THE NATURE AND CHARACTERISTICS OF PAEDIATRIC

NURSING

In the last chapter, we looked at the nature of the child. We started off by thinking that we all know what a
child was. By the end of the chapter, we may have wondered whether we knew much at all about children.
This was a good result. While we all like to think that we know a lot of things; that supposed knowledge can do
a lot of harm. Over the history of paediatric nursing, much harm has been done by well intentioned people
who thought that they knew what they were doing. It is perhaps safer for us to acknowledge our ignorance
and only see what we know within the perspective of that ocean of ignorance. Paediatric nursing is our
discipline, it is what we do with our working lives – yet this chapter will attempt to demonstrate that we know
very little about it.

What’s in a name?

Let’s start by looking at what we do know. Well, we know the meaning of one of the two words that are used
to describe our discipline; we know what ‘paediatric’ means. The word paediatric is actually an awkward,
perhaps even linguistically ugly combination of one Latin word and one Greek word. The word Paed is derived
from the Latin ‘Pais’, meaning ‘child’ (Jolley 2006). Our friends in the United States uses a rather different
spelling of paed, omitting the ‘a’ and so confusing the poor child with the Latin world for ‘feet’. In 1928, Sir
Frederick Still agreed to form the ‘British Paediatric Association’ but did so on the condition that the new
organisation used the original Latin spelling (with the ‘a’) rather than the one that had been transported to the
US by Puritans not noted for their command of Latin (Forfar, Jackson et al. 1989). So, paediatric nursing has
something to do with children, we know that much. This leaves us with the ‘iatric’ part of the word. We come
across ‘iatric’ in a number of other words used in medicine, words such as ‘iatrogenic’ for example. So
paediatric means ‘the causing of disease in children by their doctors’? Well, such an interpretation might be
appropriate from time to time but this is not what iatric means. In fact, the Greek ‘iatros’ means physician or
healer. Let us say, that it means ‘a person who intervenes in an attempt to promote healing or to ameliorate
the effects of disease’. Now, I just made that up but I would argue that it is pretty close to what those early
Greeks would have meant with this word. Let us note in passing, that those early Greeks did not enjoy the
benefit of a well educated and well disciplined bunch of ‘doctors’ with which our society is blessed. No, those
few but fortunate early Greeks who knew a physician would have known a man who was well educated, well
respected and who practiced a little physiking, more or less out of personal interest. For the most part,
physiking would have been this gentleman’s hobby.

Today’s doctor, probably interprets ‘iatros’ as meaning ‘physician’ and so for him or her the meaning of
‘paediatric’ is perfectly clear, the word means “child’s doctor”. It follows that “paediatric nurse” means ‘child
doctor nurse’ and is essentially - nonsense. It is also the case that in some countries, the form ‘paediatric
nursing’ has fallen into a degree of disrepute. In such cases, the form “children’s nursing” has sometimes been
used to replace ‘paediatric nursing’. The rationale most often provided for this is that ‘paediatric’ is a medical,
and not a nursing term. It might be worth taking a little sojourn with the dictionary and perhaps with history to
make sure we understand what is going on here.

In the nineteenth century, people who nursed children were usually referred to as children’s nurses and their
craft as ‘children’s nursing’. At this time, most doctors were generalists and there were few doctors who

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worked solely with children. Eventually, however, medical facilities for children developed to the extent that
doctors specialised in the treatment of children’s medical and surgical problems. First in the USA and then in
the UK and other countries, these ‘child doctors’ began to refer to themselves as ‘paediatric’ or as
‘paediatricians’. This did not happen in the UK until 1928 (Forfar, Jackson et al. 1989; Jolley 2006).

However, before we discard the form ‘paediatric nursing’, we should note the following:

(1) It has been in use for nearly 100 years and is readily understood around the world;

(2) The ‘iatros’ part of the word could be taken to mean ‘therapist’, rather than physician and we can argue
that nursing is indeed a ‘therapeutic’ activity;

(3) The form “children’s nursing” is grammatically incorrect in that the apostrophe before the ‘s’ is ‘possessive’
– so we are saying that the nursing ‘belongs to’ the children. Perhaps the apostrophe should be placed after
the ‘s’, but this would be wrong because ‘children’ is already plural. To example this, we sometimes use the
term ‘adult nursing’, that’s okay but we would not seek to use the term “adult’s nursing” because that would
be wrong. In this way, the word ‘childrens’ is like saying ‘sheeps’ in English. So, there is no correct form of
“children’s nursing”. To get around this we would (and should) actually use the form ‘child nursing’ or ‘children
nursing’.

