Keep pediatric skills high with competencies and education

Improve referrals by showcasing staff at case conferences

It's the classic question: Which comes first, the chicken or the egg? Or, in the case of five home health agencies in New England: Which comes first; the pediatric referrals or a nursing staff who are well-trained to handle pediatric patients?

"We were getting some referrals for pediatric patients but not enough to keep our staff's pediatric skills up to a high level," says Beth Shelton, RN, clinical team leader at Home Healthcare, Hospice and Community Services in Keene, NH. Shelton's agency, along with other home health agencies, worked together to develop a program that enhances home health nurses' pediatric skills and promotes their skill level to referral sources.

"Hospitals don't know what home health can do for pediatric patients and many home health agencies don't have staff members dedicated to pediatric patients," explains Tina Smith, RNC, maternal child manager for Concord Regional VNA in New Hampshire. "We thought it was important to develop care standards and staff competencies for pediatric care to improve our ability to care for children."

A grant from the VNA Health System of Northern New England enabled the agencies to work together to develop a pediatric care program. "We met monthly to identify the clinical areas that were most important and find information on competencies or standards that already exist," says Smith.

Diabetes and asthma were chosen as the first pediatric care standards for development for several reasons. "These are very common diagnoses for children and there was a lot of information available to help us get started," says Smith.

Although the standards or clinical pathways are important, the most important step the group took was to develop pediatric competencies for home health nurses. "Each agency in our group was different in terms of how many pediatric patients were seen and how many staff members had pediatric experience," points out Smith. "My agency has a staff of maternal child health nurses but most agencies rely upon nurses with no specific pediatric training," she says. For that reason, the group not only developed staff competencies but also planned educational sessions to teach nurses.

A skills day that is held twice a year is open to staff members of all five agencies. "It is a full day that is a combination of speakers and hands-on learning," says Smith. Speakers focus on topics such as assessment of premature infants or pain management for children. Hands-on learning stations give nurses a chance to start an intravenous line, insert nasogastric tubes, set up ventilators, and operate nebulizers, she explains. All of these stations are related to pediatric competencies, she adds.

Physical assessments of newborns and young children are very different than assessments of adults, points out Smith. "Not only are they smaller, but they can't tell you what is going on," she adds. Nurses need highly tuned assessment skills and must be able to recognize reactions, such as a facial expression, that indicate pain, she explains.

There is also a completely different psychosocial need in the home of a pediatric patient, points out Smith. "You might be seeing a five year old for wound care, but you have to be calm for both the mother and the patient's sake," she explains. "You also have to be ready to play a few minutes with the younger sibling to distract him and make everything seem normal."

Reassure nurses

The differences in adult and pediatric care creates some reluctance among nurses, admits Smith. "We make a point of showing nurses that there are a lot of similarities, such as the IV pump is the same pump you use for adults," she explains.

Although few agencies have the number of referrals that justify a pediatric-only staff, it is important to carefully choose who will be seeing pediatric patients in addition to adult patients, suggests Shelton. "When nurses join our agency, we ask for their special interest such as IV, wound care, or pediatrics," she says.

After evaluating the nurse's background and considering his or her areas of interest, they are assigned an area in which to specialize. While the nurses still see adult patients, or patients who don't fall within these specific areas, they are also assigned patients with needs in their area of interest, she explains. "Nurses attend training to improve their knowledge and expertise in their area of special interest and they know that they will see enough patients with these needs to maintain their skills," she adds.

Nurses who see pediatric patients have benefited from the additional education, the clinical pathways, and the competency standards developed by the group of five agencies, says Shelton. "In our agency, we conducted a skills survey in 2002 and in 2006 to see if competency levels increase," she says. "We found that we improved our skill level in preemie assessments, insertion of NG tubes, and placement of IVs," she explains.

Data showing skill levels and sharing the clinical guidelines developed for the care of pediatric patients demonstrate your agency's competency to referral sources, but Smith and Shelton's group of agencies goes one step further to improve their relationship with referral sources. "We hold case conferences at different hospitals to discuss different cases referred to one of the agencies," she says. Physicians, nurses, and discharge planners from the hospital attend as well as managers and nurses from the home health agencies.

"We always hear the parents' side of the story in which they tell us that the hospital staff never taught them how to do certain things, so the case conference gives us a chance to develop a stronger communication link," Smith says.

One suggestion to a hospital was that the staff use a checklist of specific activities taught to the parent at the hospital, she explains. "Our home health nurse could refer to the checklist and remind the parents that they were shown how to change the dressing," she adds.

In some cases, the home health nurse is not prepared to start an IV or change a dressing because the referral information did not mention that need. "We discuss this type of situation in our case conference and develop an action plan that identifies the type of information we need as well as contact information for who to call if we have questions," she says.

The contact information is important because sometimes the parents learn on one brand of equipment in the hospital and come home to another brand that looks different, says Smith. "The home health nurse can call the hospital nurse to find out what was used for teaching and then adjust her instruction to help the parents understand how to use the new equipment," she adds.

"Case conferences not only improve communications but they also promote our capabilities so that the hospital staff is comfortable discharging a pediatric patient to our agency," says Shelton. "Having the home health nurses at the case conference is beneficial because the hospital staff gets to meet the people providing the care, not just managers," she adds.

Pediatric referrals at all five agencies have increased since the development of a pediatric care program and the group of agencies is in the process of developing other pediatric standards, says Smith. "Failure to thrive, jaundice, and prematurity standards are in draft form," she explains.

Working with other agencies has been invaluable, says Shelton. Sharing information, ideas, and different perspectives has resulted in tools that help everyone, she says. She adds, "We've been able to work together and with our referral sources to create a smooth transition from hospital to home for children."


For more about development of pediatric care standards and competencies, contact:

  • Beth Shelton, RN, Home Healthcare, Hospice and Community Services, 312 Marlboro Street, Keene, NH 03431. Phone: (800) 541-4145 or (603) 352-2253. Fax: (603) 358-3904. E-mail:
  • Tina Smith, RNC, Maternal Child Manager, Concord Regional VNA, 250 Pleasant Street, Concord, NH 03302-1797. Phone: (800) 924-8620 or (603) 224-4093. E-mail: