Children’s nursing in the UK

1. Children’s nursing in the UK An historical background

2. The three periods of paediatric nursing • Romantic Victorianism (1852-1920) • Professionals, behaviourism and state intervention (1920-1959) • WWII and the growth of FCC (1960-2012) What next?

3. Why history? • Nursing has a rich heritage • We can learn from the past, mistakes, errors and successes

4. Paediatric Nursing • Paed - From the Latin, pais, meaning ‘child’. Paed or ped can be found in many European languages derived from Latin and also Greek • Iatric – From the Greek ‘Iatros’, meaning ‘to treat’, to intervene in illness • Note the US ‘Pediatric’ Ped, from the French form of ‘paed’. • The word paediatric was only used in Britain from 1928 (formation of the BPA)

5. Lack of evidence • The daily normalcy of parental care ? Not worth recording. • No political agenda • Undertaken by females, less educated, less power • Women’s work considered menial and un-intellectual • The notion of ‘care’ in relation to political power • Nurses not in control of nursing

6. Children have always been important to parents and to societyChildren mistreated when adults mistreated (Victorian factories etc.Children have always been loved and valued Why paint the unimportant? William Bromley 1835-1888

7. The monastic movement Monasteries did provide care to travellers and were a focus of learning but there is little evidence of the care and treatment of children.

8. Foundling Hospitals London Foundling Hospital (est. 1739) Perhaps the first children’s hospital Founded by Thomas Coram (see Besser 1977) High death rate (80% during childhood) Was briefly funded by the state (1756) Partly a response to ‘churchyard luck’, and the killing nurses Go to the website Thomas Coram Painting by Hogarth Besser, F. S. (1977). "Great Ormond Street Anniversary." Nursing Mirror 144(6): 60-63.

9. The children’s dispensaries The first children’s dispensary in Red Lion Square – London 1769 Established by George Armstrong • Before mid 19C few hospitals and almost all for adult deserving poor • Children’s dispensaries relatively common (cities) • More like OPDs than Chemist’s shops • Staffed by Drs and apothecaries • Provided experience for Drs and nurses in training

10. George Armstrong • Perhaps could not see how hospitals could be resourced • A charity only available to the deserving poor • Acknowledged that parents knew their child best • Armstrong opposed to hospitals but not foundling hospitals, may simply have wanted resources to come to his dispensary Armstrong wrote ‘an essay on the diseases most fatal to infants’

11. Dispensaries – good points • Community based – paeds in the community • Hugely successful – at one point most cities had one. • Breeding ground for ‘excluded’ medical staff, including Charles West. West worked at the Universal Dispensaries usually had no nurses but did employ some and some community nurses • Could have survived in preference to the hospital • Dispensaries reinforced paeds as an entity Go to the website

12. Dispensaries – the bad points • Financially vulnerable – failed to hit the romantic soft spot • Dispensaries small and vulnerable • Armstrong had CVA in 1781 and the dispensary went into decline • Franklin (1964) Universal Dispensary at one time had its own medical school (34 students). However, could not provide good quality medical and nursing training – that required a hospital. Children once cured had to report back to the dispensary

13. Dispensaries live on • Many developed into hospitals • Mary and Ellen Phillips’ development of the Woman’s Dispensary in Bethnal Green (QEH for children Hackney). • 1902, the Royal Universal Dispensary became the Royal Waterloo Hospital for Children and exists today as part of St. Thomas’ Hospital • Relate dispensaries to Infant Welfare Clinics (from 1878 Sophia Jex-Blake), forerunner of the Ladies Sanitary Movement (HVs) and to other forms of ‘clinic’ (child guidance clinics’ operating outside the hospital

14. Hospitals in Europe • Continental countries did possess children’s hospitals, especially France where the service was centralised, West had studied in France. • First conventional children’s hospital .. Paris 1676 (Saxton 1981, Guthrie (1960) • Initially a foundling hospital (Maison de L’Enfant Jésu) • Became L’Hôpital des EnfantsMalades in 1802 • Provided a widely copied model across Europe • Provided a rationale for Britain .. used by Charles Wilson (Edinburgh) and Charles West (GOS) Guthrie, D. (1960). The Royal Edinburgh Hospital for Sick Children. Edinburgh, Churchill Livingstone. Saxton, J. (1981). "Paediatric nursing: an historical view." Nursing Times (Spotlight on Children) 77(50): 4-7 (ABPN).

