vHEALTH VISITOR TUTORMINISTRY OF HEALTHCENTRAL HEALTH SERVICES COUNCIL

The
Welfare of Children
in Hospital
Report of the Committee

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LONDONHER MAJESTY’S STATIONERY OFFICE
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•rintedimage di§itisecLby the University of Southampton Library Digitisation UnitMINISTRY OF HEALTHCENTRAL HEALTH SERVICES COUNCIL

The

4

Welfare of Children
in Hospital

Report of the Committee

LONDONHER MAJESTY’S STATIONERY OFFICE
1959

Printed image digitised by the University of Southampton Library Digitisation UnitMEMBERS OF THE COMMITTEECOUNCIL MEMBERS*Sir Harry Platt, Bart., M.S., M.D., F.R.C.S., F.A.C.S. {Chairman)

P. H. Constable, Esq., M.A., F.H.A.

fMIss K. A. Raven, S.R.N., S.C.M.
F. M. Rose, Esq., M.B., Ch.B.

W. P. H. Sheldon, Esq., C.Y.O., M.D., F.R.C.P.

NON-COUNCIL MEMBERS
Professor Norman Capon, M.D., F.R.C.P., F.R.C.O.G.

Charles GledhiU, Esq., M.B.E., M.B., B.S., F.R.C.S.
Mrs. Elizabeth Hollis, B.Sc.(Econ.)Miss M. W. Janes, S.R.N., S.C.M., R.S.C.N.
Miss M. E. John, A.M.I.A.
Miss C. A. McPherson, M.A.
Miss E. Tylden, M.B., B.Chir., M.R.C.S., L.R.C.P.
Sir Harry Platt ceased to be a member of theT

Council when he relinquishedthe Presidency of the Royal College of Surgeons on
11th July, 1957.
Miss Raven ceased to be a member of the Council and theCommittee on
being appointed Deputy Chief Nursing Officer to the
Ministry of Health,but she continued to attend meetings as an observer onbehalf of the
Department.

Printed image digitised by the University of Southampton Library Digitisation UnitCOPY OF LETTER FROM THE CHAIRMAN OF THE
COMMITTEE TO THE CHAIRMAN OF THE CENTRALHEALTH SERVICES COUNCIL
11,

Lome Street,

Manchester, 13.
28 th October, 1958.

Dear Lord Cohen,
With this letter I send you the report of the Committee on the Welfareof Children in Hospital which the Central Health Services Council
appointed on 12th June, 1956.

The Committee have found the subject of absorbing interest and weare only sorry that its ramifications have proved too wide to permit us
to report sooner. It is clear that interest in the subject among parents
and hospitals has been growing steadily since we were appointed and webelieve that a movement towards a new concept of child care in hospitals
is already well advanced. We trust that the results of our enquiry may
be of some value in consolidating this progress and encouraging further
advance.

We should like to record our appreciation of the services of Mr.
R. G. Lavelle and Mrs. J. M. Craig, who successively acted as ourSecretaries and dealt ably and skilfully with the assembling of material
for us to study and the recording of our proceedings. We are also
grateful to Mr. A. R. W. Bavin, the Secretary of the Council, for his
help in the later stages of the drafting of our report.

Yours sincerely,(Sgd.) Harry Platt,Chairman

The Lord Cohen of Birkenhead, J.P., M.D., D.Sc., LL.D., F.R.C.P.,
Chairman,Central Health Services Council,

Ministry of Health,
Savile Row,

London, W.l.

iii

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CONTENTS
I.

Page

GENERAL

1

Introduction
The Central Problem
II.

1

2

ALTERNATIVES TO IN-PATIENT TREATMENT
Home CareHI.

HOSPITAL ORGANISATION,
STAFFING

6DESIGNAND
7

Types of Hospital Accommodation
Design of Wards
Medical Staffing
Nursing Organisation
Occupational Therapy

7

9
10
10
11

Social WorkIV.

PREPARATION FOR ADMISSION....

General Contacts

11

.12

Local Authority Staff
Hospital Staff

12
12

Leaflets and Letters

12Preparatory Talks
Preparation of the Child

13

13

RECEPTION

14

Planned Admission
Re-admission
Emergency Admissions
VI.

11

11

The Family Doctor

V.

5

5

Out-Patients and Day Patients

14
15
15

THE CHILD AS IN-PATIENT
1.

2

.

3

.

16

General16

The Admission of Mother and Child

17

Visiting Arrangements

IB

General18

Unrestricted Visiting by Parents

Evening Visits
Operating Days

19.

Interviews with Medical and Nursing Staff
Visitors other than Parents

Children with no Visitors
Facilities for Visitors

.

.21

...

21
21

21

.21
22
22

Financial Aidv

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Page
Education
Other Aspects of In-patient Care

4.
5.

23
25
25
25
26
26
26

Recreation
Discipline
Safety Measures

Personal Possessions

Food
Toilet Training
Information about Children’s Progress

..27
....
27
27
27

Transfers
Spiritual Welfare

VII.

VIII.

WELFARE ASPECT OF MEDICAL TREATMENT
GeneralPreparation
Treatment and Recovery Rooms
Premedication
Presence of Mother during Recovery from Anaesthesia.

Ward Rounds

.

.

.

28
28
28
29

.

29
29

.29

SPECIAL GROUPS

29

Long Stay Hospitals
The Blind and Deaf

29
31

Infectious Disease Hospitals

Operations for Removal of Tonsils and Adenoids.

,

Eye Operations

.

.

.

.31
.32
.33

.....

IX.

DISCHARGE AND AFTER-CAREX.

TRAINING OF STAFF

XI.

SUMMARY OF RECOMMENDATIONS

33

35

...

37

APPENDIX
List of Organisations and Individuals who gave Evidence

6

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I.

GENERALINTRODUCTION
1.

We were appointed.ata meeting of the Central Health Services Council

held on 12th June, 1956, and were given the following terms of reference:“ To make a special study of the arrangements made in hospitals for theill children
as distinct from their medical and nursing treatand to make suggestions which could be passed on to hospital

welfare of

—

—

ment

authorities
2.

We met 20 times to consider written and oral evidence and for
We invited evidence from a large number of organisations anddiscussion.

we wishtothank those named in the Appendix for the evidence theysubmitted.
3. Our inquiry had already been preceded by a number of studies by theCentral Health Services Council of particular aspects of child care in hospital.
The Council had on several previous occasions considered the question ofvisits to children in hospital and their advice had been the subject of threememoranda which were issued to hospital authorities between 1949 and
1956, asking hospital authorities to allow daily visiting for children in all
hospitals. They also published a report in 1953 on the Reception and Welfareof In-Patients in Hospital which included among its recommendations
suggestions about visiting hours for children and the help that might be given
to parents in preparing the child for admission. We have taken note of all
this work for its bearing upon our study.

4.

Public interest in the question of children in hospital is considerable,

as has been shewn by the large amount of evidence we received from organisa-

tions representing the views of parents. During the course of our enquiry the

British Broadcasting Corporation broadcast two series of programmes whichdrew a large volume of correspondence from parents and others and we are
grateful to the Corporation for making this correspondence available to us.
The work of such organisations as the Central Council for Health Educationand the Tavistock Institute for Human Relations has done much to informpublic opinion.
5.

Although the routine statistics of patients admitted to National HealthService hospitals do not show children separately, it is possible to form someidea of the numbers affected from the 1951 census figures, and from thesample analysis of in-patients undertaken by the Ministry of Health and theGeneral Register Office. On census night there were in hospital in Englandand Wales 36,856 children between the ages of 4 weeks and 14 years, 20,621
of them boys and 16,235 girls. This represents 0-387 per cent, of the childpopulation (0-15 years). Figures obtained from the sample analysis of inpatients in 1955 suggest that some 685,000 children under 15 were admitted to
non-mental hospitals in that year, compared with a total of 3-5 million for
persons of all ages,
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THE CENTRAL PROBLEM
During the past 50 years or so profound changes have taken place in theand ait school. The child of today is better housed,better clothed and better nourished than at any time in our history. His
individuality is recognised and appreciated both at home and in school andthere is a growing readiness to understand and care for his emotional needs.
Parents are adopting a much more liberal and sensitive attitude than in thepast, and since 1948 they have had available to them a wide range of
6.

lives of children, at home

domiciliary health services, including the services of a family doctor.
7. Along with this increased awareness of the child’s needs there havebeen changes in the relation of the hospital to the community and in patternsof medical treatment which are relevant to the child’s welfare in hospital.
When most of our hospitals were built, the purpose of hospital care wasprimarily to permit the nursing of sick people many or most of whom had abackground of poverty, bad housing and often malnutrition, while childrenof better off families were mused at home or in private nursing homes. Today
ten years of a National Health Service have widened the hospitals’ sphereto cover the whole community, and have removed financial barriers to general
medical care and specialist advice in the home. Hence new attitudes to patientsof all ages are demanded.
8. In addition, recent advances in medicine and surgery have made possible
a new approach to the care of the sick child. These advances, along with thesocial effects of the National Health Service, have made it possible to treat
more children at home and there is today an increasing awareness that evenwhen children have to go to hospital they do not necessarily have to be
confined to bed. This implies that more thought has to be given to the;1welfare and occupation of ambulant children in hospital.
9. The view has been expressed, rightly or wrongly, that the child who has
be admitted to hospital finds ‘himself in an environment which is unnecessarily different from that to which he is accustomed at home. The
surroundings are strange and may be uninviting, discipline is said to be more
severe, and his parents may have to be separated from him at a time when heis subjected to painful and distressing experiences. We accept that there issome substance in these opinions, and that some hospitals are more successful

tothan others in lessening the upheaval of a child’s life which admission entails.
But in fairness to those responsible for the management of hospitals it isessential that a sense of proportion be maintained in assessing the criticismsthat have been made and it would certainly be wrong to assume that medical
and nursing staffs in hospitals are generally unsympathetic. It must be
remembered that the paramount duty of a hospital is to diagnose the patient’s
ailment and to secure the appropriate treatment. This sometimes requires
unpleasant and even painful procedures, which cause distress not only to thepatient and his relatives, but to the medical and nursing staffs whose duty
it is to perform them. Furthermore, it should not be forgotten that most of
our hospitals were built over 50 years ago and that their planning included
little or no provision for amenities and services that are now regarded as;—

desirable

peril aps—for the welfare ofeven essential

patients.

In

many

hospitals the existing shortcomings have been partly overcome by skilful and2

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ingenious devices, and by a more modem approach to (the problems under10.

consideration. But much remains to be done.

Weare unanimous in our opinion that the emotional needs of a childhospital require constant consideration. Changes of environment andseparation from familiar people are upsetting, and frequently lead toemotional disturbances which vary in degree and may sometimes last well into
in

adult

life.

The Curtis Report^) dealt with, among other things, the diffi-

culties arising in the lives of deprived children,and it emphasised the partplayed by unfamiliarity and separation. The child in hospital, particularly
when separated completely from his parents, encounters conditions similar
to those of the deprived child, with the added risk of painful and frightening
experiences.

We

recognise that the training of medical students and nurses must
11.
concentrate on the physical aspects of illness but we think it takes too
accountof the child’s emotional and mental needs. Until this defectlittleis corrected there will be delay in recognising that hospital rituals anddiscipline, when maintained too strictly, may cause lasting harm, undermining
the child’s self-confidence, his established habits and his capacity to develop

and mature.
In general the responsibility for bringing up and looking after children
on the parents. So long as a child is educated and not neglected or

12.
rests

physically ill-treated, the absolute authority of the parents will noit bechallenged. Improved living conditions make it easier for parents in thisgeneration to give their children a more satisfactory home life, with adequate
The training that they give their children is appropriate
to the social setting of the family and varies, therefore, from family tofamily. Hospitals, on the other hand, still tend to impose a uniform routine
care and affection.

regardless of the child’s home background. The disciplines of hospital life
ought to recognise the authority of parents and respect their methods ofhandling their children otherwise the two modes of management may clash,presenting the child with a serious contradiction which can disrupt his
training and make him feel insecure. The younger the child the more
susceptible he is to confusion of this sort. Young children develop best in
familiar surroundings where they learn easily through constant repetition.
The hospital should, so far as is possible, avoid breaking this process ofgrowth and learning and should realise that even a short stay in strange
surroundings may seem interminable to a very young child. The new approachto the care of children in hospital should be based on a mutual understanding
between hospital staffs and parents, and, an insight on the part of hospital
staffs into the great advances in child care whioh have been made during thepast 20 years or so. Their attitudes to parents should take into accountthe general rise in the standard of living and the influence of health educationon the mind of the public. For it must tbe remembered that the school
education of many mothers has included at least elementary physiology,
nutrition and hygiene
and in some cases for example, those who have
had nursing training their knowledge reaches a fairly advanced level.
;

—

—

;

13. Children in primary school today are given a greater chance thanpreviously to learn along the lines of their own choice and to follow their0) Report of the Care of Children Committee (Cmd. 6922)

1946.

