Children’s nursing: the long road to professional recognition
Intended for healthcare professionals
Analysis Previous     Next

Children’s nursing: the long road to professional recognition

Daniel Allen Health journalist

More than a century after the first children’s nurse was registered, senior figures in the specialty fear that progress in its development has stalled

The fight to get children’s nursing established, and subsequent debates over the ‘correct’ route to becoming a specialist children’s nurse, have been controversial topics over the years.

Nursing Children and Young People. 35, 3, 6-8. doi: 10.7748/ncyp.35.3.6.s2

Published: 04 May 2023


Picture credit: John Houlihan

More than 100 years ago Evelyn Margaret Hughes was the first sick children’s nurse to be registered with the profession’s new regulatory body following the Nurses Registration Act of 1919.

The act established the General Nursing Council, mandated to maintain a register of nurses. Children’s nursing formed one of several supplementary registers – others included fever nurses and male nurses – and Ms Hughes was admitted to the child register on 28 October 1921.

A 2002 article in Paediatric Nursing, the forerunner of Nursing Children and Young People (NCYP), described the ‘sporadic periods of anxiety’ experienced by children’s nurses in subsequent years as they battled to establish a register ‘where all parties held equal status’.

Specialist training

The article’s authors, Alan Glasper and Imelda Charles-Edwards, wrote: ‘The argument by general nurses that children’s nurse education is a specialist training and should therefore be at post-registration level continued long after the passing of the (1919) Act.’

Over time, the registered sick children’s nurse qualification was phased out and children’s nurses found it difficult to advance their careers without an additional general nursing qualification. This ‘discrimination’, as Professor Glasper and Ms Charles-Edwards describe it, is recalled by the RCN’s first paediatric nurse adviser, Sue Burr, appointed in 1984.

Ms Burr says: ‘Even to this day, on saying I was a children’s nurse, the response is: “Oh, you’re not a proper nurse”.’

Ms Burr’s appointment was a significant milestone for children’s nursing. But when she took up her post at the RCN, she recalls that the college’s otherwise excellent library did not include a single guidance document relating to the care of children in hospital.

Patient’s Charter

When, in 1991, the then Conservative government published its Patient’s Charter, detailing the rights patients could expect in the NHS, Ms Burr says ‘child’ did not appear anywhere in the document. ‘We made a big song and dance about that,’ she adds.

NCYP consultant editor and independent nurse adviser Doreen Crawford says that before the appointment of Ms Burr and her successor as RCN adviser, Fiona Smith, children’s nurses were not well represented at national level.

‘Traditionally, we children’s nurses were a tightly knit, small and select group who quietly got on with nursing our young charges in the face of often considerable professional adversity,’ says Ms Crawford.

‘Sue and Fiona were our iconic leaders who took the art and science of nursing babies, children and young people forward to more prominence from the 1980s to mid-decade 2000s.’

Ms Smith, who took up the post of professional lead in 2001 and stayed at the RCN for 20 years, says the national focus on children and young people, whether in nursing, education or wider society, tends to wax and wane.

Care scandals

Scrutiny, she argues, always intensifies following scandal, and tragically there have been several of those over the past few decades, among them the deaths of children undergoing heart surgery at Bristol Royal Infirmary, the murder of four young patients by children’s nurse Beverley Allitt, which led to an inquiry by Sir Cecil Clothier, and various cases of abuse and neglect including that of Victoria Climbié, an eight-year-old girl whose death as a result of ill treatment was the subject of an inquiry by Lord Laming.

‘If you look back at the Bristol inquiry or Clothier, many of the incidents arose because staff, not just nurses but medics and others, had not had specific education and training in the care of children and young people,’ Ms Smith says.

She argues that there are financial risks as well as safety concerns to consider when staff lacking the necessary skills are tasked with caring for children, with health services facing possible litigation if things go wrong.

‘The economic argument needs to be made, alongside the softer issues around communicating with children and young people, such as engaging with families, which as a children’s nurse you do automatically, when planning and delivering care. Adult nurses may not do so to the same extent.’

Ms Crawford believes that progress made at the RCN under the leadership of Ms Burr and Ms Smith has stalled.

‘Despite talent and commitment from notable experts in the wider children and young people’s (CYP) world [including the Association of British Paediatric Nurses, which is celebrating its 85th anniversary, and the Association of Chief Children’s Nurses], child health as a field of practice has slipped back.’

The reasons why are many and complex, she says, but include changes to the way the RCN configured its specialist forums, which meant experienced nurses had to stand down from forum committees after two terms and a loss of expertise that has affected external representation at a policy level.

‘We have become less listened to,’ Ms Crawford believes.

