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Reflecting on 30 years of change in children’s nursing

Since Nursing Children and Young People's launch in 1989 there have been enormous advances in the profession

Since Nursing Children and Young People's launch in 1989 there have been enormous advances in the profession


Picture: Alamy

Cast around for views on the biggest changes in children’s nursing over the past three decades and various contenders emerge.

Judith_Ellis
Judith Ellis

30 yearsThey include more parental involvement, improved survival rates in neonatal care, technological advances, nursing degrees and a focus on mental health.

But perhaps the biggest change is in how child care is understood. This shift was articulated by children’s nurse and former chief executive of the Royal College of Paediatrics and Child Health (RCPCH) Judith Ellis, who said: ‘Children are not small adults and if you even try to say they are, they will suffer.’

Things were different 30 years ago, when Paediatric Nursing, this journal’s forerunner, was launched.

Sick children had less say in their own care, and they and their parents tended to be passive recipients of care. Hospital stays were longer, visiting times shorter and international protection of children’s rights through the United Nations’ convention was still a year away.

Scarce resources

In addition, community resources to support children discharged from hospital were scarce.

Colin Dyer
Colin Dyer

1,468

Increase in the number of children’s nurses in England, 2010-2017

Source: The Nursing Workforce 

‘That is where the WellChild nurse programme started,’ says WellChild chief executive Colin Dyer.

Now, WellChild nurses play a critical role in providing support at home for seriously ill children and their families.

‘We started with a pilot project to fund four community nurses, which went incredibly well,’ says Mr Dyer. ‘We rolled it out and have now funded more than 40 nurses.’

But children’s community nursing remains depleted. A 2017 RCPCH audit found that only 15% of acute general children’s services were supported by round-the-clock community nursing teams.

As a result, applications from healthcare organisations for WellChild nurses are rocketing and are evidence of a big gap in statutory provision.

Complex needs

Although prospects for children with complex needs have improved immeasurably, the advance is not without cost for families.

Michelle_McLoughlin
Michelle McLoughlin

Isolation is a serious issue, Mr Dyer says, and levels of parental stress and depression are significant.

For Michelle McLoughlin, chief nursing officer at Birmingham Women’s and Children’s Hospital, this shift towards family involvement is important. ‘Children and young people’s nursing has led the way with family-centred care,’ she says. ‘Support the family and you support the child.’

Ms McLoughlin believes advances in education – in particular, nursing degree programmes – have also had a profound effect on children’s nursing.

But the withdrawal of the bursary in England is having an impact, too, not least on the age of recruits. The average age used to be 27-29, but now more recruits are 18.

‘It’s not that one is better than the other,’ Ms McLoughlin says, ‘But to have a mixed economy meant I had young men and women with life-skills.’

Nursing degrees

Fiona_Smith
Fiona Smith

Two children’s nurses who between them have witnessed and helped shape some of the major landmarks in child health since Nursing Children and Young People was first published are Fiona Smith and Sue Burr, respectively the current and a former RCN children and young people’s professional lead and nursing adviser.

10.9%

Children’s nursing vacancy rate in England

Source: The Nursing Workforce 

They agree that child nursing degrees are, as Ms Burr puts it, ‘recognition that the needs of the child are different from those of adults’.

Degree programmes have resulted in most children receiving care from staff specifically educated to meet their needs.

Sue_Burr
Sue Burr

They list many other developments that have changed children’s healthcare, among them:

  • A shift in the nurse’s role from care-giver to teacher and supporter of families.
  • Recognition that mental health is as important as physical, although as Ms Burr says: ‘Child and adolescent mental health services remain vastly inadequate’.
  • A huge increase in day surgery, which has contributed to shorter inpatient stays.
  • Nursing knowledge and skills increasing in line with medical advances.

Boom and bust

As Ms Burr points out, all of these changes have been recorded in the pages of this journal, which she continues to read – not least because it was she who, in 1987, proposed a monthly children’s nursing journal to Scutari Publishing, which later became RCNi.

‘There wasn't a UK paediatric nursing journal at that time,’ she says.

But as Ms Smith argues, for all the advances in the way children are cared for, there have been instances of terrible neglect or wrongdoing.

She also highlights the ‘boom and bust’ that has characterised child health over the years, when energetic policy making is followed by a general election and a change in government priorities.

Examples include Every Child Matters in 2003; the National Service Framework for Children, Young People and Maternity Services in 2004; and the Children and Young People’s Health Outcomes Forum, which operated for four years to 2016.