15. Dispensaries into hospitals • Charles West became frustrated and resigned from the dispensary in 1849, he had already identified a house in GOS • West was well trained but socially excluded (Methodist and had to obtain his training abroad) • This was probably the reason for the establishment of many specialist hospitals in the mid 19C

16. Why the time was right for hospitals • The report by Chadwick (1842) had made the public aware of the social problems • Fear of the French Revolution spreading • The rise of religion in Victorian Britain • Charles Dickens’ books reflected a new concern for the welfare of the poor • Hospital, clear cut, new but tried approach to the social problems – they hit the romantic soft spot and could so could be funded Charles Dickens

17. Great Ormond Street (GOS) • Vision of Charles West of the Universal Dispensary • Sought influence and money from Dr and Mrs Bence-Jones • Charles Dickens, Queen Victoria, Joseph Barclay and John Fry involved • Armstrong’s lesson had been learned • GOS opened 1852, first patient Eliza Armstrong 3 ½ • West and William Jenner physicians, Mrs Willey Matron • GOS first hospital entirely for children

18. Hospitals: but not as we know them • Little if any surgery • No infectious diseases • No babies or children under 2 years • Initially small children admitted with their mothers, this stopped when sufficient nurses (Evans 1979) • Very small, usually a converted house • Only consulting (visiting) doctors • Children’s hospitals selected interesting and safe cases • Was a service to the deserving poor, aimed to educate poor women in the care of sick children

19. GOS: nurses • Nurses recruited from better class servants • Nurses required to read but not write (Srs had to write) • Had to know the Lord’s Prayer and 10 Commandments • Had to be C of E • Had to be kind and keep the children happy • Problems recruiting and keeping nurses (general and fever) • No applications for training in 1857 • Nurses left because .. not strong enough • Saxton (1981) nurses dismissed with ‘alarming regularity’ Matron Willey – first matron

20. GOS: romantic image • Had toys, a garden and garden play equipment • Had to sell a romanticist image .. income generation • The wards had many important visitors The logo used by GOS today is intended to encourage donations.

21. Florence Nightingale • Initially opposed the children’s hospitals and to children’s wards (Atkinson 1981) • FN may not have been able to see how enough children’s hospitals could be funded • May have thought that it was better to educate mothers, hence her book ‘notes on nursing’ • ‘Where adults are mixed with them, the women in the next bed, if the patients are judiciously distributed, often become the child’s best protector and nurse and it does her as much good as the child.’ FN Atkinson, B. A. (1981). "Paediatrics Past." Nursing Times 77(50): ABPN 1-2. Nightingale, F. (1860). Notes on nursing: what it is and what it is not. Version sold in the US, D. Appleton and Co.

22. FN against children’s hospitals ‘The causes of the enormous child mortality are perfectly well known; they are chiefly want of cleanliness, want of ventilation, want of whitewashing; in one word, defective household hygiene. The remedies are just as well known; and among them is certainly not the establishment of a Child’s Hospital. … We have it, indeed, upon a very high authority that there is some fear lest hospitals, as they have been hitherto, may not have generally increased, rather than diminished, the rate of mortality - especially of child mortality.’ FN Nightingale, F. (1860). Notes on nursing: what it is and what it is not. Version sold in the US, D. Appleton and Co.

23. Florence Nightingale ‘… We have a little boy of 6 years old in one of the Male Surgical Wards of our St. Thomas’ Hospital - we often have such children - it was brought in cursing & swearing - [it had never heard a good word in all its life.] with an abscess in its back - about a year ago. It can only just stand now - it will never be well, tho’ it is much better. The ‘Sister’ of the Ward (Head Nurse) did not scold or preach to Bobby -he goes by the name of Bobby, for no one knows its name. She was very gentle with Bobby - & very loving - but he must obey. {By degrees he soon found that}. She taught him his little prayers. And now if she is busy, he calls: ‘Sister, Sister, I have not said my prayers’. And it is a real speaking to God with him. And the new patients stop and listen to hear him .. So he is a little Missionary & quite an influence among the rough men Patients. And his little cot is run in at night between two of the men Patients. And they take care of him’. FN Nightingale, F. (1886). Letter sent 09/03/1886. A. Hepworth, http://clendening.kumc.edu/dc/fn/2hpwrth1.html.

24. FN eventually recognises paeds ‘It is not enough to be merely conscientious and patient, there must be genuine vocation and love for the work. A feeling as if your own happiness were bound up in each particular child’s recovery. Nothing else will carry you through the perpetual wear and tear of the spirits, of the fretfulness, the unreasonableness of sick children - nor that I think it is greater than that of many sick adults - but it is more wearing because the strain is never off for a minute. These are the peculiarities of children’s hospitals to be weighed before such are decided upon, shall you find sufficient nurses of this kind?” FN Atkinson, B. A. (1981). "Paediatrics Past." Nursing Times 77(50): ABPN 1-2.

