areas. Participants in this study generally agreed there was not enough consideration of emotional health in both theoretical and practical preparation for practice. The emphasis throughout appeared to be placed on the physical assessment. It is crucial that children’s nurses are competent and properly equipped with sufficient knowledge and skills to care for children with minimal or complex emotional needs. However, the majority of interviewees in this study reported the assessments they observed lacked an emotional element. This component of the assessment appeared to be minimal and based on personal judgement rather than any assessment tool or framework. Bryon and Hearst cited in Southall (2005) maintain that initiating more thorough assessments around the difficulties children may be experiencing could be beneficial in preventing adverse outcomes and ensure children are given every opportunity to reach their fullest potential to enjoy good emotional health. Vostanis (2007) agrees that nurses dealing with children on a daily basis are in a prominent position to fulfil this role with confidence. However, it was a lack of confidence for some interviewees, which had a marked bearing on their ability to enquire further about the child’s emotions. Some feared they could make things worse and felt unprepared for their role when dealing with more complex emotional issues. This concurs with Watson (2006) whose findings highlight an increased level of anxiety for nurses working with this client group. In this study, those who had younger siblings or were parents themselves displayed greater confidence. Hurley (2008) suggests the need for helping provides nurses with skills to develop understanding of their own emotions in order to become emotionally intelligent nurses. Whilst Holland et al. (2010) continue to encourage nurse educators to increase the emphasis on emotional assessment; and despite deficits in both theory and practice, some of the nurses in this study had developed strategies to assess this area, albeit not in any depth, giving the impression that delving any deeper was going beyond their remit. Superficial communication, especially with adolescents, was described, leading to a lack of further enquiry into problem areas. Emotional assessments were subjective and rooted in the interviewee’s own experience and interpretation. Some considered how a child may emotionally respond to surgery or his or her treatment for long-term conditions but felt the emphasis was on the physical assessment. Mental health assessment tools that could be used to promote further enquiry had, in the main, not been encountered in practice. Smith (2009) suggests the lack of use of an assessment tool, together with limited coverage of mental health issues in theory, could further reduce the importance of this area of assessment. Some of the interviewees in this study reflected McCarthy and Holt’s (2007) fears that some graduating nurses can feel ill equipped to meet the needs of children and their families. Whilst many interviewees aspired to truly holistic assessment of the child, this depended on the experience and opportunity afforded by the placement area. It was interesting to note in this study that interviewees on placements with School Nurses and Health Visitors appeared to give emotional health assessment much more credibility than in the acute setting. The community setting appeared to assist some interviewees to consider the impact of the home and school environment on the child’s emotional health within their subsequent placements. Some did appear to be able to transfer the acquired knowledge and assessment skills to the acute area. Interviewees recognized how the correlation of the level of expertise of the mentor and the placement setting affected the rigour of the emotional assessment undertaken. Jones and Baldwin
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(2004) critically reflect on this lack of proficiency of nurses as a legacy of inadequate content in preregistration nursing programmes and lack of opportunity for post registration development. This could be a reflection of the mentor’s post registration education and would be another area to investigate in a future action research cycle. Other issues highlighted in the present study include a lack of understanding by some interviewees of the role of the CAMHS and a subsequent lack of joint working when caring for a child. Interviewees suggested strategies for fostering relationships between mental health practitioners and children’s nurses. These included more exposure to this service, both in theory and in practice, as suggested previously by McDougall (2005). The opportunity for professional socialisation could prove invaluable to effectively dispel any misconceptions about professionals and their roles. There appears to be scope for more organised effort into achieving this in an attempt to come into line with governmental ambitions of collaborative working within healthy lives, brighter futures (DH, 2009b). This could help increase the nurse’s confidence, assist communication and, in turn, improve outcomes for the child.
