The Behaviour of Dental Nurses Applying Fluoride Varnish to Young Children
Condition: Dental Caries
MeSH terms: Dental Caries
Study type: Observational

Summary: 
      The behaviour of 12 dental nurses seeing 600 nursery school children in East Scotland will be
      video-taped to determine the interaction patterns adopted by the staff in the application of
      a fluoride varnish to the surfaces of the child's teeth. The aim is to test the benefit of
      certain communication strategies used by the nurses to affect an efficient application
      controlling for nursery school site, age of child and experience of dental nurse.
    

Detailed description: 
      A preliminary study has shown the following:

        1. Ethical permission for this work is attainable from a Research Ethics Committee.

        2. Parents are willing to give consent to their children participating in the study.

        3. Dental nurses are willing to give consent for their behaviours to be video recorded
           within their work settings.

        4. Video recordings are feasible with nursery school children, EDDNs and parents present at
           a nursery school setting.

        5. The technical difficulties of collecting audio-visual materials from nursery school
           settings (e.g., camera placement, storage of video data in the field setting) and
           anonymising the video data using a specialist masking software can be overcome.

        6. Importing video files into the Observer XT coding software is successful.

        7. Development of a coding system for nurse-child interaction involving a clinical
           procedure has been achieved (see Appendix 1 for a brief version of the coding scheme).

      We have collected video recordings of more than 50 varnish application sessions in the pilot
      study of separate children and 6 nurses in three nursery schools. The pilot study has
      therefore successfully demonstrated the feasibility of collecting high quality data suitable
      for intensive analysis to improve our understanding of some of the processes involved in the
      fluoride varnish application in nursery school settings. One of the most interesting findings
      from the pilot study was that the permission-seeking statements used by EDDNs were negatively
      correlated with the treatment outcome.

      Summary of next phase of study:

        -  To confirm the suitability of the preliminary coding scheme and to potentially refine
           and improve the coding scheme using a larger set of observational data collected in
           nursery school settings across three NHS Health Board regions.

        -  Further investigation to assess the generalisability of pilot study findings by
           collecting a larger set of observations of children systematically across a wider set of
           nurse pairings (with various levels of experience) and children (of different age
           groups: 3yrs vs 4 yrs) and with or without previous receipt of fluoride varnish
           application in the Childsmile programme.

        -  To identify the key features of the nurse-child interaction that can be used to predict
           a full completion of the fluoride application and to test the hypothesis that frequent
           targeted reinforcement is effective.

        -  To explore effects of some additional factors in relation to the relevant participants
           (e.g., EDDN's level of experience, child's previous dental experience) and some
           situational factors (e.g., general purpose room or specialist accommodation) on the
           treatment outcome.

        -  To develop additional training sessions for EDDNs using the findings of the study to
           improve the Childsmile programme and to increase acceptability of the varnish
           application.

      Methods

      Ethics proposal preparation

      We obtained ethics approval for the pilot study. We have successfully addressed and dealt
      with the ethical issues that arose from the study in the pilot stage. We have experienced no
      degree of difficulty in consenting staff or children for recruitment of the pilot. We believe
      that obtaining further ethical approval for an extended study should be achievable due to our
      previous experience. The difference between the pilot and this main study is an extension in
      the numbers of child observations. This will require a multisite ethics proposal to be
      entered into IRAS. In terms of ethical approval from NHS Research and Development (R & D)
      offices, we are working with the NHS Research Scotland (NRS), who will assist in obtaining
      the approvals from different NHS R & D offices.

      We have been welcomed into the setting by the nursing staff and have had no adverse effects
      in our work in the schools collecting the 50+ child observations. In the main study, we will
      collect approximately 500 child observations across several NHS Health Board regions. We will
      continue a positive working relation with EDDNs and nursery school staff developed in the
      pilot stage. We will be very careful in the consenting and recruitment of nurse and child
      participants without causing pressure for participation. Anonymity of personal details and
      confidentiality of the information provided by participants will be dealt with carefully by
      assigning a unique code to each of the participants and only the research team members will
      have access to the codes. We do not foresee any additional new factors that will jeopardise
      approval of an application to REC.

      Sample

      All EDDNs who have been trained in the Childsmile programme and participated in the delivery
      of the varnish application at nursery school settings in the three NHS Health Board regions
      (Tayside, Fife and Forth Valley) are identified as potential staff participants. All newly
      trained EDDNs who will be delivering the varnish application to nursery school children at
      the three regions are also included. All nursery school children in the three regions
      mentioned above whose parents have consented to the Childsmile varnish application programme
      are identified as potential child participants. The parents of those children are potential
      parent participants.

      Setting up the recording and coding system

      The Observer system consists of a powerful suite of programmes that integrates the input of
      digital video files and sound to a platform on the computer screen for repeated playback and
      real-time coding, diagrammatic display, simple categorical analysis and more complex
      sequential analysis. Various options are available for collection of the recordings and these
      may vary according to setting. Variables to determine the optimum system include:
      obtrusiveness of the camera and microphone, quality of video image required, and ease of use
      in the 'field'. The pilot study has shown that the materials collected from the 'field' can
      be transferred onto a university computer hard disc to be ready for coding purpose. The
      picture quality and positioning of the camera can be varied to optimise the study of the
      nurse-child interaction during the varnish application.