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own 'types of development. Children’s rates of learning vary;

their interests

Post-war schools in Great Britain have been carefully designed
meet the individual needs of growing children, recognising that children
need light, air, interesting things to look at, room for movement and scope
fluctuate.

tofor individual

activities.

Earlier generations believed in standard patterns

The design and decoration of many of our hospitals inevitably
and this cannot but makeit more difficult for medical and nursing staff to adopt the modern attitude
towards child care. We may expect new attitudes to be reflected in futureof learning.

reflect the social pattern of previous generations,

hospital design and in the renovation of existing buildings but special careis needed to ensure that the obsolete design of the older hospitals does not
influence the care of child patients in the wrong direction.
14. The effect of the separation of a child from his parents has received
some prominence in the medical Press of late. This has been excellent inthat it has drawn attention to adverse factors in hospital practice which
had not previously received adequate consideration. There are, of course,
forms of separation which do not seem to be inherently harmful. It is, forexample, common practice in this country to send quite young children away
to stay with relatives or even to place them in foster homes for periods ofweeks or months if the mother is ill. In these cases the emotional securityof the child is easily safe-guarded by frequent visits from the father orother familiar figures. Children of 5 experience the sharp break of attending
school, but this is only disruptive when the home life or school are unsatisfactory. Admission to hospital appears to be potentially more detrimental
than any other common form of separation because it so often involves anelement of fear. Hospital staff, when concerned with the care of children,and in their dealings with parents, should take account of those factors in
the child’s life that are considered by a good Children’s Officer whenarranging for a temporary break because of a mother’s illness. Hence theby parents for when a child is confused,and perhaps in pain it is especially difficult for a stranger to offer

desirability of frequent visiting
afraid,;him the sort of reassurance and comfort that makes him feel secure. Thus
parents should not be denied access to their children in hospital in the
mistaken belief that reassurance to a frightened child can be sufficiently
afforded by a succession of nurses, however sympathetic they may be, noneof whom is allocated to the child for this special purpose.
15.

The guiding principle which emerges for

hospitalisthat while

investigations

the care of children in
the child must, of course, undergo the necessary

and treatment for the condition from which he issuffering,he should be subjected to the least possible disturbance of the routines towhich he is accustomed. Every effort should be made by hospitals topreserve continuity with the home during the time the child is in hospital.
At the same time it must be recognised that children are more vulnerable
new and potentially frightening experiences and become more easily
confused in strange surroundings than do adults. The attention they require
therefore varies in a number of ways from that given to adult hospitaltopatients. It follows thatshould be paid to devising methods of managementof the sick child which avoid admission to hospital.

(1) Special attention

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(2) If a child has to go into hospital, everything possible
16.
done to meet the special needs to which we have referred.
Itisoutside our terms of reference tooffershould bea detailed study ofalternative ways in which children can be treated without becoming hospitalin-patients but we refer briefly to some possibilities in Section II below.

The remainder of the report deals first with general matters of hospitalorganisation as they affect the welfare of children and then proceeds to a
general discussion of the child’s special needs in relation to preparation foradmission, reception, in-patient care and discharge. Important as each ofthese different aspects is, in-patient care is the kernel of the problem in
relation to our terms of reference. We have devoted a separate section of thereport to the welfare aspect of medical treatment, another to types of carewhich present particular problems, and a final section to the training of staff
concerned with the care of children. We have not made a special study ofchildren in mental and mental deficiency hospitals but we consider that thegeneral approach that runs through our recommendations is applicable in:those hospitals and that some of our detailed suggestions could be adopted
but not now necesmental hospitals—-our remarks about the special problems of longstay patients are of course relevant.)in them with advantage. (For mental deficiency hospitals—

sarilyII.

ALTERNATIVES TO IN-PATIENT

TREATMENT
17. Although our terms of reference concern the welfare of children while

in hospital, we think it right to refer briefly to alternative forms of carewhich may make it unnecessary for the child to be sent to hospital. Children,
particularly very young children, should only be admitted to hospital whenthe medical treatment they require cannot be given in other ways without
real disadvantage. This may seem obvious but it is a consideration whichshould always be in the minds of those responsible for the admission ofchildren to hospital and evidence submitted to us suggests that it is still

often overlooked.

HOME CARE
18. When the nature of the illness and home conditions permit, mothers
should be encouraged to nurse a sick child at home, under the care of thefamily doctor and with assistance, where necessary, from the home nurse.
Too few local authorities as yet provide special nursing services for homecare of children and the extension of such schemes should be encouraged.
If children are to be nursed at home it is important that the mother should
not only have sufficient skilled nursing assistance when she requires it but
also such domestic help as she needs. The instruction of mothers in the careof sick children is most important we were interested to hear of classes inchild nursing that had been held for mothers in one medical practice. These,
it was claimed, resulted in a decrease in the number of admissions to;hospital of children

from the practice. The County Borough of Rotherham

have pioneered a special home nursing scheme St. Mary’s Hospital, Paddington, run an experimental scheme with a team of consultant registrar and
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who visit children in their own homes the City of Birmingham andBirmingham Children’s Hospital have collaborated in a comparable

niirses^;thescheme.
19.

,

We regard it as essential that such schemes should be based on theclosest co-operation

between the family doctor and the local authority services with the help of the hospital and specialist services as necessary, andwe trust that every encouragement will be given to the care of the sick childin his own home.

OUT-PATIENTS AND DAY-PATIENTS
20. Many children who attend hospital may require no more than a brief
They either attend out-patient clinics or are admitted
to hospital for a day only for some operation or investigation which allows
them to be discharged home the same evening or next day.
stay within the building.

21* Ideally the out-patient department to which children are sent should
be in close proximity to the children’s wards and separate from the adult outpatient department, where they may be exposed to unpleasant or, to a child,alarming sights and sounds. We realise that at present separate departments

are rarely possible, but we recommend that in future more hospitals
should have a separate children’s out-patient department, or at least arrange
for children to attend at special times when adults are not called. If for a
special reason it is inevitable that children must attend the same clinics

as adults, a separate room should be found for them to wait in.
22. Waiting time for children should be reduced to the minimum. Appointments systems for all out-patients have already been enjoined on hospitaland widely adopted, and with children it is specially importantthat the time of arrival should be close to the time when they see the doctor.
It should at the least be possible to spread attendance times
by half-hourly
block appointments or short daily sessions to which children can come without appointment may sometimes be found the best method of avoiding waits.
An appointment system should not of course operate in such a way as toauthorities;

prevent attention being given to an acutely ill child.
23. Children’s out-patient departments should have adequate accommodation for mothers and babies as well as children and should include
waitingrooms, a canteen, space for perambulators and rooms where feeds canbeprepared and babies fed. Attractive decorations and furnishings and a
supplyof suitable toys are also important. A playroom in which someform of playgroup can be organised—perhaps by voluntary helpers—is valuable, andlarge

toys like the Swedish cubes and tunnels can provide better
entertainment
than small toys for the very young. Suitable literature should be available
forthe older children. Comfortable seating for parents and forchildrenfixed,

ofdifferent sizes is important. Hospitals who want expert advice
on decorations
and furnishings can make use of the services of such 'bodies as theCouncil ofIndustrial Design.
24. To give adequate service the out-patient department needs

to have the
X-Ray and routine pathology, inand there should be extremely clear signposting as wel as

essential diagnostic services, particularly

close proximity

receptionist guides. Close liaison with the children’s wards
should be maintained. There should be in every children’s out-patient

department people

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who are responsible for answering parents’ enquiries, showing them where to
and generally ensuring that they are looked after. These people may bemost hospitals are unable
many receptionists as they need and voluntary workers canusefully supplement the services of the regular staff. Such volunteers should
be given some preliminary training in the organisation and lay-out of thehospital before they take up their duties.
go,either paid receptionists or voluntary workers ;to recruit as

25. Many of our observations about out-patient departments apply also tocasualty departments, but os these departments also present additional prob-

lems in relation to children receiving in-patient treatment we deal with themseparately under “ Reception Arrangements” (paragraphs 61-63).

A

26.
small but apparently increasing number of hospitals admit childpatients—mostly infants—-for a day only, for surgical operations of a simple
nature or special investigations. The surgical procedures undertaken include
circumcision, antrum lavage and herniotomy ; some are conducted underlocal anaesthesia. In -some hospitals patients are kept overnight and discharged

the following day.
27. The practice is no doubt based on the belief that the risk of crossinfection in a very young infant outweighs the advantages of admission, but

we would also commend it as one that conforms with the general principle
stated in paragraph 15 (1) above. It should however be used with discrimination and should be subject to the following provisos:'(a) The hospital doctors concerned should be satisfied that the treatment(

required can be given in this way without danger to the childb) It should be ascertained from the general practitioner that thehome is suitable for follow-up treatment and that adequate medical
and nursing supervision can be provided;

28.
(c) Separate

accommodation should be available in the hospital(d) Attention should be paid to the needs of waiting parents.

III.

HOSPITAL ORGANISATION, DESIGNAND STAFFINGTYPES OF HOSPITAL ACCOMMODATIONAt present children may be nursed in four kinds of accommodation:(1) In a children’s hospital,(2) In a children’s ward in a general or special purpose hospital.

(3) In a children’s unit in a special department, e.g. Ear, Nose and Throat

or Eye department.
(4) In an adult ward.

In any of these types of accommodation children may be nursed either inlarge undivided wards or in partially sub-divided wards or in wards with one

bed only.

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29. Evidence which we received from the Nuffield Foundation, Division
for Architectural Studies, and which was based on a survey of fourteen hospital groups, suggested that varying proportions of children are

admitted toadult wards. During four six-week recording periods in the hospitals surveyed
2,684 children aged

to 11

and 2,389 aged

12 to 16 were admitted to
12,757 children admitted to children’s
wards. 56 per cent of the Children aged 1 to 11 in adult wards wereadmitted for tonsil and adenoid operations or the correction of squin t and,of the total of 2,684, 819 were admitted to beds specifically set aside for theuse of children though not actually classified as Children’s beds. The propor-

wards

adult

1

comparedwith_tion of children aged 1 to 11 admitted to adult wards to the total number
admitted to children’s wards varied widely between different hospitals.
30. The nursing of children in adult wards has been defended
following grounds

on the(a) thechild can then be under the care of a particular consultant
or nursed by a particular team;(b)

one childina group of adults is quiet and appears to be bothand sometimes entertained by the adults

safely supervised(c)the single child can be “ mothered ” by the Sister of the adult ward,

who does not have to divide her attention among many children(d) finally, it is31.

;

argued that an infant may escape the bugbear of crossinfection in a children sward by being nursed in an adult ward.

Much evidence against the practice was offered to us and we do

not find the above arguments convincing when they are weighed against
theneeds of children for special care and for the stimulus of otherchildren.
There is a growing feeling that an adult ward is no place in which to nurse
sick children.

They are all too likely to see sights and hear sounds which

are an affront to them ; their habits, whether of excretion or sleeping,work
to a different time schedule ; and the noise that is natural for many
childrento make can be very disturbing to an ill adult.

We

32.
strongly recommend, therefore, that children should not
be nursed
in adult wards, whether medical or surgical. This principle

was supported

in evidenceby theRoyal College of Physicians, the Royal College ofSurgeons, the British Medical Association, the British Paediatric
Association,
the Royal Medico-Psychological Association andthe Royal College ofNursing and should only be over-ruled for periods of highly
specialised
treatment which can at present only be given in an adultward or for
emergencies when no bed in a children’s ward is available. Even
then thechild should be returned or transferred to thechildren’s unit as soon as
possible. In those hospitals where children are at present
scattered throughadult wards, they should be gathered into a children’sunit available to any
member of the medical staff.
33 ° ur remarks about children in adult wards
apply also to adolescents.
indeedour view it is even more important that adolescentsshould not
be in a position to overhear some of the conversationof an adult ward,e;g- a gynaecological ward. Ideally, adolescentsneed their own accommodation, but if the numbers admitted do not
permit this it is better for them
to be nursed with children than with adults.
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34. It has

been suggested to us that the aim should be to nurse all
There are, however, various considerations

children in children’s hospitals.

which make this proposal impracticable. It is not desirable that a childshould be removed to a children’s hospital which may be far from his
home, thus making it difficult for his parents to visit him, when he could
be nursed in a children’s ward in the local hospital, which is in the chargeof a children’s specialist visiting from a neighbouring centre sufficiently
frequently. The greater the distance from a main children’s centre the lessthe likelihood that the child will be sent to it and the greater the needfor the doctor rather than the patient to travel. Although it may be bestfor the child requiring some unusual form of treatment to be nursed where
there are special facilities, if his needs are more simple he will undoubtedly

be much happier in a children’s ward near home. The majority of children
admitted to hospital are suffering from common conditions which can be

managed in small children’s units and there is no reason why our recommendations concerning the welfare of the child should not be adopted insmall units just as in large ones. It is very difficult to lay down rules about
the minimum size of children’s units, but we believe it should be possible
to run children’s wards with as few as eight to ten beds, and that this number
would justify the appointment of a sick children’s trained nurse.

