Art & science
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Safeguarding vulnerable adults Betts V et al (2014) Safeguarding vulnerable adults. Nursing Standard. 28, 38, 37-41. Date of submission: November 20 2013; date of acceptance: January 27 2014.
Abstract This article explores some of the issues surrounding safeguarding vulnerable adults, examines some of the related legislation and literature, and outlines the responsibilities of those who care for this patient group. The article describes how one hospital that specialises in caring for people with early-onset dementia, Huntingdon’s disease and alcohol-related brain injury who require additional support, has provided staff with appropriate evidence-based information about safeguarding adults.
Authors Virginia Betts Formerly staff nurse, Forest Hospital, Nottingham; currently health visitor student, Derby University, Derby. Diane Marks-Maran Honorary professor of nursing, Kingston University, London, and St George’s, University of London, London. Trish Morris-Thompson Director of quality and clinical governance, Barchester Healthcare, London. Correspondence to: [email protected]
Keywords Abuse, duty of care, e-learning, patient care, safeguarding adults, vulnerable patients
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
ALL HEALTHCARE PROFESSIONALS have a duty to safeguard patients, particularly those who are unable to protect themselves from harm or abuse (Department of Health (DH) 2011). In 2011, the DH published principles and practice examples on the role of healthcare professionals in safeguarding adults. There are also multi-agency policies and procedures in place to protect vulnerable adults from neglect, harm and abuse (DH 2000). The Code (Nursing and Midwifery Council (NMC) (2008) states that nurses have a duty to ‘work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community’. Safeguarding adults is an integral part of patient care and a legal responsibility of all healthcare professionals. There are six main principles for safeguarding adults published by the DH (2011) (Table 1), which inform government policy in this area.
Legislation on safeguarding adults The duty to empower people to make decisions and to be in control of their care and treatment is underpinned by the Human Rights Act 1998, the Equality Act 2010 and the Mental Capacity Act 2005. Empowering adult patients includes respecting their right to make choices about their care and treatment, including making decisions about their safety – if they have the capacity to make such decisions – even where those decisions may seem to others to be unwise. Any actions taken without the patient’s full and informed consent must have a clear justification and be permissible in law (DH 2011). Mental capacity is a central concept in safeguarding that needs to be considered at all times. Person-led safeguarding should not override the duty that healthcare professionals have to protect others from harm. In other words, duty of care means taking
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 37 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science safeguarding issues every reasonable step to identify and reduce risks to patients, while respecting their rights to make decisions about care and treatment (DH 2011). The principles of proportionality and partnership involve ensuring vulnerable adults are aware their concerns are being taken seriously and the degree of risk is being discussed with them, and that all agencies will work together to protect them. Accountability is about ensuring the person understands the roles and responsibilities of all agencies involved in safeguarding.
Examples of poor care Despite legislation on safeguarding adults, there is evidence the care of vulnerable people, including those with learning disabilities, is inadequate and safeguarding issues are poorly understood by healthcare professionals. Heslop et al (2014) found evidence of health and care disparities between people with and without learning disabilities. They identified the need to examine care and service provision for people with learning
disabilities because premature deaths in this vulnerable patient group are related to care factors that can often be prevented. Safeguarding vulnerable adults is an increasing concern for healthcare providers, particularly in light of the findings at Winterbourne View hospital and Mid Staffordshire NHS Foundation Trust (Care Quality Commission (CQC) 2011, Francis 2013). Following a television programme that exposed abuse of people with learning disabilities and challenging behaviour by staff at Winterbourne View, the CQC (2011) undertook a review of care at the hospital (CQC 2011). Findings demonstrated a lack of understanding of the complex needs of people, and care and treatment that did not ensure the welfare and safety of those at the hospital. The hospital did not take reasonable steps to identify the possibility of abuse and prevent it occurring, and did not respond appropriately to allegations of abuse. Similarly, the public inquiry into Mid Staffordshire NHS Foundation Trust (Francis 2013) highlighted shortcomings in leadership, management
TABLE 1 Principles of safeguarding and implementation in practice Principle
Implementation in practice
1 – Empowerment. Presumption of person-led decisions and consent.
4Giving individuals relevant information about recognising abuse and the choices available to them to ensure their safety. 4Giving individuals clear information about how to report abuse and crime, and any necessary support.
2 – Protection. Support and representation for those in greatest need.
4Providing help and support to individuals to enable them to report abuse. 4Understanding the organisation’s reporting arrangements for abuse and suspected criminal offences, and reporting abuse and suspected criminal offences. 4Understanding risk assessments.
3 – Prevention. Prevention of harm and abuse is a primary objective.
4Understanding what abuse is, how to recognise it and what vulnerable adults can do to seek help. 4Helping vulnerable adults seek help or informing them about what they can do to seek help. 4Providing appropriate training and guidance to staff about how to recognise signs of abuse and take any appropriate action to prevent it.
4 – Proportionality. Proportionality and least intrusive response appropriate to the risk presented.
4Helping vulnerable adults to feel confident that healthcare professionals will take into account their preferred outcomes or best interests. 4Discussing with vulnerable adults and, where appropriate, partner agencies the proportionality of possible responses to the risk of significant harm before any decisions are taken.
5 – Partnerships. Local solutions through services working with communities.
4Enabling vulnerable adults to feel confident that information about them will be appropriately shared and that agencies will work together to find the most effective responses for their situation.
6 – Accountability. Accountability and transparency in delivering safeguarding.
4Ensuring the roles of all agencies and the lines of accountability are clear to vulnerable adults. 4Ensuring healthcare professionals understand what is expected of them and others. 4Ensuring agencies recognise their responsibilities to each other, act upon them and accept collective responsibility for safeguarding arrangements.
(Adapted from Department of Health 2011)
38 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
and care, and exposed neglect and abuse of patients. Francis (2013) made 260 recommendations, including ensuring robust safeguarding procedures were in place to protect vulnerable patients.
Literature review As well as examining the legislation on safeguarding adults and findings of independent inquiries, the authors undertook a literature search using CINAHL (Cumulative Index to Nursing and Allied Health Literature). The following keywords were used: safeguarding, adults and nursing, and 28 relevant articles were identified. Inclusion criteria were articles related to safeguarding adults only, those involving nurses and nursing, those based in hospital and/or care home settings, and those that emphasised awareness training in safeguarding adults. Of the 28 articles, 16 were excluded from the literature review because they focused on news items rather than academic articles, children and/or young adults, inter-agency training for safeguarding, staff background checks or nursing in community settings. The abuse of adults may take many forms, including physical abuse, neglect and acts of omission, sexual abuse, financial abuse, verbal and psychological abuse, and discriminatory abuse (DH 2000, Nisbet 2013). Lawrence and Banerjee (2010) identified several issues associated with the safe care of older vulnerable people, particularly in institutional settings, including an increased incidence of dementia and physical disability, and that most long-term care is provided in the private sector, often by staff with minimal training in caring for people with complex needs. Wang et al (2006) found that 16% of staff in long-term care facilities for older people committed acts of significant psychological abuse, such as blaming people verbally, ignoring their requests or refusing to accept their opinions. Since the independent inquiries into care at Winterbourne View hospital and Mid Staffordshire NHS Foundation Trust (CQC 2011, Francis 2013), there is increased emphasis on ensuring institutions that provide care for vulnerable adults address safeguarding issues. The CQC (2011) stated that such institutions must ensure systems, processes and practices are in place to allow vulnerable adults to live a life free from abuse and neglect. There is a growing emphasis in the literature on how healthcare institutions are acting to ensure the safety of vulnerable adults by developing policies, procedures and safeguarding practices. Elvidge and MacPhail (2009) described the Quality in Care model for safeguarding older
adults. This quality assurance initiative was developed to provide support to residential care homes for older people in one locality in south east England, to ensure the safety of older residents and to improve standards of care. Older people in residential care or nursing homes were visited by an adult protection co-ordinator and a contracts officer, whose job it was to carry out all aspects of quality assurance monitoring. Rather than having separate additional visits to monitor adult safeguarding, the contracts officer combined monitoring adult safeguarding with other quality assurance monitoring functions. The process included a tour of the residential care or nursing home, an opportunity to talk to residents, relatives and staff, and an audit of documents. The initiative led to the early identification of potential risks and the provision of information to service providers on how to improve service quality and take appropriate action to reduce any potential risks to residents. Nisbet (2013) warned that no system of safeguarding would be able to guarantee abuse would never occur. He argued that to minimise the possibility of abuse of vulnerable adults in institutional settings, organisations need to foster a safe environment in which all staff are trained in safeguarding, and managers provide regular formal checks of the organisation’s safeguarding policies, procedures and practices. Nisbet (2013) also provided advice on how information about compliance with safeguarding can be gathered, setting up a complaints system and how to approach residents who may be at risk. He also addressed the need for leadership training as well as training in safeguarding. Safeguarding training has also