Art & science | professional issues
Training to raise staff awareness about safeguarding children Jane Fleming describes how an acknowledged shortfall in knowledge about at-risk children led her organisation to improve compliance rates by increasing understanding about the issues involved Abstract To improve outcomes for children and young people health organisations are required to train all staff in children’s safeguarding. This creates difficulties for large complex organisations where most staff provide services to the adult population. Heart of England NHS Foundation Trust is a large acute and community trust that had difficulties in engaging staff in children’s safeguarding training. Compliance rates for clinical staff who were trained in children’s safeguarding were low and needed to be addressed. This article sets out why safeguarding training is important for all staff and how the trust achieved staff engagement and improved compliance rates. To evaluate, maintain and develop safeguarding knowledge, understanding, skills, attitude and behaviour further resources are planned to allow access to learning resources in a variety of formats. Keywords Child health, child protection, children and young people, outcomes, paediatric nursing, safeguarding training Correspondence jane.fleming@heartofengland. nhs.uk Jane Fleming is safeguarding educator, Heart of England NHS Foundation Trust, Birmingham Date of submission September 22 2014 Date of acceptance December 23 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ncyp-authorguidelines
HEART OF England NHS Foundation Trust (HEFT) is a teaching trust for medical, nursing, therapy and clinical support staff with professional links to local universities, colleges and schools. It is one of the top five employers in the Midlands, employing about 10,000 staff (HEFT 2015). The NHS trust consists of three acute hospitals, providing general and specialist services in medicine and research, sexual health services, plus hospital and community midwifery services with specialist premature baby care provision. In 2011, Solihull Community Care Trust, which delivers all community health care services for Solihull, merged with the acute trust. The NHS trust’s boundary has many borders in the West Midlands, creating strong links and working relationships with the safeguarding boards in Birmingham, Solihull, Staffordshire, and Coventry and Warwickshire. Health services are provided to a diverse range of communities in Birmingham
22 April 2015 | Volume 27 | Number 3
East and North, Solihull, Sutton Coldfield, and South Staffordshire. A total of 1.2 million people are seen and treated and 250,000 people attend the hospital’s emergency departments each year (HEFT 2015). HEFT is a large, complex organisation that is geographically dispersed and has a requirement to provide assurance of safeguarding knowledge and skills. The NHS is committed under Section 11 of the Children Act 2004 to ensure that robust training provision is in place and can be maintained. The Care Quality Commission (CQC) seeks assurance that standards for safeguarding children and adults are in place and applied by staff (outcome 7, regulation 11) (CQC 2010). Assurance is demonstrated through compliance rates for safeguarding training. To assess the application of knowledge and skills CQC auditors talk to patients about their experience of safeguarding processes, and patient records are examined to review outcomes. Quarterly safeguarding reports are provided to internal auditors, Birmingham and Solihull safeguarding boards, plus other reports, as required, for external audits. The organisation has begun reviewing patient stories and experiences of safeguarding through the examination of patient records and talking with those who have experienced a safeguarding referral. These reports are then discussed at safeguarding committee meetings to inform developments in processes, procedures and training. The NHS trust is required by commissioners to train all staff to safeguard children and young people and attain a compliance rate of 85% for all levels of safeguarding training. In December 2011, HEFT was 98% compliant for level one safeguarding children and 40-45% for level two. At the end NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
of September 2014, compliance rates for level one safeguarding had been maintained and the percentage of staff trained to level two had increased to 88%. This article outlines how this was achieved.