DESIGN OF WARDS

We

have not been able to make a detailed study of the design ofunderstand that some aspects of this subject are atpresent being considered by the Nuffield Foundation, Division for Architec35.

children’s wards.

We

tural Studies, and their findings will be published in due course. We have,
however, had various views expressed to us and the following comments
have some bearing on planning of future buildings

once they are beginning to talk, enjoy each other’s company and they should, therefore, when medical considerations
permit, be nursed in wards with other children and not in completely
separate single bed wards. There will of course be certain exceptions, for example, the child seriously ill or suffering from infectious
disease who has to be separated from the rest. Children who are(1) Children,

much less isolated when the glass in the partitions
separating them reaches well below eye level so that they can easily

in cubicles feelsee each other.
(2)

(3)

Children are often put in adjacent beds simply because they are under
the care of the same consultant. As far as possible children of thesame age group should be kept together within the ward, so thatthey can enjoy each other’s company. Very young children should begrouped together so that they do not isolate the older ones fromeach other.

Children who are in bed need a view and facilities for outside playwhether on a balcony or a playground. Inside the ward colour
schemes and furnishings should be bright and cheerful and there
should be a plentiful supply of toys and suitable games. We makefurther recommendations about toys in paragraph 101.
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A6

(4)

(5)

All children’s wards need a play room, preferably visible to thechildren in bed. Noise can be cut off by glass screens but the sickchild derives a stimulus to get better from seeing others play.

With the present tendency for children to be up and about to agreater degree than in the past, prevention of accidents must always
be borne in mind in designing children’s wards but it is importantthat measures to this end should not be allowed to make theaccommodation look unfriendly and forbidding.

(6)

The design of the children’s ward should be such as to permit nurses
always to keep the patients under proper supervision.

MEDICAL STAFFING
36. Sick children in hospitalcome under the care of various members of
Although the actual responsibility for care of individual
children must often rest with consultants in other specialities, a children’s
physician should have a general concern with the care of all the children,the medical

staff.

not so much in the details of medical treatment as in the general managementof the unit. This is obviously of special importance at the earlier ages. In
addition, the rapid extension of the child guidance services means that amany areas. He will not necessarily
see all the children in hospital who show evidence of emotional disturbanceschildren’s psychiatrist is available inbut he can be helpful in discussing with other members of the hospital staff
the handling of individual disturbed children and any general psychiatricproblems arising in the ward.

NURSING ORGANISATION
37. The keystone of the nursing organisation is the sister in charge of theward. She sets the whole tone of the ward atmosphere and the welfare ofboth children and parents depends greatly upon her judgment and guidance.
She should be a Registered Sick Children’s Nurse as well as S.R.N., andshould have had experience as a staff nurse in a children’s ward before being
appointed as sister. Apart from her direct responsibilities for the care of thechildren in the ward she is in a key position to interpret the needs ofchildren and their parents to other members of the hospital staff. For instanceshe can ensure that any medical auxiliaries who come into contact with thechildren are alive to the need for special care in dealing with children andfor a different approach to children of different ages.

38. The child in hospital, particularly during the first few days, should be
handled by as few people as possible. Children suffer from passing throughtoo many different pairs of hands. For the child’s own welfare, a method ofnursing which gives him a sense of security through being nursed by afamiliar person, as in patient or case-assignment, is preferable to othersystems. Shortage of nursing staff makes this type of care difficult to arrange,
but there is no doubt that it is the ideal to be aimed at. Whatever method ofnursing is used, a higher ratio of nurses to patients will be needed in children’s
wards than in most adult wards.
39. Some hospitals have found it useful to have nursery nurses to occupy
and help with the younger children, thus relieving the more highly trained

nurses for skilled nursing duties. If nursery nurses are employed, they should
be used to the fullest extent that their training and natural aptitude allows to
assist in the various aspects of care of children under 5 years of age.

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Printed image digitised by the University of Southampton Library Digitisation UnitOCCUPATIONAL THERAPY
40. Occupational therapists are at present employed in some children’s
wards in general hospitals and in many long-stay hospitals, but they are usually
fully occupied in giving treatment to individual patients and are unable togive time to group activities. Their preliminary training qualifies them toa certain extent to organise play and recreation and there is a post-graduate
course for them in play therapy and play diagnosis. If occupational therapists
were able to devote more time to this kind of work, they could not only

organise play but instruct other helpers in this important aspect of child care.

SOCIAL WORK
41. The recovery of the sick child may be retarded by emotional disturbance which can be aroused by parents who are anxious, or social factors

may have operated in producing the condition for which the child is being
The almoner therefore has an important part to play in relation
the care of children in hospital, for she is in a position to maintaincontact with the parents and the home and also to provide a link withthe social services of local authorities, voluntary organisations, etc. Almoners
and other trained case workers are skilled in eliciting hidden factors which

treated.
to

may be too diffident to discuss otherwise

parents;

they can also help inWesolving parents’ financial problems.
trust that all hospitals admitting
children will be alive to the value of the social worker’s contribution.
42. Psychiatric social workers, when available, can be of assistance withchildrenshowing more obvious behaviour disorder. These workers are
and have an important

specially trained in handling emotional disturbances

function not only in connection with the treatment of these disturbances
but in advising on relationships between staff and parents and upon thecontrol of group tensions where they exist.

IV.

PREPARATION FOR ADMISSION

The risk

that any child will be disturbed by hospital admission
can be reduced by suitable preparation of both parents and children. In
this section we discuss the kind of preparation that should be attempted,
how it should be done and by whom.
43.

GENERAL CONTACTS
44. Apart from the hospital’s role in preparing a child for imminentadmission, informal contacts between a hospital and the community domuch to increase the confidence of parents and children in the hospital’sability to look after the children should they ever have to be admitted. These
informal contacts can be fostered by various means, for example throughsuch organisations as “Friends of the Hospital”, who may collect money
for hospital funds, visit patients in hospital and be associated with thehospitals in various other ways, such as the running of hospital libraries.
Hospital staff may be reluctant to “ advertise ” the work of the hospital,
but the desire to avoid publicity can do harm if it allows prejudice andinaccurate information about the hospital to circulate in the community.
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It is helpful to have “open days” when hospital staff showround people
who are anxious to know more about hospital life. We would also welcome

more opportunities for members of the hospital staff to talk to Clubs andSocieties about the work of the hospital. In all these ways it is possible
for a spirit of co-operation and goodwill to be built up between hospital
staff and the community, and so to lessen the strangeness of the surroundings
should a child have to be admitted.

THE FAMILY DOCTOR
45.

doctor,The child will normally have been referred to hospital by the family
who has an important part to play in preparing the whole family

Many parents have anxieties and fears about hospitaland about their child’s illness, and worry is very easily communicatedto the child. The family doctor can do a great deal to help and reassure
by explaining to the parents the reason for the child’s admission, the kindof treatment he will be given in hospital and, if the parents have no knowledge of it, details of hospital routine. To enable him to fulfil these functions
a knowledge of the local hospital is essential and the hospital should accord
him all possible facilities for securing this and should welcome visits by
him t© children he has referred,
for the experience.
life

LOCAL AUTHORITY STAFF
46. The majority of mothers have attended local authority clinics with
their children at some time in their lives.
The staff of these clinics can help
to foster the understanding of parents and children so that hospital admissionis less alarming. Mention was made in the evidence submitted to us of theappointment by local health authorities of a health visitor to act as liaison
with the hospital or to keep in touch with the almoner or ward
sister. Such arrangements undoubtedly secure a smooth liaison between thehospital and local authority and make for a better understanding between

officerparents and hospital staff,

HOSPITAL STAFF
47.

When the child is referred to an out-patient department and it isdecided then to admit him

to hospital, the responsibility for explaining to
the parents and child the need for, and the implications of admission will

rest with the consultant or other senior

member of the medical staff who

makes the decision. We consider that this interview should be followed, if
possible at the same visit, by a talk with another member of the hospital
staff responsible for explaining the details of admission and answering
questions. (We discuss this fully in the section on preparatory talks below.)
are convinced that time spent in this way makes for the happiness ofWethe child later on, and would recommend that hospital staffs should
special attention to this first stage in the child’s admission to hospital

pay

LEAFLETS AND LETTERS
48. Several hospitals issue leaflets to parents of children who are to be
admitted to hospital. Some hospitals have designed their own leaflets others
make use of a standard one such as is supplied by the Central Council for
Health Education. The evidence given to us showed that leaflets wereregarded as useful both by professional workers and by the lay public,
although they are only one facet of preparation for admission.
;

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49. In designing leaflets the following points should be borne in mind
(1) It should

be clear whether the leaflet

isintended for parents orchildren. If the latter, it should be realised that children of different
ages have different requirements.

admission is likely to be delayed for a long time, the information
should be general, and limited to essentials. Too detailed instructions
given months ahead can cause unnecessary anxiety.
(3) The more detailed information given immediately before admission
should be as personal as possible. For example, parents should
always be addressed by name and the names of the doctor and theward sister should be given if possible. Parents also need to knowwhat their children should bring into hospital, and the arrangementsfor visiting and for dealing with enquiries about the child while he(2) Ifis in hospital.

(4) Leaflets will only be read if proper attention is given to lay out andillustration. Parents are used to a very high standard in advertise-ments, and leaflets for children which may include strips of “ hospital
games” should come as near as possible to the standard set bycontemporary children’s publications.
(5)

The information contained in leaflets must be kept up to date.

PREPARATORY TALKS
50. While leaflets and letters can be very helpful in paving the way foradmission we suggest that they cannot replace discussion with hospital staff.
We have already referred to the need for an interview with some memberof the hospital staff who can explain matters of detail and answer questions:when admission is on the same day as the interview with the consultant thissecond interview can, of course, take place in the ward but when as is morecommon a child is placed on the waiting list it should preferably be given
by a senior nurse on the out-patient clinic staff. Whoever sees the parents
should have some .training in the conduct of an interview and it should beknown to all the staff of the out-patient department that there is a particularperson entrusted with this duty. Some parents like to visit the ward before
their child is admitted and an opportunity to do this can best be provided
at the stage when details of admission procedure are being explained. We
doubt whether there is much to be gained by arranging for the child to pay
an advance visit to the ward.
;

51.

Another way of increasing parents’ knowledge of the hospital which

has been tried with success in some places is the holding of talks between
the ward sister and a group of parents at some pre-arranged time.

PREPARATION OF THE CHILD
52. What we have said so far about preparation for admission relates
chiefly to preparation of parents. This is because the confidence of the childdepends on the degree of security he senses in his parents. The extent to which
the child himself can be directly prepared depends on his age and emotional
maturity the child under 4 probably needs to know only that he is going;to hospital, that it is a nice place where people are made better, that thenurses will be kind and that mummy and daddy will be there at the
beginning and then come back to visit him. The information given to older

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children, depends upon their interests—
one child will want to know theexact nature of the treatment he is to have, another whether
he will beallowed to see something special, another whether he can take his favourite
book or toy. No child, whatever his age, should be threatened with being

away to hospital as a punishment and on the other hand no childshould be given the idea that going to hospital is a special sort of treat or
sentholiday. It is likely that it will fall to the parents to provide such direct
preparation of the child as is possible and they are in the best position
to know what he needs.

V.

RECEPTION

PLANNED ADMISSION
53. First

impressions are particularly

important to a child enteringof strange surroundings andparting from his parents. All his contacts with members of the hospital
staff, from the porter at the gate to the nurses in the ward, will create vivid
impressions, and the need for careful and tactful handling at each stagecannot be over-emphasised. There should be the least possible delay between
entering the hospital and reaching the ward and if he is immediately
welcomed there by the nursing staff and occupied, there is a better chancethat he will settle easily and quickly.
hospital.

When he may be naturally

fearfulWe

54.
suggest that the main admission procedure should take place inthe ward where the child will be nursed and that the amount of information

asked of parents before reaching the ward should be kept to the minimum,.

The child will be very conscious of his surroundings and we believe
that, whether the interview takes place in Sister’s office or on some other55.

part of the ward, there should be as little as possible in the surroundings
to frighten him and much to reassure him. It has been suggested to us
that a playroom is a good place for the child to be welcomed, where he canplay with toys or look at books, and where there is no frightening medical

equipment.
56. Wherever possible the Sister should welcome the child to the ward
and if she cannot be there herself, she should delegate responsibility to anurse of some seniority who will handle the situation tactfully and with

understanding.
57. We commend the practice which is already adopted in some hospitals
whereby after reaching the ward the Sister talks to parents while anothermember of the nursing staff shews the child round, introducing him to otherchildren and telling him something about ward routine. This is particularly
important in the case of the younger child. During her interview with themother, the Sister should find out about the child’s personal habits, his
likes

and dislikes, including for instancehisname for the toilet,; and anyother essential private vocabulary. Where a preliminary medical examination
is part of the routine admission procedure the mother should be allowed‘

to help.

