Scoping communication training in undergraduate children ’ s nursing programmes: A mixed method study examining delivery methods and content

A B S T R A C T Aim: The aim of this study was to scope communication curriculum reported as currently being delivered within undergraduate children ’ s nursing programmes across the Republic of Ireland and the United Kingdom. Background: Communication between a children ’ s nurse and a child/young person influences a child/young person ’ s healthcare experience. Despite an identified need for a comprehensive and effective communication curriculum within undergraduate nursing, there is a notable gap of understanding of the delivery and content of communication training within children ’ s nursing curricula. Design: A mixed method, online anonymous self-report survey design was adopted. Methods: Programme Leads of undergraduate children ’ s nursing programmes in the Republic of Ireland and the United Kingdom were asked to report on how communication training is delivered to students on undergraduate children ’ s nursing programmes. The Checklist for Reporting of Survey Studies (CROSS) was used for the reporting of this study. Results: Thirty-two programme leads completed the survey (51% response rate). Findings show variability in the delivery and content of communication training across Higher Educational Institutions. Core communication modules featured across all nursing programmes, however, only two programme leads reported delivering standalone child-centred communication modules. Communication training was not always delivered by an educator with professional experience of children and young people in healthcare. Curriculum capacity had an impact on the delivery of communication training, with clinical practice being relied on to supplement child specific communication training. Programme leads highlighted the need for greater inclusion of child voice in shaping and delivering undergraduate children ’ s nurse education. Conclusions: This study shows that while communication is covered as a core part of the undergraduate nursing curriculum across the Republic of Ireland and the United Kingdom, it generally lacks a focus on children and young people and is not always supported by educators with professional experience of children and young people in healthcare. More work needs to focus on equipping undergraduate children ’ s nurses with the unique

skills needed to communicate effectively with children and young people and incorporate learnings into nursing pedagogy.

Introduction
Communication forms the foundation in establishing effective, safe, patient-centred care (Kerr, 2022), building meaningful relationships between children's nurses, children and young people (CYP) and their families (Coad et al., 2018).For the purposes of this study, CYP are defined as individuals under the age of 18 (UNCRC, 1989).Good communication, as a core component to nursing practice (Kerr, 2020), is integral to multiple aspects of a CYP's experience of healthcare environments (Shorey et al., 2018).An ability to actively listen, acknowledge and address CYP's concerns as well as tailoring information at an appropriate level (Jepsen et al., 2019) has a positive impact on children's physiological function, with improvements to symptoms (Clarke, 2019) such as blood pressures, reporting of pain (Coad et al., 2018) and adherence with medication (Clarke, 2019).CYP characterise their positive communication experiences with children's nurses using words such as 'cheerful' (Clarke, 2021), 'fun' (Petronio-Coia and Schwartz--Barcott, 2020), 'nice' (Coyne and Kirwan, 2012), 'playful' (Clarke, 2021), 'smiles' (Petronio-Coia and Schwartz-Barcott, 2020), 'gentle' (Coyne and Kirwan, 2012) and 'children friendly' (Clarke, 2022).Aligning with Article 12 of the United Nations Convention on the Rights of the Child (UNCRC, 1989) and recognised within National Institute of Clinical Excellence (NICE) guidance ( 2021), good communication is essential to promote children's voices and control in the clinical environment (Reid-Searl et al., 2021) and facilitate their involvement in choices and decision-making about their care (Bray et al., 2023;Jacobs et al., 2023).This is important in healthcare as CYP are predominately perceived as needing protection rather than asserting their autonomy (Coyne et al., 2018;Koller, 2016).Children's nurses can empower CYP through child-centred communication that is tailored to CYP's preferences and communication styles (Navein et al., 2022;Koller, 2016), promoting an environment where CYP can elicit their perspectives (Bray et al., 2023) and safeguard their voice in the decision-making process (Sheehan and Fealy, 2020).Frequently cited as a recurring complaint within healthcare systems (Wray et al., 2022;O'Hara et al., 2018), poor communication, such as a failure to listen and respond to CYP's questions (Coad et al., 2018), using medical jargon (Coyne and Kirwan, 2012), excluding CYP from their own care (Bray et al., 2021), can cause an irrevocable breakdown in relationships between the children's nurse (s), the CYP and their families (Coad et al., 2018).