been addressed elsewhere in the literature. Cass (2012) found care home staff often receive only minimal training in safeguarding and when staff are trained individually they find it difficult to change their practice because of the culture, environment and peer pressure at work. Cass (2012) suggested providing safeguarding training for teams as a way of enabling staff to work together and support each other to improve practice. Goodall (2012) used this team training approach to implement a safeguarding training programme for residential care home staff in the north west of England, incorporating information giving, role play, learning from case studies and engaging in group activities. This was found to be helpful in improving the safety of practice. Healthcare professionals need to work in partnership with patients, their carers and family, and all others involved in their care, including agencies such as social services, to safeguard
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 39 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science safeguarding issues vulnerable adults (Francis 2013). The organisation providing care must also view safeguarding adults as a core part of its business. In other words, all staff in the organisation will have a responsibility to safeguard adults but, in addition, some staff will have specific responsibilities for managing safeguarding concerns and multi-agency procedures (DH 2011). Safeguarding policies and procedures also need to be integrated into patient safety procedures and clinical governance so that individual safeguarding concerns can be identified and managed effectively, practitioners are supported by the organisation, and the organisation understands its safety activity, accountability, learning and continued improvement (DH 2011). In summary, the literature explores the potential for abuse as well as the legal and statutory documents designed to prevent abuse of vulnerable adults. The literature also highlights the need for robust safeguarding policies, procedures and practices, including mechanisms for ensuring compliance, and the need for these to be part of the organisation’s core business. The importance of comprehensive training and education in safeguarding was also identified. All these factors were taken into consideration by the first author of this article, when developing a safeguarding initiative in one hospital that aimed to ensure staff were fully aware of their safeguarding responsibilities.
Staff training on adult safeguarding Forest Hospital in Nottingham opened in 2013 to provide specialist care for people with early-onset dementia, Huntingdon’s disease and alcohol-related brain injury who require increased levels of support. Although the hospital is run by a private healthcare provider, it works in collaboration with the local NHS trust to provide inpatient care for up to 50 adults under the age of 65. Care in the hospital is led by a multidisciplinary team that draws on the expertise of the local NHS trust and Forest Hospital. The hospital provides care and treatment programmes that are tailored to each patient and have focused outcomes. One of the guiding principles of the hospital is that ‘recovery is about whole lives, not just symptoms. It represents a movement away from pathology, illness and symptoms to health, strength and wellness’ (Nottinghamshire Healthcare NHS Trust 2013). As well as providing inpatient facilities, the hospital serves as a base for the community outreach team. The patients who receive care in Forest Hospital are all potentially vulnerable adults. One of the staff nurses, the lead author of this article,
recognised that a large number of healthcare professionals who were appointed to work at the hospital when it opened in early 2013 had not worked in the care home environment before and several were newly qualified nurses. She believed it was important to provide information about safeguarding vulnerable adults so staff would be able to recognise that all patients at Forest Hospital are potentially vulnerable and to understand what this means. However, to provide all possible information about safeguarding vulnerable adults would have made an information sheet long and cumbersome, and might have put some staff off engaging with the information. The first author’s intention was, therefore, to provide basic information with guidance on how to access any additional information about safeguarding. Therefore, a three-page information guide on safeguarding adults, including the safeguarding information sheet, was developed and introduced in 2013 for use in the hospital (Box 1). The information sheet aimed to: 4Make the information about safeguarding easy to read. 4Use simple language to make the information easy to understand. 4Make the information easily accessible. 4Reflect on national guidelines about safeguarding adults (DH 2011), the findings of inquiries into Winterbourne View hospital (CQC 2011) and Mid-Staffordshire NHS Foundation Trust (Francis 2013), The Code (NMC 2008) and recent safeguarding literature identified in the literature review. The information sheet included links to various numbered hospital policy and procedure documents, and where nurses and other healthcare professionals could find additional resources or further information on adult safeguarding issues. All staff new to the hospital receive the information guide and undertake e-learning induction modules on safeguarding vulnerable adults, followed by group discussions on some of the issues raised in the information sheet and guide, and the modules. Through the modules and group learning, staff are introduced to and informed about safeguarding vulnerable adults. Feedback was sought verbally and in writing from staff and indicated that new staff who had not previously worked in this type of care home found the information sheet on safeguarding adults informative and easy to understand. Staff stated they appreciated the opportunity to use the information sheet on safeguarding adults in group discussions. They also indicated that it was helpful having a written document to which they could refer when they needed.
