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• To understand the importance of recognising the specific healthcare needs of children and young people
• To be aware of the concerns that have been raised in response to the potential move towards a generalist approach in nursing
• To learn about some of the suggestions for protecting the field of children and young people’s nursing and optimising care for this patient group
At certain points in nursing history, it has been necessary to make a case for children and young people to be cared for by specialist nurses educated to meet their specific needs. However, in 2018 the updated Nursing and Midwifery Council (NMC) standards of proficiency for registered nurses adopted a generic rather than field-specific approach. This article reiterates that children, young people and their families have unique needs that are best met by nurses who are trained specifically to care for them. The case is made from a historical and legal perspective, concluding with a proposal that in the best interests of children, young people and their families, the NMC should embed specific competencies for children’s nurses into its standards of proficiency to future-proof this field of practice.
Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1512
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Garrow A, Bailey K, Brown J et al (2024) Protecting the integrity of children and young people’s nursing as a distinct field of practice. Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1512
AcknowledgementThe authors would like to acknowledge the contribution of the Children and Young People’s Nurse Academics UK members whose valuable discussions aided the development of this article
Published online: 07 May 2024
At certain points in nursing history, such as the Platt (1959) report on the welfare of children in hospital and the Allitt inquiry into the murders at Grantham and Kesteven General Hospital, England (Clothier et al 1994), a compelling case has been made for children and young people to be cared for by nurses who are educated in their specific needs.
Currently, nurse education is guided by the Nursing and Midwifery Council (NMC) through the publication of standards of proficiency that define the core knowledge, skills and attributes that all nurses must demonstrate at the point of registration. However, in 2018 the NMC published updated standards of proficiency for registered nurses, removing all the references to children and young people that had appeared in previous NMC standards. This has resulted in a set of general nursing proficiencies designed to apply across all four fields of nursing (adult, children’s, learning disabilities and mental health) and in all care settings – denoting a shift from the previous field-specific focus (NMC 2018).
On publication of the updated standards of proficiency, some children and young people’s nurse educators criticised the NMC for failing to acknowledge their concerns about the generic nature of the standards during the consultation period and emphasising the potential negative effect on nurses’ education programmes (Clark et al 2017). The authors contend that by removing all reference to children and young people from its standards of proficiency, the NMC has removed a necessary field-specific focus. Children, young people and their families have specific and unique needs that are best met by nurses who are educated specifically to provide care for them.
In this article, the authors argue that it is in the best interests of children, young people and their families that the NMC re-embed specific children and young people’s competencies into its standards of proficiency. This would ‘future-proof’ children’s nursing and ultimately ensure that the ongoing care of children and young people is safe and effective. In addition, the authors propose that the title of children’s nurse on the NMC register be amended to ‘children and young people’s nurse’ to reflect the scope of nursing practice involved in this field.
• The updated Nursing and Midwifery Council (2018) standards of proficiency provided a set of general nursing proficiencies designed to apply across all fields of nursing, denoting a shift from the previous field-specific focus
• Concerns have been raised that a generalist approach to nursing would be detrimental to the care of children and young people
• There are psychological, social and physiological differences between children and adults, and these needs change as children grow and develop
• Children, young people and their families have specific and unique needs that are best met by nurses who are educated specifically to provide care for them
Clarke and Corkin (2023) suggested that children’s nursing is ‘a distinct field of practice [that] may relate to a philosophy of care that recognises the individuality of each child and their family, understanding their unique needs in relation to healthcare provision and ensuring their involvement in decisions about their care’.
While this quote emphasises that children and young people have unique needs that differ from those of adults, defining exactly who should be cared for by children’s nurses can be complex because of the various debates about when adulthood actually begins. According to the Royal College of Nursing (RCN) (2021), the term ‘child’ refers to any person from birth through childhood and is inclusive of adolescence. However, the RCN (2021) also acknowledges the distinct needs of specific age groups included within the term ‘child’, for example infants, toddlers and adolescents.
In the UK, healthcare service provision for children and young people has usually been classified in terms of age, with services ending at 16 years when patients transition into adult services. However, in 2019 the NHS Long Term Plan (NHS England 2019) proposed that ‘selectively moving to a “0-25 years” service will improve children’s experience of care, outcomes and continuity of care’, effectively removing the specific children’s field of nursing practice. Subsequently, Purssell and Sagoo (2023) invoked this policy as a rationale to support a generic approach to nurse education, suggesting that the separate focus for those aged under 16 years leaves a gap in provision for young people aged between 16 and 24 years.