Background
Despite there being an identified need for a comprehensive and effective communication curriculum (Bachmann et al., 2013) which is standardised across academic and clinical practice (Li et al., 2023), there continues to be disparity and variability in how communication skills are taught within undergraduate nursing communication curricula (Li et al., 2023;Ferrández-Antón et al., 2020).Children's nursing students spend a substantial amount of time interacting and engaging with CYP and their families and therefore can have considerable influence in determining a child's healthcare experience (Clarke, 2019).However, children's nursing students report varying levels of anxiety and worry when communicating and caring for children and their families (Gibson-Young et al., 2023), referring to difficulties understanding the unique facets and nuances associated with communicating with CYP in comparison with adults (Kürtüncü et al., 2017).While children's nursing students will possess their own natural communication skills, influenced by familial and cultural communication styles (Beaird et al., 2017), it has been increasingly recognised that communication skills for nursing students still need to be formally taught (Li et al., 2023) in addition to being modelled and consolidated through experience in clinical practice (Kerr et al., 2022).Clinical practice is recognised as an essential component of undergraduate nursing programmes (Chen et al., 2023), facilitating the application of theoretical knowledge to real-world clinical environments (Moroney et al., 2022).It enables nursing students to develop knowledge and professional values, refine nursing skills and build (Chen et al., 2023).However, children's nursing students reported that a lack of child-centred communication training leads to feelings of uncertainty, fearfulness and self-doubt during paediatric clinical placements (Chang et al., 2024).Communication is recognised by the nursing regulatory authorities as a skill that children's nursing students must be able to demonstrate effectively through theoretical and practical components and assessment (Nursing and Midwifery Board of Ireland, 2023), displaying appropriate communication techniques and abilities to support CYP, their families as well as members of the multi-disciplinary team throughout their degree (Nursing andMidwifery Council, 2023a, 2023b).
Children's nursing students are required to demonstrate core and additional child-centred communication skills to achieve competence in clinical practice (Gibson-Young et al., 2023).Core communication skills refer to general communication principles (Bachmann et al., 2013) which can be applicable across adults and CYP, in contrast to child specific skills which can incorporate more fun and playful aspects (Clarke, 2021).The development of these core and child-centred communication skills requires a diverse use of innovative teaching and learning strategies (Coad et al., 2018) which are reported as including didactic lectures (Shorey and Ng, 2021;Kerr et al., 2020), role play (Gutiérrez-Puertas et al., 2020;Kerr et al., 2020), blended learning, co-operative learning and case-based learning (Gutiérrez-Puertas et al., 2020).Simulation-based education is a frequently cited teaching and learning strategy in adult-centred communication training of nursing students, incorporating role play as well as using standardised patients (Gutiérrez-Puertas et al., 2020;Kerr et al., 2020).Simulation-based education can replicate and augment real world experiences in a safe and controlled learning environment, guided by trained experts (Shorey and Ng, 2021).Simulation-based education bridges theory and practice in a physically and psychologically safe environment (Carrer-Planells et al., 2021).Here, nursing students can practice and develop skills such as decision-making, critical thinking, communication and leadership (Chabrera et al., 2021).In undergraduate children's nursing communication curricula, simulation-based education increased nursing students' self-confidence and self-efficacy before paediatric clinical placements (Zengin and Fidanci, 2024).However, it is not known how often simulation-based education is used within communication curricula for children's nursing students as research is sparse in this area.
There is also a notable gap in current understandings of the delivery and content of undergraduate communication curriculum specifically for children's nursing.This is understandable as only a few countries, such as Italy, Germany, the Republic of Ireland (ROI) and the United Kingdom (UK) provide undergraduate children's nursing degree programmes (Glasper, 2020).The ROI and the UK, the countries of focus for this study, have a unique perspective providing both undergraduate and post-graduate children's nursing programmes with the ability to register as a children's nurse (Nursing andMidwifery Council, 2023a, 2023b;Nursing and Midwifery Board of Ireland, 2018).
While the nursing regulatory authorities in the UK and the ROI stipulate that Higher Educational Institutions (HEI's) must provide an undergraduate nursing curriculum delivered by appropriately qualified and experienced educators for programme delivery (Nursing and Midwifery Council, 2023a, 2023b; Nursing and Midwifery Board of M. Kennedy et al.Ireland, 2023), they do not provide a standardised framework or curriculum development plan on how communication training should be taught and delivered (Nursing andMidwifery Council, 2023a, 2023b;Nursing and Midwifery Board of Ireland, 2023;Jestico and Finlay, 2017).
With a lack of transparency on the delivery and content of placement within undergraduate curriculum, the aim of this study was to scope and map out information about communication curriculum currently being delivered in undergraduate children's nursing programmes across the ROI and the UK.