So, where does this leave us – perhaps we should stick with paediatric nursing? In doing so, we are stating that
what child nurses do is work with children and that their function is a therapeutic one – there, we have solved
the problem.

Defining paediatric nursing

So, we are now clear what we should call ourselves. It’s a start anyway. Now, I guess, we should try to work
out what paediatric nurses do, what it is that is distinctive about paediatric nursing, what marks it out from
other disciplines. If we do understand what paediatric nursing ‘is’, we will be able to model it and define its
underlying philosophical principles.

What do paediatric nurses do?

Paediatric nurses work with children, children who are ill or have been injured. Arguably paediatric nurses also
work to promote health in well children. It is probably the case that most paediatric nurses work in acute
health care settings. In the West, comparatively few paediatric nurses work outside hospital. It is also the case
that while some paediatric nurses do work predominantly in ‘health promotion’, other practitioners, notably
school nurses and health visitors (public health nurses) spend most of their time doing this sort of thing. Both
Public Health Nurses and School nurses work with children and most of these people do not have a paediatric
nursing qualification. So, perhaps it would be fair to say that while paediatric nurses do work in areas of
‘health promotion’ this should not be regarded as core to the practice of paediatric nursing. We should note
that there are such people as community paediatric nurses. These people almost never work inside a clinical
setting. However, Community Paediatric Nurses are often chiefly involved in the care of the sick or injured
child at home, though their role does vary between different countries.

It is easy to say that paediatric nurses undertake a variety of roles. Most practitioners of any kind have a role
that is not totally and completely focussed on one activity. However, what really matters here is to be clear
about the paediatric nurses’ core role, for it is this that ultimately defines what they do. In the West at least,
most paediatric nurses spend most of their time working in clinical settings with sick and injured children. It is

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axiomatic then, that it is within this arena of practice that we search for the core role of the paediatric nurse.
Arguably then and controversially, let us say that paediatric nursing is chiefly concerned with the care of
acutely ill or traumatised children where that care takes place in the clinical environment. Again, accepting the
challenging nature of this argument, let us be courageous enough to say that the ‘essence’ of paediatric
nursing is not found in the community and it is not found in the arena of health promotion. Let us put this case
more clearly, the quickest way of locating a paediatric nurse would be to call or go to a children’s ward in a
hospital, for it is there that one would be most likely to find a paediatric nurse. So let us argue that clinical
(hospital) care of the child is at the core of what defines paediatric nursing.

We should feel free to challenge the position cited above. Similarly, we can argue that the above position is
not what paediatric nursing ‘should’ be, that it is not what we want it to be. We can also identify examples of
paediatric nurses practicing in ways other than that which was identified above. However, this has been about
defining the core practice as it is found today and perhaps we should not try to deceive ourselves into thinking
that what we want paediatric nursing to be is the same thing as what paediatric nursing really is at this
moment in time.

It should not surprise us that hospital nursing is at the core of paediatric nursing practice, indeed that it is at
the core of its ethos. Arguably, modern paediatric nursing was ‘born’ when early (medical) pioneers of
paediatric medicine established the children’s hospitals in the mid nineteenth century. Charles West was
chiefly responsible for opening Great Ormond Street Hospital in London in 1852 (West 1854; Arton 1982). Prior
to this wealthy families had employed nannies, governesses and nurses to look after children but these people
were chiefly servants and were largely untrained. They were never mobilised into a common discipline, they
were concerned with their own practice but not with the practice of ‘home care of children’ as a discipline.
With the advent of the children’s hospitals there was an urgent need to provide reasonably well educated and
experienced people to care for the children admitted to the hospital. The work of Florence Nightingale in the
UK ensured that such people had to be female (Nightingale 1969; Prince 1983; Baly 1987; Godden 1997;
Mackintosh 1997; Nightingale 2000; Jolley 2007). So it is that paediatric nursing was born, born into the
hospital environment. The early children’s hospitals, such as Great Ormond Street, did seek to provide a
community nursing service but it was expensive, the results could not easily be calculated and the ever-
increasing success and growth of the ‘hospital’ meant that its community nurses (known then is ‘private
nurses’) would be pulled back to work on the busy wards of the hospital (Great Ormond Street Hospital
Archive 1926; Great Ormond Street Hospital Archive 1935; Great Ormond Street Hospital Archive 1935; Great
Ormond Street Hospital Archive 1936; Lomax 1996). In real terms, the hospital ward was the core, the central
environment for the new paediatric nurses. It is therefore not surprising that such practice has remained core
to paediatric ever since that time.