      Pilot observations

      In order to check the feasibility of the new recording system to be used in the main study (a
      digital DVD camera instead of a web camera in the pilot stage), we will need to make a small
      number of pilot observations of the nurse-child interactions. This process is important to
      ensure that the recorded video data can be successfully digitalized and subsequently
      transferred into the Observer XT8.0 for coding and analysis. Although we have had some
      experience of dealing with this process in the pilot stage, taking additional pilot
      observations is still an important step as we are using a new recording system and an updated
      version of the Observer XT software in the main study. These pilot observations will be also
      used to double check that the coding scheme developed from the pilot data is functioning
      properly for a new set of data.

      Preparation of coding scheme

      The preparation of a coding scheme is a vital component of the study and will require
      considerable effort and thought to develop a suitable system that is not too cumbersome but
      also detailed enough to illustrate the various strategies that are adopted by the 'actors' to
      progress the intervention. Of particular interest are the cases where there is unexpected
      behaviour or events that require inclusion in the profiling of the interaction. For example
      the child may refuse certain aspects of the varnish procedure and require coaxing through
      reassurance or distraction. Interruptions of the procedure by outside events, e.g. parental
      or nursery nurse involvement, fire alarms can all be present in the scheme and included or
      ignored in subsequent analysis. The Observer XT system enables the accurate collection of
      codes from video. The advantage of the updated version of the Observer XT system is the
      modification of the coding scheme during the coding procedure itself. Previous versions of
      the software did not allow this 'luxury'. Other available ('freeware') coding systems do not
      have this capability. Therefore, the coding scheme developed from the pilot data can be
      tested for fit using new datasets collected in the main study and the coding scheme can also
      be potentially improved if certain behaviours need to be included and/or modified.

      Collection of observational data

      Observations of nurse-child interaction will be recorded in the field using a digital DVD
      camera. The video observation data, initially stored on a DVD, will be transferred in digital
      format and then stored on a computer internal hard drive for coding and analysis. The
      Observer XT system is more stable if digital video data is read directly from a computer than
      from an external hard disc (e.g., DVD), the process of digitalizing video files and storing
      in a computer is, therefore, an important step for successful behaviour coding and data
      analysis. Each of the initial raw video files stored on DVDs will be assigned a unique code
      for data protection purpose and will be locked in a secure place. All digitalized video files
      stored on a computer internal hard disc will be permanently removed from the computer once
      coding and analysis is complete. These digitalized video files will then be exported onto an
      external hard drive that will have all data encrypted and access to data files password
      protected. An audit record will be compiled to allow inspection of the progress of video data
      files from video DVD to computer hard disc for coding and then exporting to external media
      for safe long-term storage. Audit will be monitored by the School Ethics Committee on a
      6-month basis.

      Coding of video data The research assistants will be responsible for the coding of the video
      data. This task is labour- intensive and highly skilled. There will be approximately 500
      video clips to be processed, which will require a period of about 9-10 months to complete. So
      far, no specific coding schemes have been developed for this type of nurse-child interactive
      behaviours. The new coding scheme (Appendix 1) that we have devised from the pilot study
      consists of about 40 codes and we have just recently conducted a reliability analysis of the
      scheme. There was 86% agreement using a tolerance window of 2 seconds for coded events. The
      kappa statistic was 0.84 (p<.001).

      Reliability testing

      The Observer XT has appropriate reliability (kappa) statistical routines built into the
      software to provide estimates of agreement controlled for random chance. See 'Coding of video
      data' above for reliability estimate for the coding scheme.

      Analysis of data

      Video data

      The main software used for coding and analysing video data is the Observer XT 8.0. The
      rationale of the coding and analysis with The Observer system will be two-folded, a
      descriptive element. After all verbal and non-verbal behaviours of both nurse and child have
      been coded according to the coding scheme, the coded behaviours along with the time point
      when the behaviour took place (if the behaviour is coded as an event) or the duration of the
      time (if coded as a state behaviour) will be stored as a log file for one particular
      nurse-child interaction. Frequencies of certain behaviours can then be calculated, for
      example, nurse's use of praise or fantasy statements; and whether the use of these statements
      is linked with positive application outcome.

      Second, there will be an explanatory element. Sequential analysis will be employed to explore
      which behaviours tend to facilitate or impede the occurrence of other behaviours. The purpose
      of this type of analysis is to understand more complex behavioural relationships in terms of
      how nurses use motivational strategies to encourage cooperative behaviours of children in
      receiving the varnish application.
    

Intervention name(s): Fluoride varnish
Intervention type(s): Other
Intervention description(s): the topical application of fluoride varnish to all surfaces of exposed teeth
Other intervention name(s): Duraphat
Intervention MeSH terms: Fluorides; Fluorides, Topical
Observational model: Cohort
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        Nursery school children from designated nursery schools (from under resourced communities)
        in East Scotland.

        Health Boards involved include: Fife, Forth Valley and Tayside