•*.;.

‘
,

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58. If children are admitted to a ward during the day, we would recommend that, where possible on medical grounds, they should be allowed tostay up and not put to bed. It helps to lessen the strangeness of new
surroundings, if the child can play with other patients and learn his way

the younger children’s play can often be organised by
student nurses. If the child is admitted at bedtime we recommend that theto stay and help with feeding and putting to bed.
allowedmother should bestay with
It is a comfort to both the mother and the child if she is able toabout the ward

him for this short period and do for him all the things that he associateswith home, such as tucking him up in bed and saying prayers.
59. Some children are very sensitive about the kind of clothes they may
have to wear in hospital, and any clothing provided by the hospital should
be as attractive and well fitting as possible. The experiment of allowing
children to wear their own clothes in hospital, whether these are launderedby the hospital or are collected by visitors and taken home for laundering,is worth consideration. It is generally desirable to allow children to keepwith them one or two personal possessions such as toys or books which they
may have brought into hospital to provide some visible contact with home,
once the parents have departed, even if it means that such toys must be
abandoned on discharge. If a child has been used to some sort of “comforter”
it should always be allowed unless there are special medical reasons against it.

RE-ADMISSION
60. Where a child is re-admitted to hospital for treatment, it is a great
help if he can be nursed in the ward which he already knows, and we hopethat hospital authorities will arrange for this tobe done whenever possible.

EMERGENCY ADMISSIONS
61. A child may be admitted to hospital in an emergency either from
home, for example with acute appendicitis, or from outside, for example
following a street accident. Whatever the circumstances, the same principles
apply as in planned admission, but because the child is usually more shocked
and upset it will be even more important to reassure him. If the parents
do not come with the child to hospital, they should be notified at once
and when they are present, they should be given all possible help andsupport. They themselves may well be suffering from shock.
62. Special attention shouldbe paid to the arrangements, for receiving

children in casualty departments whether they themselves are seriously injured
or not. The routines of a busy casualty department provide quite unsuitablesights for children and separate accommodation screened from the rest of
the department should be provided for them. Within this separate accommodation children who are seriously injured should in turn be screened offfrom children waiting for quite trivial services. Nurses with experience inhandling children should be available. Figures collected by the World HealthOrganisation suggest that the number of children involved in accidents ishigh— in seven of twelve countries supplying figures for 1951-53 from 30
40 per cent of deaths in the age group 1—19 were due to accidents—andseems likely that in all but the smaller centres separate casualty accommodation for them would be justifiable economically.
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.

63,

Much of what we have said about out-patient accommodation forchildren applies also to casualty departments, e.g., the need for canteen andother facilities to enable parents to wait in comfort. The capacity of theparents to keep the waiting child reassured depends to a large extent on
the comfort and sustenance they themselves can obtain. Children should

never be left unattended in casualty departments.

VI.

THE CHI L|D AS IN-PATIENTGENERAL
64. As we have said, we regard the welfare of the child as an in-patientas the central subject of our enquiry and we have thought it right to preface1.

our remarks on this by some discussion of the differing needs of children of
We suggest that for this purpose children may be divided
into three groups, the under 5s, those aged 5-12, and adolescents.
different ages.

65.

Children under 5 need close emotional contact with familiar adults.

They are best cared for by their own parents but failing this should be
handled by as few people as possible. This is not only because the youngest
members of the group are extremely susceptible to cross infection but
because the effect of a multiplicity of people looking after them is to disrupt
their development and learning. They need the stimulus of other children
and opportunities for play and conversation to help them develop theirpowers of movement and speech. They also need a display of affection frompeople they can trust. Their understanding is unrelated to their superficial
reactions and it is necessary for those who look after them to learn how todevelop an insight into each individual child. Development among them isuneven, their activity is related to their mental age but their mental andemotional ages can be unrelated. Regression to infantile behaviour iscommon in the older members of the group and toilet training is extremely
important. There is therefore much for the nurse to learn if she is to lookafter these young children properly and in a later section of our report weenlarge on the need for new methods of nurse training.

Children over 5 have started school. They are thus used to being
and have encountered school discipline. They arealways searching for information and need adults whom they can trust, whowill not deceive them (even with the best of intentions), contradict themselves
or display uncertainty in handling them. Those over 8 can accept adultexplanations provided that these do not go beyond their obvious interest.
They can amuse themselves playing with the younger children and canuse reading and writing material. All children in the group still need close
contact with their parents but some have begun to understand the meaningof time.
66.

controlled in a group

67.

The requirements of adolescents differ fromthose of adults andchildren. They dislike being treated as children but are prepared toplaywith children as long as they have separate accommodation in which they
can carry on their own special interest. In this age group failure to provide
adequate educational facilities can be critical. We have already discussed

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and we discuss education in more detail in section VI. 4.

THE ADMISSION OF MOTHER AND CHILD
68. An obvious way of preserving continuity between the child’s hospitaland home life is by admitting the mother with the child and this is donein a few hospitals in this country where young children are concerned. One

2.

of the earliest hospitals to institute the practice was the Babies’ Hospital,
Newcastle-upon-Tyne, where the late Sir James Spence admitted mothers with
their babies so that they could continue to care for them. In one hospital in
New Zealand mothers were allowed into hospital with their children as andeal with the problem of cross-infection and as a result
was considerably reduced!1). If an infant is being breast-fed
and it should be rememthere is a special reason for admitting the motherbered that bottle feeding and other forms of care should not be too sharply

experimentito

cross-infection;

interrupted with children under two.
69. Hospitals that have tried admitting mothers with their children claim

young child shows less emotional disturbance on his return home,is beneficial to nurses and mothers and creates a happy
atmosphere in the ward, and that what the mother learns about the handling
child
sick
can
be of value to her if he falls ill again at home. Fearherofthat the mother may get in the way of nurses and doctors and prove aon the contrary
hindrance to the child’s recovery has not been realised
nursing of the child has been made easier and although some medical or
surgical procedures may have to take place in the mother’s absence it
seems in general to be of value to the doctor to have the mother nearby.
It is of course of the essence of the practice that the mother should help
in looking after the child including feeding, washing, keeping him enteras well as comforting
tained and putting him to bed and getting him up
him during painful or unfamiliar medical and nursing procedures.

that thethat the experience

:

;

70.

We think there is much to be said for extension of the practice, moreparticularly where children under five are concerned, and that it is particularly
valuable for the mother to be able to stay in hospital with her child during

the first day or two, and thus to obviate the harm of a sharp separation andrealise that
demonstrate mutual trust between parent and hospital staff.

We

may not always be possible for the mother to leave her own home, but this
hospital
is for her to decide. There may be accommodation problems for theitbut those hospitals that do admit mothers have been able to find theaccommodation by simple adaptations. Expensive new buildings should not
be necessary, particularly in view of the declining demand for hospital
accommodation for children. In fact when the need has been appreciatedthe accommodation has usually been found. The correspondence received by
the B.B.C. makes it clear that the practice is gaining in popularity withparents. In the undergraduate teaching hospitals the presence of the mothermight well call for a modified technique in teaching, but one of the mostvaluable lessons for students is how to deal with a child’s relatives. We lookto these hospitals to give a lead in the matter, bearing in mind their responsibility for (training the doctors of the future.

O H. P.

Pickerill, Lancet, February 28th and April, 10th, 1954.

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3.

General
71. When a child is in hospital he is in danger of losing contact with theoutside world, which has been up ito that time the background of his develop-

ment. If he is not kept in touch with the life that is familiar to him, hewill suffer emotionally and mentally and his normal development will be
retarded. It is vital that while he is in hospital he should be visited frequently
so that he does not feel that hospital life is divorced from everything that
he knows. The child “lives from day to day: he depends on the evidenceof his senses

and his understanding of the situation is fragmentary at best.
is a figure whom he is incapable ofHis roots in home are dying.”! 1)

A loving mother who remains absent
conceiving. . .

.

on visiting probably stem from three main causes, thefear that visitors will introduce infections, the belief that it is better forchildren not to be visited, and the expectation that visiting will disrupt theeven tenor of the ward routine. An investigation into cross-infection carried
72. Restrictions

out on behalf of the British Paediatric Association however, revealed noconnection between visiting and cross-infection( 2), and experience of frequent
visiting has shown the fear of infection to be generally groundless!8 ). Modern
psychologists consider that children suffer far more from not being visited
than from any temporary upset that a visit may cause, and the experienceof the majority of hospitals is that frequent visiting can be assimilated into
the life of the ward without serious difficulty.
73. It has been suggested to us that not all parents are able to takeadvantage of facilities for frequent visiting ; for instance, mothers who haveother children to look after, those who fear to see their children in pain or
distress which they cannot relieve, or those who cannot afford frequent long
distance journeys. We deal later with possible sources of financial aid for
those who need it for the rest we think that more parents, if the valueof frequent visiting were properly explained to them, would welcome themaximum facilities for it, and in any event the reluctance of some to takeadvantage of such facilities is no reason for denying them to all.
;74.. The Ministry of Health, on the advice of the Central Health Services
Council, has issued three circulars in the last ten years encouraging daily
visiting of children and daily visiting is now the practice in most hospitals,

though there are still some, particularly those for long stay cases and someisolation hospitals, that do not encourage it. The length of time allowed varies

from half an hour to two hours a day, although it usually does not exceed
one hour. Visitors are however seldom permitted on operating days, sometimes only parents may visit, and few hospitals allow visits by children under
14 years of age.

We

75.
consider it most desirable for the majority of children not onlythat they should be visited daily but that there should be as few restrictions

on visiting as is consistent with the efficient running of the ward. The younger
the child the more important is it that he should be visited frequently!

( )Anna Freud, Lancet, 28th November, 1953.

A. G. and Lewis-Faning, E„
O Watkins,
Moncrieff,
3! ) e.g.

A.A.,

17th September, 1949,
5th January, 1952.

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;

with

tiny children, who are in hospital for a long time and are not visited, theparents may find that the child who returns home is a stranger to .them andmay lead to serious domestic difficulties. The importance of frequentdiminishes to a variable extent according to the age, emotional
maturity, past history and home background of the child, but it is now
generally agreed that it is much better for a child to be visited daily, even
if he is upset at the end of visiting time, than to have no visitors and become
quiet and withdrawn. In any event, upsets on parting can be minimised bysensible stage management. We suggest that the attitude of some hospitals
thisvisitsto visiting needs tobe thought out afresh and based on a different understanding of the part visitors play in the life of the patient ; in particular
there must be appreciation of the help that the mother can give to her sickchild, by feeding him, washing him, playing with him and seeing to his
toilet, and, on occasion by holding and comforting him when medical
treatment is given. We recognise that visiting should not interfere with theeducation or treatment of children in hospital and we accept that visitors
should not be in a room in which surgical dressings are actually being
applied, for fear of spreading staphylococcal infection—but there are several
times in the daily routine of any ward when visitors could be allowed, andwe consider that the time has come to move away from the idea of strictly
limited visiting hours, even when these occur daily, towards what is co
only
described as unrestricted visiting.

mm

Unrestricted Visiting by Parents
76. “Unrestricted visiting” as we understand it, means that parents areallowed into the ward at any reasonable hour during the day. The precise
time at which visiting hours may begin and end must vary with local conditions, and in any case the Ward Sister will be able to tell parents at whichtimes of day it is inconvenient to have them in the ward. Unrestricted visiting
does not mean that parents are in the ward all the time. It does mean thatthey can arrange their visits to fit in with their other family commitments.
Hospitals which have tried the experiment of unrestricted visiting find thatsome parents want to spend a large part of the day in the ward, but many
will come in for a few minutes at a time, perhaps two or three times a day.

77. Several arguments havebeen put to us for and against unrestricted
which is not as yet widespread, and we should liketo mention these briefly. The arguments in favour of .the practice may
be summarised as follows
visiting, the practice ofmuch happier, particularly the younger ones. For
young child even daily visiting is not frequent enough whenit means that he only sees his mother for a limited period each day.

(1) Children are very

the

(2)

There is much less tension in the ward, because there is no anticipation of a set visiting hour and a feeling of anti-climax once it is over,(3)

Mothers with other children at home are able to fit visits into thefamily routine as
all

(4)

suits

them. Similarly fathers

who are at work

day can come in the evening.

Mothers who are helping to look after their children in the ward
are noticeably much more relaxed and less apprehensive than when
they come in for a limited visiting time. Relations between nursing
staff and parents are more friendly and informal.
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the mother is able to undertake some of the routine care of thehim occupied and entertained, the nurses
have more time for work that they alone can do.

(5) Ifchild, including keeping

78.