Timeline of children’s nursing: 1852-2023


Proactive and passionate

Carli Whittaker, University of Nottingham associate professor, a sister in children’s intensive care, Paediatric Critical Care Society president and, like Ms Crawford, a consultant editor of NCYP, says children’s nurses are as positive, proactive and passionate as ever.

‘The care given to children and young people is of a high standard and amazing. There’s lots of research in children’s nursing and lots of academics who are trying to drive quality, especially around mental health and critical care outcomes. But we are just not heard.’

Ms Whittaker suggests that the struggle for children’s nursing is not about clinical care but directed at policy level, where leadership, with some exceptions, seems lacking.

Ms Whittaker says the COVID-19 pandemic accelerated changes to service delivery and nurses must continue to embrace the rapid advance of technology.

The NHS Long Term Plan, with its focus on a ‘0-25 years’ service, may be changing the care infrastructure to ensure smoother transition, but Ms Whittaker says the differences between caring for a young person of 18 years and one of 25 are minimal and nurses are already sufficiently skilled to care for those at the higher end of that spectrum.

The route to becoming a specialist children’s nurse has been a topic of considerable debate over the years. Project 2000, proposed in 1986 and implemented from 1990, introduced a common foundation programme for nursing students followed by a period of specialist education.

Project 2000 and generic nurse training

In 1979, the Nurses, Midwives and Health Visitors Act gained royal assent, paving the way for a new nursing regulator, the UK Central Council (UKCC), and four national boards responsible for education and training. It was from this new governance framework that Project 2000 would later emerge.

The UKCC’s Project 2000 report, published in 1986, initiated nurse training’s move into higher education. It marked a shift away from traditional views of vocation and service and towards a modern professional identity for nursing. It also recommended that nursing students follow a common foundation programme before opting for one of four specialist branches – adult, mental health, learning disabilities or children’s nursing.

At the time Dame Elizabeth Fradd was vice chair of the English National Board, chair of its children’s nursing committee and an elected member of the UKCC. She says there was never any doubt that children’s nursing would be included in the four fields of practice proposed by Project 2000. ‘I didn’t have to do any fighting at that point,’she says. But in clinical practice it was a different matter.

Specialising from the outset

‘People in clinical practice – ward sisters, managers, people influencing local care – had to fight more on behalf of children’s nursing than those of us who were members of national committees.’

Project 2000 shaped nurse education today. But the UK’s current approach to preparing children’s nurses – specialising from the outset – puts it at odds with other countries, says University of Bedfordshire PhD student Rohit Sagoo. ‘We need to look at nurses as a global workforce,’ he argues.

Most of the many thousands who have come to work in the UK from Asia and Africa follow a generic training before further study in a specialist area.

‘There are 40,000 internationally trained nurses in the NHS and they’ve all had generic training,’ Mr Sagoo says.

‘Are we saying that a generic-trained nurse from India, with some paediatric experience, working in a paediatric intensive care unit or in a general children’s ward, their qualification is null and void because they were not trained in a British way in children’s nursing?’

Situation overseas

Other countries do things differently, with students following a generic programme and specialising only after initial registration. Is it possible, or indeed desirable, that in the future the UK will follow that model?

In an article published earlier this year, Anglia Ruskin University associate professor Edward Purssell and University of Bedfordshire PhD candidate Rohit Sagoo posed the question: ‘If the UK’s system of nurse education is so good, why does no one else follow our lead?’

The article stirred strong feelings but the pair say they were simply trying to further the debate about generic education followed by specialisation rather than cause an argument.

‘When we talk about generic training some people are misunderstanding that and calling it adult training,’ Mr Purssell adds. ‘But we’re not. The point we are making is that whatever the situation now, it’s not tenable in the future.’

He adds: ‘The world is changing. We have had informal feedback from employers and they are distressed by the lack of flexibility in the system.’

The pandemic exposed that, Mr Purssell argues. COVID-19 mainly affected adults, so children’s wards closed or were reconfigured to increase adult capacity. ‘Children’s nurses had to go and look after adults, about whom they had no experience whatsoever.’

Mr Sagoo says: ‘We are not downplaying children’s nursing. We are actually giving it kudos. You could have a generic nursing course that gives you experience across all fields of nursing and then your specialist field comes into your master’s course, for example. And that’s real specialism.’

Improved outcomes

When Ms Burr retired from the RCN in 2001, she reflected on her time in post in an article in Paediatric Nursing. And if lessons from the past can help shape the future, her final thoughts may still resonate.

She wrote: ‘I encourage all children’s nurses to participate in actively developing policy and practice. Use the structures that are there and the processes that have been shown to work and, together, you will achieve improved outcomes for children and families.’

She concluded with a quotation from philosopher Georg Wilhelm Friedrich Hegel: ‘Nothing great in the world has been accomplished without passion.’

Share this page