Development of Educational Content for Nurses to Prevent Safety Accidents of Hospitalized Children: Delphi Approach

Article information

Child Health Nurs Res. 2019;25(1):74-84

Publication date (electronic) : 2019 January 29

doi : https://doi.org/10.4094/chnr.2019.25.1.74

Yun Sil Lee¹, Won-Oak Oh^,2

¹Staff Nurse, Anam Hospital, Korea University · Graduate Student, Graduate School, College of Nursing, Korea University, Seoul, Korea

²Professor, College of Nursing, Korea University, Seoul, Korea

Corresponding author Won-Oak Oh College of Nursing, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Korea TEL +82-2-3290-4928 FAX +82-2-928-9108 E-MAIL wooh@korea.ac.kr

*This article was adapted from a thesis by Yun Sil Lee in partial fulfillment of the requirements for the master's degree at Korea University of Korea.

*This study was supported by a harmony scholarship from the Seoul Nurses Association in 2016.

Received 2018 December 11; Revised 2018 December 22; Accepted 2018 December 23.

Abstract

INTRODUCTION

In 2016, the death rate of South Korean children aged 1 to 14 years was 2.8 per 100,000 children [1]. The proportion of safety accidents among children under 14 years of age was 32.7% in 2016 and 36.2% in 2017, showing a steady increase [2]. Child safety accidents accounted for 28.3% of the total safety accidents in the United States of America in 2015 and 12.4% in Australia indicating that Korea has a significantly higher incidence of safety accidents than other advanced countries [3,4].

In young children, 74.3% of these accidents occurred in indoor environments such as homes, playgrounds, and educational facilities [2]. Child safety accidents in medical facilities such as hospitals, where caregivers are present and observant, accounted for a relatively small proportion of the total (0.7%). However, safety accidents in hospitals are mostly predictable events that can be prevented through active education and monitoring [5]. Therefore, focusing on safety accidents among hospitalized children is important.

Parents expect their children to be treated in a safe environment when they are hospitalized for an illness. Children who are hospitalized, like other patients, have the right to receive safe, high-quality medical care, which requires the clinical workforce to be extremely diligent [6]. "Patient safety" refers to protection of a person receiving treatment from any further risk or accident, and involves reducing the risk of unnecessary harm associated with health care to an acceptable minimum [7]. For children, the unfamiliar surroundings of the hospital and the use of unfamiliar medical devices for treatment increase the incidence of safety accidents, with reduced physical function due to the illness posing an additional danger. Despite the high likelihood of safety accidents involving inpatients owing to their physical/psychological characteristics and environmental influences, most studies have been limited to falls [8,9].

Domestic studies related to falls among hospitalized children have included research on the effectiveness of fall prevention education for caregivers [8] and the development of fall risk prediction tools for hospitalized children [9]. No study has yet investigated all types of safety accidents among hospitalized children in Korea, and even studies involving falls among hospitalized children are in the early stages.

Outside of Korea, Cooper and Nolt [10] developed fall risk assessment tools and fall prevention programs for hospitalized children, and Razmus et al.[11] developed a tool known as CHAMPS, which includes an assessment of fall risk factors and interventions for hospitalized children. Moreover, a variety of fall risk assessment tools, such as the I'm Safe tool [12] and the Humpy Dumpty Falls Scale [13], have been developed to provide fall risk prevention education appropriate for each level according to the actual clinical fall risk score. The Safety in the Seconds Program [14] was developed to prevent not only falls, but also safety accidents more broadly, among hospitalized children. Parents of children admitted to pediatric emergency rooms were also included in this study, and the effectiveness of the program was confirmed [14]. Thus, in other countries, various fall assessment tools have been developed and standardized preventive education interventions are attempted according to the risk level.