‘People change posts and things wane, and then they come back again, but we haven’t got consistency,’ Ms Smith says. ‘From my perspective, provision and services became siloed and fragmented over the past decade.’

It remains to be seen whether  NHS England’s Long Term Plan, published this year, will break the cycle. The plan details how children can be given ‘a strong start’, for example by receiving more support from school nurses.

Play as distraction

It is not only nurses who have changed the child care landscape, Action for Sick Children’s acting chair Margaret Jeal, a children’s nurse, emphasises the growing role of play.

5.8%

Reduction in neonatal mortality in England and Wales since 2010

Source: NHS Long Term Plan 

‘Play was never seen as a necessity,’ she says, adding that hospitalised children were once expected to ‘sit on their beds and be quiet all day’.

‘But play specialists are wonderful. They help with distraction, and provide something normal and of the outside world, which is needed because hospital is a foreign environment.’

Meanwhile, the part played by charities, such as Action for Sick Children, in easing the burden on statutory services is growing.

Andy Fletcher
Andy Fletcher

Some of these charities have grown alongside the NHS, others have been created because there was too little mainstream provision to meet identified needs.

Together for Short Lives chief executive Andy Fletcher says that, 30 years ago, children’s palliative care was barely recognised as a separate discipline.

But from the establishment of Helen House in Oxford in the early 1980s to the present day, more than 50 children’s hospices have opened in the UK.

Ethical issues

Alfie
Card and flowers in memory of Alfie Evans at Goodison Park stadium,
Liverpool. Picture: Getty

Difficult ethical questions have arisen, however, such as those surrounding Charlie Gard and Alfie Evans, who both died following legal battles between parents and medical teams over the children’s best interests.

‘The challenge is in what we can do to sustain life from a very early age for longer,’ Mr Fletcher says. ‘And this is blended with public understanding of what palliative care is.’

These ethical and moral dilemmas are likely to multiply, he suggests.

Underpinning recent advancements in children’s nursing has been a burgeoning body of research that did not exist 30 years ago, suggests Edge Hill University professor of children’s nursing Bernie Carter.

Bernie_Carter
Bernie Carter

‘People weren’t known to be interested in research then,’ she says. ‘Now, we’ve got a real flowering of research talent coming through.

There is more co-production of research, too. ‘Everything’s now grounded in what’s important to children and families.’

She adds that parents today are expected to be highly skilled in caring for their sick children.

‘For children with complex needs, parents are undertaking care that would require nurses several certificates to do. If I had to give a medal for admiration, I would give it to parents.

‘I don’t think we could have predicted this 30 years ago because nursing belonged to us. Now we share it.’

Stark reminders – some of the major child care failings

Baby P
A memorial for Baby P on the anniversary of his death, London.
Picture: Getty

  • 2000 – eight-year-old Victoria Climbié was tortured and murdered by her guardians. A public inquiry revealed ‘blinding incompetence’ among agencies that had failed to act. Major changes in child protection policies followed.
  • 2001 – an inquiry report into the deaths of babies undergoing heart surgery at Bristol Royal Infirmary states that staff shortages, lack of leadership, lax safety and an ‘old boy’s culture’ among doctors were contributing factors.
    Also in 2001, a report on the organ retention scandal at Alder Hey Children’s Hospital found that hearts and other organs had been stripped from dead children and stored without permission.
  • 2007 –  ‘Baby P’, later revealed to be 17-month-old Peter Connelly, died after sustaining more than 50 injuries. Peter, like Victoria Climbié, had been seen repeatedly by health and social services. The case sparked debate about child protection and suggestions that social workers had been scapegoated.

The emergence of community children’s nursing

Mark_Whiting
Mark Whiting

Mark Whiting, consultant nurse at the Peace Children’s Centre in Watford and WellChild professor of community children’s nursing at the University of Hertfordshire, says:

‘In the summer of 1988, the RCN Community Paediatric Nurses Special Interest Group held its first-ever networking event at RCN headquarters.

‘Thirty nurses came together at what was perhaps a pivotal moment in the emergence of community children’s nursing in the UK.

‘These 30 nurses represented over half of all the children’s community nurses (CCNs) working in England and Scotland. At that time, there were no CCNs in Wales or Northern Ireland.

‘By 1996, 50% of UK health authorities were commissioning local CCN services and this trend continued through the first decade of the 21st century.

‘However, although there is much to celebrate, major inconsistencies remain in nursing provision for children and their families in the community.

‘Far too many can access CCNs only during weekday office hours and few services offer 24-hour care.’

 

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