Universal training There are national and local drivers to improve outcomes for children and young people. Healthcare staff are required to work to the guidance from the National Institute for Health and Care Excellence (NICE) (2009). The General Medical Council (GMC) provides further guidance for doctors on promoting the health and wellbeing of children and young people (GMC 2012). Working Together to Safeguard Children (Her Majesty’s Government 2013) provides safeguarding guidance for all agencies involved in the care of children, including multi-agency information sharing. These documents inform local policies and procedures in the recognition, escalation and intervention of safeguarding concerns. The evidence for understanding safeguarding recognition, intervention, multi-agency and multidisciplinary working relationships is obtained from serious case reviews. These are commissioned by local safeguarding children’s boards (LSCBs) who review child deaths. Key professionals from the LSCB will request such a review when a child or young person is killed or seriously and significantly harmed, and abuse or neglect is a known or suspected factor. The findings from the reviews frequently recommend how multi-agency working can be a contributory factor to improved outcomes for children and young people. Internal management reviews are undertaken when concerns are identified from a single agency, this type of review also contributes to improved outcomes for children and young people (Laming 2009, Broadhurst et al 2010, Munro 2011, Office for Standards in Education (Ofsted) 2011). Following a case review, an action plan, with clear timescales, is developed to ensure that all recommendations are implemented and embedded in practice. Safeguarding boards monitor the implementation of the actions through a robust audit trail and reporting process. Nationally, information from serious case reviews is collated and researched. Ofsted provides published reports on the lessons learned from the reviews to raise awareness among professionals (Ofsted 2011). Laming (2009), Broadhurst et al (2010) and Munro (2011) have undertaken further analysis of serious case reviews, systems and processes to provide recommendations to changes in practice. The recommendations from local or national NURSING CHILDREN AND YOUNG PEOPLE
reviews may include developments in local policies, guidance, procedures and changes to the content or focus of safeguarding training. Updating the content of safeguarding training, in accordance with the recommendations, provides assurance that front line staff are engaged and informed of the lessons learned from serious case reviews or research. This provides all healthcare staff with an evidence base of safeguarding knowledge and understanding to underpin their professional development of skills, attitude and behaviour. Nurses are required to deliver evidence-based care for their patients, families and carers (Nursing and Midwifery Council (NMC) 2008). Remaining compliant with safeguarding training requirements offers an opportunity to deliver evidence-based safeguarding assessment and interventions when there are potential or actual safeguarding concerns. However, large complex health organisations have many competing training priorities. This can create confusion about training requirements. There are different levels of safeguarding children and safeguarding adult training for different staff groups, which can add further confusion. Before June 2012, HEFT employees were confused about their safeguarding training requirements. This was demonstrated through a training needs analysis, which identified that staff accessed the incorrect level of training for their employment requirements, some staff repeated the same training without moving to the next level and some clinical staff considered themselves trained if they had attended level one safeguarding training.
Levels of training The levels of safeguarding training are determined by competency frameworks outlining the required knowledge, skills, attitudes and behaviour for staff groups in health and partnership agencies. Safeguarding children frameworks for healthcare staff are developed by Royal College of Paediatrics and Child Health (RCPCH 2014). Local safeguarding children boards and the Department for Education and Skills (2005) also provide frameworks for staff working with children and young people. Safeguarding adult frameworks for health and partner agencies, who provide care for adults, are developed by local safeguarding adult boards (LSABs) with further guidance from the national competency framework developed by Bournemouth University (2010). Organisations are required to demonstrate compliance by mapping training content, delivery and evaluation to the competency frameworks. April 2015 | Volume 27 | Number 3 23
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science | professional issues There are five levels of safeguarding children’s training (RCPCH 2014) and five levels for adult safeguarding training (Bournemouth University 2010) (Table 1).
Improving compliance rates In December 2011, the head of safeguarding at the NHS trust appointed a safeguarding educator [the author] to improve the compliance rates for level two training. The children’s safeguarding named doctor, nurse and midwife focused on the development and delivery of the level three children’s training required for the children’s workforce (RCPCH 2014). The matron for safeguarding adults developed a level three safeguarding adults session for senior staff who provide support and advice to front line staff on actual or potential safeguarding adult concerns (Bournemouth University 2010). There are more than 7,000 clinical staff providing a wide range of health services in HEFT. The organisation defines clinical staff as employees who are involved in patient assessment, treatment, care or intervention services, including senior medical staff, nursing and midwifery staff, allied health professionals, pharmacists, radiologists, healthcare scientists, clinical educators, and various clinical support staff. This range of staff requires level two safeguarding children and adults training.
