Concerns have been raised that the current NMC Future Nurse Standards have become overly adult-centric in their focus. Glasper and Fallon (2021) argued that students in the field of children's nursing will be knowledgeable in nursing at the point of registration but may lack the specialist knowledge within their own field of practice. There are early indications that the quality of educational programmes is insufficient for smaller fields of nursing. Colleagues from the field of mental health, under the movement Mental Health Deserves Better (2023), presented an open letter to the NMC, claiming that the standards have led to some erosion of mental health nursing education. A move towards generic education is a significant deviation from the existing standards, which offered more robust delineation of separate skills and knowledge for each field of practice (NMC, 2010; Haslam, 2023). In the field of learning disability, the same concerns have been identified that patients need the specialist knowledge and skills of those adequately equipped to do so (Cogher, 2023). This article explores the potential impact of the education standards on children's nurses and the children and young people we care for.
Historical context
There are currently 587,885 adult nurses on the NMC register, in comparison to 57,014 children's nurses, 95 485 mental health nurses and only 16 840 learning disability nurses (NMC, 2023). Further focus on the number of children's nurses has shown a decline over the last 10 years (Royal College of Paediatrics and Child Health [RCPCH], 2020a). The NHS England's (2023:16) Long Term Workforce Plan notes that ‘there is currently a sufficient number of training places to meet demand for children's nursing’; however, this has led to practitioners and educators expressing concern that the shortages of children's nurses are having an impact on the care of children and neonates (RCPCH, 2023). The NHS Long Term Workforce Plan (2023) has made clear plans to increase adult nursing student places by 92% and 38 000 students. The assumption that children's nursing is not in need of review, alongside the planned increases in adult nursing, has created a fear that education provision will continue to centre on its generic focus, consequently putting children's nursing at risk of being eroded. Students will, as a result, be less adequately prepared to care for their child patients and families. This would be history repeating itself.
‘The assumption that children's nursing is not in need of review, alongside the planned increases in adult nursing, has created a fear that education provision will continue to centre on its generic focus, consequently putting children's nursing at risk of being eroded.’
Over the last 150 years children's nurses have fought for focused education and preparation (Glasper and Charles-Edwards, 2002). The Registered General Nurse (RGN) was at one point the only initial qualification possible with courses that lead to becoming a Registered Sick Children's Nurse (RSCN) available at post-registration (Glasper and Charles-Edwards, 2002). The acceptance of the need for an RSCN came under further scrutiny, which led to the phasing out of this qualification in the United Kingdom (UK) by the 1960s. Children's services, which were staffed predominantly with RGNs without the RSCN qualification led to poor quality of care for children and young people, which later led to the reinstatement of children's nursing as a separate registration as part of Project 2000 (Glasper and Fallon, 2021).
Leading up to the introduction of the NMC's 2010 Standards for pre-registration nursing education, concerns were raised by practice leaders and nursing academics during consultation over the threat of a generic model of nursing (Ellis et al, 2008). During the consultation phase, the NMC leant upon examples from other parts of the European Union, which at that time offered nursing as a generic programme of education. In 2015, following the Shape of Caring review, Lord Willis recommended that pre-registration education should take the form of two years of generic preparation, followed by one year of specialist field-related preparation (Willis, 2015). However, Carter et al (2015) presented the argument that models of generic training are insufficient to provide quality in the specialist education needed to prepare student children's nurses for their specific role in caring for children and their families. These concerns were also shared among those in the other fields of nursing (McKeown and White, 2015; McClimens and Burns, 2016).
Disparity of curricula across the United Kingdon
A key lesson from the past is that nursing education must be tailored to the diverse and specific requirements of different populations. Children and young people's nursing stands as a distinctive discipline and vital field of healthcare, driven by the acknowledgement that preventing, and caring for child illness, injury and/or disability is unlike any other professional endeavour or health paradigm. This uniqueness emanates from several key facets including knowledge and application of developmental diversity; skills of exceptional flexible communication methods; recognition of the importance of family; facilitation of the ‘child's voice’; understanding of the distinctiveness of psychosocial challenge; and possessing exceptional emotional resilience.