Study design
A descriptive mixed-method online anonymous self-report survey consisting of three closed-ended and five open-ended questions (supplementary file 1), collected both open-ended and closed-ended data on how communication training in undergraduate children's nursing programmes is currently delivered.Integration of qualitative and quantitative forms of data has become a central feature of mixed methods research (Creswell and Hirose, 2019), incorporating attributes from both methodologies to deliver a diverse and expanded view of a topic (Creswell and Creswell, 2023).The survey was administered between December 2022 and March 2023.The Checklist for Reporting of Survey Studies (CROSS) (Sharma et al., 2021) was used for the reporting of this study.

Participants and recruitment
A total population sample of 63 HEIs, who offer an undergraduate children's nursing programme in ROI (n=4) and the UK (n=59), were invited to participate in this study.HEIs were identified through their country's respective nursing regulation board's website.Programme leads of undergraduate children's nursing programmes and their contact details, were acquired from their public profiles on their associated HEI's websites.An invitation email to participate, containing a weblink to the survey as well as a weblink to a detailed information sheet, was sent to programme leads at the 63 HEIs in December 2022.Reminder emails were sent out to all programme leads in January and February 2023.

Data collection
Programme leads were invited to complete an anonymous self-report survey through an online survey platform (Qualtrics).The survey was designed for this study by the lead author in consultation with the research team and informed by the literature.Content validity of the survey (Sharma et al., 2021) was checked by two expert children's nursing academics, based in the ROI and the UK.As the focus of the survey was only relevant to a very niche sample, it was not feasible to conduct a pilot test.The survey had a completion time of 15-20 minutes.Three closed-ended questions, requiring yes/no/other answers, gathered information concerning communication curriculum such as enrolled class size and identification and delivery of child-centred communication modules.Five open-ended questions were used to gather programme leads' perceptions of current communication training, seeking their views on teaching and learning practices that work well, areas for improvement and challenges to facilitating communication training in their undergraduate children's nursing programmes.No identifying demographics, related to the individuals or their respective institutions, were requested from programme leads.Anonymity was prioritised over the possibility of multiple participation as we felt the subject matter may have been viewed as professionally sensitive.Additionally, the qualitative nature of the survey itself made it unlikely for repeated responses.Data security was ensured by storing it on secure and encrypted online servers managed by Qualtrics (Qualtrics, 2022).

Data analysis
Numerical data from the closed response questions were summarised descriptively, using frequencies and percentages.Responses to the five open-ended questions were analysed inductively using a process of conventional content analysis, where the responses were coded and then categorised according to the frequency of the codes (Hsieh and Shannon, 2005).Conventional content analysis was appropriate for this study as although the open-ended questions allowed for expansive insights, some of the responses were generally brief and concise (Vears and Gillam, 2022).Initial coding was conducted by the lead author [M.K.] and checked and discussed between the rest of the team [L.B., H.S. & L-M.B.] to confirm interpretation and agree the presentation of results.

Ethical consideration
Ethical approval was granted by the University Health-related Ethics Committee [ETH2223-0020].Programme leads provided informed consent online by ticking a box to confirm they had read the study information and agreed to participate in the study prior to commencing the survey.Programme leads were informed that once they had submitted the online survey, they would not be able to withdraw their data.The 'anonymise response' was selected within Qualtrics, preventing the survey platform from collecting contact information or IP addresses.Due to the small sample size, careful consideration was made in reporting the data as the provision of undergraduate children's nursing programmes varies slightly in the ROI and the UK (Table 1).HEIs in ROI could be identified if reference was made to year 4 or year 4.5 in the survey, so data related to the final years of the undergraduate nursing programme is classified as 'year 3-4.5'.

