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More education in paediatric audiology needed for child welfare clinic nurses and doctors
Public Health (1997) 111, 93-96 o The Society of Public Health, 1997
More education in paediatric audiology needed for child welfare clinic nurses and doctors E Maki-Torkko’, M Sorri’ and M-R Jarvelin’ ‘Department of OtolaQJngologY, Universiq of &lu, and General Practice, University of Oh, Finland
Finland; and =Department
of Public HealthScience
@$ons on formal and further education in paediatric audiology were surveyedby interviewing nursesand doctors in 28 Fash child welfare clinics. Over half of the nursesrecalledthat they had been taught hearing screeningduring their period of practical training. Regarding formal teaching in paediatric audiology, the majority of doctors referred to Copsesin either otolaryngology, paediatricsor both. None of the doctorsand only three of the nurseshad taken part in any updating coursesdealing with paediatric audiology during the last three years,and it turned out that no suchcourses had been arranged in three of the five hospital dist&s. However, 17 out of the 27 doctors and 23 out of the 28 nurses expressedtheir interest in further education. The present amount of formal education in paediatric audiology was ascertainedfrom all five Finnish medical faculties and the five nursing schoolsin the provinces of Oulu and Lapland. The university departmentsof otolaryngology carry the major responsibilityfor teaching in paediatric audiology, which includes one to two hours of lectures and none to four hours of tutorials, depending on the faculty concerned. The amount of audiometric training at nursing schoolsvariesfrom none to five hours and that of lecturesin otolaryngology from three to twenty hours. Better co-ordination between departments of otolaryngology, general practice and paediatricsis neededwhen arranging teaching in paediatric audiology for medical students.Trainee child welfare nurses seemto need more guided practice in audiometry, and there is an obvious need for increasingthe amount of practice in audiologicaldepartments.Specialistclinics should plan and implement a programme for updating training in paecliatric audiology, including evaluation of the programme. Keywords:
hearing; screening;paediatric audiology; education
Introduction Under the Public Health Act of 1972, each local authority in Finland is responsible for providing primary health care for its inhabitants. This is implemented in practice by a network of over 200 health centres covering the whole country, which has a population of roughly five million living in an area of 337 010 square kilometres. Each centre has at least one child welfare clinic where nurses and general practitioners perform routine examinations, including hearing screening, free of charge. Although the system of welfare clinics dates back to the 1920s and became statutory during the 194Os, a national programme for examining the hearing of all children was not established until the 1970s. According to the latest instructions given by the National Board of Health,’ each child should have his/her hearing screened once before leaving the maternity unit and three times in a clinic before school age. Similar screening systems have been established in the other Nordic countries. Despite such screening programmes, there is evidence from many countries that the age at which even severe hearing impairments are diagnosed remains far too high*-’ relative to the internationally accepted goal of identification and start of rehabilitation of such impairments by the age of Six months.’ Diversity of target populations makes :omparisons between studies almost impossible. For :xample, origin and age range of the target populations VW, as do the types and degrees of severity of hearing impairments. In a Finnish study including children born zomespondence: Dr E Maki-Torkko, Department of Otolaryngology, Facultyof Medicine,FIN-90220, Oulu, Finland. 4ccepted26 October1996
19751990 with average air conduction thresholds of 0.5,l and 2kHz (PT&.s2 pure tone average) ~50dB in the better hearing ear, the median age of identification was 2.1 y, and with milder impairments (PT&.5_2 L 35 dB) 2.9y.’ Using the latter criteria Parving4 reported median identification ages of 3.2~ and 1.4~ for Danish children born between 1970-75 and 1980-85, respectively. In our clinical material of children born 1975-79 and 1985-89 and with PTA,-,%=2 5OdB the median identification ages were 2.3 and 2.Oy, respectively (M&i-Torkko et al, unpublished information). The existence of a programme as such does not guarantee a good result, and neither near-optimal attendance by the target population nor updated equipment and methods alone can lead to a favourable outcome. The persons performing the screenings are in a key position as far as the success of a screening programme is concerned. They have to be well trained and highly motivated. The aim of our survey was to use an interview technique to assess opinions on formal education in paediatric audiology and need for f&ther education and training among the staff of child welfare clinics. The present situation regarding the amount and forms of formal education in paediatric audiology provided for both nurses and doctors in medical faculties and at nursing schools was also surveyed.