Arguments which are sometimes advanced against unrestricted visit-

ing may be summarised as follows

The presence of parents in the ward from early morning until late(i)in the evening prevents the staff getting on with their duties andhinders ward rounds.

The wards are said to be noisier and less tidy.
The application of the practice to a teaching hospital might present

(ii)
(iii)

special difficulties in relation to teaching ward rounds.

The child who has no visitors will feel neglected.
(v) The limitation of unrestricted visiting to parents may occasionally(iv)

give rise to invidious distinctions.
79.

We have considered all these arguments carefully and in our judg-

ment the advantages of unrestricted visiting far outweigh the disadvantages.
We attach particular importance to the argument that children are muchhappier when there is unrestricted visiting and we have received evidence
that the normal life of a hospital can continue even though the_ wards areopen to parents and that nurses can be helped rather than hindered byhaving mothers present to look after the child in many small ways. Indeed,
the evidence submitted to us has convinced us that where the practicehas been adopted, both in teaching and non-teaching hospitals, all thedifficulties mentioned above have yielded to simple adjustments, including
teaching.
if necessary a change in the technique of ward80.

We hope therefore that all hospitals where children are treated will

adopt the practice of unrestricted visiting, particularly for children below
school age. Again, this applies perhaps with particular force to the teachto medical
ing hospitals, in view of their responsibility for demonstrating
students the special needs of the child in hospital.
Settling In

The time when a child most needs to see his parents is during the
few days following admission. It is sometimes thought that if a childnot need to be visited, or thatis only in hospital for a few days he does
“ settled
The reverse is true whilea child should be left alone until he is
the support of someone
his surroundings are new and strange he needs
he is more
he knows and trusts once he has settled into hospital routine
particularly encouragedbesecure and relies less on his parents. Parents should
81.

first

;

;

frequently as possible at the beginning of the child’s stay inshort-stay cases should be visited at least as frequently as
referred to thechildren admitted for a longer period. We have alreadyduring the first few
value of allowing the mother to stay with her childtime (which
someforhospital. The hospitals that have done thisto visit ashospitalanddays inparents maintain
include infectious diseases hospitals) comment that theon. mutual trust andsatisfactory relationships with their children based
overcrowded with visitors.
gradually visit less frequently so that the ward is not

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Evening Visits
should also be encouraged to visit in the evening, when they
have an opportunity to help in settling the child for the night. They
may be able to give the child supper and look after his other needs. There
are obvious advantages to both the parents and ohild in letting them spend
82. Parents

willsome time together just before he goes to sleep. (Moreover, the child’s relationship with the father is of the greatest importance and evening visits allow thewho works to maintain contact with the child without incurring
financial loss or jeopardising the efficiency of the home.

parentOperating Days
83.

days.

We

should like to see the restrictions lifted on visiting on operating
If parents are properly prepared and are willing to help, they canbepresent both immediately before, and when the child is recovering from theanaesthetic. We return in paragraphs 114-15 to the part the parent canplayin this.

Interviews with Medical and Nursing Staff
84. The difficulty parents have in getting enough authoritative information
about the treatment, progress and after care of their children is a common
and well-founded complaint, and there is we are sure a wide need for a moreforthcoming attitude on the part of hospital authorities in this direction.
We do not suggest that parents should be able to have an interview with theconsultant or sister whenever they visit indeed with unrestricted visiting
this would manifestly be out of the question
but it is essential that there
should be certain fixed times, known to the parents, at which they can get
authoritative information at first hand. We have no doubt that complaints
about importuning of medical and nursing staff by parents reflect failure to
make proper organised arrangements to meet parents’ legitimate needs.

——

Visitors other than Parents
85. Some hospitals allow no visitors other than parents or guardiansothers admit adult visitors, but do not permit children under 14 to visit.

The most important visitors from the child’s point of view are his motherand father, and we suggest that unrestricted visiting by others than parents
is not necessary to the child’s welfare unless there is some other person inloco parentis ; it should be possible, however, to have set visiting hours forother relatives and friends once or twice a week. Although an occasional
visit froma brother or sister, or a young friend, may be much appreciated by

the sick child,

we realise

that

this

entails risks of introducing infections

that do not arise with visits by adults.

Children with No Visitors

We

86.
have had a good deal of evidence about the problem presented bychildren who have no visitors. The reasons for this may be economic, or the_parents of children in problem families may visit less frequently or not atall. Also a single parent with a family may find visiting extremely difficult.
In spite of this it was pointed out to us that social workers were able topersuade parents to visit children who had remained unvisited for months oreven years on end, in spite of difficulties in the home, thus avoiding theneed for the child to be “ taken into care ”. It

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the responsibility ofhospital

staff to tellparents simply, avoiding any suggestion of 'blame, that

There may however bewhich cannot be overcome in this way, as in a case where themother, a widow, was herself in a long-stay hospital. It is generally agreed
that some arrangements should be made for visiting by others in such cases.
There are various ways in which this can be encouraged mothers of otherchildren in the ward are often very willing to entertain those without
visitors ; sometimes there are relatives or friends of the child living near
the hospital ; voluntary helpers may also assist in this way. It is importantthat there should be only one or two visitors allocated to each child, andthat visiting should not be organised on a rota system. This may be adifficult recommendation to put into practice when the time that can be given
by voluntary helpers is limited, but we believe that the benefit may be lostIt is
if a series of visitors, all unfamiliar, tries to comfort the child.
particularly important with children under five that they should get to know
theofknowledge
somehaveshouldvisitorone particular person and that thekind of occupation and entertainment the child needs.

visiting is part of the treatment which the child needs.
difficulties;

Facilities for Visitors
87.

At present too few hospitals have been able to provide amenities forfrom towns,
waiting rooms and we should like to see this deficiency made good. Suchamenities are an integral part of a fully-developed hospital, but if more urgent
demands on Exchequer funds make it difficult to fit them into official
building programmes voluntary organisations such as Leagues of Friends
may be able to help. Another amenity which is much appreciated is avisitors, e.g. canteens, or in the case of hospitals at a distanceplayroom where mothers who cannot leave their other children at home
may bring them to the hospital and leave them in the care of a memberof the hospital

staff

or of voluntary helpers.

We hope that as soon as

possible all hospitals dealing with children will make every effort to provide
these essential facilities.

Financial Aid
88.

Some parents may incur considerable expense in visiting frequently,
when their children are in hospital for some time, or at someparticularly

distance from home. These difficulties will increase with the increase in
we confidently expect. There are already certain ways in which

visiting thatA

survey, to which we have hadparents in need can receive financial aid.
access, carried out by the Institute of Almoners shows that the main sourceof financial help comes from Hospital Samaritan Funds, which may be partly
derived from Endowment Funds and partly from voluntary contributions
from the public. Other sources of help and the extent to which they are used,

are as
(1)

(2)

(3)

follows:

Local health authorities have certain powers to
but it is probable that very few actually do so.

assistwith grants,

give grants to those who are
already entitled to national assistance or who would be so entitled
if the cost of travel were deducted from their resources.

The National Assistance Board

The railway authorities give a concession to relatives of patients inlong-stay hospitals, which entitles them to a return journey at
reduced cost.

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(4) In the case of tuberculosis patients, tuberculosis afer-care

'

.

tees,

commitwhich are often voluntary bodies acting as agents of local
sometimes make available voluntary funds to relatives

authorities,

visiting patients in sanatoria.
(5)

Local education authorities may be willing to give financial assistance to enable parents who would otherwise be unable to do so

89.

The arrangements

to visit children

who are receiving education in hospital.

for distributing hospital Samaritan Funds varyfrom hospital to hospital, but the most common arrangement seems to be
for regular grants from these funds to be at the disposal of the almoner.
Parents are sometimes informed in the initial letter that is sent to them
before the child is admitted that help may be available or they may be toldby the Sister on admission. They should always be told at this early stage
that the almoner or other social worker is available to discuss with themany difficulties of this kind. If good liaison is maintained between the Sisterand the almoner, there should be no difficulty in referring any needy cases
to her.
90.

We hope that hospitals will make even

Endowment and Samaritan Funds

tomore extensive use of

assist relatives

whofind visitingafinancial burden.

4.

EDUCATION“In general, there are two main reasons for educating children in
an endeavour is made to ensure that they do not fall behindin their school work, and that they will be able to return to their normal
91.

Jiospital. First,

places in the ordinary school. Secondly (and this applies particularly to theunder fives) they are assisted to develop mentally in an orderly andharmonious manner. The child has been uprooted from his normal homeenvironment. We have every reason to believe that the school makes animportant contribution to the child’s mental health.”
92. This quotation

tofrom the “ Health of the School Child ”(*) seems to us

sum up the reasons why every opportunity should be taken to provide

education for children in hospital, and in recent years there has been agrowing realisation of the importance of this. For over a quarter of acentury a number of long-stay hospitals have had recognised hospital
schools attached to them. In addition since the passing of the Education
Act, 1944, education authorities have had power to make arrangements for,'teachers towork in hospitals where there are groups of children of school
may be put on the school roll and where

age. Any child over the age of 2

is a large enough group of these children, the education authorities
can provide nursery teachers in addition to teachers for the older children.
School hours are usually from 9.30 to 11.30 in the morning and again from1.30 to 3.30 in the afternoon. In September 1956 the Ministry of Health andMinistry of Education sent memoranda to hospital and local education
authorities drawing attention to the importance of education in hospitals
and stressed the need for liaison between the two types of authority bothin regard to the identification of need for education in hospital and to theprovision to be made on discharged2)

there(') ‘'The Health of the School Child” Report of the Chief Medical Officer, Ministry of
Education, for 1954 and 1955, Chapter XV,(9 Ministry of Health Memorandum H.M. (56)81 and Ministry of Education Circular 312.
,

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93. We understand that in January 1957 there were 114 hospital schools,
with 5,844 pupils and that in January 1958 there were 206 other hospitals
in which arrangements had been made for teaching to be done. These latterarrangements covered 1,689 children. Thus the total number of children
covered may not represent more than a quarter of the total number inchildrenhospital, and, even allowing for the fact that a proportion of thethat
are under two and a proportion not medically fit to receive it, it seems

profitthere may still be a substantial number of short stay cases who wouldfrom education but are not receiving it. Those in adult wards are speciallyin education
liable to be overlooked. Even with a short stay case a break
may be positively harmful, and whenever a child is admitted, hospitaland beenoughauthorities should consider whether he is likely to stay longno regular teaching arrangements
fit enough to receive education. If so, and if

already exist within the hospital, they should notify the local educationifauthority so that they will have time to make ad hoc arrangements
possible.

are about to
94. Children should not be admitted to hospital when theyThetake important examinations unless they require urgent treatment.
the parents
unlesshospital will not know that an examination is imminent
them
for
it
is
that
it
clear
make
shouldparents
tell them and leaflets for
Arrangements
to seek postponement of admission on this ground if necessary.
for children in long stay hospitals to take examinations from hospitalshouldbe encouraged.
95.

Co-operation by the hospital

staffwith the teacherisessential.

Inenoughparticular the medical staff can help by saying when a chiM is well
work better if
to receive instruction. Similarly, the teacher can plan thehospital.
she knows for approximately how long a child is likely to be in

A particularly close liaison between sister and teacher is essential.
in the same
96. Teaching is much easier if children of the same age arelessons
ward, or the same part of the ward. Older children who are doing
be distracted if there are younger ones playing nearby. Beds can often

may

are

be rearranged for teaching periods so that all the children being taught
while thetogether. There are bound to be some interruptions to teaching

work of the ward is carried on, but there is considerable variation at present
Whenever possible
in the amount of disturbance caused in different hospitals.
treatment and visiting should be so arranged as to avoid school hours.
she can prepare
97. An efficient hospital teacher needs a room in whichward
her work and ample storage space for books and equipment in thesee that satisfactory
units, and it is incumbent upon the hospital authorities to
in
bed
ten
child
accommodation is provided. It should also be realised that
may be given activities that are messy and untidy, such as modelling, cooking

and even scientific experiments.
98.

During school holidays various arrangements can be made fororganised activities to take the place of school. Some education authorities
engage staff especially for holiday periods, perhaps students or retired
take only
teachers. Others arrange for the teaching staff at the hospital toshorter. It is important that
3 weeks’ holiday at a time, so that the breaks are
hosterm
children should be given organised activity outside the school
should not hesitate to ask local education authorities for help to;pitalsoccupy children during holidays.
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5.

OTHER ASPECTS OF IN-PATIENT CARE
99.