However, very few studies in Korea have investigated strategies to prevent safety accidents among hospitalized children. Considering that the safety system of the hospitals in a given country is very important for patients' safety [15], it is necessary to develop educational content for safety accident prevention that would be applicable in the hospital environment of Korea. The development of assessment tools for the safety of hospitalized children has focused only on falls [8,9,16], and no interventions have been conducted to comprehensively prevent safety accidents among hospitalized children and caregivers. In addition, there is no information on the types of safety accidents to which hospitalized children are exposed, and no details are available on the actual contents of safety education and concrete implementation methods for the prevention of child safety accidents, although such information is a prerequisite for further studies.

Therefore, through the Delphi method involving expert groups, this study was designed to develop educational contents to prevent safety accidents among hospitalized children according to their risk factors, based on a consideration of the characteristics of inpatients, facilities, and the environment. Moreover, by investigating the actual status of safety education for accident prevention among hospitalized children, it was expected that clinical nurses could provide basic data to support the further development of education and nursing strategies.

METHODS

RESULTS

1. Results of Safety Education Content for Preventing Safety Accidents among Hospitalized Children

The results of the first, second, and third rounds of the Delphi method are summarized as follows. Seven distinct themes, with 44 sub-topics, were identified among the educational content for preventing safety accidents among hospitalized children (falls, injury, electric shocks/burns, suffocation/aspiration, poisoning/abuse, kidnapping, and medical devices) (Table 1).

Table 1.

Final Content for Safety Education for the Prevention of Safety Accidents of Hospitalized Children

The sub-topics were as follows: nine related to preventive education methods for the prevention of safety accidents among hospitalized children, six related to the timing of preventive education, and three related to preventive education subjects. Additional management strategies to be implemented in addition to direct education for the prevention of accidents among hospitalized children were confirmed in two domains with 22 detailed topics (Table 2).

Table 2.

Inpatient Child Safety Accident Prevention Education Methods, Timing of Education, Targeted Subjects, and Additional Management Strategies

2. Actual Status of Safety Education for Hospitalized Children

1) General characteristics of the nurses

All 159 participants were women. Among the participants, there were 31.45%(50 participants) under the age of 25, 42.77% (68 participants) from 26 to 30 years old, 21.38%(34 participants) from 31 to 35 years old, 3.14% (5 participants) from 36 to 40 years old, and 1.26% (2 participants) over 41 years old. The vast majority of the participants (80.50%; 128 participants) were single, while 19.50% (31 participants) were married. Regarding total clinical experience, 6.92% (11 participants) had worked for less than 1 year, 49.69% (79 participants) for 1 to less than 5 years, 33.33% (53 participants) for 5 to less than 10 years, and 10.06% (16 participants) for more than 10 years. Regarding job position, 47.17% (75 participants) were general nurses and 52.83% (84 participants) were charge or head nurses.

A minority of participants (33.33%; 53 participants) reported that they had performed children's safety education, while 66.67% (106 participants) did not. Among those who responded that they had performed child safety education, 45.28% (24 participants) answered that they had done so once or twice, 41.51% (22 participants) that they had done so three to five times, and 13.21% (7 participants) that they had done so more than 6 times.

2) Nurses' perceptions of the importance of safety education for hospitalized children and actual status

Nurses' perceptions of the importance of safety education for hospitalized children were evaluated on a 5-point scale; the total score was 4.18±0.51. Domain 1 (falls) showed the highest score (4.27±0.49), while domain 5 (poisoning/abuse) showed the lowest (3.98±0.82) (Table 3).

Table 3.

Comparative Analysis of Nurses' Perception of the Importance of Hospitalized Children's Safety Education (N=159)

Significant differences in perceptions of the importance of hospitalized children's safety education were found according to age (F=3.76, p=.006), total clinical experience (F=3.47, p=.018), marital status (t=-1.99, p=.049), and job position (t=-2.31, p=.022). According to the Duncan test, nurses over 42 years old (4.58±0.43) were more aware of the importance of child safety education than were younger nurses (3.98±0.49). Awareness was higher among married participants (4.35±0.44) than among single participants (4.14±0.52). Longer total clinical experience (4.26±0.40) was associated with higher the perceptions of importance. In addition, charge or head nurses (4.27±0.49) had higher perceptions of the importance of child safety education than did general staff nurses (4.08±0.52).