Community paediatric nursing does exist and we are right to take note of that fact (Fradd 1990; Burr 1991;
Whiting 1994; Hunt and Whiting 1999; Editorial 2005). Arguably, however, the influence of community
paediatric nursing has (a) been too small to contribute to the core nature of paediatric nursing and (b) has
tried, at least in the West, to separate from hospital paediatric nursing and to create itself as a separate
discipline with its own training and own disciplinary orientation (Myers 2005). Perhaps community children’s
nursing has come to align itself more closely with public health nursing and adult community nursing than it
has with hospital paediatric nursing.

A discipline

For paediatric nursing to exist as an occupational group, there must be a discipline formed by and formed for
paediatric nurses. Individual paediatric nurses must have ‘mobilised’ themselves into a professional group. In
this way, paediatric nurses must have found a way to say to the world, ‘we are the same as each other and

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different from people outside our discipline’. To some degree, this enables the paediatric nurse to be
considered a professional. A professional ethos exists when each practitioner is not simply working for a
patient but at any one point in time is also conscious of contributing to the profession as a whole. Such a
contribution can exist in the form of professional writing, contributing at conferences and participating in
research. The paediatric nurse is a nurse and may make a contribution to the nursing professional. However, if
paediatric nursing exists as a sub-discipline or a separate discipline of nursing, then we should be able to see
these people actively contributing to the life and knowledge-base of the discipline of paediatric nursing.

So, paediatric nurses must be mobilised, that is motivated to come together, to meet and to share their
knowledge, their work and their research. We have already noted the existence of nineteenth century
household servants, many of whom were employed to care for children when they were sick and when they
were well. Yes, we have also seen that these people, many though they were, were not ‘children’s nurses’ as
we understand the term today. Indeed, these good people fail one of the most important criteria of
professional life – they were not mobilised, they did not see themselves as members of a wider professional
discipline and indeed, such a discipline shows no sign of ever existing.

It is right, then, to ask the question ‘is there a discipline of paediatric nursing’? I think that we can say that
there is. Many journals exist whose orientation is clearly that of paediatric nursing. Conferences for paediatric
nurses are help all over the world and there are organisation which purport to represent paediatric nurses,
such as the Association of British Paediatric Nurses (Jolley 2008; Randall 2008). In a practical sense, when a
paediatric nurses works on a new therapeutic approach, s/he will seek to publish the work and will probably
choose to do so within her own discipline as a priority. Paediatric nurses think of themselves, not as an isolated
nurse, doing an isolated job but as a one of many other paediatric nurses all over the world with which our
nurse has an affinity, an affinity which crosses national, cultural and many other boundaries. So it is, indeed
that paediatric nursing ticks all the boxes for existing a professional discipline and it is the valid existence of
such a discipline that makes paediatric nursing ‘real’. Paediatric nursing does truly exist, it has a presence in
the world of health care, it makes a contribution and in most countries in the world, it has a postal address.
Paediatric nursing exists.

Occupational closure

Occupational closure is a term used by Hardyment (1995) to denote the degree to which an occupational
group can limit the degree to which other occupational groups can practice in its field. In most developed
countries, for example, it is not lawful to practice surgery without being a licensed surgeon. In this example,
surgeons have achieved occupational closure – they are able to prevent other occupational groups, including
nurses, practicing their craft.

In some countries, the title ‘registered nurse’ can only lawfully be used by nurses who are registered as nurses.
However, in general, nurses have a much weaker hold on occupational than do surgeons. In fact, in most,
perhaps all countries, just about anyone can practice nursing, even if they can’t call themselves registered
when they are not registered. Indeed, the word ‘nurse’ has a number of different meanings, even to suckle a
baby! So, we will have to cope with the fact that the occupational name we choose to use to refer to ourselves
is used in several other contexts. This is a problem because it makes it difficult for us to identify ourselves
clearly. It is true that everyone knows what is a nurse but their concept of ‘nurse’ may be coloured all too
easily by images of non-qualified nurses, of assistant nurses and even of household servants.