Results
Of the 63 undergraduate children's nursing programme leads invited to participate from the ROI and the UK, 32 completed the survey (response rate 51 %).Programme leads were asked to report their average annual student intake over the last five years, with most programmes reporting an intake of between 30 and 51 students (n=16, 50 %), followed by 0-30 students (n=10, 31 %), 61-90 students (n=4, 13 %) and 91+ students (n=2, 6 %).Results of the closed and openended responses will be reported alongside each other under the following headings: (1) Reported delivery (how) and ( 2) content (what) of communication training within the undergraduate children's nursing programme.

Delivery of communication teaching and training: the 'how' in undergraduate nursing programmes
Programme leads were asked to provide details about how communication training was currently delivered within their undergraduate children's nursing programme (Fig. 1), with reports of distinct communication focused sessions and delivery being interwoven across various modules and academic and clinical assessments.Over half of programme leads reported (n=19, 59 %) that specific modules or sessions dedicated to communication training were delivered.Ten programme leads (31 %) responded that specific modules on communication were not delivered and three (9 %) selected 'other', stating that communication training was a part of core modules shared across nursing disciplines in year 1 of undergraduate programmes.
Most programme leads (n=26, 81 %) reported that communication training was 'integrated throughout other modules or sessions' within the undergraduate children's nursing programme.Four programme leads (13 %) responded that communication training was not integrated through other modules and two (6 %) selected 'other', noting that communication training was provided in general nursing modules as well as modules specific to children's nursing.Addressing where communication training features in undergraduate children's nursing curriculum, 16 programme leads (50 %) reported its inclusion within core communication modules delivered to all nursing disciplines (not solely undergraduate children's nursing) within the first year.With a strong focus on core principles of communication in year 1, programme leads observed that child-centred communication training is expanded on in year 2 and years 3-4.5.Communication training was reported as covered within specialised modules such as leadership, end of life care and module specific child-centred nursing care (n=7, 22 %).
The responses show that child-centred modules are not always facilitated each year of the undergraduate children's nursing programme, with one programme lead stating that 'the importance of teaching child centred communication from the first year through to the third year -this is what our students are not getting' (P6).Out of 32 programme leads, only two (6 %) identified a communication module which exclusively focused on communication with CYP and families in first year of the undergraduate children's nursing programme.
A variety of teaching and learning strategies were reported as being used to provide communication training (Fig. 2).Simulation-based education was the most widely reported teaching and learning strategy (n=20, 63 %) with sixteen (50 %) programme leads acknowledging simulation-based education as the preferred mode of delivery for communication training which 'enable more practice and honing of skills.Especially where in clinical practice the opportunities are not available' (P28).Programme leads reported the benefits of incorporating simulation-based education into their communication training, noting that children's nursing students can 'put concepts into practice and consider how they may feel or other things that may influence their communication' (P7), allowing them 'to understand themselves and the impact on others' (P18).
Programme leads (n=8, 25 %) identified a need for further integration of simulation-based education into their communication training, incorporating more scenarios, role play and the use of CYP as standardised patients.Three (9 %) programme leads stated that they are currently using standardised patients, however only one programme lead detailed that these involved CYP.Programme leads acknowledged that while there is 'limited opportunity for simulated practice with CYP (due to the nature of the client group)' (P15), there is a growing desire to include CYP in simulation-based education: "It is easy to practice communication with adults by role play but further exposure to communication 'sim' [Simulation-based education] sessions with real children would be good" (P17).
Programme leads cited logistical challenges in recruiting CYP to be involved in communication training (n=3, 9 %) as well as ethical concerns (n=4, 13 %): "To involve lived experience but is challenging with young person age group but is an area we are aiming to address and have commenced enquires" (P29).
Additionally, programme leads referred to factors affecting how child-centred communication training was currently delivered in their undergraduate children's nursing programme.Curriculum capacity (n=11, 34 %), cost of resources (n=3, 9 %), time (n=5, 16 %) and nursing registration body's standards (n=3, 9 %) were all noted to have an impact on the delivery of child-centred communication training in HEIs.Programme leads noted that with programmes 'very tightly packed … most of the students develop their communication skills in practice' (P14).Clinical practice placement was perceived as an appropriate substitute for teaching child-centred communication in an academic environment (n=10, 31 %), understanding that practical experience of communication training 'would tend to take place on placement when students will be communicating with children of all ages' (P27)" "This [communicating in clinical practice placement] is pretty much learning on the job" (P1).
Another factor, concerning how child-centred communication training was delivered, related to the experience of the educators.If educators, who had experience with CYP in healthcare, were not leading the sessions, 'the information is all adult based' (P15) and child focused communication was seen as overlooked and not addressed: "Many adult lecturers refuse to talk about CYP in general in classstudents have told me this in verbal feedback, so they want field specificity they are not getting."(P13).