Conclusions The findings of this small-scale study have implications for curriculum development and could provide direction on how to prepare undergraduate nurses in this area, both in theory and in practice. This should be considered in light of the study’s limitations, which include incorporating the views of a small, all-female sample, and that the study had a low response rate of 38%, from one institution. This did, however, provide a depth and richness of data that may not have been obtained from a larger sample. Alongside this, the lack of practitioner input could be seen as a threat to the validity of the study. The mentors in practice were obvious stakeholders in this issue. However, their exclusion can be rationalized, by this being a faculty matter, involving only students in this first cycle of the research. Practitioner’s voices could be heard in a later cycle and actively engaged in critically reflecting on their knowledge to further illuminate this area of assessment in practice. Once qualified, these students’ views could be heard again and could inform another cycle researching their practice. The feasibility of this research was that it needed to focus on a small facet, undergoing one cycle in this instance, to make it manageable in the given timescale. In future studies, the age range of children to be addressed could be more clearly delineated as the findings covered a wide age range and may well have been more specific, as to discussion around either the younger child or adolescent. Despite these limitations, it may be concluded that there is little existing research into the subject of emotional needs’ assessment for children. Nevertheless, skilled nursing assessment is pivotal in uncovering the emotional needs of children and the interrelationships this has with their families. The findings of this study point to the need for better preparation of children’s nurses in the area of emotional health. There is a need to develop course content and methods of preparation to best meet the needs of prospective learners, if they are to fulfil their responsibilities within children’s nursing. A curriculum with a continuous child and adolescent mental health thread running through it is required to prepare nurses to meet the needs of today’s children and their families. Also strategies for improving collaborative working are required, involving all stakeholders, including lecturers, mentors and CAMHS in a bid to provide optimal care for children and adolescents. To conclude, it would appear that a repackaging around the whole area of emotional development and assessment, both in preregistration and post registration nurse education, with a well-being approach to teaching and learning, is needed.
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Funding This research received no specific grant from any funding agency in the public, commercial or notfor-profit sectors. References Bowling A (1998) Research Methods in Health: Investigating Health and Health Services. Maidenhead, UK: Open University Press. Centre for Economic Performance’s Mental Health Policy Group (2006) The Depression Report: A New Deal for Depression and Anxiety Disorders. London: Centre for Economic Performance. Clark E and McCann T (2005) Researching students: An ethical dilemma. Nurse Researcher 12(3): 42–51. Cohen L, Manion L and Morrison K (2005) Research Methods in Education. 5th ed. Falmer, Oxon, UK: Routledge. Denzin NK and Lincoln YS (1998) Collecting and Interpreting Qualitative Materials. Thousand Oaks, CA: Sage. Department of Health (DH) (2008) Children and Young People in Mind: The Final Report of the National CAMHS Review. London, UK: Department of Health. Department of Health (DH) (2009a) Healthy Child Programme from 5-19 Years Old. London, UK: Department of Health. Department of Health (DH) (2009b) Healthy Child Programme Pregnancy and the First Five Years of Life. London, UK: Department of Health. Department of Health (DH) (2011) No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. London, UK: Department of Health. Department for Children Schools and Families/Department of Health (DCSF/DH) (2009) Healthy Lives, Brighter Futures: The Strategy for Children and Young People’s Health. London, UK: Department of Health. Holland K, Roxburgh M, Johnson M, Topping K, Watson R, Lauder W, et al. (2010) Fitness for practice in nursing and midwifery education in Scotland, United Kingdom. Journal of Clinical Nursing 19: 461–469. Hooton S (1999) Results of a Survey undertaken to Establish the Degree to which Pre-registration Programmes address Child and Adolescent Mental Health. London, UK: ENB. Hurley J (2008) The necessity, barriers and ways forward to meet user-based needs for emotionally intelligent nurses. Journal of Psychiatric and Mental Health Nursing. 15: 379–385. Immelt S (2006) Psychological adjustment in young children with chronic medical conditions. Journal of Paediatric Nursing 21(5): 362–377. Jones J (2003) The Post-Registration Education and Training Needs of Nurses Working with Children and Young People with Mental Health Problems in the UK. London, UK: Royal College of Nursing. Jones J and Baldwin L (2004) Tiers before bedtime: A survey of post-registration CAMHS education is missing the mark. Mental Health Practice 7(6): 14–17. Koshy V (2010) Action Research for Improving Educational Practice. UK: Sage. Macnee C and McCabe S (2008) Understanding Nursing Research. 2nd ed. Philadelphia: Lippincott Williams and Wilkins. McCarthy J and Holt M (2007) Complexities of policy-driven pre-registration nursing curricula. Nursing Standard 22(10): 35–38. McDougall T (2005) Child and adolescent mental health services in the UK: Nurse consultants. Journal of Child and Adolescent Psychiatric Nursing 18(2): 79–83.