On starting in post, the safeguarding educator undertook a training needs analysis, which identified that of the 7,000 clinical staff about 5,500 provide services to the adult population and do not understand or see the relevance of attending children’s safeguarding training. They were disengaged and confused about their requirements and responsibilities for undertaking this training, which was identified through the training needs analysis. This showed that staff did not understand which level of training they required and those in adult services often failed to attend children’s safeguarding training. Likewise, the children’s workforce did not see the relevance of attending adult safeguarding training. To improve engagement and understanding, the training strategy was updated and a training matrix developed to clarify children and adult safeguarding training requirements for all health disciplines, departments and staff groups. A DVD was produced as a level one safeguarding resource delivered to the non-clinical workforce by a facilitator rather than a member of the small safeguarding team. This learning resource raised awareness of everyone’s role in safeguarding. The DVD outlined how, where and when to escalate safeguarding concerns and when to seek advice. The safeguarding educator focused on the content and delivery of level two training, using sections
Table 1 Safeguarding training levels Training level
Required knowledge, skills, attitudes and behaviour
Workforce: training requirements
Level 1: children and adults Awareness of safeguarding responsibilities, recognition and escalation. Non-clinical staff, including laboratory staff. Level 2: children and adults As above, plus enhanced understanding of assessment, recognition, intervention, escalation, information sharing and referral processes to build on knowledge received at level 1.
All clinical staff involved in the patients care.
Level 3: children
Advanced recognition, intervention, information sharing and escalation Children’s workforce acute and community, including sexual health services, midwives of safeguarding concerns. Interagency working, early intervention and the emergency department. processes, including the common assessment framework.
Level 3: adults
Advanced recognition, intervention and escalation, plus understanding of the investigation of safeguarding adult concerns. Providing support and advice for front line staff.
Level 4 and 5: children and adults
Named doctors, nurses and Demonstrate skills, knowledge and understanding required to develop midwives for safeguarding children. close working relationships with partner agencies at strategic level, Matron for safeguarding adults. manage data collection to produce and oversee safeguarding audits for internal and external scrutiny. Produce safeguarding compliance reports for internal and external reporting processes; contribute to serious case reviews, internal management reviews and domestic homicide reviews. Plus a strategic overview for the organisation and raising public awareness. Undertake safeguarding supervision of front line staff.
24 April 2015 | Volume 27 | Number 3
Head nurses, matrons, ward/ departmental managers, designated senior nurses/team leaders.
NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Figure 1
Evaluation report for 2013/14 (n=2,397, with 2,110 evaluation forms completed)
1,400
Number of responses
1,200 1,000 800 600 400 200 Understanding of what constitutes maltreatment
Key: Exceeded
Yes
Categories of abuse
Partly
Know how to seek advice and support
No
from the DVD. The DVD merged safeguarding messages for children and adults in raising awareness of who is at risk of abuse, the categories of abuse, how to recognise abuse and what to do if and when safeguarding concerns are identified. The DVD is split into sections, and these video clips are used in level two safeguarding training, along with video clips on domestic abuse and poor patient care. The clips are used to generate group discussion for the clinical workforce. The newly developed resources and programme of training for level two was ready for delivery in June 2012; staff now attend one taught session for level two safeguarding children and adults. The evaluations of these sessions has been positive (Figures 1 and 2), with many staff stating that the session is meaningful and relevant to their practice. Evaluation forms are completed at the end of the session; positive comments are often recorded from all levels of staff, as well as via e-mail post attendance. Ad-hoc sessions continue to be delivered to employed staff, and levels one and two safeguarding training is delivered at corporate induction. A total of 2,110 forms were completed by 2,397 participants between April 2013 and March 2014. Overall, the evaluations were positive as indicated (Figure 1). The feedback forms ask participants to give three examples of information gained and how this will change their practice. Figure 2 summarises their responses. Combining the safeguarding message for children and adults has engaged staff in the safeguarding process, raised awareness of the importance NURSING CHILDREN AND YOUNG PEOPLE
Understanding of information sharing
Know what to do about child abuse
Know what to do about adult abuse
Did you find the session useful?