Content included in communication teaching and training: the 'what' in undergraduate nursing programmes
Programme leads provided a limited insight into what communication training content was currently being taught in their undergraduate children's nursing programme.
However, programme leads described core communication content, delivered in year 1, as providing a foundation for general communication principles and practices in healthcare (n=9, n=28 %).Programme leads felt the delivery of core communication modules to all nursing disciplines (n=20, 63 %) worked particularly well, reporting that focusing communication training solely on CYP could 'potentially limit this exposure and subsequent benefit' (P16).The importance of interprofessional communication training was seen as helpful as 'there is a need to have a range of communication strategies given that there is a need to deal with children, young people and their families from a range of backgrounds and cultures' (P16).However, one programme lead reported that core communication delivered to all nursing disciplines Fig. 2. Reported teaching and assessment methods used to deliver communication training organised according to (Hughes and Quinn, 2013) categories.

M. Kennedy et al.
lacked 'child specific' content as nursing regulatory authorities' standards and requirements informing this 'are so generic' (P24).With an understanding that CYP will use a broad spectrum of healthcare services, it was identified as 'probably essential that communication with CYP should be delivered to all fields' (P1) of nursing, further noting 'possibly more so as their connection with CYP will not be as frequent as CYP trained nurses' (P1).
In relation to child-centred modules, some programme leads (n=12, 38 %) noted that communication training was facilitated primarily alongside content such as stages of child development, child and family centred care as well as content relating to augmentative and alternative communication such as Makaton and Sign Language.Delivery of augmentative and alternative communication content in undergraduate children's nursing programmes was noted by programme leads as an aspect of their communication training that they feel works well (n=6, 19 %).When asked how communication training could be improved, a few programme leads (n=3, 9 %) drew attention to augmentative and alternative communication, noting that implementation comes down to 'funding and space in the curriculum' (P20).Communicating with CYP with mental health and 'challenging behaviours' (n=3, 9 %) and inclusion of the voice of the child (n=5, 15.6 %), was also identified as content that some programme leads felt could be improved in undergraduate communication training: "I think we need to develop this further to include communicating with CYP as if we don't communicate with them then we can't capture the voice" (P27).
While not the direct voice of the child, one programme lead shared that they support the delivery of parent-led lectures, with parents discussing their experience of having a child in hospital, while another programme lead shared the facilitation of sessions where children's nursing students receive feedback on their communication abilities from young adult actors with learning disabilities.