25. 20th century nursing

26. The three periods of paediatric nursing • Romantic Victorianism (1852-1920) • Professionals, behaviourism and state intervention (1920-1959) • WWII and the growth of FCC (1960-2012) What next?

27. Early views on parents • By 1905 Glasgow had an annex for resident parents, funded by surgeon James Nicoll who argued that the ‘best and safest place for a child after an operation was in its mother’s arms’ (Dopson 1983, p. 8) • Home nursing also took place there from 1880. Senior home nurse was Sr Laura under who’s name was marketed baby food in 1911.

28. Nurses and doctors • Paediatric nurses were important and valuable • But not as important or valuable as doctors • Not as ‘clever’ as doctors • Medicine more ‘interesting’ than nursing • Nursing not a science, no sense of responsibility to develop it Nursing was a science with the thinking turned off

29. Nurses • Nursing: a micro-culture • Regimented discipline • Nurses proud of their work history • Cared about children • Emotional neutrality • Nursing was ‘comfortable’ • Did not want responsibility • Skilled but not problem solving • Nursing possessed a ‘known way’ • Doing the job properly was most important

30. Science and professionalism ‘They [nurses] must always remember that discipline and obedience are the keynote to satisfactory and efficient work in life, for to rule well they must first learn to obey … the importance of this [cleanliness] is emphasised when one realises that practically all the triumphs of modern surgery have been achieved through the adoption of a scientific system of cleanliness’. Ashdown, A. M. (1927). A complete system of nursing. London, Waverley Book Company Ltd.

31. Science and professionalism ‘… we went by the textbooks. If for example a person comes in with appendicitis and they had to go to theatre. We would do the observations, we took their history, they were premeded, we went with them to theatre and in the anaesthetist’s room they were anaesthetised. We went in to the theatre with them and then we brought them back into the anaesthetic room, we brought them round, then we took them back to the ward and we looked after them in the ward. That’s how it was in the textbooks and we did it. You wouldn’t deviate from that because it was what worked fine and the patient was recovered as a result of it. So you know we never questioned how anything could be done differently because everything was right.’ Jolley, J. (2004). A social history of paediatric nursing: 1920-1970. History. Hull, The University of Hull.

32. A different time • Lower dependency • Better relationship with the child • More ‘civilised’ • Able to ‘do things properly’ • The child – nursed until better • Learning nursing was a challenge • Nurses were proud of the learning and achievement • Being accepted as a member of the ‘team’ was important

33. Senior staff • Respected • Respect important • Respect came with the job • Modern nursing criticised for the lack of respect

34. Parents and children - separated ‘And so this Toddler that by now was distraught, sobbing, I went to pick him up. because he was just, he was just left on the cot to break his heart and sob, so I went to pick him up and just as I did, he was like a little monkey, his arms around me, and [laugh] I can still see him today, his little fingers … I'm going to get upset again [crying] hanging up to me. [crying] [pause] [pause] it was awful [crying] [pause]. And so [crying] the good children's nurse came and put a harness on him and fastened him down [emphasis] [pause] and sob, sob, sob [meaning the child] it was awful. I think, one of the worst things and he was just left to get on with it [pause]. And I don’t know why, I don't know why, I don't know why, I don't know why [emphasis].’ Jolley, J. (2004). A social history of paediatric nursing: 1920-1970. History. Hull, The University of Hull.

35. Hospitals did change 1960s 1940s

36. An explanation • Early nursing expressed romanticised view of children • Emphasis on Christian values • 20th C behaviourism • Parents ignorant, damaging and stupid • Built on fears of cross infection • Science accepted too easily • Science and professionalism and emotional neutrality • Emotional neutrality caused children trauma

37. How did things change • Behaviourism • Word War II • Mass evacuation of children • Freedom and democracy • The NHS in the public domain • The 1960s • Bowlby, Platt, NAWCH

38. Background Assumptions • Nursing as a regimented discipline • Unthinking though skilled • Lack of understanding of psychological and social needs of children • Separation of children and parents • Separation most damaging for children under 5 years • Separated children went through the three stages of Protest Despair and Denial – with long-lasting effects on the child parent relationship • Cause of psychological trauma identified by Bowlby, Robertson etc. • Platt Report 1959 • Re-education of paediatric nurses led to family centred care John Bowlby

39. Lessons for the future • Nursing may be a science but children are ‘soft’ • The danger of the institutionalisation of nurses • The danger of an over-prescribed mentality • Each child is an individual, separate, individual and unique • Children need affection, they need love.

40. Children’s nursing in the UK Historical background