n/a
Figure 2 Summary of responses from evaluation forms 1,000 Number of responses
0
800 600 400 200 0 fe
Sa
g
in
rd
a gu
l , s n n d d … ta ce te s re rie tio tio nd nt are ervi t… Men Act go use pec ath ma ring nta a e e c h c s r a x e t b e t rig nt/ city do nt Ca of a Une d Info sh um o e a igh c tie tt R o ns ap a a D P h Co C W
of assessing the carers/parents, the strength and relevance of good, accurate and concise documentation. The safeguarding team monitor children’s safeguarding referrals and have noted an improvement in relevant referrals to children’s social care services. The monitoring process has also highlighted that further training is needed in some departments to support staff with making a good quality referral. A well-written referral enables social care services to prioritise the safeguarding assessment of healthcare staff. A short three-minute DVD has been produced with information on what makes a good quality referral. This was a joint project with Birmingham Children’s Safeguarding Board, who provided the funding for filming. The engagement of the adult workforce with children’s safeguarding concerns has also improved. April 2015 | Volume 27 | Number 3 25
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science | professional issues There has been an increase in contacts for advice and support received by the children’s named nurse from the adult workforce. The ‘Think Family’ message (Department for Children, Schools and Families 2009) is visible through the number of referrals made due to concerns about parental capacity (Figure 3). These are initiated by the adult and children’s workforce. To assess staff’s understanding and application of safeguarding knowledge and skills, HEFT senior personnel undertake walkabouts, during which clinical staff are interviewed at random to assess their safeguarding knowledge and understanding. This process will continue to be developed, so that safeguarding knowledge and skills can be monitored. This will ensure that future learning resources are developed to address gaps and develop strengths. The results are positive, demonstrating greater awareness and understanding. This evaluation process needs to be refined by tailoring the interview questions to reflect the roles and responsibilities of different grades of staff. Post-training evaluations will be developed when the NHS trust’s new training database has been implemented this summer. This will allow for an automated e-mail to be sent to participants three months after training. This will contribute to the information of knowledge and skills obtained through the walkabouts and other audit processes, such as the review of patient records to monitor understanding and application of safeguarding knowledge and skills.
Maintaining compliance Safeguarding levels one and two continue to be delivered at weekly corporate induction; this will ensure that the compliance rates are maintained with newly appointed staff. Ad-hoc sessions across the three sites continue to be provided for employed
Figure 3 Parental problems identified 123
Domestic abuse
188
Mental health
48
Substance misuse History of child removed
14
Previous involvement 2 as a child
Discussion 45
Other
0
untrained staff who are notified individually and through line managers of the requirement to be trained. There is support and engagement with this process from heads of service, line managers, clinical leads and educators. Research shows that learning is more effective when delivered through blended learning (De Ciccio and Kennedy 2012), which combines face-to-face and computer-aided activities. The HEFT education faculty encourages educators to develop blended learning, to ensure that learning objectives are met. The competency framework (RCPCH 2014) acknowledges that different methods of learning are required to improve safeguarding knowledge, understanding and skills. Safeguarding training in HEFT involves face-to-face learning, e-learning, supervision, group discussions, experiential learning, action learning and reflective practice. Safeguarding training resources include the level one DVD; the level two update e-learning programme also includes sections from the DVD. Two short videos on ‘managing challenging behaviour’ and ‘how to make a good quality safeguarding children’s referral’ are viewed in the taught sessions and are also available to watch on smartphones and other mobile devices. HEFT staff access e-learning through a Moodle site – an open source interactive environment used by educational institutions to deliver course content online. The online system enables the clinical leads for the modules to monitor participants’ activities, such as the learning resources accessed or ignored. It also captures responses to assessment questions; module leads can analyse the data, which is recorded in the organisation’s training database, and identify participants’ gaps in knowledge and strengths to inform the development of learning resources. Taught sessions will continue to be provided for the level three workforce, alongside developments in e-learning resources. As the level three adult workforce is trained and their knowledge, understanding and skills develop, they will support the safeguarding leads in delivering new safeguarding recommendations. This approach will provide the organisation with an opportunity to deliver face-to-face sessions within mandatory training days, delivering service-specific safeguarding messages to develop knowledge, understanding and skills for that service or department.