Methods Child health nurses and general practitioners were interviewed at child welfare clinics in the provinces of Oulu and Lapland in Finland. Since the aim was to compile a comprehensive body of information on the screenings, the localities were chosen to include both small and large
94
Paediatric
audiology-education needed E MakLTorkko et al
clinics run by single and joint health authorities, and in both rural and urban areas in all five hospital districts in the two provinces. The interviews were eventually carried out at 28 child welfare clinics representing 14 health centres. Each child welfare clinic was contacted in order to arrange an interview with one nurse and one doctor, and they all agreed to take part in the study. One of the doctors was in charge of two child welfare clinics, which is the reason why the number of doctors is smaller than that of nurses (27 vs 28). The interviews were performed between May 3rd and September 29th, 1994 by the first author. A semi-structured questionnaire was used. The items covered education, working history and opinions on updating training. Multiple choice forms were used in questions with clear selection of possible answers (opinion on sufficiency of the supply of updating training), while open questions were used when answers could be expected to be greatly varying and unpredictable (ways of teaching paediatric audiology during formal studies, types of updating courses attended during the last three years and expectations with regard to specialist clinics). The questions were formulated and presented in the same manner to both the doctors and the nurses as appropriate. A telephone inquiry on updating courses dealing with paediatric audiology arranged during the past five years in all five hospital districts in the two provinces was carried out during September and October, 1994. Each of the five medical faculties in Finland and each of the five nursing schools in the provinces of Oulu and Lapland was contacted either by mail or by telephone between February 19th and March 2Oth, 1996, in order to form a general idea of the amount of teaching in otolaryngology and audiology, especially paediatric audiology, received during formal medical and nursing studies. The heads of departments of otolaryngology, general practice and paediatrics and the principals of nursing schools were the primary persons contacted.
Interviews with staff The interviewees represented health centres responsible for screening the hearing of 18 500 children by the age of seven
Table
years. Time since graduation varied from 2-36~ (medial 17.0~) for the nurses and from one to 25 y (median 14.0~ for the doctors. The time for which each interviewee hat been working in child health at that particular health centn varied from O-34 y (mean 11.4, median 7.0 y) for the nurse: and from &20 y (mean 6.3 y, median 6.0 y) for the doctors Only full years were taken into account. All of the nurser were specialised in child health. In contrast to many othe, European countries, general practice is one of the rnab medical specialities in Finland, and doctors working iI primary health care are obtaining specialist qualifications ti increasing numbers. Eight of the present doctors were specialists, six in general practice and two in paediatrics and five were undergoing training in general practice. Over half of the nurses recalled that they had beer taught hearing screening during their period of practica training at nursing school, but two stated that there hat been no teaching in paediatric audiology. Six doctor! indicated that’ they had had no training in paediatric audiology at medical school, while nearly half of tht doctors referred to courses in either otolaryngology paediatrics or both (Table 1). None of the general practitioners and only three of tht nurses had taken part in any updating courses dealing witl paediatric audiology during the last three years. Two of tht courses had been arranged by the local central hospita district and one by a summer school. There was no pre-se upper limit to the number of courses per year that could bc attended by nurses as far as their employers wen concerned, but three of the doctors stated that the maximun number of courses per year was six. The most common explanation for non-participation was that there had beer no such courses available. Our inquiry proved that this hat indeed been the case in three of the five hospital districts. As indicated in Table 1 both groups were quite unanimous that the opportunities for further training ir paediatric audiology were limited and this result was no1 affected by the time since graduation. No major difficulties had been experienced in getting leave to attend courses Slight difficulties were reported by two nurses, while mosl emphasised that it was no problem to attend courses arranged by the local hospital district. The doctors’ comments were very similar, only one of them stating thal
1 Reported sourcesof formal education and opinions on the sufficiency of supply of updating training
Formal education on paediatric audiology No teaching Practicaltraining Coursesof otolaryngology and/or paediatrics Theory/lectures Theory and practice Cannot recall Othe?
