Children in our present society are given ‘rights’ that were not accorded to children in previous generations. In Victorian times it was often said that children should be ‘seen but not heard’. In today’s society, children have rights under the United Nations Convention on the Rights of the Child (United Nations General Assembly 1989). This sets out the basic human rights that all children are entitled to without discrimination. The Convention is underpinned by four guiding principles, which are those of non-discrimination (Article 2), the best interests of the child (Article 3), survival and development (Article 6) and participation (Article 12). The British government ratified the document in 1991 and, by so doing, committed itself to protecting and ensuring children’s rights and agreed to hold itself accountable before the international community. Although in itself it is not a legal statute, the United Nations Convention on the Rights of the Child can be used to support the rights of children. Legislation, which builds on the Articles contained in the Convention on the Rights of the Child, seeks to offer further protection to one of the most vulnerable groups within our society.

The Children Act (1989), which applies in England and Wales, is based on the principle that the child’s welfare is the paramount consideration and that effective interventions should be in place to ensure the safety and well-being of children who are at risk of harm. It states that children should, wherever possible, be brought up and cared for within their own family, with both parents playing a full part in their lives, without resorting to legal proceedings. Only in situations where there is fundamental disagreement between parents, or concerns about the child’s welfare, will the Courts make orders about a child’s place of residence and contact arrangements. The Act emphasises the rights of children to be kept informed about issues that affect them.

The Children (Scotland) Act (1995), which applies in Scotland, is based on the following key principles:

With the introduction of the Human Rights Act (DoH 1998) some of the rights set out in the European Convention for the Protection of Human Rights and Fundamental Freedoms (1950) became part of British law. Many rights are set out in the Act but of particular relevance to children’s nurses, and indeed to all health professionals, are:

The Human Rights Act, which is central to the right to self-determination by children and young people, includes their right to consent to or refuse treatment (Lowden 2002). However, the Children Act (1989) and the Children (Scotland) Act (1995), although providing legislation that relates to the care of children and their upbringing and protection from harm, do not go beyond establishing their right to be involved in decision making about their welfare. The Human Rights Act enables action to be taken if it is proved that children’s rights have been infringed (Power 2002).

Children in our society are without a political voice and, until recently, played no significant role in the political processes that impact and influence their lives.

The recent appointment of Children’s Commissioners in Wales, Northern Ireland and Scotland is a response to the need to address the rights of children. England delayed the appointment of a children’s commissioner after lengthy discussions about the proposed role and powers. The role was felt to fall short of the United Nations international guidelines. In the interim, Margaret Hodge, the Minister for Children in England, held responsibility for children’s services, childcare and the protection of the under-fives as part of her portfolio. Al Aynsley-Green was appointed Commissioner for Children in England in March 2005. The appointment of Peter Clarke in Wales, Nigel Williams in Northern Ireland and Kathleen Marshall in Scotland ensures that children in these countries have an advocate in all matters that affect them, either directly or indirectly. Part of the role of the Commissioner is to monitor all proposed legislation to ensure that the needs and best interests of children are met. They will also have a remit in relation to child protection (see Chapter 19). Undertaking and commissioning research is another strand of their work. This activity should contribute to the body of knowledge on which sound decisions can be made on matters affecting children.

With rights come societal responsibilities and subsequently new challenges for nurses caring for children and their families in hospital and community. In the past, children were considered as individuals with needs, whereas in contemporary society they are considered to be individuals with rights. The two standpoints are not mutually exclusive. However, the task facing children’s nurses today is very different from the task faced by those caring for children at the time of the inception of children’s nursing in 1852.

The material that follows traces the origins of children’s nursing in the UK in the context of changing concepts of childhood. Consideration will be given to the fight for registration for sick children’s nurses and the evolution of children’s nursing in response to greater understanding of the needs of children and their families. Consideration will be given to the educational provision that seeks to ensure that the children’s nurses of tomorrow are equipped to provide high standards of care for children and families. Finally, an overview will be given of some of the challenges currently facing children’s nurses in the UK.

Children’s nursing has undergone a number of fundamental changes since its inception in the mid-18th century. The changes reflect developments within the nursing profession but also changes in societal views towards children themselves and to the needs of children and families. Reference to the sociological analysis of childhood provides substantial evidence of the ambivalent attitude of the British towards children (Scraton 1997). Indeed, this began to change in the time of the European Enlightenment when, rather than looking at children as poor and weak, whose survival was little valued, society increasingly recognised that children were its future and that their healthy survival was essential for the continuation of society (Seidler 1990). However, there is continued evidence of a lack of respect for children and their specific needs within society in general, and this attitude is even more evident in the NHS than in the general population.

It is generally agreed that the perspective from which they are considered influences perceptions about children and childhood. Writers on the subject rarely reach a consensus. Thomas, cited by Avery & Briggs (1989), highlights the difficulties of unravelling the concept of childhood by suggesting that historians and modern writers continue to write the history of adults’ attitudes towards children rather than the history of childhood. This can still be seen in society today, when debates about what constitutes the best interests of children often centre on what adults define as ‘best interests’.