40
26 April 2015 | Volume 27 | Number 3
80
120
160
200
Large complex organisations that provide services mainly to the adult population may find that their staff have difficulty in understanding their roles and responsibilities in safeguarding children and NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
young people. The merging of the safeguarding message for children and adults has improved HEFT’s training compliance rates. The clinical workforce has engaged in the process and referrals have improved, indicating greater awareness of safeguarding in relation to protecting children, young people and adults at risk of harm. It is also acknowledged that this has been achieved in a short time frame of two years, during which more than 5,000 staff have been trained, with untrained staff also frequently receiving messages about the need to attend training. About 400 staff still require level two safeguarding training. The level two update e-learning module was launched in December 2014 to staff trained before June 2012. This staff group were given an option to either complete the e-learning module or attend the taught level two children and adults session because they had not received this type of training in the past. In the first three months of the launch, 148 staff completed the level two update module and about 100 opted for the taught session. Staff are engaged with safeguarding training, which is demonstrated through the attendance rates and the queries received for information on updates and so on. In 2015/16, the focus will be the e-learning level two update module, monitoring compliance and the effectiveness of the learning resources. The level one DVD and level two training are being updated to embrace the changes in the Care Act 2014. It must be acknowledged that the approach outlined here may not be suitable for all organisations. However, to ensure that staff are
engaged in understanding their safeguarding roles and responsibilities, organisations need to provide clear, unambiguous guidance within a training strategy of individual and departmental educational requirements. This helps prevent disengagement and confusion. Safeguarding leads and educators have a responsibility to develop meaningful learning resources that are accessible and relevant to practice, encouraging independent learning. HEFT has developed e-learning materials that staff can access independently via mobile devices. Further resources will be developed to take advantage of the social media network, which help improve access for diverse staff groups, geographically dispersed with heavy workload commitments. The Moodle team has agreed to develop a safeguarding hub on the online site, so that resources can be easily identified and accessed. Learning resources will be developed to enable clinical educators in departments to share and deliver safeguarding updates. Plans include the development of short video clips of patient stories to show positive outcomes from patients who had safeguarding interventions identified by staff in the HEFT.
Online archive
Conclusion The developments outlined in this article provide opportunities for staff to develop their personal and professional safeguarding knowledge and skills, leading to better outcomes for children and young people at risk of harm.
For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Bournemouth University (2010) National Competency Framework for Safeguarding Adults. Bournemouth University, Bournemouth. Broadhurst et al (2010) Ten Pitfalls and How to Avoid Them. What Research Tells Us. tiny. cc/7sndvx (Last accessed: March 13 2015.) Care Quality Commission (2010) Guidance about Compliance. Essential Standards of Quality and Safety. tinyurl.com/pklpkle (Last accessed: March 19 2015.) De Cicco E, Kennedy S (2012) Learning in a Digital Age: Extending Higher Education Opportunities for Lifelong Learning. tinyurl. com/m4p8yh9 (Last accessed: March 13 2015.)
Department for Children Schools and Families (2009) Think Family Toolkit. Improving Support for Families at Risk. Strategic Overview. tinyurl. com/m4x9mk9 (Last accessed: March 19 2015.) Department for Education and Skills (2005) The Children’s Workforce Strategy: A Strategy to Build a World-Class Workforce for Children and Young People. DfES, London.
Her Majesty’s Government (2013) Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. Stationery Office, London. Laming WH (2009) The Protection of Children in England: A Progress Report. Stationery Office, London.
General Medical Council (2012) Protecting Children and Young People: The Responsibilities of Doctors. GMC, London.
Munro E (2011) The Munro Review of Child Protection. Interim Report: The Child’s Journey. Stationery Office, London.