Supply of updating training Sufficient Not entirely sufficient Insufficient Cannot answer ‘Audiometers
not available
in their nursing
schools.
Nurses
Doctors
(n = 28)
(n = 27)
2
15 3 2 2 4
6 1
13 I -
6 2
3 2
19 1
18 4
Paediatric audiolo -education E MaklTorkko et a$
there had been problems in attending courses during the past two years. Two of the doctors mentioned that the work load left behind and piling up while attending a course WCIS apt to reduce their interest. The interviewees’ interest in further training emerged from their answers to the question concerning their expectations with respect to the central hospitals, since 23 out of the 28 nurses and 17 out of the 27 doctors expected more training to be arranged by specialist clinics. Sixteen nurses and nine doctors spontaneously expressed ideas on this topic. The most popular choice, mentioned by seven nurses and three doctors, was information on recent scientific reports and new methods for hearing examinations, treatment and rehabilitation. One of the nurses po&.exl out that after an updating course one usually pays more attention to working habits, especially in tasks related to the topic of the course.
Present formal
education
Nurses: The present formal education for health nurses at a nursing school takes three and a half years. The amount of theoretical and practical training in otolaryngology is shown in Table 2. The amount of lectures varies from three to twenty hours. Practical training dealing with audiometric measurements is included in the curriculum of three out of the five nursing schools in Northern Finland, the length varying from two to five hours. A short two to four-hour visit to the department of audiology is arranged at three nursing schools. During the period of practical training students work in welfare clinics under supervision of local qualified nurses. The time spent on the screening of
Table
needed
95
children’s hearing varies between students and cannot be estimated in this type of survey. The length of the medical qualification in Finland is six years. The total number of lectures in audiology during the course in otolaryngology varies from three to ten hours, including only one to two hours of teaching in paediatric audiology (Table 3). Likewise, the total amount of tutorial training in audiology varies greatly between the five faculties, the minimum being two hours and the maximum twenty hours. The teaching of phoniatries in one of the faculties also included a one-hour lecture on paediatric audiology, and thirty minutes of the two-hour tutorial training session was reserved for going through the methods for paediatric hearing examinations. The exact amount of teaching with regard to hearing examinations and screenings during the courses in paediatrics and general practice proved to be difficult to define in this type of survey. The period of practical training at a health centre included in the course in general practice in each faculty can include varying amounts of practice in dealing with children’s hearing. Other forms of teaching include a group lecture on how to fill in a child’s health card and other routines involved in child welfare clinic work, and a group session on general health advice, including hearing screening. The heads of the paediatric departments of three faculties stated that teaching in child health work was the responsibility of the department of general practice, and in only one faculty was the major responsibility for teaching in the hands of department of paediatrics. In one faculty a handout dealing with paediatric hearing examinations was given to students in connection
Doctors:
2 Theoretical and practical studies in otolaryngology for trainee child health nursesat the five nursing schoolsin Northern Finland Practicaltraininga
Nursing school
Lectures (h)
audiometry at school (h)
Visit to a department of audiology Q 2-3 2-3 0
Training
in
Kajaani
3
Oulainen
34
oulu
6
5 2 2
4
0
0
20
0
2-4
Rovaniemi Kemi
-
‘In addition, practical training in child welfare clinics under the supervision of qualified health nurses belongs to the curricuhun at each school, but the amount of practice in audiology varies between students and could not be estimated in this survey.