One of the glaring issues with the current (NMC, 2018) Future Nurse Standards of proficiency for registered nurses is the focus on developing primarily physical healthcare skills, procedures, and management across the whole lifespan for all nurses is that it has led to a homogenisation of the future nurse and significant disparity in curricula across the UK. Individual interpretation by each Higher Education Institute (HEI), means that there is a lack of uniformity of content, this therefore undermines the consistency and quality of Children's Nursing Education.
‘In contrast, the previous NMC educational standards from 2010 included entire sets of field-specific competencies for adult, mental health, learning disability and children's nursing, providing protection and professional focus particularly for the smaller fields of practice.’
This is evidenced within a recent survey (Reynolds et al, in preparation) where across 76 children and young people's nursing programmes, nationally (england and wales), cross-field lectures (adult, mental health, learning disability and child learners together) are the most frequently used teaching method accounting for 86.8% of cases (n=66). This survey's data highlighted that 50% of the respondents (programme, field or professional leads) reported that the theoretical content has changed since the introduction of the new standards (NMC. 2018). In particular, in 27 programmes (35.5%) there was a decrease in child-specific content.
Another discernible shortcoming emerges from the absence of explicit language within the NMC's (2018) Future Nurse Standards that directly relates to the expertise of children's nursing. This has led to challenges for HEIs designing curricula for children's nursing resulting in some HEIs having few child focused modules whereas others feature a more extensive array of child-specific content. Results from Reynolds, et al, (no date) survey further substantiates these disparities, particularly in Part 3 of the Programme, where students are in their final year before qualification, most (60.5%) use a mix of child and cross field modules. A quarter of the programmes (25%) have cross-field modules. A smaller proportion of the programmes (13.2%) have child-focused modules. Part 2 of the programme shows a similar picture.
The disparity is also noted for child-specific placements within the Survey dataset (Reynolds et al, no date) since the introduction of the NMC (2018) standards across the 76 participating programmes. While a significant majority (82.9%, n=63) reported no change in child-specific placements, a smaller fraction of programmes (7.9%, n=6) reported a decrease in such placements. These observations collectively underscore the concerning inconsistency in the interpretation and implementation of the NMC (2018) standards within the domain of children's nursing.
Language matters
The NMC's Future Nurse: Standards of proficiency for registered nurses (2018) specify knowledge and skills that all registered nurses must be able to demonstrate. The standards apply to nurses caring for people of all ages, yet the terminology used throughout is at best generic, and at worst adult-centric.
Language matters. The idea of ‘person-centred’ care is threaded throughout the standards, and although its definition is generic, this phrase has an overly adult flavour. The driving philosophy of children and young people's nursing is child- or young person-centred care within a family unit. This approach relies on collaboration, participation, partnership, shared decision-making, and relationship building between children and young people, their families and carers and clinicians (Gerlach and Varcoe, 2021; Royal College of Nursing, 2021; Foster and Blamires, 2023). As children and young people are continually developing their autonomy, agency and decision-making capacity, this makes it a unique and complex approach which goes wholly unrecognised in the NMC Standards.
This creeping genericisation has long been the direction of travel for nurse education (Glasper and Fallon, 2021) and is reflected by the use of the word ‘child’ just three times throughout the 40-page document. In contrast, the previous NMC educational standards from 2010 included entire sets of field-specific competencies for adult, mental health, learning disability and children's nursing, providing protection and professional focus particularly for the smaller fields of practice.
All students need to develop a strong field identity and those in children's nursing find their educational standards so broad and diluted that their primary group of service users is not even recognised. In common with mental health colleagues who are ‘trying to keep the unique intricacies of what it is to be a mental health nurse present throughout the nursing curriculum’ (Colwell et al, 2023:18), children's nursing students struggle to find meaning in these standards to inform their emerging roles and effectively meet children and young people's needs.
A fundamental tenet of children's nursing is upholding children's rights and hearing their voices, as reflected in the United Nations Convention on the Rights of the Child (UNCRC, 1989). However, during the consultation period in developing the standards, reservations were raised by children's nurses, but many felt drowned out by the ‘loudest voice’ coming from the adult field (Glasper and Fallon 2021).
