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The Journey of the Paediatric Work Scheme - A Reflection

Improvements to Nurse Staffing in Paediatric Inpatient Wards

by Dawn Parry, Paediatric Project Lead

As the second duty of the  Nurse Staffing Levels (Wales) Act 2016 has recently been extended to paediatric inpatient wards. It’s important to take the opportunity to pause and reflect on all the fantastic work that the paediatric workstream and the stakeholders have been involved in to ensure that paediatric inpatient wards are prepared for the extension of the Act and comply with the requirements.

Since I started my secondment as the Paediatric Project Lead, the work has gathered at pace and scale. This has not only been in developing the Paediatric Welsh Levels of Care tool (used to assist nurses in measuring the acuity and dependency of their patients), but also in evidencing the other areas that support the triangulation of data to calculate the nurse staffing levels.


A new tool for nurses, created by nurses

Developing the Paediatric Welsh Levels of Care in collaboration with frontline paediatric nursing teams across Wales has been a significant part of the project. This was undertaken through a series of national workshops, masterclass sessions and discussions, and listening to comments and suggestions.

In an already busy working environment, the challenges that nursing teams faced in learning to utilise the tool is not to be underestimated. As a dedicated project lead, I was able to work with them offering tailored support using quality improvement techniques to enable them to ensure the data they were submitting was reliable and complete. I am very proud to say that the document in use today as been created by paediatric nurses for paediatric nurses.


A need for questionnaires to help give people a voice

The lack of evidence for nurse sensitive quality indicators that relates specifically to paediatric inpatient wards has proved challenging. Once again, the experience of frontline paediatric nurses was essential and by using a consensus approach, we have identified four quality indicators to support the calculation of the nurse staffing levels;

  • medication errors
  • pressure ulcers
  • extravasation and infiltration injuries
  • patient and staff experience.

Three of the indicators identified can be captured using current incident reporting methods. However, there were varying systems in place to capture both patient and staff experience. The workstream group have developed a staff shift survey. Two pilots have been completed and feedback from staff on completing questionnaires has been very positive. The aim is to complete the survey alongside the biannual audit. The group and our stakeholders, namely the children and young people, agreed that this was a great opportunity to develop national patient experience questionnaires and in order to capture the experience of all our patients and their families, three separate questionnaires have been devised:

  1. one for children and young people aged 4-11 years
  2. one for those aged 11years+
  3. and a separate questionnaire for parent and carers.

The questionnaires have been designed to consider the needs of children and young people that may have additional learning needs using symbols that they are familiar with from their schools.

Learning disability teams have supported the development of a poster which aid parents and/or nursing staff to support the children and young people with additional learning needs to complete the questionnaires, to ensure that their voice is heard. These questionnaires are now being rolled out in health boards across Wales.


An innovative board game for nurses – professional judgement

The final part of the triangle is professional judgement. This has been described as a critical factor in assuring effective high-quality care is delivered to our patients. It is validated by triangulating the narrative against the other two data sources to calculate the nurse staffing level.

As a method of enhancing professional judgement, we have developed an innovative board game. It provides frontline nurses with a platform to explore, learn and develop experiences, as well as build on their practical wisdom in a safe environment.

The game is scenario based where the participants are asked to build their ward using a variety of components. The scenarios present the players, specifically the nurse in charge, with an opportunity to make moral and ethical choices that are often more complex than just ‘doing the right or wrong thing’. It also provides the opportunity for questions, reflections and does not offer prescriptive answers.

The paediatric workstream are collaborating with the Accelerate group, (part of the Life Sciences Hub which supports new and innovative ideas that can be adapted into healthcare) and colleagues in academia. These collaborations provide us with the added benefit of extensive expertise and experience in user-centred design, user-experience evaluation, and behavioural analysis. These extra skills will enable us to further refine the game into a professional and digital version that could potentially have both national and international participation.



Throughout this journey, engagement with stakeholders has been a pivotal factor; from frontline nursing and management teams, parent and carer groups, and the children and young people themselves.

Ensuring we engaged with children and young people, following a Children’s Rights approach, at an early stage of the project was an important element to the progression of the work.

I have been privileged to have been able attend youth board meetings at Swansea Bay University Health Board (SBUHB) and Cardiff and Vale University Health Board (CVUHB). I’ve also had the pleasure of engaging in workshops at the residential weekends for Public Health Wales Youth Ambassador Group, where children and young people from all over Wales meet regularly.

The groups have supported the development of a range of fantastic information materials that are suitable for children and young people. These include their own version of the Paediatric Welsh levels of Care and a Frequently Asked Questions poster to enable children and young people to understand the Act. The groups have also been pivotal in the development of the patient experience questionnaires.

The role of project lead has been both exciting and challenging. I personally have developed skills that have been far outside my comfort zone; from delivering national engagement events, developing new and innovative products, presenting at national conferences, delivering training sessions to nursing teams and working with our important group of stakeholders.

The impact of the extension of the second duty of the Act will empower nursing teams. It will enable them to have a stronger voice to ensure they have the right nurse staffing levels to deliver high quality, safe and effective care to our patients and their families within Wales.

More information about the All Wales Nurse Staffing Programme is available on our dedicated webpages via HEIW’s website.