Table 3 Lectures and tutorial tr&ing in audiology included in the course in otolaryngology length of the medical qualification is six years
at Finnish medical faculties. The total
Lectures (Ii) Medical faculty Kuopio oulu Helsinki -hkU Tampere “hottat
Total @I 3 10 7 6 8
of teaching could not be defined.
Tutorial training
Amount of paediatric audiology of the total (b) a 2 2 1 2
(h)
Total (h)
Amount of paecliatric audiology of the total (b)
2 4 2 20 6
0.25 a 0 4 2
96
Paediatric
audiology-education needed E Maki-Torkko et al
with lectures on child neurology and child welfare clinic work. Discussion The work of nurses and doctors at child welfare clinics includes taking care of the vaccination programme, monitoring motor and psychosocial development and growth, screening for both vision and hearing impairments etc. According to this survey there seem to be gaps in the training of both doctors and nurses where paediatric audiology is concerned. This could have an adverse effect not only on the performing of such screenings but also on the interpretation of the results and decisions as to whether turther referral is needed. Although a specific analysis of the amount of teaching in otolaryngology, and especially paediatric audiology, would need a follow-up of a defined group of medical and child health nursing students, the present survey supports the interviewees’ opinions that their formal education is deficient in many ways. The current economic recession does not seem to have had any major adverse effect on the possibilities for attending updating courses, but it may be necessary to set a minimum attendance requirement in the future. This survey suggests that there is marked demand for further training in paediatric audiology among child health personnel, and it is to be hoped that this will lead to actions on the part of the hospital clinics responsible for providing educational services for their districts. The planning and implementing of an updating programme is a challenging task. The authorities or hospital clinics should respond to, and even actively inquire about, the opinions and preferences of the personnel, as suggested by Kelly and Murray9 based on the results of their survey on general practitioners’ views on continuing medical education (CME). The interviewees’ spontaneous comments recorded in our survey will help the planning of an updating programme. Moreover, the somewhat contradictory results obtained in the trials dealing with the outcome of the CME programmes’“‘2 bring out the need to assess their effects not only on doctors’ knowledge but also on their ability to improve patient care. McCormick et UP report successin reducing the number of late diagnoses, and suggest that this is partly due to the intensive initial and follow-up training of the community health staff. Based on the present survey, the major proportion of teaching in the performing of the hearing screenings, both adult and paediatric, still remains the responsibility of senior child health nurses in clinics during the period of practical training. We suggest that some part of the training period should be arranged in a department of audiology. This would enable practice under the guidance of qualified
audiological assistants. As far as medical students are concerned, the forms of teaching in paediatric audiology should be better co-ordinated between departments of otolaryngology, general practice and paediatrics. A programme of updating training should be planned and implemented by specialist clinics at university hospitals for both child health clinic doctors and nurses. A plan for auditing such a programme should be introduced as well.
Acknowledgements Support was received from the Alma and KA Snellman Foundation, Oulu, Finland, Oulu University Hospital and the Academy of Finland.