Recreation

Much of the evidence we have received has emphasised the need to'give children in hospital plenty of occupation for their spare time. An unoccupied childis less likely to be happy than one with interesting things
to do. Where play can be organised under skilled supervision it is particularly

100.

useful but student nurses, cadets
entertain the children.

and voluntary workers canallhelp toChildren’s activities fall into two types, spontaneous and organised.
Since all children’s activities are necessarily restricted in hospital, it is essentialthat there should be a daily programme. This should include rest periods,
and periods of unorganised play, but those in charge should realise that thesebe constructively used unless children are provided with somethingwhich they are allowed to play with during their free times. It is importantto see that every child’s needs are catered for in this way. The child who cannot
participate in an activity feels doubly left out unless he is given special
will notattention of some sort, even if that special attention is somebody offering him

an alternative activity such as reading, listening or drawing. On the other
hand, diversion need not depend on elaborate organisation: a child may behappier watching traffic or a mechanical polisher than taking part in a carefully
devised game.
101. For younger children a variety of suitable toys is essential. Voluntaryorganisations such as Leagues of Friends can often help with the supply ofthese but the supply should be under the supervision of the hospital, whoshould ensure that skilled advice is obtained, e.g. from the nursery schools
associations, on the suitability of the toys provided. Older children may takepart in club activities such as Scouts and Guides. When children have particular
hobbies such as gardening, painting and handicraft these should be respected
and encouraged as far as possible. Wireless and television are becoming
increasingly common in hospital wards and selected parts of the programmes

can be a great boon to the children. We have already suggested that it is anadvantage if there is a separate playroom where children who are up andabout can go without disturbing more ill children.
102.

These suggestions obviously apply with greatest force to long-stay
can and should be applied in varying degree to those

hospitals, but theyhospitals where stay is normally short.

Discipline
103. Children vary in their response to the disciplinary techniques of adults

and an orderly ward depends very much upon fairness, reasonable firmness
and harmonious relationships between all the staff. It is well known thatcertain adults find it easier to maintain discipline with children than do others,

and that approaches vary from individual toindividual. Nevertheless thefollowing general observations should be useful(1) It is extremely difficult for anyone to maintain discipline with children
if hisor her requests and instructions are countermanded by someone

else in higher authority.
(2)

who participate in an orderly and sensibly devised programme with sufficient diversion to avoid boredom will not present

Children25

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a disciplinary problem. Conversely the child in an otherwise empty
cot sitting and staring into space is a potential disciplinary problem.
(3)

The child who has violent tantrums and is not restrained, as many
are, by the presence of other children presents a special problem.

A

patient attempt to get to the cause of the outburst is obviously better
than severity, but on the other hand a child in a ward with acutely

children cannot be allowed to disturb them, and in the extreme
case a child in a tantrum may have to be removed to a side ward.
This will only be successful if the removal is presented as a matterillof ward administration and not as a punishment, and if the childis not shut in there alone but is accompanied by a sympathetic adultuntil he can recover, and the reasons for the outburst can beascertained.
(4)

A great deal of this report deals with the relationships between
hospital staff and parents. A good relationship with the parents ofcontradiction between parents andwhich the child perceives can give rise to acute problems ofa child makes discipline simpler
staff

;

discipline even in adolescence. It

isbetter to convert a parent toaAcontradiction between staff andpoint of view than to over-rule him.
parents can be the reason why the child is not visited and the sourceof much later disturbance.

Safety Measures104. The safety of the child is obviously a prime consideration of hospital
staff and it is understandable that hospital authorities, because they are legally
responsible for the children during their stay in hospital, take precautions
which would not be necessary at home. We wonder however whether
there is sufficient appreciation of the harmful psychological effects of suchthings as restrainers and high sided cots on all but the very youngest children,and sufficient readiness to explore other ways of preventing accidents, notably
by closer supervision. In our view restrainers should be necessary only in
exceptional circumstances, and children who are accustomed to sleep in beds
at home should be allowed to do the same when in hospital.
Personal Possessions
105. We have already suggested (paragraph 59) that children should beallowed to take personal possessions such as toys and books with them intohospital and preferably they should keep these beside them. The choice ofwhat to bring must be the child’s, and neither parent nor hospital should stpp
him bringing something he loves on the ground that it is not clean orrespectable enough to take into hospital. Hospitals should provide lockers,
boxes or bags for each child which he can reach easily. Even very young

children need accessible storage space.

Food
106. Children’s food should look attractive, should be served in suitable
implements of the right size and shape to eat it with, andshould be chosen to suit the age of the child. Portions should be small with anopportunity to ask for more; mountainous helpings often daunt the uncertain

utensils, withappetite.

For infants sievingisimportant but different constituents should

not all be mashed together. It will not be conducive to a properly balanced
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diet if the child eats food brought by his parents and the aim should be to seethat the food he gets in hospital satisfies him. Although a mother can sometimes persuade her child to eat when no one else can it is also possible that thereversemay be true.

Toilet Training
107. Some parents complain that young children regress in their toilet
training after a period in hospital. This may be due either to the emotional

upset of separation, or to inadequate attention to the child’s toilet needs while
in hospital. Children are shy about making their needs known, particularly
during the first few days before they get to know the nursing staff. Hospital
staff can avoid some embarrassment for the child if they learn his private
vocabulary for the toilet and his home routine. Whenever possible children
should be allowed to get out of bed to go to the toilet, but if they are bedfast
they must have some means of making known their need for a bedpan orbottle. We have heard of hospitals where children in cubicles have no meansof communicating such needs and this causes very great discomfort andunhappiness. No hospital staff should treat toilet “ accidents ” as occasions forpunishment or rebuke of the child.

Information about Children's Progress
108. We have already referred to the need for organised arrangements to
supply visiting parents with information about a child’s progress. If parents
are unable to visit it is equally important that they should be able to get
information by letter or telephone from a responsible and knowledgeable
person, preferably the Ward Sister, so that they can get full and sympathetic
answers to their questions. It is not enough for a parent to be given aformal “ bulletin ” by, for instance a telephone operator. Obviously sisters
cannot come to the telephone at frequent intervals throughout the day but itshould be possible to ensure that someone with direct knowledge of thechild’s condition is available to answer telephone enquiries fromclose
relatives at certain prearranged times. If parents are able to speak to
medical staff when they visit their children they are less likely to seek information by telephone during the intervals between visits.

Transfers
109. It is important to explain to the child, and to inform parents, when
the child is to be moved from one ward to another, to another hospital or to aconvalescent home. Children can become very worried lest their parents are
not able to find them in their new surroundings and it should be made clear
to them that their parents know what is happening. Indeed parents should begiven the opportunity to accompany their children when the move takes place.
If they cannot do so, a familiar member of the hospital staff should go with thechild.

Spiritual Welfare
110. This part of the child’s welfare should not be neglected while he isin hospital. We were impressed by the interest in it shown by several of thebodies who gave evidence to us. Daily prayers are an important part of life
in a children’s ward. Much of the evidence we received from parents showedthat they appreciated arrangements made for evening prayers. Where parents

are allowed tovisit theirchildren every evening, they27

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may prefer to say

prayers privately with them, but this is not to say that there should not
be an opportunity for the whole ward to take part in prayers. The Ward
Sister is normally the most appropriate person to conduct prayers. In addition

to ward prayers, hospitals should make arrangements for children to takepart in Sunday School. Hospital chaplains and visiting clergy are always
willing to visit children in hospital and parents should be told that theservices of a Minister of any denomination are available. The main object
in this, as in other aspects of the care of the child, should be to preserve

as far as possible the thread of his experience and the certainty that his

normal life will be resumed.

VII. WELFARE ASPECT OF MEDICALTREATMENTGENERAL
111. Although our terms of reference specifically exclude the medical
and nursing treatment of children in hospital we do not interpret this asprecluding us from commenting on the impact of various medical procedureson the child’s general welfare. For example, we think it right to draw attention

to the harmful effects of postponing an operation once it has been fixed,
and to the importance of careful scrutiny of the need for any medical

procedures that involve unpleasant experiences.

PREPARATION
112. The aim of all hospital staff is naturally to make treatment as little
frightening as possible to children. This means spending time and care in
explaining to children what is to happen to them ; careful preparation at
this stage is amply rewarded later. Children’s anxieties may seem fanciful,
but they are none the less real to the child, and an opportunity should betaken to talk to the child about his forthcoming treatment and, as far as

possible within the limits of his understanding, to explain to him what
involved. It is never safe to assume that a child will be afraid of anexperience that an adult regards as frightening, or conversely that an
is
is

A

experience which has no terrors for an adult will have none for a child.
may be more afraid of a white coat than a painful procedure, anddarkness and solitude can seem more terrifying than an operation. In
reassuring a frightened child it is necessary to try to deal with his fears
and not with what the adult thinks he is likely to fear. It should not benecessary to dwell on the painful aspects of treatment: a child should be
warned if he is going to be hurt but the hurt can be exaggerated by an
exaggerated warning, especially if this is given too long in advance. Blamefor crying or for being afraid not only makes the child feel guilty andashamed but can increase his degree of pain. Conversely, strong suggestion,
approval and support can minimise pain. Where the child is to undergo an
operation, it is a great help if he knows that he will have a familiar personwith him, for example his mother or a nurse he knows, as long as he isconscious. One of the most upsetting experiences for the child is to be
child

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removed, when he is already apprehensive, from the environment and people
he knows. The special needs of the blind, the deaf and those with language
difficulties should be carefully considered in this context.

TREATMENT AND RECOVERY ROOMS
113. We agree with the recommendations made to us that there shouldbe treatment rooms separate from the wards available for children so that
unpleasant procedures do not have to take place in the presence of otherchildren. For the same reason we believe that children should not be withinsight of other children when they are being anaesthetised or coming roundafter an operation.

PREMEDICATION
114. Premedication has been of the greatest value in lessening the alarming
aspects of operations and we believe that it should always be given unlessthere are medical reasons for not doing so. It may often be helpful if themother is allowed to be present until the child goes to sleep. Premedication
should also be used much more widely for minor procedures taking placein the ward unit, e.g., lumbar puncture.

PRESENCE OF MOTHER DURING RECOVERY FROM ANAESTHESIA
115. The mother may also be present when the child is coming roundfrom the anaesthetic, provided that she is not present at too early a stage.

Whenever the mother is allowed to be present during recovery it is importantthat the probable after-effects of anaesthesia on the child should have been
explained to her.

WARD ROUNDS
116. Children often 'absorb much more of what is said in their presence
than adults realise and they are liable to misinterpret what they hear and toworry about it afterwards. For these reasons, we believe that any discussion
during medical ward rounds should take place as far as possible out of earshot
117. children, or if discussion takes place round the bed, exceptionalof thediscretion should be used in what is said or left unsaid in front of them.

VIII.
1.

SPECIAL GROUPSLONG-STAY HOSPITALS
Most of our recommendations apply equally to acute hospitals, wherechildren may be discharged 'after a few days, and to long-stay hospitals. There
are, however, certain aspects of hospital care which need particular emphasis
in long-stay patients, because of the particular problems created by prolonged

separation from home and parents and the need for the child to become fully
adjusted to the life of the hospital. We should therefore stress the following
points(a) Careful preparation of both parents and child is particularly necessary.

Normally children are not admitted to long-stay hospitals in an
emergency and there is therefore plenty of time to accustom the29

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family to the idea of the child’s admission. For the parents, aninterview with the member of the medical staff who will be in chargeof treatment is essential. Parents must be sufficiently informed about
the hospital’s regulations and routines so that once their child has
settled in their attitude will be much the same as it would be if thechild was starting life at a boarding school. They need assurance
that they will be notified of changes in their child’s life and theyshould be asked to co-operate in the process of settling in.
(b)

During the settling in period, before the child becomes accustomed
to his surroundings, the hospital should be prepared, where necessary, to provide accommodation for the mother so that she can stayfor a night or two. This short stay will ensure a better understanding

between the staff, child and parents and may be essential in children
whose home are many miles away,(c)

Visiting in long-stay hospitals presents more of a problem than inacute hospitals since many parents are unable, because of the

distance of the hospital from the home or for financial reasons, toIn addition, many long-stay hospitals haveschool hours and are therefore -restricted as to the times when they

visit their children daily.

can welcome visitors. Although visiting should not be allowed tointerfere with education, we see no reason why this principle should
entail rigid adherence to set times for all visitors and we suggestthat parents should be allowed tovisit, by arrangement with theward sister, at whatever times outside school hours suit them best.
Once the child has settled in, regular visits can be less frequent.

Our remarks about amenities for visitors (paragraph 87) are of particular relevance to long-stay hospitals, which are often at somedistance from towns. If a child has no visitors he may be given a“foster home” close to the hospital where he can enjoy family life.
(d)

Education and organised recreation have been for some time an
essential part of the life of the child in hospital for a long period,
but we should like to emphasise the importance of ensuring that suchchildren are kept 'happily occupied during school holidays and ofproviding a well run children’s library. The hospital school will
provide some books and help with the library staffing but it is for thehospital to see that a library is provided and fully stocked and to
make suitable accommodation available for it.

