Implementation of training to improve communication with disabled children on the ward: A feasibility study

Abstract Background Parents of disabled children report poorer inpatient experiences when they stay in hospital, and some staff report finding communicating with disabled children challenging. This study tested the feasibility of implementing a training package for staff on paediatric wards to improve communication with disabled children, especially those with communication difficulties, and their families. The package was developed with parent carers and clinicians, and comprises a manual, a video of parent carers talking about real experiences, discussion points and local resources. The 50‐minutes training is intended for in‐house delivery by local facilitators. Methods Thirteen training sessions were delivered in paediatric wards across four hospitals in England, totalling 123 staff who took part. Participants completed questionnaires before (n = 109) and after (n = 36) training, and a sample of champions (senior clinicians) and facilitators were interviewed at the end of the study. Results Facilitators found the training easy to deliver, and participants felt they took away important messages to improve their practice. After the training, further changes were reported at an organizational level, including offering further training and reviewing practices. Conclusions This study provides supporting evidence for the implementation of a low‐cost, minimal‐resource training package to support staff communication with children and their families in hospitals. It provides promising indication of impact on behavioural change at the individual and organizational level. Patient and public contribution Parent carers identified the need and helped to develop the training, including featuring in the training video. They were also consulted throughout the study on research design, delivery and reporting.

with children who may have communication difficulties and their families in ward settings. The training was not intended to focus on children with specific conditions, but all those who experience communication difficulties, whether influenced by learning disability and dysarthria, and/or users of Alternative and Augmentative Communication. It encourages prioritizing communication, cultivating empathy, improving knowledge and developing confidence, and reinforces four key messages around communicating with disabled children: 1) ask the parent/carer for advice on how to communicate best with the child; 2) communicate directly with the child; 3) identify how a child says yes and no; and 4) it is okay not to know how best to communicate with a child and to ask for advice. The training draws upon the theory of planned behaviour, 20 the construct of selfefficacy 21 and common principles of adult learning, and incorporates behavioural change techniques. The logic model for the intervention can be found in our previous paper. 19 The intervention is a standalone, peer-led, 50-minute training programme, intended to be delivered to mixed groups of ward staff. The training is based around video footage of parent carers discussing real experiences in hospital wards, along with intermittent interactive tasks, discussion, personal reflection and intention planning. Generic and local resources are provided in a handout booklet. The training also aims to raise awareness of communication with disabled children at an organizational level.
The training was previously delivered successfully on several occasions at one hospital. 19 There was good take-up with 80 staff attending training across four sessions, and it was well received by participants and the organization. Participant feedback was used to optimize training content and delivery, and all the information required for intervention delivery was documented in a manual with video files. The next step was to evaluate implementing the training in a small number of other hospitals. 22,23 Considering the context of an intervention, its implementation and mechanisms of impact are important parts of developing and evaluating a complex intervention and can be particularly useful at the feasibility and piloting phase of development in order to optimize intervention design. 22 Table 1 outlines the aims and objectives of the current study.

Consideration of implementation was guided by Damschroder's
Consolidated Framework for Implementation Research. 24 This model includes five core domains: the intervention (eg evidence strength and quality), the outer setting (eg recipient needs and resources), the inner setting (eg culture, leadership engagement), individual characteristics and the process (eg plan, evaluate and reflect). We reflected whether constructs relevant to these domains would influence the success of implementation (positively or negatively). This included reflecting on the core and adaptable components of the intervention, and identifying contextual influences on the delivery of training (such as time and clinical pressures, shift patterns, information-sharing practices, ward culture and relevant policies). It also included reflecting on the approaches used to engage key influencers to enable the training to take place and motivate staff to participate in the training.

| Stakeholder involvement
Six parents of disabled children with communication difficulties from the PenCRU Family Faculty collaborated at various times to develop and evaluate the training. Parent carers suggested the topic, helped design the training, recorded experiences for the video content and participated in meetings to reflect on the training delivery. The involvement of parent carers profoundly influenced the content of the training to include real family experiences and deliver messages they feel are important. Paediatricians and nurses were represented, and other ward staff were consulted about the design of the intervention. Disabled students from a local college designed the poster, which acted as an aide memoire on the ward to remind staff of the key messages around communication that are taught in the training.

| Setting
We sought at least three hospitals to provide sufficient variability in context to address the research questions. Hospitals in England where there was at least one children's ward were invited to take part via the NHS England Children's Experience of Care Lead. We also registered interest at conferences when presenting on the pilot study. 19 Interested clinicians made contact with the research team and were asked to identify potential training facilitators and provide contact details for their Research and Development team so that the study researcher(s) could request local sign-off for the study.
Hospitals included in the study therefore consisted of those who volunteered to take part and who had sufficient capacity and local sign-off to take part.