However, it gets worse. We have been thinking about the title ‘nurse’ here but this text is about children’s
nursing, paediatric nursing. The lack of clarity about the occupational closure or nursing becomes even more
unclear when we begin to think about paediatric nursing as a separate or sub-discipline. How do we distinguish

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paediatric nursing from general or adult nursing? On what parameters do we make such a distinction?
Specifically (in terms of occupational closure) to what degree is the work of (specifically) a paediatric nurse
protected from other nurses who may wish to do that work? Can a sick child be certain of getting help from a
paediatric nurse or is it possible that any nurse may turn up to provide that help. In most countries, paediatric
nursing has no, or almost no occupational closure in relation to wider nursing. It is worth thinking about this a
little, particularly in relation to whether we would want to achieve occupational closure from the wider
professional of nursing. In the UK paediatric nurses have managed to go further down the route of
occupational closure than has been the case in almost any other country in the world. In the UK it is very
difficult for a non-paediatric nurse to get a permanent post on a children’s ward. It follows that in the UK, a
sick child in hospital really can be fairly sure of being nursed by a qualified paediatric nurse. However, even
here, the occupational closure enjoyed by paediatric nurses really only applies to hospital settings and to areas
within the hospital that are considered centrally ‘paediatrics’. In this way, a child admitted to the accident
department or to theatre might well be nursed by nurses other than paediatric nurses.

Arguably, there is a downside to the occupational closure of paediatric nursing. It can lead to isolation of
paediatric nurses within the profession as a whole. Paediatric nurses can be seen as ‘different’ and perhaps as
‘not proper nurses’. Occupational closure brings with it a degree of tribalism in nursing which is usually
unhelpful and is often referred to as ‘professional rivalry’. This is exacerbated when entry to the discipline is
‘direct’, a situation where people only ever train as paediatric nurses. Professional rivalry may be less clearly
demonstrated where paediatric nurses are first of all general nurses but who undergo a rite of passage to
paediatric nursing at a post-registration stage in their career.

So, occupational closure is an important issue for paediatric nursing. The degree of occupational closure
achieved by the discipline is one way in which it becomes defined and understood. Put simply, if ‘anyone’ is
allowed to nurse children, the discipline will be seen to be less well developed than if only paediatric nurses
are allowed to nurse children. Occupational closure signified the degree of ‘control’ that paediatric nurses
have over their work.

It may be useful to consider the advantages and disadvantages of moving toward occupational closure in your
own country. Consider also, how you might steer your discipline to achieve a greater level of occupation
closure within the social and professional parameters present in your own country.

Models of paediatric nursing

When nurses first start training, they are usually asked to consider ‘models’ of nursing. This they do with some
reluctance for they are probably much more interested in clinical and practical aspects of the role of the nurse.
It is useful, however, to return to them here because models exist, at least in part to define nursing and in this
chapter, defining paediatric nursing is what we are trying to do.

Models of nursing have a reputation for being wholly theoretical things. However, when a child plays with a
toy car or a ‘model’ house or a model soldier it is not philosophical theory with which the child plays. A model
house or car is a model of a real house or car. It is a visual and perhaps tactile representation of a real car or
house. In most cases, that is all it is. In more advanced models, the car doors might open, a little plastic driver
can be inserted and the car bonnet can be lifted up to reveal an engine. Perhaps the engine even works and
our model car can be made to propel itself along the floor. In these cases, the model shows us, not only what
a car looks like but how it works. So it is with nursing models, they show us what nursing looks like and
sometimes they show us how nursing works. Nursing models are a (usually) visual reflection of nursing. We
can (usually) draw a nursing model on a piece of paper. That’s the point of models, they exist as a
representation of the real thing. A model car helps a child imagine what it is like to drive a real car. In the same

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way, a nursing model helps us to imagine real nursing, to construe the components of nursing and perhaps to
see how those components interrelate and work together.

If paediatric nursing really does exist, we will be able to model it. Conversely, if paediatric nursing doesn’t
really exist, if it is nebulous, more fiction than truth, we will sit looking at our pencil and paper, not knowing
where to place our first mark, what shape to draw, where to begin the task. Being able to model something is
in a very real sense, proof of that thing’s existence. Furthermore, the more we understand something, the
better we will be able to draw it on paper. Think of your building you are sitting in now, you could draw a
detailed map of it. On that map you could identify every room, wall and cupboard. This might take you some
time because you know so much about that building. No draw a model of a ghost, what shape will you draw it,
what colour will it be, will it be solid or transparent, what do ghosts look like anyway? Being as some of us
have never seen a ghost, you will be drawing a model (your picture) of something in your mind alone, not in
mine. So, your model of a ghost is more difficult to draw and it is less useful because the ghost in my mind
might be quite different. Why is that, it is because none of us know much about Ghosts, we don’t even know
that they exist. So now to the nub of this discussion; if we can’t easily model nursing, it will be because we
don’t ‘know’ nursing. Not being able to model nursing is a strong indication that nursing, like our ghost, does
not really exist. I can imagine a ghost, but that does not mean it exists and my failure to model it is an
important indication that indeed, my ghost does not exist. In the same way, if we looked at your model of a
ghost, we may find that that model simply doesn’t work for other people. The ghost may exist in your mind but
not in the mind of others. So, models of nursing do exist, but if they do not work for others, then again, they
are but ghosts of an idea and not models of something real. It follows that we should never criticise models of
nursing but instead we should criticise the thing being modelled. The model is poor, when the things being
modelled is hard to identify, nebulous in character and more a figment of our imagination that anything that
could be regarded as real.

