It's chaos on a Tuesday morning in the office of a physicians' group high above downtown Chicago. In the large front waiting room, several children chase each other in what appears to be a crude-and loud-form of tag. Close by, a handful of parents scramble after their babies and toddlers across the carpeted floor. Down a hallway to the right, a nurse tries to weigh a blue-eyed, 1-year-old boy wearing only a diaper as he fights to get off the scale. In a nearby room, an 18-month-old girl shrieks as a nurse quickly injects a vaccine into her tiny thigh. Screams of various pitches emanate from behind several other closed doors as doctors and nurses stream in and out of the hallway in something akin to a human rush hour.

And lunch is still several hours away.

This is the world of pediatric nursing, a hectic, heartbreaking and hope-filled place-and one of the most diverse fields in nursing. From the occasional bedlam of a pediatrician's office to the more serious atmosphere of a children's critical care unit, pediatric nurses confront everything from diaper rash to diabetes to death.

"There's so much diversity here," said Gail Smart, MS, CNS, RN, of The Children's Hospital in Denver. "Almost any specialty can be found in pediatrics."

Affinity for kids

While their duties may run the gamut, the 30,000 men and women who work as pediatric nurses share at least one common trait: an overwhelming desire to help children. "You really have to have a true love of children, from their stories to their language to the creative ways they communicate with you," said Barbara Larson, M.Ed., RN, national vice president of the Society of Pediatric Nurses and a pediatric nurse for many years.

Of course, there's much more needed for the job than just a strong affinity for kids. From the patience of Job to the people skills of a politician, nurses who care for children must use a wide array of abilities.

One of the most fundamental of these skills, many nurses say, is an understanding that children are not merely small adults, but unique beings who require special treatment. And that begins with their bodies. "Everything is done on such a smaller scale," Larson said, explaining, for example, that starting an IV on the often-veinless arm of a child is "like starting one on a rock."

The stark cognitive differences between children and adults also require a special approach. "If you treat children as abstract-thinking adults, you won't connect with them," said Lauren Sorce, a nurse practitioner in the critical care unit of Children's Memorial Hospital in Chicago. "You can't just tell them that they need to take their insulin shots before meals. You have to explain it to them and make them understand why they need to do it."

Larson added, "Kids really need things spelled out for them. A large part of our job is teaching children what's wrong with them."

Of course, another significant part of the job is simply getting kids through their office visit or hospital stay. Because they often are scared and confused, children are seldom the most cooperative patients. "They rarely hold still for an IV or other types of procedures," Smart said. "You have to be flexible and creative and be able to use distractions."

Smart added that many nursing schools across the country now teach various distraction techniques, as well as special holding positions to ease pain and anxiety and help children feel more secure. "The idea is to come up with other ways than the use of sedation," she said.

It starts at home

Another key aspect of pediatric nursing is the ability to communicate well with parents and caregivers. An important part of treating children, health professionals say, is promoting family-centered care, or the notion that a child's family should play a pivotal role in his or her health. It is the job of pediatricians and pediatric nurses to foster this form of care by enabling and empowering parents-that is, by providing them with the necessary information and confidence they need to properly care for their children.

"It's important that we're committed to family-centered care," Smart said. "Children count on a strong family unit, and so we have to be able to promote that." Larson added, "We normally send kids home still sick, so the family plays a large role in helping them get better."

Bringing parents into the fold and making them feel that they are a part of the team is no small task. Caregivers often have their own ideas about what is wrong with a child, and they can be put off by diagnoses or instructions that don't jibe with their own.

"Unlike with adult patients, in pediatrics you're dealing with a minimum of two patients-parent and child," Larson said. "And you have to walk a fine line between what the parents are telling you and what the child is saying and make everyone feel comfortable."

Parent watch

More challenging still is when parents themselves are a detriment to their child's health and well-being. Larson said that yet another vital role of pediatric nurses is to keep a keen eye out for child abuse, something that is not always apparent. "The signs are often subtle," she said. Abused children sometimes are the very ones who look and act like they're leading "Ozzie and Harriet" lifestyles, she said. "Children who are abused are often very bright and articulate and seem very happy. They think that if they dance faster and sing louder, they are less likely to be hurt," Larson said.

For all the balls that pediatric nurses seem to have in the air, there are always more to juggle. People often forget that pediatricians see most patients from birth through college-and, thus, pediatric nurses must know all the nuances of attending to infants, toddlers, teen-agers and even young adults. "It's a constant learning process," Larson said, adding that many pediatric nurses continually take courses to keep themselves well-versed on the many changes children undergo as they move from Big Wheels to four-wheel drive.

If all that weren't enough, some in the pediatric nursing community are embarking on forms of more specialized care. At Children's Hospital in Denver, Smart said, officials have developed increasingly focused care units-such as bed-wetting and eating disorder clinics, and even a fussy-baby clinic-each enabling doctors and nurses to provide more intense and targeted help for their patients.

Even with all they have on their plates, most pediatric nurses say they could not imagine choosing another calling. Of course, they lament-as most others do in the nursing profession-the relatively low pay as well as the problems created by the major personnel shortage.

Smart said that the vacancy rate at Denver's Children's Hospital is nearly 10 percent. Meanwhile, the rate of unfilled nursing positions at another prominent pediatric care facility-Children's Hospital & Regional Medical Center in Seattle-hovers at around 8 percent. "We definitely have shortages in those areas that are seeing vacancies in the profession as a whole, such as the operating room, intensive care and the oncology unit," said Susan Heath, a nurse executive and the administrator of patient care services at the medical center.

Heath added that her hospital also is feeling the pinch from a lack of experienced nurses. She said that this has prompted an intense effort-complete with support groups and rotating shifts-to ensure that new nurses do not get overwhelmed or burned-out. "We want to create a work experience for new nurses in which they ultimately want to stay on at Children's, or at the very least, say, 'This is the profession for me,' " Heath said.

There is, however, at least one professionwide difficulty that pediatric nurses say they rarely face-tense relations with doctors. "It's a much better relationship than it is in some other nursing fields," Larson said, adding that "pediatricians as a group make less money than other doctors. They're mainly here for the same reason we are-a love of kids."

Contact H. Cheever Griffin at cgriffin@chi.syn.net.