40 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
BOX 1 Safeguarding Adults Information Sheet Safeguarding adults is everybody’s business: 4Living a life that is free from harm is a fundamental right of every person. This handout may help you to identify what may constitute abuse and explain the responsibilities of staff working with vulnerable adults. It will help you to recognise and report any detected or suspected abuse. Staff should aim to prevent abuse by improving the quality of life and care that vulnerable adults receive by providing better protection, patient empowerment, support in raising concerns, and identifying and improving bad practice. 4All staff have a responsibility for ensuring they safeguard the interests of patients at all times. The misuse of power within the staff-patient relationship can affect any patient regardless of age, gender, ethnicity, level of ability, sexuality, culture or religious belief. 4Although illness and disability can make people vulnerable, some groups of patients are potentially more vulnerable to abuse than others, for example those who are physically frail, or who have mental health problems or learning disabilities. 4Staff must always treat patients with dignity and respect. This involves identifying the patient’s preferences regarding care and respecting these within current standards of practice. Staff are personally accountable for ensuring that they promote and protect the interests of patients in their care in a non-discriminatory manner. Abuse is ‘violation of an individual’s human and civil rights by any other person or persons’ (Department of Health 2000). Abuse whether intended or not can be carried out by any person. It may arise out of poor or ill-informed practice, individual cruelty, negligence or neglect. Abuse may consist of a single act or repeated acts and can occur between a staff member and patient or between patients. It may be physical, psychological, sexual, financial, emotional or verbal. It may be neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial transaction or sexual relationship to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person.
Conclusion Safeguarding patients has always been a professional ethical issue. However, recent media coverage of, and inquiries into, poor care have illustrated that vulnerable patients may not be adequately protected from harm and abuse. One way that all healthcare providers can ensure that staff are fully aware of
their responsibilities with regard to safeguarding vulnerable adults is by providing simple and easy to understand information and training. Forest Hospital has developed an information sheet on safeguarding adults to increase staff awareness and understanding of this area to improve patient care and safety NS
References Care Quality Commission (2011) Review of Compliance: Castlebeck Care (Teesdale) Ltd. Care Quality Commission, London. Cass E (2012) Commissioning Care Homes: Common Safeguarding Challenges. Social Care Institute for Excellence, London. Department of Health (2000) ‘No Secrets’: Guidance on Developing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse. The Stationery Office, London. Department of Health (2011)
Safeguarding Adults: The Role of Health Service Practitioners. The Stationery Office, London. Elvidge F, MacPhail G (2009) The ‘Quality in Care’ model of quality assurance and safeguarding for older people in institutional care. Journal of Adult Protection. 11, 1, 28-37.
Heslop P, Blair PS, Fleming P, Hoghton M, Marriott A, Russ L (2014) The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. The Lancet. 383, 9920, 889-895.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Final Report. The Stationery Office, London.
Lawrence V, Banerjee S (2010) Improving care in care homes: a qualitative evaluation of the Croydon care home support team. Aging and Mental Health. 14, 4, 416-424.
Goodall S (2012) Safeguarding adults: practical tips for training. Nursing and Residential Care. 14, 11, 600-603.
Nisbet RJ (2013) A practical guide to safeguarding. Nursing and Residential Care. 15, 1, 45-48.
Nottinghamshire Healthcare NHS Trust (2013) Recovery Strategy. Health Partnerships – Local Services – Forensic Services: 2013-2016. Nottinghamshire Healthcare NHS Trust, Nottingham. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Wang JJ, Lin JN, Lee FP (2006) Psychologically abusive behavior by those caring for the elderly in a domestic context. Geriatric Nursing. 27, 5, 284-291.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 41 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Safeguarding vulnerable adults Betts V et al (2014) Safeguarding vulnerable adults. Nursing Standard. 28, 38, 37-41. Date of submission: November 20 2013; date of acceptance: January 27 2014.