One of the most influential writers on the subject of childhood is Aries (1962), a French historian. He and de Mause (1995) are referred to in many childcare texts. Aries’ (1962) views are often misrepresented, as he did not consider the absence of a concept of childhood as detrimental to children. He noted that children in the Middle Ages mingled with adults and spent considerable time in their presence, working and playing. In his opinion the separation of adults from children occurred in the 17th century, with the start of education dominated by religion-based morality. Not all historians agree with this view and, in his writings, de Mause makes the dramatic statement:

During the 18th century the needs of children were increasingly recognised and by the 19th century children were considered valuable and therefore in need of protection (Stone 1977). It was this change in attitude that led to the establishment of foundling hospitals and dispensaries for children. In the 20th century the individuality of the child has become more evident. Family life has become increasingly important. The status of the child has increased significantly with the introduction of the European Convention on the Rights of the Child in 1989 and the Human Rights Act (1998). In our society today children have the right to expect protection from harm and a right to self-determination. This is in stark contrast to the Victorian view of children, whom they considered should be seen and not heard. It has been suggested that changing perceptions of childhood over the years can be analysed by studying the themes of play, art and literature (Watt & Mitchell 1995).

Children throughout history and in all cultures engage in some form of play through which they learn to make sense of the world of which they are part. They use imitation and experimentation to learn and experience essential social roles and values. Before the 17th century, little evidence exists for children’s play, although in the 4th century BC Aristotle – a proponent of play as a prerequisite to health – advocated that children under the age of 5 years should not work. He considered that to do so would be detrimental to their health and well-being. Singer (1973) suggests that it is likely that children did play but, as it was not considered an important activity, adults did not comment upon it.

According to Aries (1962) there were few attempts to portray childhood in art before the 12th century. This reflected society at that time and the place of children within it. In some of the early artwork images children were depicted as miniature adults. It was not until the 15th and 16th centuries that it became popular to portray children in a social context. The Dutch artist Rembrandt achieved popular acclaim for his work, which included portraits of individual children.

There is limited evidence of children’s literature prior to the 18th century. Orbis Sensualism Pictus by Comenius, which was printed in 1658, is said to be the earliest illustrated book specifically designed for children. Much of the early children’s literature was written to appeal to adults and often contained moral messages. Der Stuwwelpeter, is a good example of this. Heinrich Hoffman (1809–1894), a German psychiatrist, wrote and illustrated it in 1845 for his son.

In Britain in the mid-18th century, many parents – faced with extreme poverty – abandoned their infants and children. They did so in the hope that they would be taken by adults who were in a better position to love, nurture and care for them (Schwartzman 1978). Interestingly, the mortality rate among children who remained with their natural families was higher than among those who were abandoned and subsequently taken in by other adults. This was because the original home conditions for many children were squalid, with poor sanitation, overcrowding and high levels of poverty (Kosky & Lunnon 1991). It is estimated that during the 1850s, 50,000 deaths occurred each year, of which over 21,000 were children less than 10 years of age.

Thomas Coram (1668–1751) was born in Dorset and spent much of his life at sea. After working in the ship-building business he moved to London, where by 1732 he was a successful merchant. The sight of abandoned infants and children appalled Thomas Coram and in response to what he saw he applied for and was granted a Royal Charter by George II to open the Foundling Hospital, in Hatton Gardens in London in 1741 (Franklin 1964). By taking abandoned infants and children into the Foundling Hospital, Coram wanted to prevent the murder of infants at birth and to stop the practice of parents abandoning their infants and children to die on the streets of London. The primary aim of the Foundling Hospital, which was not a hospital as we know it today, was the provision of care and education. The visionary work of Thomas Coram was widely recognised and many famous artists became patrons and governors of the hospital. Some of their artwork was displayed in the Foundling Hospitals during the 18th century. Today examples of the work of Hogarth, Reynolds and Gainsborough are now on view in the Foundling Museum, established in London in 1998.

There were many such hospitals and, as the name suggests, they were places to which children who were the illegitimate offspring of the poor or who had been abandoned by their parents were taken. Members of the public viewed the foundling hospitals with a high degree of suspicion, considering them to be places of death because of their high mortality rates. In 1756 the governors appealed to the House of Commons for financial assistance. Although granted, the assistance was conditional and required that the governors accepted all children offered to them. The number of sick and seriously debilitated infants and children arriving at the hospital increased dramatically. According to Franklin (1964), the indiscriminate admission of 14,934 babies over a 46-month period in the 1760s resulted in 10,389 deaths. The majority of the infants who died were under 6 months of age. Increasingly it was recognised that children who survived until their second birthday had a significantly improved chance of surviving childhood.

In the UK, the response to the growing problem of sick children involved the setting up of charitable dispensaries. Dr George Armstrong (1719–1789), a Scottish surgeon, is credited with the establishment of the first dispensary or ‘ambulatorium’ in Red Lion Square, London, in 1769. His work is an early example of ambulatory care and some today consider him to be the ‘father of ambulatory care’. The main aim of dispensaries was to lower the toll of mortality among infants and children by providing advice and administering medicines to children of the poor, from birth to 10–12 years of age. This provision was designed to meet the needs of infants and children who, at that time, were often refused admission by most hospitals. Children were acknowledged to be susceptible to infection often as a result of poor nutrition.