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An exploration of children’s nursing graduates’ ability to assess children’s emotional health and well-being
Journal of Child Health Care 2015, Vol. 19(3) 370–380 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513509032 chc.sagepub.com
Moira Catherine Little Edge Hill University, UK
Abstract This exploratory, qualitative study was designed to be the first stage of an action research project to investigate whether graduates from BSc children’s nursing programmes are sufficiently prepared to assess children’s emotional health. Early identification of children’s and young people’s emotional problems is important for timely interventions to be initiated. Data were gathered from a focus group and a series of semi-structured interviews and interpreted using thematic analysis approaches. The findings indicated those interviewed can recognise when a child was emotionally unwell, reporting that assessments were brief, subjective and completed without the use of age-appropriate assessment tools. It is concluded that assessment of a child’s emotional health appears to take low priority in comparison to its physical counterpart. Keywords Child and adolescent mental health, emotional health assessment, nursing curriculum, preregistration children’s
Background Growing evidence shows an increased incidence of children experiencing mental health problems (World Federation for Mental Health, 2003). In the United Kingdom (UK), 1 in 10 children, between the age of 1 and 15 years, experience mental health disorders, with the incidence increasing in adolescents (Office for National Statistics [ONS], 2005). For example, among the 5- to 10-year age group, 10% of boys and 6% of girls are affected by depression. This figure increases to 13% of boys and 10% of girls aged 11–13 years (Mental Health Foundation,
Corresponding author: Moira Catherine Little, Senior Lecturer, Edge Hill University, St Helen’s Road, Ormskirk, Lancashire, L39 4QP, UK. Email: [email protected]
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2009). Figures also show the prevalence of self-harm and suicide is increasing in young people (ONS, 2005). Some groups of young people are at particular risk of mental health problems. These include children with physical disabilities, learning difficulties and those in adverse family circumstances. Children experiencing serious or chronic illness are twice as likely to develop an emotional disorder (Immelt, 2006). In addition, a number of other groups seem especially vulnerable, such as looked-after children, homeless young people and young offenders (Sutton, 2006). Poor child mental health can be related to unsatisfactory educational achievement, dysfunctional family life, antisocial behaviour and consequent involvement with the criminal justice system (Stevenson and Goodman, 2001). It has been suggested that the preservation of the mental health of children is the means to prevention of mental disorder throughout the lifespan (Department for Children, Schools and Families [DfCSF]/Department of Health [DH], 2009). Scott et al. (2001) consider that mental health problems in childhood mark the early stages of difficulties that often continue into adult life. With one in six adults in the UK reported to have a mental health problem and the wider costs of mental health problems in the UK reaching as high as £77b, this appears to be a major concern of our society (Centre for Economic Performance’s Mental Health Policy Group, 2006). Emotional well-being is increasingly becoming a feature of government strategies for people of all ages, for example, within ‘No Health without Mental Health’ (DH, 2011). Other recent policies also stress the importance of this area of health promotion for children within the Healthy Child Programmes (DH, 2009a, 2009b). Furthermore, the ‘Child and Adolescent Mental Health Service Review’ (DH, 2008) recommends that all bodies responsible for the initial training and continuous professional development of the children’s workforce should provide basic training in child development, mental health and psychological well-being. The Royal College of Nursing (RCN) contributed to this review and suggests that nurses caring for children in both acute and community settings appear to be ill-equipped to assess emotional and psychological needs. This could result in an overemphasis on physical needs and a subsequent incomplete assessment of the child. The government’s response within ‘Healthy lives, brighter futures: The strategy for children and young people’s health’ (DCSF/DH, 2009) also emphasises the need for core skills and competencies relating to psychological well-being and mental health, together with the need for confidence of those in universal services being able to recognise more serious problems and know how to work with them or refer on to specialist services. This brief review of the literature and the policy backdrop demonstrates the importance of assessment of children’s emotional needs in conjunction with their physical needs. However, there is evidence that nurses caring for children are not skilled to carry out this holistic assessment, which gave impetus for the study undertaken.
Aim The aim was to investigate graduating children’s nurses’ perceptions of their abilities to assess children’s emotional health. It was intended that the information gained would be used to inform curriculum development.