Abstract This article explores some of the issues surrounding safeguarding vulnerable adults, examines some of the related legislation and literature, and outlines the responsibilities of those who care for this patient group. The article describes how one hospital that specialises in caring for people with early-onset dementia, Huntingdon’s disease and alcohol-related brain injury who require additional support, has provided staff with appropriate evidence-based information about safeguarding adults.
Authors Virginia Betts Formerly staff nurse, Forest Hospital, Nottingham; currently health visitor student, Derby University, Derby. Diane Marks-Maran Honorary professor of nursing, Kingston University, London, and St George’s, University of London, London. Trish Morris-Thompson Director of quality and clinical governance, Barchester Healthcare, London. Correspondence to: [email protected]
Keywords Abuse, duty of care, e-learning, patient care, safeguarding adults, vulnerable patients
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
ALL HEALTHCARE PROFESSIONALS have a duty to safeguard patients, particularly those who are unable to protect themselves from harm or abuse (Department of Health (DH) 2011). In 2011, the DH published principles and practice examples on the role of healthcare professionals in safeguarding adults. There are also multi-agency policies and procedures in place to protect vulnerable adults from neglect, harm and abuse (DH 2000). The Code (Nursing and Midwifery Council (NMC) (2008) states that nurses have a duty to ‘work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community’. Safeguarding adults is an integral part of patient care and a legal responsibility of all healthcare professionals. There are six main principles for safeguarding adults published by the DH (2011) (Table 1), which inform government policy in this area.
Legislation on safeguarding adults The duty to empower people to make decisions and to be in control of their care and treatment is underpinned by the Human Rights Act 1998, the Equality Act 2010 and the Mental Capacity Act 2005. Empowering adult patients includes respecting their right to make choices about their care and treatment, including making decisions about their safety – if they have the capacity to make such decisions – even where those decisions may seem to others to be unwise. Any actions taken without the patient’s full and informed consent must have a clear justification and be permissible in law (DH 2011). Mental capacity is a central concept in safeguarding that needs to be considered at all times. Person-led safeguarding should not override the duty that healthcare professionals have to protect others from harm. In other words, duty of care means taking
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 37 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science safeguarding issues every reasonable step to identify and reduce risks to patients, while respecting their rights to make decisions about care and treatment (DH 2011). The principles of proportionality and partnership involve ensuring vulnerable adults are aware their concerns are being taken seriously and the degree of risk is being discussed with them, and that all agencies will work together to protect them. Accountability is about ensuring the person understands the roles and responsibilities of all agencies involved in safeguarding.
Examples of poor care Despite legislation on safeguarding adults, there is evidence the care of vulnerable people, including those with learning disabilities, is inadequate and safeguarding issues are poorly understood by healthcare professionals. Heslop et al (2014) found evidence of health and care disparities between people with and without learning disabilities. They identified the need to examine care and service provision for people with learning
disabilities because premature deaths in this vulnerable patient group are related to care factors that can often be prevented. Safeguarding vulnerable adults is an increasing concern for healthcare providers, particularly in light of the findings at Winterbourne View hospital and Mid Staffordshire NHS Foundation Trust (Care Quality Commission (CQC) 2011, Francis 2013). Following a television programme that exposed abuse of people with learning disabilities and challenging behaviour by staff at Winterbourne View, the CQC (2011) undertook a review of care at the hospital (CQC 2011). Findings demonstrated a lack of understanding of the complex needs of people, and care and treatment that did not ensure the welfare and safety of those at the hospital. The hospital did not take reasonable steps to identify the possibility of abuse and prevent it occurring, and did not respond appropriately to allegations of abuse. Similarly, the public inquiry into Mid Staffordshire NHS Foundation Trust (Francis 2013) highlighted shortcomings in leadership, management
TABLE 1 Principles of safeguarding and implementation in practice Principle
Implementation in practice
1 – Empowerment. Presumption of person-led decisions and consent.
4Giving individuals relevant information about recognising abuse and the choices available to them to ensure their safety. 4Giving individuals clear information about how to report abuse and crime, and any necessary support.
2 – Protection. Support and representation for those in greatest need.