Now we must come to the hard reality of models. The fact is that there is no model of nursing and less still of
paediatric nursing which has ever been much good. Do we have nurses who are deeply dedicated to the use of
one model over another, do they wax lyrical about them, play with them for hours as children play with a
model car or a model house? Nope; we don’t. This tells us something important about nursing and about
paediatric nursing; nursing – does not exist. If it did we would be able to map it, model it just as people have
mapped countries of the world and modelled almost every car from the humble Model-T Ford to the Ferrari.
We can’t map it because it doesn’t exist! Remember, don’t blame the model (or those who try to create them),
blame the thing being modelled.

Let’s get back to earth, of course nursing exists. However, what we have discerned here is that the degree to
which nursing is independent of other health care disciplines is limited. We can’t see nursing clearly because it
merges with the background created by many other health care disciplines. Our model is blurred at the edges
because in reality, nursing is blurred at the edges too. We have to decide whether we are happy with nursing
like this or whether we would like to change it. One of the ways in which we can begin to change it is to
redefine it. It is pursuance of this that nursing theorists have ‘tried’ to develop models of nursing and
theoretical approaches to nursing. In much the same way, the nursing process was an attempt to define the
ways in which nurses worked. The nursing process was an attempt to identify nurses as being problem-solvers,
thinking, rational people and nursing as a thinking, problem-solving discipline. So it is that even if we may not
like the results of these people’s work, we should still be cognizant of ‘why’ it is that they embarked upon this
task. What these people have been trying to do is to define nursing, so that it can be successfully modelled, so
th
that we can say we know what nursing is and what it is not. In the mid 19 century, Florence wrote her key
text on nursing and entitled it ‘Nursing, what it is and what it is not’ (Nightingale 1860), I suspect she might be
a little disappointed with the progress we have made since that time.

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Philosophical underpinning of nursing

Another aspect of professional life is that it is ‘underpinned’ by a philosophical approach. In this way,
Hippocrates provided Medicine with a particular stance on healing which came, through the Hippocratic Oath,
to define medicine from that time to this. Doctors were only to deal with what they knew, the patient’s
interests were to come before that of the doctor and the doctor was to work for everyone, the poor as well as
the rich, the bad as well as the good. It is partly because of the noble aspirations of the Hippocratic oath that
doctors are viewed relatively positively, even though the reality of their practice today does not always seem
to relate easily to Hippocrates vision of medicine.

We could argue that nursing has ‘borrowed’ the philosophical position of medicine. Perhaps it has and perhaps
this is why nurses and doctors have managed to work together so well, in adopting the same philosophical
underpinning, they ‘see’ things in the same way. We have already noted that nursing is blurred at the edges
because it all to easily ‘merges’ with the health care background in which it operates, perhaps this is one way
in which that happens.

In recent years, nursing has undergone something of a backlash against it being seen as a sub-discipline of
medicine. Indeed, in the West, the usage ‘paediatric nursing’ has fallen from favour because it is seen to be too
medical. Nursing programmes in the UK and US have become distinctly less orientated to the medical sciences
of pathology, pharmacology, histology etc and these subjects are now seldom formally taught within nursing
programmes. Their place has been taken by modules which are seen to be more nursing focussed, though it is
often difficult to be clear about what that focus is exactly. In fact, this is something of a problem, in giving up
our ‘traditional’ allegiance to medicine, nursing has been left in something of a philosophical void. Nurses
often talk about an emphasis on ‘care’ but it is not clear what is meant by ‘care’. After all, everyone cares,
doctors care, physiotherapists care. ‘Caring’ fails to distinguish nursing from medicine, from anything really.
Nurses know that they care and they probably know that what they do is different from what doctors and
physiotherapists do but they cannot clearly state the nature of the uniqueness of what it is they do.

Your task
So we have been clear about the nature of the problem but not very clear about what to do about it and how
to move this issue forward. Now it’s your turn. You think you know what a paediatric nurse is, here is your
chance to tell us all.

Try to draw a theoretical (construct) map of paediatric nursing, identifying the nature, purpose, and internal /
external relationships core to the discipline. This should be a graphical construct map which communicates the
conceptual basis of the discipline;

In writing, define what paediatric nursing means to you, what you think it should mean and how its identity
should develop in the coming years.

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