The authors agree with Purssell and Sagoo (2023) and NHS England (2019) that there is a need to improve the transition between child and adult services. However, in the authors’ opinion, Purssell and Sagoo (2023) and NHS England (2019) have failed to recognise that children’s nurses are vital to developing a safe, person-centred and age-appropriate transition between services. For example, the Ready Steady Go transition programme (readysteadygo.net) was developed to support healthcare professionals to enable children with long-term health conditions and their families to gain the knowledge and skills to manage their condition into adulthood. Similarly, in the authors’ opinion, the way to achieve safer transition between services at any age is not by removing nursing fields from the register.
Children and young people’s nursing differs from adult nursing due to the age-specific stages of development involved. Not only are there psychological, social and physiological differences between children and adults, but children’s nurses also have to understand concepts such as growth, development and play, which have less importance for adult nurses. Nurses who care for children and young people understand that children are not the same as adults – their biopsychosocial needs change as they grow and develop, and this must be taken into consideration to ensure effective support of the child and their family. These nurses also need to understand how children and young people’s social and environmental circumstances influence their development and how to adapt care accordingly (Glasper and Charles-Edwards 2002a).
According to the World Health Organization (2005), a person’s health status in childhood can determine their health throughout their lifespan, with ill health in childhood being perpetuated into adulthood. This further emphasises the importance of a continued and sustained focus on the health of children and young people. Approximately 21% of the UK population are aged under 15 years and about 3% are aged between 16 years and 18 years (Office for National Statistics 2022, Northern Ireland Statistics and Research Agency 2023, Scotland’s Census 2023). The percentage of those aged 0-4 years admitted to hospital each year is higher than the average for all ages (Public Health Scotland 2022), and there were notable increases in the number of children aged under 15 years accessing urgent and outpatient care between 2007 and 2017 (Ruzangi et al 2020).
Ensuring the welfare of children and young people requires healthcare professionals who possess specific knowledge of the care of this patient group. Purssell and Sagoo (2023) suggested that the separate fields of nursing for adult, children, learning disabilities and mental health artificially divide the population into adults and children in a way that is not reflected in real life. However, this observation does not acknowledge that children and young people are considered separately from adults in many ways, for example due to their physical differences and in the legal context.
There are important anatomical and physiological differences between children and adults starting from birth, moving through infancy and childhood, then into adulthood. For example, the positioning of vital organs such as the heart, lungs, liver and kidneys changes as a child grows and develops. These organ systems are immature at birth and need to mature and develop into fully functioning adult systems (Glasper et al 2021).
Consequently, there are unique and complex differences in the pathophysiology, healing process and treatment of children and adults. For example, daily fluid requirements for adults and children differ due to the child’s immature renal system and precautions are required for the administration of medicines to children due to their immature liver development. In addition, children’s physiology and responses to disease are different from those of an adult; there are also many types of diseases or conditions that affect children and young people specifically, such as bronchiolitis. As Figaji (2017) stated, healthcare professionals who primarily care for adults often underestimate the differences between adult’s and children’s anatomy and physiology, which has repercussions for the assessment and management of children.
Child development textbooks often outline the legal distinction between childhood and adulthood, which is reflected in the differences in their physical, mental, social, cognitive and emotional development (Keenan et al 2016, Beckett and Taylor 2019, Sharma et al 2022). Because of these differences in development, children are deemed to be vulnerable and therefore require the legal protection of adults and society.
The United Nations Convention on the Rights of the Child (United Nations International Children’s Emergency Fund 1989) defined a child as anyone aged under 18 years and it contains 54 articles that identify children’s unique rights, emphasising how these differ from the rights of adults. The UK ratified the convention in 1991, recognising these rights and embedding many of them into legislation, policy and service delivery. For example, Article 24 specifically relates to healthcare, citing the child’s rights to the highest attainable standard of health and stating that all parties must strive to ensure children are not deprived of their right of access to healthcare services. This is further endorsed in Article 6.1 of the European Association for Children in Hospital (2024) Charter, which states that: ‘Children shall be cared for together with children who have the same developmental needs and shall not be admitted to adult wards’. In addition, Article 8 states that: ‘Children shall be cared for by staff whose training and skills enable them to respond to the physical, emotional and developmental needs of children and families.’
Therefore, there is an established legal position that delineates the care of children and young people from that of adults and specifies that any care should be provided by appropriately skilled and trained staff.