4Providing help and support to individuals to enable them to report abuse. 4Understanding the organisation’s reporting arrangements for abuse and suspected criminal offences, and reporting abuse and suspected criminal offences. 4Understanding risk assessments.
3 – Prevention. Prevention of harm and abuse is a primary objective.
4Understanding what abuse is, how to recognise it and what vulnerable adults can do to seek help. 4Helping vulnerable adults seek help or informing them about what they can do to seek help. 4Providing appropriate training and guidance to staff about how to recognise signs of abuse and take any appropriate action to prevent it.
4 – Proportionality. Proportionality and least intrusive response appropriate to the risk presented.
4Helping vulnerable adults to feel confident that healthcare professionals will take into account their preferred outcomes or best interests. 4Discussing with vulnerable adults and, where appropriate, partner agencies the proportionality of possible responses to the risk of significant harm before any decisions are taken.
5 – Partnerships. Local solutions through services working with communities.
4Enabling vulnerable adults to feel confident that information about them will be appropriately shared and that agencies will work together to find the most effective responses for their situation.
6 – Accountability. Accountability and transparency in delivering safeguarding.
4Ensuring the roles of all agencies and the lines of accountability are clear to vulnerable adults. 4Ensuring healthcare professionals understand what is expected of them and others. 4Ensuring agencies recognise their responsibilities to each other, act upon them and accept collective responsibility for safeguarding arrangements.
(Adapted from Department of Health 2011)
38 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
and care, and exposed neglect and abuse of patients. Francis (2013) made 260 recommendations, including ensuring robust safeguarding procedures were in place to protect vulnerable patients.
Literature review As well as examining the legislation on safeguarding adults and findings of independent inquiries, the authors undertook a literature search using CINAHL (Cumulative Index to Nursing and Allied Health Literature). The following keywords were used: safeguarding, adults and nursing, and 28 relevant articles were identified. Inclusion criteria were articles related to safeguarding adults only, those involving nurses and nursing, those based in hospital and/or care home settings, and those that emphasised awareness training in safeguarding adults. Of the 28 articles, 16 were excluded from the literature review because they focused on news items rather than academic articles, children and/or young adults, inter-agency training for safeguarding, staff background checks or nursing in community settings. The abuse of adults may take many forms, including physical abuse, neglect and acts of omission, sexual abuse, financial abuse, verbal and psychological abuse, and discriminatory abuse (DH 2000, Nisbet 2013). Lawrence and Banerjee (2010) identified several issues associated with the safe care of older vulnerable people, particularly in institutional settings, including an increased incidence of dementia and physical disability, and that most long-term care is provided in the private sector, often by staff with minimal training in caring for people with complex needs. Wang et al (2006) found that 16% of staff in long-term care facilities for older people committed acts of significant psychological abuse, such as blaming people verbally, ignoring their requests or refusing to accept their opinions. Since the independent inquiries into care at Winterbourne View hospital and Mid Staffordshire NHS Foundation Trust (CQC 2011, Francis 2013), there is increased emphasis on ensuring institutions that provide care for vulnerable adults address safeguarding issues. The CQC (2011) stated that such institutions must ensure systems, processes and practices are in place to allow vulnerable adults to live a life free from abuse and neglect. There is a growing emphasis in the literature on how healthcare institutions are acting to ensure the safety of vulnerable adults by developing policies, procedures and safeguarding practices. Elvidge and MacPhail (2009) described the Quality in Care model for safeguarding older
adults. This quality assurance initiative was developed to provide support to residential care homes for older people in one locality in south east England, to ensure the safety of older residents and to improve standards of care. Older people in residential care or nursing homes were visited by an adult protection co-ordinator and a contracts officer, whose job it was to carry out all aspects of quality assurance monitoring. Rather than having separate additional visits to monitor adult safeguarding, the contracts officer combined monitoring adult safeguarding with other quality assurance monitoring functions. The process included a tour of the residential care or nursing home, an opportunity to talk to residents, relatives and staff, and an audit of documents. The initiative led to the early identification of potential risks and the provision of information to service providers on how to improve service quality and take appropriate action to reduce any potential risks to residents. Nisbet (2013) warned that no system of safeguarding would be able to guarantee abuse would never occur. He argued that to minimise the possibility of abuse of vulnerable adults in institutional settings, organisations need to foster a safe environment in which all staff are trained in safeguarding, and managers provide regular formal checks of the organisation’s safeguarding policies, procedures and practices. Nisbet (2013) also provided advice on how information about compliance with safeguarding can be gathered, setting up a complaints system and how to approach residents who may be at risk. He also addressed the need for leadership training as well as training in safeguarding. Safeguarding training has also been addressed elsewhere in the literature. Cass (2012) found care home staff often receive only minimal training in safeguarding and when staff are trained individually they find it difficult to change their practice because of the culture, environment and peer pressure at work. Cass (2012) suggested providing safeguarding training for teams as a way of enabling staff to work together and support each other to improve practice. Goodall (2012) used this team training approach to implement a safeguarding training programme for residential care home staff in the north west of England, incorporating information giving, role play, learning from case studies and engaging in group activities. This was found to be helpful in improving the safety of practice. Healthcare professionals need to work in partnership with patients, their carers and family, and all others involved in their care, including agencies such as social services, to safeguard