The actual status of safety education for hospitalized children was evaluated on a 5-point scale, with a total score of 3.72±0.58. In terms of sub-area. Domain 7 (medical devices) scored highest (4.02±0.80), and domain 3 (electric shocks/burns) scored the lowest (3.40±0.77) (Table 3).

Significant differences in having performed child safety education were found according to age (F=4.43, p=.002) and marital status (t=2.00, p=.047). According to the Duncan test, nurses from 26 to 30 years old (3.85±0.58) and those 41 and above (4.33±0.21) were more likely to have performed child safety education than nurses under 25 years old (3.53±0.46) and those between 36 and 40 (3.13±0.60). Married nurses (3.91±0.68) had performed more safety education than unmarried nurses (3.67±0.55).

3) Comparative analysis of nurses' perceptions of the importance and actual status of safety education for hospitalized children

Nurses' responses regarding the importance of each item were compared to the performance score the corresponding item; in all cases, except for two items in domain 1 (falls) and item 29 in domain 6 (kidnapping), the actual performance status was lower than the perceptions of importance (t=11.58, p<.001) (Table 3).

4) Actual status and timing of educational methods for safety accident prevention among hospitalized children

The oral education method received a score of 4.38±0.66 on a 5-point scale, and it was the most commonly used method of child safety education. Child safety education was most frequently performed at the time of admission, with an average score of 4.52±0.67 (Table 4).

Table 4.

Method and Timing of Safety Education Content for Hospitalized Children (N=159)

5) Nurses' Perceptions of the priority of the seven education domains by child developmental stage (ranked by item)

For children under 12 months, 55.35%(88 participants) indicated that suffocation and aspiration required the most emphasis. For those aged 1~3, 4~6, and 7~12 years old, the highest score was given for falls, with response rates of 79.87%(127 participants), 76.10%(121 participants), and 45.91%(73 participants), respectively. For ages 13-18, injury ranked highest, with 43.40%(69 participants) (Table 5).

Table 5.

The Importance of Safety Education Domains according to Hospitalized Children's Developmental Stage (N=159^*)

DISCUSSION

According to the Delphi method, seven distinct domains were identified for the content of safety education. The domains derived in this study are different from existing analyses of indoor or outdoor areas where safety accidents may occur. The Child Safety Accident Survey released by the Korea Consumer Agency [2] classified safety accident areas as those where there is the possibility of "injury caused by fixed or moving objects", "falling", "tripping/sliding", "cut/stab lacerations", and so on. In Nam's study [18], daycare center safety accidents were categorized as "lacerations", "falling", "collisions with objects", and "collisions between people". The hospital environment has a variety of devices and spaces, such as wheeled beds, wheelchairs, and poles, and hospitalized children are exposed to very unfamiliar environments. Their movement is limited by the intravenous (IV) injection lines and other medical devices. For this reason, the domains to be considered for accident prevention education for hospitalized children must be more specific than those identified in previous studies. Therefore, the results of this study, which presented detailed sub-topics and classifications of the areas where hospitalized children can have safety accidents, can be considered to provide a basis for hospitalized children's safety education in the future.

Meanwhile, as suggested by previous research, the present study also identified falls as an important area in the prevention of safety accidents [8,9,16]. Similar findings were reported by the Korea Consumer Agency in their 2017 Child Safety Accident Trend Analysis [2]. The importance of falls is underscored by the very high fall rate of 67.8% that was documented in the Risk of Serious Injury Report [2]. Therefore, it is believed that focusing on the details of the fall domain described in this study will lead to a decrease in fall incidence.

A comparative analysis of nurses' perceptions of the importance of hospitalized children's safety education and the actual status of such education showed statistically significant differences in all seven domains (t=11.58, p<.001). In other words, the actual safety education provided by nurses was poorer than their perceptions of importance for all content domains of safety education. This discrepancy exists because nurses are well aware of the necessity of safety education to prevent accidents among hospitalized children, but they do not know which content to implement owing to insufficient data. As such, we consider that children and caregivers are not provided with appropriate education. Therefore, this study can be used as a basis for the development and implementation of safety education methods by providing nurses with basic data related to safety education for hospitalized children.