| Participants, recruitment and consent
A senior member of staff at each hospital was identified to oversee the project and was responsible for promoting and facilitating approval for the training to be delivered within the organization.
This staff member was also responsible for identifying clinicians to facilitate the training-where more than one clinician was to be involved in facilitating the training, it was recommended that they represent more than one profession. Facilitators were then responsible for advertising, setting up and running the training for their ward/s. The training was developed for all staff who come into contact with children during, or in preparation for, an inpatient episode.
Potential participants consisted of doctors, nurses, allied health professions, receptionists and ancillary staff working on an inpatient or pre-admission children's ward. Staff attending the training were encouraged to sign up, and read the study information sheet and consent using an online form. The process included a short baseline survey about experience and confidence in communicating with disabled children, their attitudes and reasons for participating, and their knowledge and views about communication support provided within their hospital. Paper versions of these documents were also available. Staff who wanted to attend training but who did not wish to take part in the research were permitted to do so.

| Facilitator briefing
Designated facilitators at each hospital were sent a training pack, which included the intervention manual and video files, advertising posters, paper copies of the consent and survey documents, participant handouts and an audio recording device. Prior to

Aims Objectives
To investigate the feasibility of implementing the training intervention

| Data collection and analysis
Several different approaches and sources of data were used to address the aims and objectives of the research, including the following: • Training attendance records, completed by facilitators-to capture interest and feasibility of delivery.
• Pre-and post-training anonymous online surveys for staff attending training (Appendix S1)-to capture experience, attitudes and confidence in communicating with disabled children before training and 4-6 weeks after attending. Survey responses were downloaded and collated in an Excel spreadsheet. • Telephone interviews with senior clinicians, facilitators and staff attending training at the end of the study (Appendix S3)-to gather information about the implementation of the training overall, including any barriers or enablers identified, and the impact of training on staff behaviour and organizational policy or practice. Interviews were audio-recorded and transcribed. Transcripts were reviewed to identify key themes in responses, which were subsequently discussed amongst the research team to confirm accurate interpretation and to reduce bias.
All evaluation measures were reviewed with parent carers. Data collected from the above sources were triangulated where appropriate, and are reported collectively below.

| Participants
Five hospitals including two Children's Hospitals, two District General Hospitals and one University Hospital agreed to take part; one Children's Hospital did not manage to deliver any training during the project period due to time constraints. Hospitals 1 and 2 were involved in the study for 9 months, and Hospitals 3 and 4, for less than One hundred and nine staff attending training agreed to take part in the research; a further 26 registered for and attended a session but did not provide consent to take part in the research beyond registration ( Table 2). The participating sites delivered the training to both targeted and mixed groups. Table 3 provides an overview of the different professional roles who attended training, separated by hospital (note this information was gathered at registration, so reports on the full 135 staff who attended). A third of staff had been working in their role for more than 5 years (38%), and just under a third had been in post less than a year (30%).

TA B L E 2 Training sessions and attendees by hospital
Thirty-six (39%) staff from three hospitals who attended the training completed the post-training survey 4-6 weeks after training took place (see Table 2). These staff covered a range of roles including nurses (Staff, Nursery, Auxiliary, and Student), Healthcare Support Workers, Play Specialists, Medical Students and Clerical Staff. Six staff expressed interest in a telephone interview at the end of the study, but unfortunately, these could not be arranged before the project completed. An email was sent to all consenting participants to ask whether there was any feedback relating to the above they would like to share, but no responses were received.

| Feasibility of implementing the training and review of delivery strategies
Information gathered from participant surveys and feedback forms, training attendance records, facilitator check-ins and participant interviews is collated below.

| Facilitator preparation
The facilitators who were interviewed reported that they volunteered to take part and indicated their experience of involvement had been positive. The training manual was intended to be selfexplanatory, and facilitators reported finding it easy to use; the telephone briefing session was considered helpful but not essential. Two facilitators who delivered the training session alone said that they would have preferred a co-facilitator, and another said it would have been useful to experience the training before delivering it.

| Advertising and recruiting attendees
Information about recruitment strategies was gathered from Hospitals 1, 3 and 4, who reported using a range of methods to  hard it must be not to be able to talk to others. I will feel more able to ask parents without feeling awkward or shy' (Health-Care Support Worker, HCSW). A few participants felt that they already used the techniques covered in the training, but acknowledged that it was a helpful reminder and reinforced current practice.
Facilitators also felt that staff responded well to the training and echoed the importance of hearing from the parents' perspective: 'The training highlighted the need for practice to be person-centred, and not to be afraid to ask' (LD Nurse). They also found it useful to direct staff to support already available: 'People didn't realise the extent of the things we have at our disposal' (Practice Educator).
Facilitators also commented that the training made them reflect on their own practice.