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 39 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science safeguarding issues vulnerable adults (Francis 2013). The organisation providing care must also view safeguarding adults as a core part of its business. In other words, all staff in the organisation will have a responsibility to safeguard adults but, in addition, some staff will have specific responsibilities for managing safeguarding concerns and multi-agency procedures (DH 2011). Safeguarding policies and procedures also need to be integrated into patient safety procedures and clinical governance so that individual safeguarding concerns can be identified and managed effectively, practitioners are supported by the organisation, and the organisation understands its safety activity, accountability, learning and continued improvement (DH 2011). In summary, the literature explores the potential for abuse as well as the legal and statutory documents designed to prevent abuse of vulnerable adults. The literature also highlights the need for robust safeguarding policies, procedures and practices, including mechanisms for ensuring compliance, and the need for these to be part of the organisation’s core business. The importance of comprehensive training and education in safeguarding was also identified. All these factors were taken into consideration by the first author of this article, when developing a safeguarding initiative in one hospital that aimed to ensure staff were fully aware of their safeguarding responsibilities.
Staff training on adult safeguarding Forest Hospital in Nottingham opened in 2013 to provide specialist care for people with early-onset dementia, Huntingdon’s disease and alcohol-related brain injury who require increased levels of support. Although the hospital is run by a private healthcare provider, it works in collaboration with the local NHS trust to provide inpatient care for up to 50 adults under the age of 65. Care in the hospital is led by a multidisciplinary team that draws on the expertise of the local NHS trust and Forest Hospital. The hospital provides care and treatment programmes that are tailored to each patient and have focused outcomes. One of the guiding principles of the hospital is that ‘recovery is about whole lives, not just symptoms. It represents a movement away from pathology, illness and symptoms to health, strength and wellness’ (Nottinghamshire Healthcare NHS Trust 2013). As well as providing inpatient facilities, the hospital serves as a base for the community outreach team. The patients who receive care in Forest Hospital are all potentially vulnerable adults. One of the staff nurses, the lead author of this article,
recognised that a large number of healthcare professionals who were appointed to work at the hospital when it opened in early 2013 had not worked in the care home environment before and several were newly qualified nurses. She believed it was important to provide information about safeguarding vulnerable adults so staff would be able to recognise that all patients at Forest Hospital are potentially vulnerable and to understand what this means. However, to provide all possible information about safeguarding vulnerable adults would have made an information sheet long and cumbersome, and might have put some staff off engaging with the information. The first author’s intention was, therefore, to provide basic information with guidance on how to access any additional information about safeguarding. Therefore, a three-page information guide on safeguarding adults, including the safeguarding information sheet, was developed and introduced in 2013 for use in the hospital (Box 1). The information sheet aimed to: 4Make the information about safeguarding easy to read. 4Use simple language to make the information easy to understand. 4Make the information easily accessible. 4Reflect on national guidelines about safeguarding adults (DH 2011), the findings of inquiries into Winterbourne View hospital (CQC 2011) and Mid-Staffordshire NHS Foundation Trust (Francis 2013), The Code (NMC 2008) and recent safeguarding literature identified in the literature review. The information sheet included links to various numbered hospital policy and procedure documents, and where nurses and other healthcare professionals could find additional resources or further information on adult safeguarding issues. All staff new to the hospital receive the information guide and undertake e-learning induction modules on safeguarding vulnerable adults, followed by group discussions on some of the issues raised in the information sheet and guide, and the modules. Through the modules and group learning, staff are introduced to and informed about safeguarding vulnerable adults. Feedback was sought verbally and in writing from staff and indicated that new staff who had not previously worked in this type of care home found the information sheet on safeguarding adults informative and easy to understand. Staff stated they appreciated the opportunity to use the information sheet on safeguarding adults in group discussions. They also indicated that it was helpful having a written document to which they could refer when they needed.