As well as keeping children out of hospital, the work of Dr George Armstrong was based on the belief that to separate children from their families was to ‘break their heart’ (Miles 1985). Accounts about the dispensaries suggest that cost of hospital care was a factor for many parents. Armstrong shared the concern that the economic pressure of looking after a child in hospital would place an intolerable financial burden on many parents. However, the overriding view of Armstrong was that children should ‘remain at home, however humble, surrounded and affectionately nursed by their dearest relations, and by those who feel a natural and earnest interest in their welfare’ (Miles, 1986a and Miles, 1986b).

John Bunnell Davis founded the Universal Dispensary for Children in 1816. In 1823 it became the Royal Universal Dispensary, located in Waterloo Road in London (Franklin 1964). It was intended to provide a centre-point of medical attention for the investigation of diseases in children and young people. Although initially teaching and home visits appeared central to the work of the dispensary, these elements gradually ceased. Other cities throughout the UK opened dispensaries based on similar principles, for example in Manchester in 1829 and Liverpool in 1851. The figures from the Universal Dispensary for Children during the first 3.5 years after its introduction demonstrate a significant improvement on the statistics from the foundling hospitals. It is reported that during this time 7820 sick infants were treated and 7030 cured, 300 vaccinated, 130 died and the remainder continued to receive ongoing care (Franklin 1964). Charles West, the founder of the Hospital for Sick Children, Great Ormond Street, worked for almost 10 years as the physician from 1842. John Bunnell Davis died at the young age of 44 but is credited with being one of the most important influences on British paediatrics, having established an early version of a school of medicine linked to the Universal Dispensary for Children that he founded (Franklin 1964).

Although dispensaries met with some success in reducing the mortality rate amongst infants and children, physicians were forming the opinion that specialist inpatient care was becoming increasingly necessary. In their first argument for such a provision they cited examples of the European cities where children’s hospitals were already established. The number of children’s hospitals in Europe had increased steadily throughout the 17th, 18th and 19th centuries, starting with the La Maison de l’enfant Jesus (which was an orphanage, although reported by some writers to be a foundling hospital; Guthrie 1960), which opened in 1679. This institution was subsequently converted to L’Hôpital des Enfants Malades in 1802 at the Rue de Sevres in Paris. Other European cities that opened hospitals include St Petersburg in 1834, Vienna in 1837, Budapest in 1839 and Moscow in 1842. However, the mortality in such places was a cause for concern. The high mortality rate reported in L’Hôpital des Enfants Malades was attributed to infectious diseases and the scarcity of nurses with the necessary knowledge and skills (Lomax 1996). Around this time, Louis Pasteur’s work on microorganisms was gaining momentum and the knowledge and understanding of microorganisms and cross-infection steadily increased (Craig 1977). Pasteur (1822–1895) provided the impetus for microbiology and contributed to the development of the first vaccines.

In London in 1850 it was estimated that children under the age of 10 years occupied approximately 3% of available hospital beds but that the deaths in the same age group accounted for 50% of all deaths in London (Franklin 1964). In 1851, a public meeting approved the idea of establishing a children’s hospital and the Hospital for Sick Children, in Great Ormond Street, opened in 1852 with 10 beds (Arton 1982). In 1858 the purchase of a second house adjacent to the original provided much needed additional accommodation and the number of children who could be admitted rose to 75. The novelist Charles Dickens, a close friend of Charles West – the founder of the Hospital for Sick Children, Great Ormond Street – was himself a strong advocate of the idea of a children’s hospital and his depiction of the nurse Sairey Gamp in his novel ‘Martin Chuzzelwit’ (Dickens 1984) has been credited with providing ammunition that undermined the early working-class domiciliary nursing movement in favour of a medically dominated, nurse subservient workforce (Rafferty 1995). Queen Victoria, who subscribed to the project, subsequently became its patron (Arton 1982) and Lord Shaftesbury (1801–1885), the factory reformer and philanthropist, was another supporter of the venture to build a children’s hospital. The slogan used at the time of fundraising in the late 19th century was ‘children’s health, the nation’s wealth’. Today, as the Hospital for Sick Children, Great Ormond Street plans new and exciting developments, the centrality of the child continues to be reflected in its mission statement ‘the child first and always’.

During his time at the Universal Dispensary for Children, West had had the opportunity to visit the homes of sick children and was aware of the acute problems, such as overcrowding and lack of ventilation, that made the home environment unsuitable for many of the children. Before establishing the Hospital for Sick Children, Great Ormond Street, he also visited the National Children’s Hospital in Dublin, the first hospital in Britain entirely dedicated to the care of sick children.

The aims outlined by West in 1852 formed the basis for other similar institutions throughout the UK. They reflected a change in emphasis from reducing mortality to a stronger focus on teaching. This shift in emphasis acknowledged that specially trained children’s nurses would be vital in the overall efficiency of care of sick children. By 1888 it was estimated that there were 38 hospitals for sick children in the UK (Franklin 1964

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