Discussion
The aim of this study has been to explore and scope out the current reported delivery and content of communication training in undergraduate children's nursing programmes across the ROI and the UK.Programme leads provided insight on current communication curricula, highlighting examples of innovative teaching and learning strategies, but also tensions and gaps in the delivery and content of child-centred communication curricula.The findings re-enforce that communication training continues to be an important element in undergraduate children's nursing programmes (Reid-Searl et al., 2021).This is important as good communication can underpin every interaction of nursing practice in healthcare (Kerr et al., 2020).
Whilst core communication modules were reported as being delivered within the first year of some undergraduate children's nursing programmes, there was variability across programmes and reports of generic communication modules not meeting the specific needs of children's nurses or being blended and dispersed across multiple modules.There is an international drive for the implementation of core communication curriculum across healthcare disciplines (Bachmann et al., 2013), with recognition that the content needs to be adaptable and responsive to changing population, societal needs (Kerr et al., 2022) and with the ability to address discipline specific skills (Wittenberg et al., 2021).This is important to address as without consensus or guidelines on a communication framework for delivery in undergraduate nursing programmes (Cannity et al., 2021), governed by nursing regulatory board standards and requirements, children's nursing students will continue to graduate from HEI's with varying levels of ability in communicating with CYP in healthcare (Kerr et al., 2022;Jestico and Finlay, 2017).To date, research on core communication curricula is primarily focused on undergraduate general nurse education (Bachmann et al., 2022), highlighting a need for research dedicated to children's nurse education.
The findings also highlight that programme leads encounter a lack of resources and time in the curriculum to deliver communication training in undergraduate children's nursing programmes, with some relying on clinical practice to supplement children's nursing students' communication training with CYP.These challenges are already acknowledged in recent literature, showing the pressures in curriculum delivery (Wittenberg et al., 2021;Fawaz et al., 2018).Whilst clinical practice placements observing real-world communication skills by experienced clinical nurse mentors are valuable (Slater and Herbert, 2023), it is important to acknowledge that a reliance on clinical practice only guarantees children's nursing students will learn to mimic communication styles (Kerr et al., 2022).Furthermore, multiple factors can affect nursing student's experiences of clinical practice such as a lack of supportive learning environments (Gonzalez-García et al., 2021), attitudes of multidisciplinary team members, lack of collaboration and poor communication skills (Panda et al., 2021).There are also inconsistencies and a lack of research (Panda et al., 2021) concerning the abilities of clinical nurse mentors to scaffold the application of undergraduate nursing education to clinical practice (Gonzalez-García et al., 2021).Positive clinical learning experiences are influenced by clinical nurse support, guidance and motivation (Panda et al., 2021).This form of peer learning enhances student nurses' experience (Panda et al., 2021) and provides opportunities to meet their learning needs (Pedregosa et al., 2021).However, with a global shortage of an experienced nurse workforce, it cannot be assumed that children's nursing students will be able to benefit from the experience of clinical nurse mentors (Jassim et al., 2022).
It has been suggested that to develop children's nursing students' communication skills, training must take place in HEI's, providing a foundation in theoretical knowledge and practical skills (O'Connor and Andrews, 2018) before consolidation in clinical practice (Gamble, 2017).Demonstration of effective communication skills, as established by regulatory bodies for nursing and midwifery professions in all HEIs delivering education and training programmes (Nursing and Midwifery Board of Ireland, 2023;Nursing andMidwifery Council, 2023a, 2023b), is only possible when theoretical knowledge is successfully applied to clinical practice (Flinkman et al., 2017).Additionally, nursing students self-report satisfaction with their ability to integrate theory and practice, which positively impacts their experience of clinical practice placements (Cant et al., 2021).
Quality delivery of communication training in HEIs requires welltrained and experienced nurse educators, with the ability to combine evidence-based educational strategies and practical experience (Fawaz et al., 2018) providing nursing students with a strong foundation in communication skills and training (Wittenberg et al., 2021).Notably, some programme leads reported that not all communication modules were delivered by educators with professional experience of CYP in healthcare.It was suggested that the lack of specialised communication training delivered by experienced educators leads to communication training that was not representative of CYP's experience of their healthcare journey (Clarke, 2019).With most countries not having a standalone undergraduate children's nursing programme, there has never been more of an opportunity for HEI's that do, to lead and innovate communication training in children's nursing education.
Development of undergraduate children's nursing communication training requires nurse educators to implement diverse and innovative teaching and learning strategies (Clarke and Lippe, 2022).Corresponding with recent literature (Gutiérrez-Puertas et al., 2020;Kerr et al., 2020), programme leads stated that they are using a blended approach when delivering communication training, ranging from didactic lectures, case studies, workshops and objective structured clinical examination (OSCE).Simulation-based education was the most identified teaching strategy in this study and programme leads reported looking for more opportunities to incorporate it into their undergraduate children's nursing curriculum.This is unsurprising as simulation-based education has been established as an impactful teaching strategy to help nursing students improve not only their communication skills but also their critical thinking skills, clinical competence (Gibson-Young et al., 2023) teamwork and self-confidence (Chabrera et al., 2021) especially when clinical opportunities with CYP are limited (Clarke and Lippe, 2022).
Programme leads expressed an interest in the use of standardised patients, particularly looking at how to involve CYP in their simulationbased education.Involving CYP as standardised patients in simulationbased education is relatively new (Zengin and Fidanci, 2024;Reid-Searl et al., 2021;Kubin and Wilson, 2017;Gamble et al., 2016) but where possible should be considered where benefit clearly outweighs any possible negative outcomes (Gamble et al., 2016).One programme lead explicitly stated that they are using this teaching strategy, involving children when educating children's nursing students on how to obtain children's vital signs.Nurse educators, clinical faculty members and nursing students simulating children in clinical scenarios is not considered best practice (Wittenberg et al., 2021), presenting experiences of communication in children's healthcare through an adult frame of reference (Tisdall, 2017).
While one HEI reported involving children in simulation-based education, incorporating the voice of CYP in developing or delivering communication training was limited.Programme leads cited uncertainty about the best way to meaningfully involve CYP.In many cases 'child voice' was represented by proxies such as through parents or young actors.The findings from this study show that despite research highlighting the benefits of co-design in nursing education (Hardie et al., 2022) and examples of CYP being included in the design and delivery of children's nurse education (Allan, Luders, 2021;Clarke, 2019;Coyne et al., 2018), there is still a lack of involvement of CYP in communication curriculum.Despite a growing interest in incorporating the voice of CYP, their voice continues to be underrepresented in research (Foster et al., 2023).The United Nation's Convention on the Rights of the Child (UNCRC) Article 12 states a child's right to be heard and express their own viewpoints in all matters affecting them, with Article 14 addressing a child's right to the enjoyment of the highest achievable standard of healthcare (Convention on the Rights of the Child, 1989).To fulfil this promise, assessment, planning, development and improvement of children's health care services requires meaningful collaboration with CYP (Bray et al., 2023;Brady et al., 2022).Recognition of the importance of children's unique perspectives on their view of interactions in healthcare (Coyne and Carter, 2018) is acknowledged in Irish and English nursing authorities' regulatory standards and frameworks for undergraduate nursing education.In the ROI, NMBI specifically address that children's nursing students must be responsive and adaptive to CYP's unique experience of health (Nursing and Midwifery Board of Ireland, 2023) while in the UK, the NMC state that HEI's must ensure nursing curricula co-produced with stakeholders who have experience relevant to the programme (Nursing andMidwifery Council, 2023a, 2023b).With an ever-changing landscape of childhood experiences worldwide, it's important, as gatekeepers of the profession, that nurse educators listen and engage with CYP, advocating for their voice to be a prominent feature of children's higher education (Allan, Luders, 2021).