40 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
BOX 1 Safeguarding Adults Information Sheet Safeguarding adults is everybody’s business: 4Living a life that is free from harm is a fundamental right of every person. This handout may help you to identify what may constitute abuse and explain the responsibilities of staff working with vulnerable adults. It will help you to recognise and report any detected or suspected abuse. Staff should aim to prevent abuse by improving the quality of life and care that vulnerable adults receive by providing better protection, patient empowerment, support in raising concerns, and identifying and improving bad practice. 4All staff have a responsibility for ensuring they safeguard the interests of patients at all times. The misuse of power within the staff-patient relationship can affect any patient regardless of age, gender, ethnicity, level of ability, sexuality, culture or religious belief. 4Although illness and disability can make people vulnerable, some groups of patients are potentially more vulnerable to abuse than others, for example those who are physically frail, or who have mental health problems or learning disabilities. 4Staff must always treat patients with dignity and respect. This involves identifying the patient’s preferences regarding care and respecting these within current standards of practice. Staff are personally accountable for ensuring that they promote and protect the interests of patients in their care in a non-discriminatory manner. Abuse is ‘violation of an individual’s human and civil rights by any other person or persons’ (Department of Health 2000). Abuse whether intended or not can be carried out by any person. It may arise out of poor or ill-informed practice, individual cruelty, negligence or neglect. Abuse may consist of a single act or repeated acts and can occur between a staff member and patient or between patients. It may be physical, psychological, sexual, financial, emotional or verbal. It may be neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial transaction or sexual relationship to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person.
Conclusion Safeguarding patients has always been a professional ethical issue. However, recent media coverage of, and inquiries into, poor care have illustrated that vulnerable patients may not be adequately protected from harm and abuse. One way that all healthcare providers can ensure that staff are fully aware of
their responsibilities with regard to safeguarding vulnerable adults is by providing simple and easy to understand information and training. Forest Hospital has developed an information sheet on safeguarding adults to increase staff awareness and understanding of this area to improve patient care and safety NS
References Care Quality Commission (2011) Review of Compliance: Castlebeck Care (Teesdale) Ltd. Care Quality Commission, London. Cass E (2012) Commissioning Care Homes: Common Safeguarding Challenges. Social Care Institute for Excellence, London. Department of Health (2000) ‘No Secrets’: Guidance on Developing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse. The Stationery Office, London. Department of Health (2011)
Safeguarding Adults: The Role of Health Service Practitioners. The Stationery Office, London. Elvidge F, MacPhail G (2009) The ‘Quality in Care’ model of quality assurance and safeguarding for older people in institutional care. Journal of Adult Protection. 11, 1, 28-37.
Heslop P, Blair PS, Fleming P, Hoghton M, Marriott A, Russ L (2014) The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. The Lancet. 383, 9920, 889-895.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Final Report. The Stationery Office, London.
Lawrence V, Banerjee S (2010) Improving care in care homes: a qualitative evaluation of the Croydon care home support team. Aging and Mental Health. 14, 4, 416-424.
Goodall S (2012) Safeguarding adults: practical tips for training. Nursing and Residential Care. 14, 11, 600-603.
Nisbet RJ (2013) A practical guide to safeguarding. Nursing and Residential Care. 15, 1, 45-48.
Nottinghamshire Healthcare NHS Trust (2013) Recovery Strategy. Health Partnerships – Local Services – Forensic Services: 2013-2016. Nottinghamshire Healthcare NHS Trust, Nottingham. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Wang JJ, Lin JN, Lee FP (2006) Psychologically abusive behavior by those caring for the elderly in a domestic context. Geriatric Nursing. 27, 5, 284-291.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 41 RCNi.com by ${individualUser.displayName} on Dec 04, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