The wording of many Annexe A and B nursing procedures set out in the standards immediately brings to mind adult service users rather than children. For example, some procedures include terminology largely irrelevant to children such as assisting with shaving, falls risk, living wills and lasting powers of attorney. Common health conditions listed as examples which nurses should be able to discuss and manage include dementia, cardiac disease, stroke and arthritis. One procedure even mentions undertaking rectal examination and manual evacuation, which in most cases would be wholly inappropriate and even unethical for a nurse to attempt in a child or young person. Other procedures such as venepuncture, cannulation and catheterisation are extended roles in many children's healthcare settings, acquired after registration and therefore could be unrealistic and inappropriate to achieve as mandatory for pre-registration students (Glasper and Fallon 2021).
‘One procedure even mentions undertaking rectal examination and manual evacuation, which in most cases would be wholly inappropriate and even unethical for a nurse to attempt in a child or young person.’
‘…the current NMC Future Nurse Standards have allowed for further dilution of the specialist child health content in nurse education curricula. History is going to repeat itself with a workforce lacking the specialist skills and knowledge to care for our future, children and young people.’
The generic and adult-centric language used in the NMC Future Nurse Standards does children's nursing students, and children and young people themselves, a disservice by marginalising and deprioritising the needs of this specific group of service users with well-recognised needs. The multitude of anatomical, physiological, psychological, emotional and social differences between children and young people and adults deserve to be recognised and explicit in the expectations of what children's nurses should know and demonstrate at the point of registration.
Bringing it back to children and young people – getting it right for them
Children and young people are our future. There are 14 000 000 children and young people under the age of 18 living in the UK (UNICEF, 2023). They are significant users of healthcare and should have a voice in shaping the future children's nursing workforce. However, their voice is continuously not heard and key documents are not considering their needs. This has already been highlighted in the article with the lack of children and young people input into the NMC's Future Nurse Standards (2018) and the NHS England's (2023) Workforce plan.
The UNCRC (1989) article 13 states ‘Every child must be free to express their thoughts and opinions and to access all kinds of information’ and article 24 highlights the need to ensure children and young people have access to the best possible health. These articles are still relevant and important in our role as children's nurses now and crucial to understanding children and young people needs in relevance to their health. The Voice matters project (RCPCH and Us, 2020) was led by young people aged 11–22 from the UK. The project emphasised the need for health professionals caring for them to know about their rights and the importance of being listened to. Similarly, the National Children's Bureau (2021) report echoes this and shares insightful feedback from children and young people's experiences of healthcare, importantly from a young age they want a chance to share their opinions.
It is important that we seek to understand children and young people's views of what skills, knowledge and attributes children's nurses of the future will need; Fletcher et al (2011) found that children and young people wanted a ‘cool’ nurse. Nurses who listen to them, understand that the developing child must learn the skills of self-care, has good knowledge of what children and young people like, from music, television, dress, language. Fletcher at al (2011) made suggestions for nurse education and also stressed the need to include the teaching of play and distraction within curriculums. Fast-forward 12 years and Clarke's (2023) study stressed the importance of listening to the views of children and young people to help shape their healthcare experience and children's nurses caring for them. Similarly to Fletcher et al (2011), there was a strong theme of the need for improved communication and inclusion of play. Clarke (2023) found that children's nurses often lacked education on child development and age-appropriate communication skills. In addition to this, the RCN (2021) stated that children and young people should be cared for in appropriate settings, by those with specific training. With this in mind, we know the importance of listening to children and young people, we know that those caring for them can have deficits in knowledge; however, the current NMC Future Nurse Standards have allowed for further dilution of the specialist child health content in nurse education curricula. History is going to repeat itself with a workforce lacking the specialist skills and knowledge to care for our future, children and young people.
Conclusions
The ongoing concerns need to be addressed and explored, to ensure we have a workforce with the right knowledge and skills to care for children and young people. The Fit4CYP project has been established to address a gap in the body of evidence (Carey and Neill, 2022). Further research is needed to not only capture children and young people's experiences of healthcare and those caring for them, but to understand the impact on children's nurses to, in turn, continue to shape our future children's nurses.
KEY POINTS
- There are consistent concerns being raised within children's nursing across the UK about the NMC's (2018) Future Nurse Standards for education.
- There is significant disparity of children's nursing curricula across the UK.
- History tells us that children need to be cared for by those with the right skills and knowledge.
- Children and young people should be at the centre of decision-making about those caring for them.