Heart of England NHS Foundation Trust (2015) About Us. www.heartofengland.nhs.uk/about-us (Last accessed: March 13 2015.)
National Institute for Health and Care Excellence (2009) When to Suspect Child Maltreatment. Clinical Guideline 89. NICE, London.
NURSING CHILDREN AND YOUNG PEOPLE
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurse and Midwives. NMC, London. Office for Standards in Education, Children’s Services and Skills (2011) Ages of Concern: Learning Lessons from Serious Case Reviews. A Thematic Report of Ofsted’s Evaluation of Serious Case Reviews from 1 April 2007-31 March 2011. Ofsted, London. Royal College of Paediatrics and Child Health (2014) Safeguarding Children and Young People: Roles and Competencies for Health Care Staff. RCPCH, London.
April 2015 | Volume 27 | Number 3 27
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Training to raise staff awareness about safeguarding children Jane Fleming describes how an acknowledged shortfall in knowledge about at-risk children led her organisation to improve compliance rates by increasing understanding about the issues involved Abstract To improve outcomes for children and young people health organisations are required to train all staff in children’s safeguarding. This creates difficulties for large complex organisations where most staff provide services to the adult population. Heart of England NHS Foundation Trust is a large acute and community trust that had difficulties in engaging staff in children’s safeguarding training. Compliance rates for clinical staff who were trained in children’s safeguarding were low and needed to be addressed. This article sets out why safeguarding training is important for all staff and how the trust achieved staff engagement and improved compliance rates. To evaluate, maintain and develop safeguarding knowledge, understanding, skills, attitude and behaviour further resources are planned to allow access to learning resources in a variety of formats. Keywords Child health, child protection, children and young people, outcomes, paediatric nursing, safeguarding training Correspondence jane.fleming@heartofengland. nhs.uk Jane Fleming is safeguarding educator, Heart of England NHS Foundation Trust, Birmingham Date of submission September 22 2014 Date of acceptance December 23 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ncyp-authorguidelines
HEART OF England NHS Foundation Trust (HEFT) is a teaching trust for medical, nursing, therapy and clinical support staff with professional links to local universities, colleges and schools. It is one of the top five employers in the Midlands, employing about 10,000 staff (HEFT 2015). The NHS trust consists of three acute hospitals, providing general and specialist services in medicine and research, sexual health services, plus hospital and community midwifery services with specialist premature baby care provision. In 2011, Solihull Community Care Trust, which delivers all community health care services for Solihull, merged with the acute trust. The NHS trust’s boundary has many borders in the West Midlands, creating strong links and working relationships with the safeguarding boards in Birmingham, Solihull, Staffordshire, and Coventry and Warwickshire. Health services are provided to a diverse range of communities in Birmingham
22 April 2015 | Volume 27 | Number 3
East and North, Solihull, Sutton Coldfield, and South Staffordshire. A total of 1.2 million people are seen and treated and 250,000 people attend the hospital’s emergency departments each year (HEFT 2015). HEFT is a large, complex organisation that is geographically dispersed and has a requirement to provide assurance of safeguarding knowledge and skills. The NHS is committed under Section 11 of the Children Act 2004 to ensure that robust training provision is in place and can be maintained. The Care Quality Commission (CQC) seeks assurance that standards for safeguarding children and adults are in place and applied by staff (outcome 7, regulation 11) (CQC 2010). Assurance is demonstrated through compliance rates for safeguarding training. To assess the application of knowledge and skills CQC auditors talk to patients about their experience of safeguarding processes, and patient records are examined to review outcomes. Quarterly safeguarding reports are provided to internal auditors, Birmingham and Solihull safeguarding boards, plus other reports, as required, for external audits. The organisation has begun reviewing patient stories and experiences of safeguarding through the examination of patient records and talking with those who have experienced a safeguarding referral. These reports are then discussed at safeguarding committee meetings to inform developments in processes, procedures and training. The NHS trust is required by commissioners to train all staff to safeguard children and young people and attain a compliance rate of 85% for all levels of safeguarding training. In December 2011, HEFT was 98% compliant for level one safeguarding children and 40-45% for level two. At the end NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
of September 2014, compliance rates for level one safeguarding had been maintained and the percentage of staff trained to level two had increased to 88%. This article outlines how this was achieved.