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Methods Design The study was designed to be the first stage of an action research project. As a work-based venture ultimately aimed at curriculum development, the use of action research methods was thought to be the most appropriate. Assumptions underlying action research methodology are that it is a cyclical process, where the results of the last stage inform the first stage of the next cycle (Ritchie and Lewis, 2006). The exploratory, qualitative study undertaken was therefore used as the first stage of an action research project. That is, the baseline data gained would be used to inform curriculum development. Qualitative approaches were used, with an initial focus group undertaken to help formulate and refine questions for a subsequent one-to-one interview study.
Participants Non-probability sampling methods were used. Cohen et al. (2005) suggested that this method, where participants are chosen because of their typicality, is well suited to small-scale, indepth studies. Recruitment strategies for the sample involved sending letters and information sheets to 42 graduating children’s nurses inviting them to participate in the study. They had all commenced the course at the same time and were at the point of completion, awaiting final results. Seventeen graduating children’s nurses agreed to participate (response rate of 38%). They were randomly allocated to take part in either the focus group or the interview study. In total, 6 nurses were selected to take part in a focus group and 11 to take part in the semistructured interviews.
Ethical considerations Ethical approval for the study was given by the University Ethics Committee. Voluntary participation was stressed, so the participants did not feel under pressure to take part. However, as the participants were graduating nurses, it was felt that the potential ethical problems of studies using student samples may apply. Clark and McCann (2005) reflect on the ethics of lecturers conducting research on their students and identify the chief impediment to informed consent is the unequal power relationship between students and lecturers. In the present study, whilst the participants had completed their theoretical studies, they could still fear adverse employment references if they refused to take part. Therefore, everyone approached to take part in the study was assured that their refusal or withdrawal would not lead to any form of penalty or discrimination and decisions whether or not to participate would not affect their relationship with the researcher. The researcher’s dual position as lecturer and researcher could be viewed, in the positivist tradition, as a limitation to this study. The researcher needs to remain detached, carefully exploring all the data gathered, regardless of any personal need to develop the curriculum. Anti-positivists, such as Bowling (1998), would argue that it is difficult to be a detached, objective observer. Therefore, rather than deny the situation, the researcher tried to recognise this, affirming the role of the interviewer as human and inherent in the nature of interviewing. Robson (2007) claims the effect the presence of the researcher has on the situation is vital to action research, rather than a methodological problem.
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Data collection Data collection in this study took the form of a focus group of six students. The remaining 11 students were interviewed in order to legitimise findings and add to the overall rigour of the study. Trochim (2006) suggests such multiple measures help achieve a better view of what is happening in reality. Both the focus group and the semi-structured one-to-one interviews took place in a quiet, private area within the university. The focus group proved quite informal and the spontaneous discourse generated greatly assisted in shaping the interview schedule and resulted in the formulation of interview questions. These highlighted a number of issues concerning assessment of children’s emotional health. Included were questions about skills the interviewee required to assess children’s emotional health, if they felt equipped to contribute to such an assessment, if they had observed the use of any emotional assessment tools within the practice settings and their knowledge or experience of Child and Adolescent Mental Health Services (CAMHS). The interviews and the focus group were recorded with the participants’ consent. The aim was to collect insightful data of the phenomena under investigation. Such data collection methods provide a good opportunity for recounting and detailed understanding of personal perspectives. Seidman (2006) suggests that as a method of inquiry, interviewing and focus group studies are most consistent with people’s ability to make meaning through language. Both the interviews and the focus group were most appropriate because it allowed the participants to speak with ‘richness and spontaneity’ (Oppenheim, 2003: 81). Whilst the interview schedule was alluded to, the intention was to be as flexible as possible. With reduced adherence to the interview schedule, the interviews became increasingly free flowing as they progressed. This natural approach can help put the interviewee at ease and afford more informative answers (Walliman, 2005). Wellington (2003) suggests these experiences are not usually heard outside of formal arrangements for student evaluation. Therefore, many opportunities for clarification and detailed understanding arose.