(e)

As the time of discharge approaches the hospital should make contact
with the family doctor, the local health and education authorities
and all those who will be concerned with the child’s after-care. In
particular where a child is of school age, provision should be madefor continuing education once he has returned home, his special
educational requirements having been made known to the local
education authority without delay.

f After a long-stay in hospital readjustment to home life can be diffi-()

cult. It will be less so if parents have been able to visit sufficiently
frequently, and also if the child has been home for occasional visits

during his stay in hospital. During visits parents should be instructed

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any special care the child will need after his return home. The
who has been kept well in touch with events at home will
The almoner should be informedchildfind readjustment less difficult.

about parents who fail to visit -their children in long-stay hospitals
so that she can find out the difficulties and see if they can beovercome. Health visitors can prevent the parents losing touch andcan also help in dealing with problems which may arise after
discharge. Long-stay hospitals should have under continual review-the possibility of children having periods at -home before treatment is completed and should of course discharge them permanently
as soon as it is medically justifiable to do so.
2.

THE BLIND AND DEAF

118. Again our general recommendations for the care of sick children
apply with particular force to the child who is blind or deaf. The needs ofchildren with such handicaps include those of other ill children and some
additional ones, and particular consideration should be shown to them inthe following ways(i)

The hospital should maintain close contact with the home or schoolfrom which they are admitted. Such children need plenty of prenew surroundings may be moreparation because adjustment todifficult than for the normal child.

These children need special materials and equipment to occupy themThey also need even more than do other children the companionship of adults they know.
(iii) The education of the blind or deaf child in hospital need not present
as great a problem as is sometimes supposed, since teachers without
special qualifications can often, with the help of a school for theblind or deaf, give the child what he needs for the time he is in
hospital. None the less, hospitals should ask local education authorities to do their best to provide specially qualified teachers, eventhough this may mean one teacher -being attached to several(ii)

selves.

hospitals.
(iv)

Parents should be kept as fully informed as possible of their child’s
progress while in hospital. Particular care and sympathy is neededfrom -hospital staff in talking to parents of blind and deaf children

and everything possible should be done to(v)

3.

allay fears

and mis-understandings about their child’s handicap.
Occasionally children may become blind or deaf while in hospital.
For example, a child may become deaf as a result of tuberculous
meningitis. There is a danger that the special needs of such a child
may be overlooked and there should be no delay in providing any
necessary -hearing aid and the services of a teacher of the deaf.

INFECTIOUS DISEASES HOSPITALS
119. The character of infectious diseases hospitals has changed immensely

in recent years. Many of the -old“ isolation hospitals” were built at a distancefrom towns to house a large number of patients for indefinite periods of time.
Immunisation, changes in incidence and severity and new methods of treatment have meant that the number of cases o-f infectious illness has fallen
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considerably and that relatively more of them are nursed ait home. “ Isola55
hospitals are now being used for the treatment of a much wider rangeof children’s ailments.
tion

120. These changed circumstances should be reflected in the managementof children admitted to infectious diseases hospitals. In particular, more
attention needs to be devoted, on the lines we have suggested for hospitals

generally, to the occupation and education of children in these hospitals ; andour recommendations on admission of mothers and unrestricted visiting areintended to apply to infectious diseases hospitals as to others. It is still
being argued in some districts 'that parents cannot be allowed to see theirchildren because of the danger of spreading infection, but we have had
evidence that in other districts hospitals have allowed unrestricted visiting

and admission of mothers without any increase in the incidence of infection.

We should like to see the restrictions on visiting in infectious disease hospitals
so that the parents can have access and talk to the child save in
exceptional cases where there is a real risk to the community. There may be a
few occasions on which parents must be asked not to visit because of risk tocontacts at home or at work but these should be exceptional particularly if
lifted,can be given protective clothing to wear when necessary. More harmthan good is done, however, by allowing parents to see their children only
through a glass partition this seems to us an unimaginative restriction,
visitors;

where very young children are concerned, and since we knowof hospitals which are able to dispense with it we hope it will disappear

particularly
altogether.

121. The change in the role of the infectious diseases hospital also
demands that it should have a nucleus of nursing staff with special training
in the care of children and that a children’s physician should be
associatedwith the children’s medical care. This association should preferably takethe form of provision in the children’s physician’s contract for regular sessions
at the infectious diseases hospital.

OPERATIONS FOR REMOVAL OF TONSILS AND ADENOIDS

4.

The care of children before and after operations for removal ofand adenoids merits particular attention. It has been calculated thatnearly one child in three has his tonsils out before the age of
13, and that122.

tonsilsnearly 200,000 operations for removal of tonsils and adenoids are performed
each year in England and Wales—largely in the 5-8 age group. In fact
is the commonest reason for admission of children
to hospital,

this

and

because these cases are usually dealt with in batches and are usually
only
in hospital for a short period, there may well be a tendency
to consider
that their problems are less important than those of longer staychildren.
123. Preparation for admission should include carefully preparedleaflets
so that, shortly before his admission to hospital, the mother isable to givethe child a simple explanation of what is likely to happen tohim. This
important matter has frequently been neglected in the past. The

mothershould be encouraged to discuss any problem with the Ward Sister
beforeand there are also obvious possibilities for grouoathe time of admission,

F

discussion.
124. Itunits

ifinadvisable for these operations to be carried out in
small
there are inadequate facilities for the handling of children.
is

There

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accommodation. In a large centre it will no doubt be possible to provide
a ward, separate from the adult accommodation, in the main E.N.T. Department, but if this cannot be done the children should be nursed in a ward
within the children’s unit. Wherever they are nursed, the staff should beproperly trained to give the specialised pre- and post-operative care which
is so necessary for this type of case, and a larger nursing establishment
may be needed than for ordinary children’s nursing.
125. The same arrangements for admission, reception and welfare in
the ward should apply to children admitted for tonsil and adenoid operations as for other children, and special care should be taken that children
awaiting operation do not see those just returning from the operating theatre.
The same visiting arrangements should apply as elsewhere. There is noevidence of any increased incidence of infection where this has been done.
Parents should be allowed in as often as possible, including the day ofoperation, although it may be better for them not to see their children
until they have fully recovered from the anaesthetic. On discharge a simple
leaflet setting out the after-care necessary will be very helpful to most parents.
5.

EYE OPERATIONS

126. These operations also account for a large number of hospital admissions of children and again all our general recommendations about preparation for admission, visiting, etc., apply. It is best for the children to benursed in a separate children’s unit: in big centres this may be also a
specialist eye unit

127.

but elsewhere it will be a general children’s ward.

To have his eyes bandaged, as commonly happens after for instancean operation for squint, is profoundly disturbing to a child. Some hospitals
have found it possible to avoid bandaging children’s eyes after squint operaand while it is not within our province to discuss the medical arguments for and against bandaging, we would express the earnest hope thatbandaging will not be resorted to without the most careful weighing of its
serious disadvantages for the emotional welfare of the child. Whenever
bandaging is necessary, time must be devoted to the reassurance of the128.
child and arrangements must be made for his occupation. These above all
are cases in which the parents should be given every opportunity to playtions

their part.

IX.

DISCHARGE AND AFTER-CARE

Some of the criticisms we have heard of the treatment of children
hospital have been made because some children show evidence of
psychological disturbance after discharge. A certain amount of such disturbance appears to be inevitable, and results from separation and fear atvulnerable ages: the impossibility of arriving at an exact quantitive assessin

ment is shown by the wide variation in the estimates offered to us, whichranged from 20 per cent to 90 per cent. The disturbances which children show
on discharge from hospital fall into four main groups:
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1.

Regression to earlier stages in child development.

2.

Aggressive behaviour of various sorts.

3.

Terrors, timidity and sleep disturbance.

4. Difficulties at school.

129. Regressive behaviour due to stress means a reversion to forms of
behaviour which the child had previously grown out of. The commonest
forms are loss of sphincter control, loss of speech and demands for cuddling,rocking or the feeding bottle long after infancy. Regressive behaviour may bepatchy in its occurrence, and a child’s behaviour can vary from hour to hour

between that normal to a seven year old and that of a four year old.
130. Aggressive behaviouristhe natural response to being hurt or the

memory of being hurt. It is not possible for the child in hospital to beallowed to act out his aggression when he is hurt or frightened as he wouldin the playground or at home. Hence aggression is stored up and released
at home.
131. Night terrors and sleep disturbance are the commonest reactions of
the individual of any age to stress of any sort. In hospital the positive
provisions of a night light and a nurse who is sympathetic recognise this.
When the child goes home he can miss this provision and parents need to
be warned to deal with the problem with understanding. The fear of doctors
and of white coats can persist throughout a person’s life, or the white coatand the nurse’s uniform can equally stand for security and reassurance. Whichof these happens to a child depends on a meticulous attention to the detailsof the life of the child in hospital.
132. Preparation for discharge can be almost as important for bothparents and child as preparation for admission and parents should be given
as long notice as possible. We do not agree with those who hold thatchildren should never be told before the parents when they will be discharged it may not always be possible to inform the parents first, andprovided they are told at the first opportunity, there is no harm in the child:in advance. Telling the parents the date when the child will besent home is only one step in the preparation for discharge. They should
be told, by the doctor concerned or a senior member of the nursing staff,
what treatment the child has received in hospital and how this may haveto be followed up at home. Special instructions may have to be given aboutknowingfeeding habits, diet, medicine, appliances, reference to the family doctor or
return visits to the hospital. Where the child has been given special treatment
in hospital which is to be continued at home it may sometimes be desirable
to admit the mother to hospital for a day or two before discharge to beshown what she will have to do once the child is at home. Written instructions
should be given to mothers about such matters as the making up and timingof infants’ feeds.
133.

nursing

At the time of discharge the Ward Sister or a senior member of theshould be available to talk to parents who come to take thestaffhome. Times of discharge vary greatly, but hospitals should try tochoose times which suit parents as well as themselves. For example, where
the hospital' is at some distance from a town, discharge should be arranged
to fit in with bus services.
child

134.

The need to inform the family doctor promptly about discharge ofhis patients has been stressed in the report of the Committee on the Recaption

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and Welfare of In-patients (H.M.S.O. 1953) and what is said in paragraphs
84-5 of that report applies to children no less than to adults. While weappreciate that it is often impracticable for a full report to go to the family
doctor for some days after the patient has been discharged it should bepossible, e.g. by using a printed form with space for the insertion of theminimum essential information in manuscript, for a brief notification to besent off as soon as discharge on a particular day is certain, with the promiseof a detailed note as soon as possible thereafter. When there is need forcontinued treatment or nursing at home after discharge, there should be fullconsultation with the family doctor to find out whether the home conditions
are suitable, and he should always be told what advice has been given to
the parents.

may not be aware of the services provided by local
ill children, and we understand that these are not always
invoked as they should be. The local health authority provides guidance
for the mothers of children under 5 under the supervision of the maternity
and child welfare staff. It is important that a liaison be preserved so thatthe. advice given by the hospital on discharge does not conflict with thatgiven by the health visitor. The local education authority is also responsible
for the provision of special education for handicapped children, and forthe education of children who cannot attend school for long periods. Hence
it is essential that the Medical Officer of Health (who is usually also the
Principal School Medical Officer) should be notified as soon as possibleof the discharge of any children needing any of these services. Otherwise
time may be lost which can prove vital in for instance the care of a child
who has lost one of its special senses. In this chain of communication theservices of the almoner should be invoked and the part that can be playedby the Ward Sister should not be overlooked. It goes without saying that
all that is done to arrange for after-care should be with the knowledge of
135. Hospital staff

authorities forthe family doctor.
136. For some children, follow-up visits to the out-patient department by
appointment made at the time of discharge will be neoessary for a period,
but these should be reduced to the minimum by keeping the family doctor
fully informed about after-treatment and making full use of his services.
The family doctor is in the best position to call in the services of Health
Visitors and Home Nurses, when needed, through the local health authority.

X.

TRAINING OF STAFF

While the child is in hospital he is under the skilled care of medical,
nursing and other staff. For a shorter or longer period the hospital ishis home and whether he is happy there depends more on the staff looking
it is therefore very important thatafter him than on any other single factor
all who have to look after sick children should learn not only how to deal
with the child’s ailment but also how to meet his emotional and other needs.
137.