References
4 5 6 7 8 9 10 11 12 13
National Board of Health. Lastenneuvolaopas (in Finnish). Valtion painatuskeskos, Helsinki, 1990. Shah CP, Chandler D, Dale R. Delay in referral of children with impaired hearing. The Volta Review 1978; 80: 206-215. Mauk GW, White KR, Mortensen LB, Behrens TR. The effectiveness of screening programs based on high-risk characteristics in early identification of hearing impairment. Ear Hear 1991; 12: 312-319. Parving A. Detection of the infant with congenital/early acquired hearing disability. Acta Otolaryngol (Stockh) Suppi 1991; 482: 111-116. Kvaemer KJ and Amesen AR. Hearing impairment in Osla born children 1989-91. Incidence, etiology and diagnostic delay. Stand Audio1 1994; 23: 233-239. Robertson C et al. Late diagnosis of congenital sensorineural hearing impairment: why are detection methods failing? Arch Dis Child 1995; 72: 1 l-l 5. Marttila TI and Karikoski JO. Identification of childhooc hearing impairment in Uusimaa County, Finland. Int ti Paediatr Otorhinolaryngol 1996; 34: 45-5 1. American Speech-Language-Hearing Association. Joint Corn, mittee on Infant Hearing 1994 Position Statement. Asha 1994 36: 38-41. Kelly MH and Murray TS. General practitioners’ views or continuing medical education. Br J Gen Pratt 1994; 44: 469 471. Pinkerton RE, Tinanoff N, Willms JL, Tapp JT. Residen physician performance in a continuing education formal JAMA 1980; 244(19): 218%2185. Sibley JC et al. A randomised trial of continuing medica education. New Engl J Med 1982; 306(g): 511-515. Haynes RB, Davis DA, McKibbon A, Tugwell P. A critica appraisal of the efficacy of continuing medical education JAMA 1984. 251(1):61+l. McCormick B, Wood SA, Cope Y, Spavins FM. Analysis o records from an open-access audiology service. Br J Audio1 1984; 18 127-132.
More education in paediatric audiology needed for child welfare clinic nurses and doctors E Maki-Torkko’, M Sorri’ and M-R Jarvelin’ ‘Department of OtolaQJngologY, Universiq of &lu, and General Practice, University of Oh, Finland
Finland; and =Department
of Public HealthScience
@$ons on formal and further education in paediatric audiology were surveyedby interviewing nursesand doctors in 28 Fash child welfare clinics. Over half of the nursesrecalledthat they had been taught hearing screeningduring their period of practical training. Regarding formal teaching in paediatric audiology, the majority of doctors referred to Copsesin either otolaryngology, paediatricsor both. None of the doctorsand only three of the nurseshad taken part in any updating coursesdealing with paediatric audiology during the last three years,and it turned out that no suchcourses had been arranged in three of the five hospital dist&s. However, 17 out of the 27 doctors and 23 out of the 28 nurses expressedtheir interest in further education. The present amount of formal education in paediatric audiology was ascertainedfrom all five Finnish medical faculties and the five nursing schoolsin the provinces of Oulu and Lapland. The university departmentsof otolaryngology carry the major responsibilityfor teaching in paediatric audiology, which includes one to two hours of lectures and none to four hours of tutorials, depending on the faculty concerned. The amount of audiometric training at nursing schoolsvariesfrom none to five hours and that of lecturesin otolaryngology from three to twenty hours. Better co-ordination between departments of otolaryngology, general practice and paediatricsis neededwhen arranging teaching in paediatric audiology for medical students.Trainee child welfare nurses seemto need more guided practice in audiometry, and there is an obvious need for increasingthe amount of practice in audiologicaldepartments.Specialistclinics should plan and implement a programme for updating training in paecliatric audiology, including evaluation of the programme. Keywords:
hearing; screening;paediatric audiology; education
Introduction Under the Public Health Act of 1972, each local authority in Finland is responsible for providing primary health care for its inhabitants. This is implemented in practice by a network of over 200 health centres covering the whole country, which has a population of roughly five million living in an area of 337 010 square kilometres. Each centre has at least one child welfare clinic where nurses and general practitioners perform routine examinations, including hearing screening, free of charge. Although the system of welfare clinics dates back to the 1920s and became statutory during the 194Os, a national programme for examining the hearing of all children was not established until the 1970s. According to the latest instructions given by the National Board of Health,’ each child should have his/her hearing screened once before leaving the maternity unit and three times in a clinic before school age. Similar screening systems have been established in the other Nordic countries. Despite such screening programmes, there is evidence from many countries that the age at which even severe hearing impairments are diagnosed remains far too high*-’ relative to the internationally accepted goal of identification and start of rehabilitation of such impairments by the age of Six months.’ Diversity of target populations makes :omparisons between studies almost impossible. For :xample, origin and age range of the target populations VW, as do the types and degrees of severity of hearing impairments. In a Finnish study including children born zomespondence: Dr E Maki-Torkko, Department of Otolaryngology, Facultyof Medicine,FIN-90220, Oulu, Finland. 4ccepted26 October1996
19751990 with average air conduction thresholds of 0.5,l and 2kHz (PT&.s2 pure tone average) ~50dB in the better hearing ear, the median age of identification was 2.1 y, and with milder impairments (PT&.5_2 L 35 dB) 2.9y.’ Using the latter criteria Parving4 reported median identification ages of 3.2~ and 1.4~ for Danish children born between 1970-75 and 1980-85, respectively. In our clinical material of children born 1975-79 and 1985-89 and with PTA,-,%=2 5OdB the median identification ages were 2.3 and 2.Oy, respectively (M&i-Torkko et al, unpublished information). The existence of a programme as such does not guarantee a good result, and neither near-optimal attendance by the target population nor updated equipment and methods alone can lead to a favourable outcome. The persons performing the screenings are in a key position as far as the success of a screening programme is concerned. They have to be well trained and highly motivated. The aim of our survey was to use an interview technique to assess opinions on formal education in paediatric audiology and need for f&ther education and training among the staff of child welfare clinics. The present situation regarding the amount and forms of formal education in paediatric audiology provided for both nurses and doctors in medical faculties and at nursing schools was also surveyed.
Methods Child health nurses and general practitioners were interviewed at child welfare clinics in the provinces of Oulu and Lapland in Finland. Since the aim was to compile a comprehensive body of information on the screenings, the localities were chosen to include both small and large
94
Paediatric
audiology-education needed E MakLTorkko et al
clinics run by single and joint health authorities, and in both rural and urban areas in all five hospital districts in the two provinces. The interviews were eventually carried out at 28 child welfare clinics representing 14 health centres. Each child welfare clinic was contacted in order to arrange an interview with one nurse and one doctor, and they all agreed to take part in the study. One of the doctors was in charge of two child welfare clinics, which is the reason why the number of doctors is smaller than that of nurses (27 vs 28). The interviews were performed between May 3rd and September 29th, 1994 by the first author. A semi-structured questionnaire was used. The items covered education, working history and opinions on updating training. Multiple choice forms were used in questions with clear selection of possible answers (opinion on sufficiency of the supply of updating training), while open questions were used when answers could be expected to be greatly varying and unpredictable (ways of teaching paediatric audiology during formal studies, types of updating courses attended during the last three years and expectations with regard to specialist clinics). The questions were formulated and presented in the same manner to both the doctors and the nurses as appropriate. A telephone inquiry on updating courses dealing with paediatric audiology arranged during the past five years in all five hospital districts in the two provinces was carried out during September and October, 1994. Each of the five medical faculties in Finland and each of the five nursing schools in the provinces of Oulu and Lapland was contacted either by mail or by telephone between February 19th and March 2Oth, 1996, in order to form a general idea of the amount of teaching in otolaryngology and audiology, especially paediatric audiology, received during formal medical and nursing studies. The heads of departments of otolaryngology, general practice and paediatrics and the principals of nursing schools were the primary persons contacted.