Data analysis The focus group and semi-structured interview data were transcribed verbatim. Miles and Huberman’s (1994) thematic content analysis was used to analyse the rich data, thus ensuring relevance and accuracy. The process involved reading, then rereading through data, whilst listening to the interviews, obtaining a general sense of information and getting a first impression from the tone and ideas portrayed. By identifying recurring patterns of responses, this led to a more detailed analysis with a coding process, organizing material into themes and sub themes for further analysis. Miles and Huberman (1994: 10) indicate the features of qualitative data that contribute to its strength are that it focuses on naturally occurring ordinary events in everyday settings to get a handle on what ‘real life’ is ‘like’. Whilst becoming immersed in the data gathered, in an attempt to de-contextualise interview material and make sense of it, the researcher has an ethical duty to analyse and draw conclusions from it (Macnee and McCabe, 2008). Emerging themes identified by the author were verified by a senior nurse academic and a clinical psychologist in order to ensure accuracy and credibility in the findings (Polit and Beck, 2010). Each of these individuals examined and discussed the final version of analysis, so
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Table 1. Participant characteristics (n ¼ 17). Characteristic Age
Sex Marital status
Placement experience Parents
Focus group
Interviews
4 1 1 0 6 3 2 1 0 3 3 4 2
10 1 0 0 11 9 2 0 0 8 3 10 1
21–30 years 31–40 years Over 41 years Male Female Single Married Divorced Widowed CAMHS placement experiencea No CAMHS placement experience No children One or more children
a
Children and Adolescent Mental Health Services (CAMHS)
as to ensure the concluding interpretations and data patterns were consistent and coherent. Such analytical strategies involving investigator triangulation (Denzin and Lincoln, 1998) encompass the use of different people to check the integrity of inferences drawn from the data. Miles and Huberman (1994) highlight the debate that exists about whether the value of triangulation is to validate qualitative evidence, or lies in extending understanding, through the use of multiple perspectives. It is, however, important these principles remain at the centre of data gathering, analysis and the writing of projects (Koshy, 2010).
Findings All participants were female and a substantial number in this study were under 30 years old (Table 1). Interestingly, the interviewees’ age in this study had little relationship with their confidence and appeared to relate more to their own emotional intelligence. The findings challenge the work of Shepherd (2008) who highlights concerns of younger students, when caring for patients of a similar age. This had a marked bearing on the ability to recognise emotional issues for the child and adds credence to Hurley’s (2008) suggestions around helping provide nurses with skills to develop thoughts and understanding of their own emotions in order to become emotionally intelligent nurses. The data gathered around the students’ own life experience, for example, the diabetic student who recognised the diabetic teenager’s reluctance to take insulin (Table 2), helped influence their understanding of fragile behaviour in children and young people. Having younger siblings or being a parent themselves also influenced their beliefs and understanding of children’s emotional health. Overall eight themes were identified in the analysis, which subsequently highlighted issues for both theory and practice development of the curriculum (Table 2). The interviewees felt that physical assessment was overemphasised by lecturers, and the majority felt unprepared to manage children admitted to general wards with complex emotional issues. This reveals a need for more emphasis on the emotional components of assessment with greater theoretical consideration of age-appropriate emotional assessment tools.
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Table 2. Data themes, examples of data motifs and curriculum development issues. Data theme
Examples of interview/focus group quotes
Recognition/awareness of ‘I know that children should be asked more emotional health about how they are feeling, for instance when they are not taking their insulin, because they just want to be like the other kids’ ‘You get a perspective of how scared they are before an operation and how emotionally unstable they may be’ Over emphasis on physical ‘It’s mostly around physical assessment. I health assessment know how to physically assess very, very well but mentally maybe not too much’ ‘I don’t think emotional health is really considered unless a problem comes up’ ‘We had a child who’d overdosed. I think Confidence when you need to know the right things to say undertaking assessment because you could put your foot in it and of a child’s emotional make it ten times worse’ health. ‘If I knew a bit more they’d probably feel a bit more confident in me as well, and I’d have more confidence in myself to speak to them’ Theoretical preparation ‘Learn skills to do with children’s cognitive development. Emotional developmental age . . . if they are meeting their standards’ ‘Something that I think is an issue CAMHS might not . . . what information would they want to know?’ CAMHS ‘It needs to be made a bit more memorable, talked about earlier and revisited a little later on’ ‘I know it’s for children that need that sort of intervention, but I’m not sure where exactly’ ‘A couple of nurses on the ward didn’t have a clue what it even meant, what CAMHS stood for their role fits in to be honest’ Referral to other services/ ‘I’m nearly qualified. I should know who to expert practitioners liaise with. And I think it would be good to know the way you go around it as well’ ‘I had to tell the CAMHS team everything she told me. I didn’t hear anything about it after’
Curriculum development issues Encourage recognition of fragile behaviour in children and young people and their families.