The history of children’s nursing in the UK reflects the challenges the specialty has experienced in terms of being accepted as a distinct field of nursing. The earliest references to the unique needs of the ‘sick child’ and the requirement for children’s nurses to have specific training is often credited to Catherine Jane Wood, a nurse and ‘lady superintendent’ at the then Great Ormond Street Hospital for Sick Children in London, as far back as 1888 (Wood 1888, Glasper 2020). However, Wood suggested that she was actually carrying out the vision for children’s nursing put forward by her colleague Charles West, a doctor who was a leading figure in children’s medicine and was the founder of the hospital in 1852. Before the establishment of Great Ormond Street Hospital, children had to rely on outpatient care (Glasper 2020). Therefore, the conception of children’s nursing stemmed from the work of two reputed figures at the centre of children’s health who recognised that these patients’ needs differed from those of adults.
More recently, Sir Ian Kennedy (2001), who chaired the 1998-2001 public inquiry into children’s heart surgery at the Bristol Royal Infirmary, acknowledged the differences in children’s physiological, psychological, intellectual and emotional development and recognised how this affected their healthcare needs. He emphasised the importance of ensuring that any staff caring for children and young people were sufficiently knowledgeable and skilled to deliver age-appropriate care.
The Nurses Registration Act 1919 and subsequent state registration of nurses by the General Nursing Council sanctioned the current structure of the UK nursing register, which requires that nurses must register with a professional body. The 1923 register included 191 sick children’s nurses (Glasper and Charles-Edwards 2002b).
By the late 1980s, the registered general nurse (RGN) had become the core nursing qualification in the UK, with opportunities to complete a post-registration course leading to a registered sick children’s nurse (RSCN) qualification. This was recorded on part 8 of the register governed by the then UK Central Council for Nursing, Midwifery and Health Visiting (UKCC), which became the NMC in 2002 (Glasper and Charles-Edwards 2002b). However, access to post-registration RSCN courses was limited by the lack of available funding and of nursing schools that provided them, which meant that children’s services were staffed predominantly by RGNs without the RSCN qualification. Subsequently, the Allitt inquiry emphasised the many issues related to suboptimal care that resulted from this lack of RSCNs (Clothier et al 1994). As a result, children’s nursing was established as a separate entry registration (part 15 on the register) with the advent of Project 2000, which brought an increased focus on nursing students’ academic education (Glasper and Fallon 2021). In addition, the Allitt inquiry recommended that children’s services be staffed with at least two RSCNs per shift (Clothier et al 1994).
The current debate about whether children’s nursing should be retained as a field of practice on the NMC register is centred on notions of ‘specialism’ and ‘generalism’ and whether there should simply be one nursing qualification that encompasses the care of the whole population, rather than having separate categories for adult and children’s nursing. Although no evidence-based rationale is offered for the argument that there should only be one generic category of nursing, these debates often involve comparisons with countries such as Australia and the US, which do not have a separate children’s nursing qualification. In these countries, a registered nurse who works with children can undertake post-registration training in children’s nursing – much the same as in the UK before the establishment of Project 2000 (Glasper 2020).
While no overt announcements have yet been made by the NMC to support a shift to generic nursing registration, there are calls from children’s nurse academics to halt ‘genericism by stealth’ (Editorial Advisory Board of Nursing Children and Young People 2023), which has been demonstrated by actions such as the removal of the term ‘children’ from the current NMC (2018) standards of proficiency, despite assurances from the NMC that this is simply a move to reflect holism (Holt and Dixon 2022). However, the NMC (2018) standards of proficiency also require all nursing students to demonstrate a range of skills, listed in Annexe B: Nursing Procedures. Significantly, many of these skills are adult focused and have little utility for children’s nurses, for example undertaking venepuncture and cannulation. Therefore, there is a risk of the NMC diluting important field-specific content to meet adult health requirements (Loveday 2019).
The authors of this article are not alone in their frustration with developments in nursing specialisms. Warrender (2022) and Connell et al (2022) have also expressed frustration at the dilution of mental health field-specific content caused by the focus on adult physical health in the NMC (2018) standards of proficiency, suggesting that core mental health nursing skills are being undervalued.
At the time of writing there is no ‘general’ nurse qualification in the UK. Instead, there are four registered fields of practice – adult, children’s, learning disabilities and mental health nursing. However, as discussed, there have been calls to replace the children’s and adult fields of practice with one overarching generic nursing qualification (Purssell and Sagoo 2023).
The terms generalist and specialist in this debate can be somewhat misleading because there is a lack of understanding that UK children’s nurses are in fact educated to be ‘generalist’ nurses, but that their patient group comprises children and young people rather than adults. Children’s nurses may go on to specialise in a specific clinical area such as emergency nursing, oncology or neurology in the same way that adult nurses do. In this way, children’s nursing is not typically ‘specialist’.