Interviews with staff The interviewees represented health centres responsible for screening the hearing of 18 500 children by the age of seven
Table
years. Time since graduation varied from 2-36~ (medial 17.0~) for the nurses and from one to 25 y (median 14.0~ for the doctors. The time for which each interviewee hat been working in child health at that particular health centn varied from O-34 y (mean 11.4, median 7.0 y) for the nurse: and from &20 y (mean 6.3 y, median 6.0 y) for the doctors Only full years were taken into account. All of the nurser were specialised in child health. In contrast to many othe, European countries, general practice is one of the rnab medical specialities in Finland, and doctors working iI primary health care are obtaining specialist qualifications ti increasing numbers. Eight of the present doctors were specialists, six in general practice and two in paediatrics and five were undergoing training in general practice. Over half of the nurses recalled that they had beer taught hearing screening during their period of practica training at nursing school, but two stated that there hat been no teaching in paediatric audiology. Six doctor! indicated that’ they had had no training in paediatric audiology at medical school, while nearly half of tht doctors referred to courses in either otolaryngology paediatrics or both (Table 1). None of the general practitioners and only three of tht nurses had taken part in any updating courses dealing witl paediatric audiology during the last three years. Two of tht courses had been arranged by the local central hospita district and one by a summer school. There was no pre-se upper limit to the number of courses per year that could bc attended by nurses as far as their employers wen concerned, but three of the doctors stated that the maximun number of courses per year was six. The most common explanation for non-participation was that there had beer no such courses available. Our inquiry proved that this hat indeed been the case in three of the five hospital districts. As indicated in Table 1 both groups were quite unanimous that the opportunities for further training ir paediatric audiology were limited and this result was no1 affected by the time since graduation. No major difficulties had been experienced in getting leave to attend courses Slight difficulties were reported by two nurses, while mosl emphasised that it was no problem to attend courses arranged by the local hospital district. The doctors’ comments were very similar, only one of them stating thal
1 Reported sourcesof formal education and opinions on the sufficiency of supply of updating training
Formal education on paediatric audiology No teaching Practicaltraining Coursesof otolaryngology and/or paediatrics Theory/lectures Theory and practice Cannot recall Othe?
Supply of updating training Sufficient Not entirely sufficient Insufficient Cannot answer ‘Audiometers
not available
in their nursing
schools.
Nurses
Doctors
(n = 28)
(n = 27)
2
15 3 2 2 4
6 1
13 I -
6 2
3 2
19 1
18 4
Paediatric audiolo -education E MaklTorkko et a$
there had been problems in attending courses during the past two years. Two of the doctors mentioned that the work load left behind and piling up while attending a course WCIS apt to reduce their interest. The interviewees’ interest in further training emerged from their answers to the question concerning their expectations with respect to the central hospitals, since 23 out of the 28 nurses and 17 out of the 27 doctors expected more training to be arranged by specialist clinics. Sixteen nurses and nine doctors spontaneously expressed ideas on this topic. The most popular choice, mentioned by seven nurses and three doctors, was information on recent scientific reports and new methods for hearing examinations, treatment and rehabilitation. One of the nurses po&.exl out that after an updating course one usually pays more attention to working habits, especially in tasks related to the topic of the course.
Present formal
education
Nurses: The present formal education for health nurses at a nursing school takes three and a half years. The amount of theoretical and practical training in otolaryngology is shown in Table 2. The amount of lectures varies from three to twenty hours. Practical training dealing with audiometric measurements is included in the curriculum of three out of the five nursing schools in Northern Finland, the length varying from two to five hours. A short two to four-hour visit to the department of audiology is arranged at three nursing schools. During the period of practical training students work in welfare clinics under supervision of local qualified nurses. The time spent on the screening of
Table
needed
95
children’s hearing varies between students and cannot be estimated in this type of survey. The length of the medical qualification in Finland is six years. The total number of lectures in audiology during the course in otolaryngology varies from three to ten hours, including only one to two hours of teaching in paediatric audiology (Table 3). Likewise, the total amount of tutorial training in audiology varies greatly between the five faculties, the minimum being two hours and the maximum twenty hours. The teaching of phoniatries in one of the faculties also included a one-hour lecture on paediatric audiology, and thirty minutes of the two-hour tutorial training session was reserved for going through the methods for paediatric hearing examinations. The exact amount of teaching with regard to hearing examinations and screenings during the courses in paediatrics and general practice proved to be difficult to define in this type of survey. The period of practical training at a health centre included in the course in general practice in each faculty can include varying amounts of practice in dealing with children’s hearing. Other forms of teaching include a group lecture on how to fill in a child’s health card and other routines involved in child welfare clinic work, and a group session on general health advice, including hearing screening. The heads of the paediatric departments of three faculties stated that teaching in child health work was the responsibility of the department of general practice, and in only one faculty was the major responsibility for teaching in the hands of department of paediatrics. In one faculty a handout dealing with paediatric hearing examinations was given to students in connection
Doctors:
2 Theoretical and practical studies in otolaryngology for trainee child health nursesat the five nursing schoolsin Northern Finland Practicaltraininga
Nursing school
Lectures (h)
audiometry at school (h)
Visit to a department of audiology Q 2-3 2-3 0
Training
in
Kajaani
3
Oulainen
34
oulu
6
5 2 2
4
0
0
20
0
2-4
Rovaniemi Kemi
-
‘In addition, practical training in child welfare clinics under the supervision of qualified health nurses belongs to the curricuhun at each school, but the amount of practice in audiology varies between students and could not be estimated in this survey.