Consideration of emotional components during all assessments
Need to include more clinical skills/ role play opportunities
Inclusion of emotional assessment as a recurrent theme. Cross field teaching to capture expertise.
Need to include series of sessions from practitioners working in CAMHS. Explore the use of emotional assessment tools.
Need for more collaborative working with CAMHS
(continued)
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Table 2. (continued) Data theme Practice placement experience
Role of mentors/qualified nurses
Examples of interview/focus group quotes
Curriculum development issues
‘Children come onto the ward with mental Better preparation in practice by involving students in all aspects of health problems. I feel we are kept away assessment. from them. I think they should try and expose students a bit more to these types of patients, because I am going to qualify in a few weeks and don’t feel that I have had any exposure to them really’ ‘I’ve heard of mental health assessments, but I’ve never seen them or anything’ ‘You can’t do that with emotions can you?’ ‘I think it’s the parents who pick up on it Partnership working with Mentors around their skills and knowledge. more than the staff do. They could slip through the net. They’d never get the help that they could potentially need’ ‘When you report back to people it just kind of gets dismissed. I feel that sometimes the assessments aren’t looked at in depth like they should be’
The inclusion of emotional assessment, alongside the physical assessment as a recurrent theme throughout the course, was deemed to be necessary. The nurse’s lack of exposure to more detailed assessment in practice, together with a lack of confidence, appeared to reinforce the assertion that it is not a part of their role. There was a general sense of the emotional assessment being someone else’s domain. It was felt that developing clinical skills and role play opportunities for the students in theory could enhance confidence in practice. Stronger partnership working between the university, mentors and CAMHS practitioners was considered necessary to strengthen collaborative working and support better preparation for practice. The interviewee’s perceived lack of inclusion by their mentors, in any complex emotional health assessment in practice, left some feeling ill prepared. This could be addressed within a future action research study with mentors and may assist in determining their knowledge and skills around assessment of emotional health.
Discussion The findings show there is broad agreement among interviewees around the need for further theoretical and practical preparation for assessing children’s emotional health. This echoes the concerns of the Nursing Midwifery Council (NMC, 2008), calling for children’s nurse education to have a greater emphasis on mental health. Generally, the nurses felt they had some skills necessary to assess emotional health including observation, listening and communication. However, their clinical observations gave the impression that commonly nurses’ emotional assessment appears to be subjective and lacking in depth.
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Early findings from an exploratory survey into preregistration nursing curricula by Hooton (1999) found the inclusion of child mental health issues to be weak. Jones (2003) also highlights inadequate curriculum content of child and adolescent mental health, which Richardson et al. (2006) suggest could be the consequence of an overstretched curriculum, resulting in cursory visits to some subject areas. Participants in this study generally agreed there was not enough consideration of emotional health in both theoretical and practical preparation for practice. The emphasis throughout appeared to be placed on the physical assessment. It is crucial that children’s nurses are competent and properly equipped with sufficient knowledge and skills to care for children with minimal or complex emotional needs. However, the majority of interviewees in this study reported the assessments they observed lacked an emotional element. This component of the assessment appeared to be minimal and based on personal judgement rather than any assessment tool or framework. Bryon and Hearst cited in Southall (2005) maintain that initiating more thorough assessments around the difficulties children may be experiencing could be beneficial in preventing adverse outcomes and ensure children are given every opportunity to reach their fullest potential to enjoy good emotional health. Vostanis (2007) agrees that nurses dealing with children on a daily basis are in a prominent position to fulfil this role with confidence. However, it was a lack of confidence for some interviewees, which had a marked bearing on their ability to enquire further about the child’s emotions. Some feared they could make things worse and felt unprepared for their role when dealing with more complex emotional issues. This concurs with Watson (2006) whose findings highlight an increased level of anxiety for nurses working with this client group. In this study, those who had younger siblings or were parents themselves displayed greater confidence. Hurley (2008) suggests the need for helping provides nurses with skills to develop understanding of their own emotions in order to become emotionally intelligent nurses. Whilst Holland et al. (2010) continue to encourage nurse educators to increase the emphasis on emotional assessment; and despite deficits in both theory and practice, some of the nurses in this study had developed strategies to assess this area, albeit not in any depth, giving the impression that delving any deeper was going beyond their remit. Superficial communication, especially with