;

138. The members of the staff who come most into contact with children
in hospital are of course the nurses, and their proper training is of theutmost importance to the child’s welfare. The nurse’s real competence with
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sick children comes not from text books but fromthe close personal contacts
with patients. In nursing sick children the nurse needs
to understand not
only the diseases of children and disease in children
presents many special——

features not found in disease in adults
tiie development of the normalchild,

but also the factors that influence
including his emotional reactions,family circumstances and the importance of hisother social relationships. As we have already indicated children’s
needs vary at different ages
and the nurse must have an understanding of these differences.

his139. All this requires special study andw e trust that those responsible
for nursing curricula will give all possible
priority to the adaptation oftraining courses for the purpose.
few lectures are not enough experience
with well children in a nursery school or a residential
or day nursery would
be a great advantage where practicable and the nurseA:knowledge of the results of reoent studies
child s needs and development.

should be given someby educationalists of the normal^5®*children s nurse needs to know all that she
can learn about
the functions and difficulties of parenthood andthe significance of family
life. It is not possible for thisinformation to be acquired theoretically,
though lectures from a social worker could be of value.
More useful would
be practical work with a home nurse assisting in thehome care of children
in the district surrounding the training school.
In this way also, the nursefitraining would get insight into the problems
which the averagejsurmounts. It w as suggested to us in evidence by several

mother7

bodies that nurses
m training should be trained in the taking of essential social
histories
and;we agree that such activity can establish the necessary confidence
betweennurse, child and parent, and teach the nurse
a particular approach topatients which the training may not afford atWe

present.
have already drawn
attention to the key position occupied by theward sister. The special
a nurse’s training which we have just outlined should beafeature of the refresher courses arranged for ward

elementsmsisters.

141. Training of medical staff should
also take more account of theemotional and social needs of children and their parents.
Though the doctor’scontacts with the child are less prolonged thanthose of the nurse he isa figure of great importance in the hospital ward andthe way inwhich hehandles both parents and children can be vital to their welfare.
It is notenough that those specialising in children’s medicine should receive

specialinstruction in this aspect of the child’s well-being:

every practising doctor

and particularly every family doctor must frequently find himself insituations
where this knowledge is essential to the proper management of patients.
142. Children in hospital also come into contact with a numberof staffother than medical and nursing staff, e.g., radiographers, physiotherapists
andlaboratory technicians. All these people are concerned with procedures

which
may be frightening or painful and during their training they should leam
about the need for special care in dealing with children and that the approachto the child must differ at different ages. Complicated techniques
can only
be performed on a willing child, and the technician will therefore normallybe alive to their immediate emotional effect less obvious is the reactionof a child to a daily blood count a pricked finger can assume greater
importance, particularly if force is used, than a major operation. The

—

;

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technician should be taught to explain that a prick will be felt, and to act
meanwhile talking about something which will interest the child.

rapidly,

143. Another group of staff who should receive special instruction aboutchildren in hospital are hospital teachers. These are in a slightly different
category because they require training in the needs of the sick child inshould like to see an extension of the existing
relation to education.

We

arrangements for this kind of training.

XI.

SUMMARY OF RECOMMENDATIONSGENERAL
Greater attention needs to be paid to the emotional and mental needs
child in hospital, against the background of changes in attitudes
towards children, in the hospital’s place in the community, and in medical
1.

of theand surgical practice. The authority and responsibility of parents, theindividuality of the child, and the importance of mitigating the effects ofthe break with home should all be more fully recognised. (Paragraphs 6-14.)

ALTERNATIVES TO IN-PATIENT TREATMENT
2. Children should not be admitted to hospital
avoided (paragraph 17).

if

itcan possibly be

3. Special nursing facilities for looking after sick children at home should
be extended (paragraphs 18-19).

4.

There should be separate out-patient* departments for children, withand staff. Waiting time should be kept to the minimum

suitable facilities(paragraphs 20-24).
5. Some simple surgical operations can be undertaken at the hospital,
subject to certain safeguards, without fully admitting the child (paragraphs

26-27).

HOSPITAL ORGANISATION, DESIGN AND STAFFING
6. Children and adolescents should not be nursed in adult wards (paragraphs 29-33).

Separate children’s hospitals for all children are impracticable and forrun of cases a small children’s unit at the local hospital should
suffice (paragraph 34).
7.

the general

8. Children should be nursed in company with other children of thesame age group. They should have facilities for inside and outside play andcolour schemes should be cheerful. Supervision and prevention of accidents

are important (paragraph 35).
9.

A children’s physician should have a general concern with the careof all children in hospital (paragraph 36).
10. The Sister in charge of the ward should be R.S.C.N. as well as
S.R.N. The child should be able to get to, know his, own nurse? Nursery
nurses can help with children under 5 (paragraphs 37-39).

11. Social workers

and occupational therapists have a valuable contribu-

tion to make (paragraphs 40-42).

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PREPARATION FOR ADMISSION
12. The risk of disturbance to the child can be reduced by proper preparation. This can be achieved by the promotion of a better understanding of
the hospital’s place in the community, by explanations from the family

doctor and local authority clinic

staffs,and by suitable measures on thehospital’s part in arranging admissions. These should include(i)

explanation of the reasons for admission by the doctor who makes
the decision(ii)

an interview with a suitably trained person to discuss details(iii)

properly designed leaflets and letters.

;

Talks between the ward sister and groups of parents may also be useful. The
information suitable to be given to the child himself depends on his age, but
a period in hospital should never be threatened as a punishment, nor promised
as a treat (paragraphs 43-52).

RECEPTION
13. First impressions are important. The main admission procedure should
be in the ward and there should be the least possible delay in reaching it.

Sister should welcome the child in reassuring surroundings and should find out
from the parents about his idiosyncrasies (paragraphs 53-57).

14. Children admitted during the day should not be put to bed unless thisis medically necessary. Where children are admitted at bedtime the parents
should be allowed to help put them to bed (paragraph 58).
15. Clothes provided by the hospital should be attractive and well-fitting.
The experiment of allowing children to wear their own clothes is worth
considering and they should be allowed to keep a favourite toy (paragraph;

59).

Re-admission should be to a familiar ward (paragraph 60).

16.

Proper reception is specially important for emergencies. There should
be separate accommodation for children in casualty departments and suitable
17.

amenities for waiting parents (paragraphs 61-63).

THE CHILD AS IN-PATIENT
General18. The differing psychological needs of children of different ages aredescribed (paragraphs 64-67).

Admission of Mothers
19. There is much to be said for admission of mothers along with theirchildren, especially when the child is under five and during the first few daysin hospital. This is of great benefit to the child and if the mother is allowed
to play a full part in his care she can be a help rather than a hindrance tothe hospital staff (paragraphs 68-70).

Visiting

20.

A child in hospital must be visited frequently to preserve the conlife, and the arguments formerly advanced against frequent
no longer valid. Parents should be allowed to visit whenever
and to help as much as possible with the care of the child,tinuity of his
visiting arethey can,(paragraphs 71-80).

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21. Visiting is specially important in thestay in hospital (paragraph 81).
22. Evening visits should
allowed (paragraphs 82-83).
23. Parents should

toe

toe

few days of the child’s

firstencouraged andvisitson operating days

able to get authoritative information about theirchild’s progress when they visit (paragraph 84).

24. Visitors other than parents

shouldtoe

permitted at certain times(paragraph 85).
25. Special arrangements shouldtoemade for children whose parents

cannot visit them (paragraph 86).
26.

More amenities for visitors are needed (paragraph 87).

27. Parents in genuine need of financial assistance to enable them to visit
frequently should toe helped to get it (paragraphs 88-90).

Education
28.

The provision of educational facilities is important, for shorter stay

as well as long stay patients, and it is the hospital’s responsibility toapproach the local education authority for the purpose (paragraphs 91-93).

29. Children should not normally toe admitted to hospital when they areabout to take important examinations (paragraph 94).
30. Teaching requires the co-operation of the hospital staff, suitablearrangement of the ward and the provision of space for storage of equipment(paragraphs 95-97).

31. Organised activity outside school terms is important (paragraph 98).

Other Aspects of In-Patient Care
32. There should be an organised programme of recreation with suitabletoys and other diversions (paragraphs 99-102).
33. Happy discipline depends not only on correct management but on

harmonious relationships between all the staff, and between staff and parents.
If there is sensiblyorganised diversion disciplinary problems will toe reduced(paragraph 103).
34. Physical restraints should not be needlessly applied (paragraph 104).
35. Children should be able to keep the personal possession they treasureby their beds and all should have accessible storage space (paragraph 105).
36. Food should be attractively served and satisfying (paragraph 106).
37. Toilet needs should be adequately attended to. Private vocabularies
should be learned and children allowed to get up to go to the toilet if at
all possible (paragraph 107).
38. Parents should be able to get information about their children’s
progress from a knowledgeable and responsible person. They should be told
given the opportunity to go
if their child is to be transferred and should bewith him (paragraphs 108-109).
39. Daily prayers,(paragraph 110).

Sunday school and visits by clergy are important
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MEDICAL TREATMENT
minimum and40. Unpleasant medical procedures should be kept to thecarried out with tact and understanding of children’s reactions (paragraphs
111 - 112).
41. There should be separate treatment rooms and children should not bewithin sight of other children when they are being anaesthetised or coming
round after an operation (paragraph 113).
42. Premedication should normally be used before operations. It will
help the child if the mother can be present until he goes to sleep and when
he is coming round (paragraphs 114-115).
43. Exceptional discretion is needed in the discussion of children’s cases
during ward rounds (paragraph 116).

SPECIAL GROUPS
44. Most of our recommendations apply to long stay hospitals and we
make some additional comments on preparation, settling in, visiting, education,
Children should not
be kept in long stay hospitals for longer than their medical condition requires
and should be allowed to go home for short periods while they are under
treatment (paragraph 117).
recreation and discharge in relation to such hospitals.

45. Blind and deaf children

and their parents have special needs, e.g. in

relation to contact with the home, occupation, education and contact between

hospital and parents. If a child becomes blind or deaf in hospital there should

be no delay in providing the special services he needs (paragraph 118).
46. Isolation hospitals are being used for a wide range of children’s
ailments than formerly and this should be reflected in their staffing andmanagement. In particular restrictions on visiting should be lifted (paragraphs

119-121).
47. Regard must be had to the welfare of the large numbers of children
admitted for tonsil and adenoid operations notwithstanding the shortness of
their stay. They should not be nursed with adults and our recommendations

regarding admission, reception and in-patient care (including visiting)apply equally to them (paragraphs 122-125).

all

48. Children admitted for eye operations should be nursed in a separate
children’s unit. Bandaging of children’s eyes should not be lightly resorted toand if it is medically imperative should be accompanied by special arrangements for the reassurance and occupation of the child concerned (paragraphs
126-127).

DISCHARGE
49. Parents should be warned about behaviour problems thatafter discharge and advised how to deal with them. They

may arise

should also be toldof their part in any treatment required after the child’s discharge
hospital (paragraphs 128-131).

from

50. Discharge times should be chosen with due regard to parents’ convenience and a senior nurse should be available to speak to the parents(paragraphs 132-133).
51. The family doctor should be told in advance when his patient iscoming out of hospital and he should be provided with a full report as soon

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as possible. There should be adequate liaison with the local health andeducation authorities about any after care or special educational require-ments. Follow-up visits to the out-patient department should be reduced tothe minimum (paragraphs 134-136).

TRAINING OF STAFF
52 Nurses need training not only in the special aspects of disease in.

children but in the factors that influence the development of the normal child.
Part of this training should take the form of practical experience in the careof well children both in nursery schools, etc. and in their homes. The emotional
needs of children in hospital should be stressed in refresher courses for Ward
Sisters (paragraphs 138-140).
53. Doctors generally also require more training in the child’s emotional
needs (paragraph 141).
54. Ancillary hospital staff should be taught
cedures to children’s needs (paragraph 142).

how to adjust their pro-

Wilfrid Sheldon
P. H. Constable
F. M. Rose
Norman B. CaponCharles Gledhill
E. Hollis

Margaret W. Janes
Marjorie E. John
C. A. McPherson
Elizabeth Tylden

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APPENDIX
LIST OF ORGANISATIONS AND INDIVIDUALSWHO GAVE EVIDENCE
1.

ORGANISATIONSAssociation of Children’s Officers
Association of Hospital Administrators
Association of Hospital Matrons
Association of Occupational Therapists
Association of Psychiatric Social Workers
British Medical Association
British Orthopaedic Association
British Paediatric Association
British Paediatric Nurses Association
Central Council for the Care of Cripples
Central Council for Health Education
College of General Practitioners
Institute of Almoners
Institute of Hospital Administrators
Ministry of Education
National Association for Maternal and Child Welfare
National Institute for the Deaf
National Federation of Women’s Institutes
National Union of Townswomen’s Guilds
Nuffield Foundation

Mothers Union
Royal College of Nursing
Royal College of PhysiciansRoyal College of SurgeonsRoyal Medico-Psychological Association
Royal National Institute for the Blind
Society of Medical Officers of HealthTavistock Institute for Human Relations
Women Public Health Officers’ Association
2.

INDIVIDUALS
Dr. Portia Holman, M.D., M.R.C.P., D.P.M (Ealing Child

G

Centre)Dr.

Dermod MacCarthy, M.D., M.R.C.P.

(Amersharn

Hospital)Dr. Charlotte Naish, MJ3., B.Ch., M.D. (Cumberland)Miss Joan Woodward, M.A. (Psychiatric Social Worker, Burns
Birmingham Accident Hospital)

42(87440) Wt. 3667—9239

K120

1/59 D.L.

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