At the time of writing, there is little evidence on how various higher education institutions (HEIs) are approaching curriculum development to ensure the readiness of newly registered nurses to care for children and young people and their families. However, Glasper and Fallon (2021) argued that those calling for a generalist approach to education failed to acknowledge that what often results is a focus on adult nursing with a subsection of the curriculum dedicated to children’s nursing.
Many HEIs across the UK use the term ‘generic’ interchangeably with ‘adult’, with many nursing students across all fields expected to learn core or generic content. In practice this means that lectures are focused on adult physical health, but then applied in some way for field-specific groups. For example, a lecture on cardiac nursing care might focus on adult anatomy and physiology and adult conditions such as congestive cardiac failure; however, in a subsequent child-specific lecture, students might be informed about the significant differences in paediatric cardiac conditions such as tetralogy of Fallot. Concerns about this approach have been raised by some academics (Glasper and Fallon 2021), especially since children’s nursing students not only spend their time learning about an adult patient group they will not provide care for, but also use up valuable time that could be spent learning about their specific field of practice.
Another important factor in this debate is that adult nursing students do not need to make a case for field-specific education because in most HEIs they comprise the highest proportion of students in each cohort. Additionally, little is known about how nursing content is being delivered in lectures attended by nurses from all four fields. Given that most nurse lecturers will have gained their experience and knowledge in adult nursing, they may unintentionally display bias that leads to their lectures being adult-centric (Glasper and Fallon 2021).
These points provide some insight into the ongoing challenge of maintaining child-specific course content given the larger numbers of adult nursing students. While the NMC places responsibility on individual HEIs to prepare nurses for their field of practice, ultimately it is the regulatory body that validates nurse education programmes. At the time of writing, an exploratory study is being undertaken by the University of Plymouth (2023) with the aim of exploring how programme content affects children’s nurses’ readiness for practice.
The call for a generic nursing curriculum by authors such as Purssell and Sagoo (2023) comes at a time when many children and young people’s nurse academics are already concerned about the limited space on their nurse education programmes for field-specific content, in particular children’s mental health (Clark et al 2017).
The case put forward by the authors of this article is for a specific nursing qualification that focuses on children and young people, particularly since the numbers of nursing students or staff in HEIs is currently weighted towards adult nursing. The number of children’s nurses in England has declined (Royal College of Paediatrics and Child Health (RCPCH) 2020), and as of March 2022 in the UK there were 567,291 registered adult nurses compared with 55,062 children’s nurses, 92,780 mental health nurses and 16,953 learning disability nurses (NMC 2022). Moreover, while the NHS Long Term Workforce Plan (NHS England 2023) stated that there were sufficient numbers of training places for children’s nurses, this was refuted by the RCPCH (2023), which distinguished between the number of training places and the number of registered children’s nurses in the workforce. The RCPCH (2023) argued that a shortage of registered children’s nurses is having a negative effect on care delivery and that failing to address this would undermine the ambitions of the NHS Long Term Plan (NHS England 2019).
The authors of this article propose that an alternative approach to nurse education would include two fields of practice – children and young people’s nursing and adult nursing – with both programmes encompassing mental health and learning disability, both of which impact across the life-span. If this were to be the case, undergraduate nurse education programmes would need to ensure that each field or programme focused either on children and young people’s nursing or on adult nursing. The authors are not advocating for this two-field approach and recognise that colleagues would argue that their own field should take primacy. Rather, this proposal aims to promote discussion and strongly counter any move towards a generalist nurse education curriculum in which children’s health, mental health and learning disabilities are tokenistic.
Such an approach would also address the current lack of mental health resources and the high number of children accessing mental health services (NHS England 2022). Children’s nurses would be trained to care for children with mental health issues, rather than the current situation in which children’s mental health is often the responsibility of mental health nurses (Healthcare Conferences UK 2022). Although child and adolescent mental health services tend to be staffed by children’s and mental health nurses, this is not the case in acute mental health settings, where some young people are admitted and subsequently cared for by nurses without the relevant skill set (Clark et al 2017).
At present, nurse education and registration in the UK is field-specific, separated into adult, children’s, learning disabilities and mental health nursing. However, it has been suggested that there should be a move towards a more generalist education pathway for nursing students. The authors of this article argue that such a move would be detrimental to the care of children and young people, and could result in a situation where the most vulnerable in society are cared for by nurses who lack the necessary knowledge of their specific needs. It is essential that children and young people’s nurses are trained in the specific needs of this patient group so that they can provide the best possible care.
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