In our analysis of the importance of safety education content domains according to the child's developmental stage, it was found that falls and injury were important topics for children of all ages. In addition, suffocation and aspiration education was found to be more important for young children than for school-age children. However, education on medical devices was considered to be important for school-age children. This result is similar to that found in a study of age-related injury characteristics of hospitalized children undergoing emergency medical care [19]. Among younger children, falling, slipping, and foreign body aspiration were ranked high; however, as children grow older, the importance of blunt trauma increased. Therefore, it can be said that education regarding nearby medical devices is important for older children.

In the survey conducted in this study on methods of preventive education for safety accidents among hospitalized children, oral education was the most commonly-used modality, which shows that current clinical practice is limited to either oral or written methods. This demonstrates the necessity of more actively using the above-described methods to prevent safety accidents among hospitalized children. As shown in Jung's study [20], which confirmed the positive effect of education using videos and booklets on patients' understanding of hospital life and satisfaction, and Kim's study [21], which confirmed the effectiveness of mathematics education application, educational materials using visuals and concrete manipulations stimulate sight and hearing simultaneously and provides surrogate experiences to promote more accurate understanding. Thus, using more diverse teaching methods can contribute to improving the efficiency of nurses' work and increasing the effectiveness of education.

In this study, it was concluded that both the primary caregiver and the child should be included in prevention education for safety accidents at the time of admission. According to Shin, Yoo and Park's study [22], safety behavior practice is higher for individuals who have experienced of safety education. For children who spend more time with caregivers than with nurses, safety education is especially important for the caregivers. In addition, it can be expected that the efficiency of child safety accident prevention education can be enhanced by providing continuing education both during and after admission owing to the nature of child hospitalization, where caregivers frequently change.

In our investigation of additional safety accident prevention management strategies, the importance of educational management and environmental management was confirmed. In terms of educational management strategies, standardized manuals, continuous education, brief report writing, and educational material development were suggested. In the current clinical education on prevention of safety accidents among hospitalized children, guidance on falling and abduction is mainly based on Joint Commission International certification standards [11]. This reflects real-world circumstances, where there is no specific guidance on the measures to be taken in the event of safety accidents other than falls and abduction. Moreover, although there is a format to be followed when reporting falls, the procedure is complicated, potentially contributing to mistakes and omissions. Although prevention education should be customized according to age, there is a practical limitation in implementing safety accident prevention education because there is no data exist on interventions for the prevention of age-related safety accidents. Based on the results of the hospital environmental management strategy, it is necessary to establish a safe environment so that accidents do not occur, and it is necessary to collect the opinions of caregivers and children, as well as those of nursing providers.

Korean research on the safety education of children has mostly been conducted in elementary schools and childcare facilities, and there is a lack of research on safety accident prevention education for hospitalized children [23]. As the participants of the previous studies were also focused on falls, this poses a limitation in terms of comparing these results with those of previous studies. Therefore, further studies should investigated the full range of safety accidents among hospitalized children. In particular, educational research should be actively carried out to promote the safety of hospitalized children. Through these studies, comprehensive and systematic educational materials can be developed and implemented using various methods to enhance nurses' child safety knowledge and how they impart such education. The provision of adequate education to caregivers and children will increase the safety of hospitalized children.

CONCLUSION

The purpose of this study was to develop educational contents to enable nurses to prevent safety accidents among hospitalized children and to assess the safety education that nurses impart to hospitalized children and their caregivers. This study was conducted to provide a basis for the development of programs for practical safety education. Although education regarding the prevention of safety accidents among hospitalized children is necessary, this study confirmed that it is being imparted in a limited manner in clinical practice. The results of this study, if applied to clinical practice, can help contribute to child safety.

Article information Continued