Children and young people as a distinct patient group

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.

Case for a unique focus on the health of children and young people

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.

History of children’s nursing in the UK

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.

Generalist versus specialist education

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.

Solutions

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).

Conclusion

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.