adolescents, was described, leading to a lack of further enquiry into problem areas. Emotional assessments were subjective and rooted in the interviewee’s own experience and interpretation. Some considered how a child may emotionally respond to surgery or his or her treatment for long-term conditions but felt the emphasis was on the physical assessment. Mental health assessment tools that could be used to promote further enquiry had, in the main, not been encountered in practice. Smith (2009) suggests the lack of use of an assessment tool, together with limited coverage of mental health issues in theory, could further reduce the importance of this area of assessment. Some of the interviewees in this study reflected McCarthy and Holt’s (2007) fears that some graduating nurses can feel ill equipped to meet the needs of children and their families. Whilst many interviewees aspired to truly holistic assessment of the child, this depended on the experience and opportunity afforded by the placement area. It was interesting to note in this study that interviewees on placements with School Nurses and Health Visitors appeared to give emotional health assessment much more credibility than in the acute setting. The community setting appeared to assist some interviewees to consider the impact of the home and school environment on the child’s emotional health within their subsequent placements. Some did appear to be able to transfer the acquired knowledge and assessment skills to the acute area. Interviewees recognized how the correlation of the level of expertise of the mentor and the placement setting affected the rigour of the emotional assessment undertaken. Jones and Baldwin
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(2004) critically reflect on this lack of proficiency of nurses as a legacy of inadequate content in preregistration nursing programmes and lack of opportunity for post registration development. This could be a reflection of the mentor’s post registration education and would be another area to investigate in a future action research cycle. Other issues highlighted in the present study include a lack of understanding by some interviewees of the role of the CAMHS and a subsequent lack of joint working when caring for a child. Interviewees suggested strategies for fostering relationships between mental health practitioners and children’s nurses. These included more exposure to this service, both in theory and in practice, as suggested previously by McDougall (2005). The opportunity for professional socialisation could prove invaluable to effectively dispel any misconceptions about professionals and their roles. There appears to be scope for more organised effort into achieving this in an attempt to come into line with governmental ambitions of collaborative working within healthy lives, brighter futures (DH, 2009b). This could help increase the nurse’s confidence, assist communication and, in turn, improve outcomes for the child.
Conclusions The findings of this small-scale study have implications for curriculum development and could provide direction on how to prepare undergraduate nurses in this area, both in theory and in practice. This should be considered in light of the study’s limitations, which include incorporating the views of a small, all-female sample, and that the study had a low response rate of 38%, from one institution. This did, however, provide a depth and richness of data that may not have been obtained from a larger sample. Alongside this, the lack of practitioner input could be seen as a threat to the validity of the study. The mentors in practice were obvious stakeholders in this issue. However, their exclusion can be rationalized, by this being a faculty matter, involving only students in this first cycle of the research. Practitioner’s voices could be heard in a later cycle and actively engaged in critically reflecting on their knowledge to further illuminate this area of assessment in practice. Once qualified, these students’ views could be heard again and could inform another cycle researching their practice. The feasibility of this research was that it needed to focus on a small facet, undergoing one cycle in this instance, to make it manageable in the given timescale. In future studies, the age range of children to be addressed could be more clearly delineated as the findings covered a wide age range and may well have been more specific, as to discussion around either the younger child or adolescent. Despite these limitations, it may be concluded that there is little existing research into the subject of emotional needs’ assessment for children. Nevertheless, skilled nursing assessment is pivotal in uncovering the emotional needs of children and the interrelationships this has with their families. The findings of this study point to the need for better preparation of children’s nurses in the area of emotional health. There is a need to develop course content and methods of preparation to best meet the needs of prospective learners, if they are to fulfil their responsibilities within children’s nursing. A curriculum with a continuous child and adolescent mental health thread running through it is required to prepare nurses to meet the needs of today’s children and their families. Also strategies for improving collaborative working are required, involving all stakeholders, including lecturers, mentors and CAMHS in a bid to provide optimal care for children and adolescents. To conclude, it would appear that a repackaging around the whole area of emotional development and assessment, both in preregistration and post registration nurse education, with a well-being approach to teaching and learning, is needed.
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