Table 3 Lectures and tutorial tr&ing in audiology included in the course in otolaryngology length of the medical qualification is six years
at Finnish medical faculties. The total
Lectures (Ii) Medical faculty Kuopio oulu Helsinki -hkU Tampere “hottat
Total @I 3 10 7 6 8
of teaching could not be defined.
Tutorial training
Amount of paediatric audiology of the total (b) a 2 2 1 2
(h)
Total (h)
Amount of paecliatric audiology of the total (b)
2 4 2 20 6
0.25 a 0 4 2
96
Paediatric
audiology-education needed E Maki-Torkko et al
with lectures on child neurology and child welfare clinic work. Discussion The work of nurses and doctors at child welfare clinics includes taking care of the vaccination programme, monitoring motor and psychosocial development and growth, screening for both vision and hearing impairments etc. According to this survey there seem to be gaps in the training of both doctors and nurses where paediatric audiology is concerned. This could have an adverse effect not only on the performing of such screenings but also on the interpretation of the results and decisions as to whether turther referral is needed. Although a specific analysis of the amount of teaching in otolaryngology, and especially paediatric audiology, would need a follow-up of a defined group of medical and child health nursing students, the present survey supports the interviewees’ opinions that their formal education is deficient in many ways. The current economic recession does not seem to have had any major adverse effect on the possibilities for attending updating courses, but it may be necessary to set a minimum attendance requirement in the future. This survey suggests that there is marked demand for further training in paediatric audiology among child health personnel, and it is to be hoped that this will lead to actions on the part of the hospital clinics responsible for providing educational services for their districts. The planning and implementing of an updating programme is a challenging task. The authorities or hospital clinics should respond to, and even actively inquire about, the opinions and preferences of the personnel, as suggested by Kelly and Murray9 based on the results of their survey on general practitioners’ views on continuing medical education (CME). The interviewees’ spontaneous comments recorded in our survey will help the planning of an updating programme. Moreover, the somewhat contradictory results obtained in the trials dealing with the outcome of the CME programmes’“‘2 bring out the need to assess their effects not only on doctors’ knowledge but also on their ability to improve patient care. McCormick et UP report successin reducing the number of late diagnoses, and suggest that this is partly due to the intensive initial and follow-up training of the community health staff. Based on the present survey, the major proportion of teaching in the performing of the hearing screenings, both adult and paediatric, still remains the responsibility of senior child health nurses in clinics during the period of practical training. We suggest that some part of the training period should be arranged in a department of audiology. This would enable practice under the guidance of qualified
audiological assistants. As far as medical students are concerned, the forms of teaching in paediatric audiology should be better co-ordinated between departments of otolaryngology, general practice and paediatrics. A programme of updating training should be planned and implemented by specialist clinics at university hospitals for both child health clinic doctors and nurses. A plan for auditing such a programme should be introduced as well.
Acknowledgements Support was received from the Alma and KA Snellman Foundation, Oulu, Finland, Oulu University Hospital and the Academy of Finland.
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