Limitations
This research represents a scoping of communication curriculum reported as delivered in HEIs in the ROI and the UK, however the response rate of 51 % (n=32) incurs the risk of missing potential insights from those who chose not to complete a survey.UK universities engaged in strike action through part of the data collection phase, possibly affecting response rates.Some responses from programmes leads were brief and due to the survey being anonymous, it was impossible to follow up responses for clarity.While this study included a comprehensive sample of programme leads from HEIs who were delivering undergraduate children's nursing programmes in the ROI and the UK, it is important to note that these findings may not be applicable to different settings internationally where undergraduate education is delivered differently.

Conclusions
Good communication is fundamental to providing CYP with positive experiences of their interactions with nurses and facilitating them to build meaningful relationships in the clinical environment.Despite the importance and impact of good communication, this study has shown that formal education on the topic of communicating with CYP in undergraduate children's nursing programmes continues to vary across HEIs.Robust children's communication training appears to be impeded by an absence of a standardised framework, dense curriculum, teaching sessions shared with other disciplines and lack of nurse educators with experience of CYP.Future research should focus on the development of a standardised framework for communication training in undergraduate children's nursing curricula, achieved through meaningful collaboration with CYP and nurse educators.This research focused on the viewpoints of nurse educators.Subsequent research should investigate undergraduate children's nursing students' experiences of child-centred communication training.

Fig. 1 .
Fig. 1.Overview of reported communication training within undergraduate nursing provision for children's nurses.

Table 1
Description of undergraduate children's nursing programmes in the Republic of Ireland and the United Kingdom.