Universal training There are national and local drivers to improve outcomes for children and young people. Healthcare staff are required to work to the guidance from the National Institute for Health and Care Excellence (NICE) (2009). The General Medical Council (GMC) provides further guidance for doctors on promoting the health and wellbeing of children and young people (GMC 2012). Working Together to Safeguard Children (Her Majesty’s Government 2013) provides safeguarding guidance for all agencies involved in the care of children, including multi-agency information sharing. These documents inform local policies and procedures in the recognition, escalation and intervention of safeguarding concerns. The evidence for understanding safeguarding recognition, intervention, multi-agency and multidisciplinary working relationships is obtained from serious case reviews. These are commissioned by local safeguarding children’s boards (LSCBs) who review child deaths. Key professionals from the LSCB will request such a review when a child or young person is killed or seriously and significantly harmed, and abuse or neglect is a known or suspected factor. The findings from the reviews frequently recommend how multi-agency working can be a contributory factor to improved outcomes for children and young people. Internal management reviews are undertaken when concerns are identified from a single agency, this type of review also contributes to improved outcomes for children and young people (Laming 2009, Broadhurst et al 2010, Munro 2011, Office for Standards in Education (Ofsted) 2011). Following a case review, an action plan, with clear timescales, is developed to ensure that all recommendations are implemented and embedded in practice. Safeguarding boards monitor the implementation of the actions through a robust audit trail and reporting process. Nationally, information from serious case reviews is collated and researched. Ofsted provides published reports on the lessons learned from the reviews to raise awareness among professionals (Ofsted 2011). Laming (2009), Broadhurst et al (2010) and Munro (2011) have undertaken further analysis of serious case reviews, systems and processes to provide recommendations to changes in practice. The recommendations from local or national NURSING CHILDREN AND YOUNG PEOPLE
reviews may include developments in local policies, guidance, procedures and changes to the content or focus of safeguarding training. Updating the content of safeguarding training, in accordance with the recommendations, provides assurance that front line staff are engaged and informed of the lessons learned from serious case reviews or research. This provides all healthcare staff with an evidence base of safeguarding knowledge and understanding to underpin their professional development of skills, attitude and behaviour. Nurses are required to deliver evidence-based care for their patients, families and carers (Nursing and Midwifery Council (NMC) 2008). Remaining compliant with safeguarding training requirements offers an opportunity to deliver evidence-based safeguarding assessment and interventions when there are potential or actual safeguarding concerns. However, large complex health organisations have many competing training priorities. This can create confusion about training requirements. There are different levels of safeguarding children and safeguarding adult training for different staff groups, which can add further confusion. Before June 2012, HEFT employees were confused about their safeguarding training requirements. This was demonstrated through a training needs analysis, which identified that staff accessed the incorrect level of training for their employment requirements, some staff repeated the same training without moving to the next level and some clinical staff considered themselves trained if they had attended level one safeguarding training.
Levels of training The levels of safeguarding training are determined by competency frameworks outlining the required knowledge, skills, attitudes and behaviour for staff groups in health and partnership agencies. Safeguarding children frameworks for healthcare staff are developed by Royal College of Paediatrics and Child Health (RCPCH 2014). Local safeguarding children boards and the Department for Education and Skills (2005) also provide frameworks for staff working with children and young people. Safeguarding adult frameworks for health and partner agencies, who provide care for adults, are developed by local safeguarding adult boards (LSABs) with further guidance from the national competency framework developed by Bournemouth University (2010). Organisations are required to demonstrate compliance by mapping training content, delivery and evaluation to the competency frameworks. April 2015 | Volume 27 | Number 3 23
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science | professional issues There are five levels of safeguarding children’s training (RCPCH 2014) and five levels for adult safeguarding training (Bournemouth University 2010) (Table 1).