Suggested improvements
There were a number of suggested improvements to the training, which participants felt could increase its usefulness and impact,  Induction was suggested as a potentially useful point at which to introduce this training to new staff. One consultant reflected that a two-pronged approach, introducing the training into inductions whilst at the same time trying to reach as many existing staff as possible was the best way to implement it and impact on practice.

| Impact on ward or hospital practices and procedures
She also noted that she would like her consultant colleagues to receive the training.

| D ISCUSS I ON
This study provides evidence that local in-house nurses, practice educators and clinical specialists were able to deliver a focused educational session using our training manual and supporting videos to staff at several different hospitals where children are inpatients.
Feedback from staff attending and facilitating training was generally positive, in terms of the programme content and also the impact the training might have on their practice-both at the individual staff member level and the wider ward/organizational level. Whilst it is difficult to measure the real impact of implementing this training on staff behavioural change, the results regarding implementation feasibility and take-up appear promising. Below, we outline our key findings with regard to our three core aims (Table 1).

| Feasibility of training implementation
The study aimed to recruit at least three hospitals to participate and This would, however, need to be weighed up against the overall duration of the training considering time was also identified as a barrier to participation in training more generally.

| Strategies to inform implementation
Hospitals 1 and 2 participated in the programme for approximately 9 months, but the remaining sites were involved for <5 months.
Facilitators were responsible for advertising the training and recruiting staff to attend; posters, emails, social media and newsletters were the main strategies used. The short time available to advertise and deliver training sessions as part of this study was a limitation and inevitably influenced the ability of hospitals to fully implement the training. Indeed, one hospital who was keen to participate failed to arrange a session within the allocated time and therefore was unable to contribute to the research.
As mentioned, the majority of sessions were incorporated or added into pre-existing time allocated for training and development activities on the ward. As such, many of the sessions were held with groups where participants worked in similar roles (though not all), and where individuals did not volunteer to take part. This means that we have no information about the things that may influence individuals to take part in the training or not. Future research needs to allow more time for hospitals to plan for and recruit participants to enable them to choose how and when best to deliver the training to staff, and to encourage the recruitment of staff who were not involved in this research, such as doctors and allied health professionals.
In accordance with previous studies, the biggest challenge hospitals faced in implementing the training was a lack of time and staff capacity in order to release staff to attend this non-mandatory training. 26 In this study, managers and senior staff support enabled these sessions to take place, and facilitators found that adding the sessions to pre-arranged study days was a useful way to recruit staff. Including the training in induction processes was mentioned by more than one hospital going forward as a way of targeting staff who are otherwise difficult to pin down. This helps to address prior research concerns, suggesting that induction training does not fully prepare health-care workers for the realities of the ward. 26 Some facilitators highlighted the time-consuming nature of the research paperwork required at the start of the session where staff had not signed up online. We suggest that implementing the training will be considerably easier for facilitators and staff when it is not delivered as part of a research study.

| Evaluation of training impact
Unfortunately, only 39% of staff who attended the training and completed the baseline survey returned the follow-up survey, which was sent 4-6 weeks after the training had taken place. Such a low response rate was unsurprising, but disappointing nonetheless. We cannot therefore make any clear conclusions about the impact of the training on staff. Further, for the training to make a significant impact, it requires commitment to cultural change and leadership in the hospital organization, in staff groups and in individuals over the long term. The limited time provided for such activity within this study is likely insufficient for the training to be delivered to enough staff and create on-going conversations to impact in a significant and enduring way on hospital culture. Despite this, two hospitals shared that they had plans to create working groups and carry out other more specific actions as a direct result of being involved in the study.
All hospitals expressed their intention to continue using the training and resources with staff going forward.
A limitation to this study, and one that was identified by a num-

| Future considerations
This training focused on addressing the challenges of communication that may arise on a paediatric ward. Other more comprehensive resources, such as those offered by Disability Matters, 27 may be more suitable for professionals working with disabled children and their families across different settings. We also recognize the need to evaluate the effectiveness of this training in actually improving children's experience of care as inpatients in hospitals. The premise of the logic model that underpins the training is that increased staff knowledge, skills and confidence will lead to behavioural change, which will in turn improve children's experiences of care.
A key learning point for the researchers involved in the study was the impact of the parent collaborators on all aspects of the design of the programme. The original proposal came from a parent carer, and throughout the design and delivery of the training and research study, we were guided by their experiences in shaping the key messages. We feel that it is important to recognize that although this training was initially developed with disabled children in mind, the principles and key messages about good practice when communicating with children and families are applicable to all children who visit a paediatric ward, and indeed could be extended to communicating with vulnerable adults and adults with communication difficulties.
Furthermore, it is useful to note that whilst the training was developed for face-to-face delivery, given that the video clips and subsequent discussion points form the main part of the training, there is the potential for this session to be delivered virtually. This is important to note given that current working practices are moving into an increasingly virtual world, and also opens up the possibility of the training being delivered to practitioners who otherwise would be unable to attend.

| Conclusions
Despite national and international policies calling for action to improve communication and inpatient hospital experiences for disabled children, these inequalities persist. Under the day-to-day pressures of providing health care, this agenda can become lost.
This study demonstrates a desire and need for training in this area, supporting the delivery of a low-cost, fixed-time, minimal-resource training package to raise awareness about good practice when communicating with children and their families at the organizational level. The training package can be delivered in diverse hospital settings, and staff both delivering and receiving the training appear to find it useful.