ten years later the Bristol Inquiry (Secretary of State, 2001) still saw fit to comment that: ‘All healthcare staff who treat children must have training in caring for children.’
In summary, in order to be held professionally accountable one must have at least a minimum level of competency and skill relevant to that profession or discipline. Aristotle, referring to Greek citizens, expected a basic univer-sal level of moral discernment in order for individuals to be held morally responsible. In the same way, in the example of specialised professional prac-tice, there is a specific body of knowledge that one must possess in order to be able to practise one’s art. The possession of this specific professional know-ledge carries with it certain obligations.
Obligations
One of the many obligations which may follow increased awareness con-cerning the knowledge of a child’s psychosocial and physical development may be the need for a certain measure of political activism, in order to ensure that children in our society receive and are aware of their minimum human rights. This type of social and professional awareness may therefore involve lobbying local councils and health authorities for better facilities for chil-dren. Alternatively, it may also mean the need for closer liaison with other childcare workers, for example playleaders and nursery schoolteachers.
Certainly, awareness of the needs of children and youngsters does not and should not finish with the completion of an eight-hour shift. It should form part of one’s total value system and, therefore, be fundamental to our understanding of child welfare and most significantly, influence our ethical and professional and personal decision-making processes.
Unfortunately, we are made most aware of lapses in this area when some-thing goes seriously wrong, such as the lack of follow-up and communica-tion among childcare workers as evidenced during the brief life of Victoria Climbie. Victoria was a young girl who was physically and mentally abused by her relatives, and an inquiry concluded that, despite having been admit-ted and treaadmit-ted for injuries several times on a paediatric unit, paediatricians and paediatric nurses did not adequately follow up her care (The Victoria Climbie Inquiry: www.victoria-climbie-inquiry.org.uk).
One of the obligations that befalls paediatric healthcare workers is the duty to communicate with the entire healthcare and social work team about prob-lematic cases, even after the strictly medical side of concerns is taken care of. Children are by definition vulnerable members of society, not always in a position to speak up for themselves, and unfortunately their parents or guardians do not always care properly for them. Better communication among the childcare team members who are alerted to potential problems would go a long way to solving some of these complications and prevent-ing tragedies from occurrprevent-ing.
104 Working with Children: Accountability and Paediatric Nursing
Such high levels of knowledge about ill children, and a commitment to children and adolescents in the community and society at large, do not come vicariously. It falls upon professional paediatric nurse lecturers to inculcate the next generation of nurses, not only with the crucial level of paediatric values which will form the moral core of paediatric nursing, but also the necessary levels of appreciation for the paediatric arts and sciences. As Cook (1990) observed:
If nursing education is the core of the profession, the nurse educationalists have a responsibility to the practitioner, the helper and the manager, since they must, to some extent, provide the knowledge and skills for profes-sionals to become accountable.
That nurses need a certain level of competence in order to be held accountable for creative, positive practice seems reasonable, but what about the parents who share in the child’s care?
Involving parents
Modern paediatric nursing is practised together with a child’s parents, and accountability for paediatric practice includes the concept of collective accountability of all those working with a child – not only qualified profes-sionals. Since the most important beings in the life of a child are the child’s parents, and it is they who predominantly care for the child, it is also they who bear the greatest share of moral and social responsibility for the wel-fare of the child. The relevant question, therefore, is what level of expertise and ability can be expected of parents in order for them to be considered accountable, together with the nurse, for the care of a child? This question has been posed and investigated by several sociologists and legal experts who have concluded that parents, like anyone else, need to be informed about their children’s welfare in order to be fully competent to make meaningful consents to treatment on behalf of their children. With older children the children themselves need to be consulted together with the parents (Alderson, 1996; Alderson, 2000).
The educative role of nurses is well documented. It starts with educative antenatal classes, where prospective parents are helped and guided, as neces-sary and appropriate, by various members of the professional nursing team right through the child’s infancy and childhood. Parents of the chronically ill child however, may quickly outstrip professionals in specific knowledge of their child. This is certainly the case as regards specific habits, social customs, preferences and even information where physiological norms are concerned. The educative role of the professional in such circumstances is, literally, to fill in the gaps, in order for the parents to make a more coher-ent picture of the whole that will enable them to continue caring for and being responsible for their own child. It is all the more interesting, therefore, that many professionals in the healthcare field still regard parents’ knowledge
Involving parents 105 and abilities with considerable suspicion. Alderson (1990), in her landmark book Choosing for Children, which concerns parental informed consent for children, superbly documents the attitude of some surgeons to the decision-making capacities of parents. Thus she records one consultant as saying:
Don’t expect much of parents. Some are good witnesses and some are vague and not terribly helpful. In episodic events I may rely on them, but I tell them what is likely to happen, that the child may become blue. . . . It’s a way of handling it and involving parents. I don’t rely on their opinion. I prefer to go on objective clinical data. (Alderson, 1990) Obviously the surgeon is clinically responsible for performing the right opera-tion at the right time, but it is the parents who have to agree to the surgery and it is they who are accountable to society for caring for their child and providing, by consent, adequate medical care. The incompetence of some cardiac surgeons which recently came to light at the Bristol Royal Infirmary (BRI) reminds us of the inordinate pressures which parents feel when making decisions for their children concerning life-saving treatments and interventions. Although the paediatric team is responsible for maintaining a high level of competence, and the Bristol Inquiry upheld this position very clearly, the parents also feel emotionally and morally responsible for the care of their child. It is they who have to agree to surgery and they feel violated and let down when it transpires that there is a cloak of secrecy and con-spiracy regarding poor work practices and incompetence that affects the care and outcomes of their children’s admission to hospital (Secretary of State, 2001). As the inquiry noted: ‘there must be openness about clinical per-formance. Patients should be able to gain access to information about the relative performance of a hospital.’
The level of parental accountability for making correct decisions, and appro-priately caring for their child, is immeasurably increased and augmented by the intervention and cooperation, if not the advocacy, of paediatric nurses.
This truism is most clearly demonstrated when it is absent. The parent who refuses reasonable treatment for a child is an obvious example. Even more startling are the instances where nurses agree with parents about decisions not to treat a child for an otherwise treatable disorder or symptom. It is of course the case that often it is not clear what clinical decisions should be made in the child’s best interest, and not only does the welfare of an individual child come into play but also aspects of the parents’ religion and culture. Accountability of parents for their children’s welfare, however, is of paramount legal, social and emotional importance. Moreover, in law, parental participation in the consenting process is considered to be a responsibility rather than a right.
This observation was upheld by the High Court in the Gillick case. In that case, Lord Scarman told Mrs Gillick that, in effect, she had parental rights over her children only as long as she also fulfilled her parental respons-ibilities (i.e. those of parenting) and was actively involved in parenting her
106 Working with Children: Accountability and Paediatric Nursing
children (Dyer, 1985). The fundamental task of paediatric nurses is to work with parents so that they can continue actively parenting their child through-out the child’s illness, and to be in a reasonable position to be accountable for the care given to their child. In many respects modern paediatric nurs-ing is care delivered by proxy. Accountability is, therefore, also referred out to parents to the extent that parents have been given the necessary skills and competence to do so by paediatric nurses and the entire childcare team (Alderson, 1990).