Improving compliance rates In December 2011, the head of safeguarding at the NHS trust appointed a safeguarding educator [the author] to improve the compliance rates for level two training. The children’s safeguarding named doctor, nurse and midwife focused on the development and delivery of the level three children’s training required for the children’s workforce (RCPCH 2014). The matron for safeguarding adults developed a level three safeguarding adults session for senior staff who provide support and advice to front line staff on actual or potential safeguarding adult concerns (Bournemouth University 2010). There are more than 7,000 clinical staff providing a wide range of health services in HEFT. The organisation defines clinical staff as employees who are involved in patient assessment, treatment, care or intervention services, including senior medical staff, nursing and midwifery staff, allied health professionals, pharmacists, radiologists, healthcare scientists, clinical educators, and various clinical support staff. This range of staff requires level two safeguarding children and adults training.
On starting in post, the safeguarding educator undertook a training needs analysis, which identified that of the 7,000 clinical staff about 5,500 provide services to the adult population and do not understand or see the relevance of attending children’s safeguarding training. They were disengaged and confused about their requirements and responsibilities for undertaking this training, which was identified through the training needs analysis. This showed that staff did not understand which level of training they required and those in adult services often failed to attend children’s safeguarding training. Likewise, the children’s workforce did not see the relevance of attending adult safeguarding training. To improve engagement and understanding, the training strategy was updated and a training matrix developed to clarify children and adult safeguarding training requirements for all health disciplines, departments and staff groups. A DVD was produced as a level one safeguarding resource delivered to the non-clinical workforce by a facilitator rather than a member of the small safeguarding team. This learning resource raised awareness of everyone’s role in safeguarding. The DVD outlined how, where and when to escalate safeguarding concerns and when to seek advice. The safeguarding educator focused on the content and delivery of level two training, using sections
Table 1 Safeguarding training levels Training level
Required knowledge, skills, attitudes and behaviour
Workforce: training requirements
Level 1: children and adults Awareness of safeguarding responsibilities, recognition and escalation. Non-clinical staff, including laboratory staff. Level 2: children and adults As above, plus enhanced understanding of assessment, recognition, intervention, escalation, information sharing and referral processes to build on knowledge received at level 1.
All clinical staff involved in the patients care.
Level 3: children
Advanced recognition, intervention, information sharing and escalation Children’s workforce acute and community, including sexual health services, midwives of safeguarding concerns. Interagency working, early intervention and the emergency department. processes, including the common assessment framework.
Level 3: adults
Advanced recognition, intervention and escalation, plus understanding of the investigation of safeguarding adult concerns. Providing support and advice for front line staff.
Level 4 and 5: children and adults
Named doctors, nurses and Demonstrate skills, knowledge and understanding required to develop midwives for safeguarding children. close working relationships with partner agencies at strategic level, Matron for safeguarding adults. manage data collection to produce and oversee safeguarding audits for internal and external scrutiny. Produce safeguarding compliance reports for internal and external reporting processes; contribute to serious case reviews, internal management reviews and domestic homicide reviews. Plus a strategic overview for the organisation and raising public awareness. Undertake safeguarding supervision of front line staff.
24 April 2015 | Volume 27 | Number 3
Head nurses, matrons, ward/ departmental managers, designated senior nurses/team leaders.
NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Figure 1
Evaluation report for 2013/14 (n=2,397, with 2,110 evaluation forms completed)
1,400
Number of responses
1,200 1,000 800 600 400 200 Understanding of what constitutes maltreatment
Key: Exceeded
Yes
Categories of abuse
Partly
Know how to seek advice and support
No
from the DVD. The DVD merged safeguarding messages for children and adults in raising awareness of who is at risk of abuse, the categories of abuse, how to recognise abuse and what to do if and when safeguarding concerns are identified. The DVD is split into sections, and these video clips are used in level two safeguarding training, along with video clips on domestic abuse and poor patient care. The clips are used to generate group discussion for the clinical workforce. The newly developed resources and programme of training for level two was ready for delivery in June 2012; staff now attend one taught session for level two safeguarding children and adults. The evaluations of these sessions has been positive (Figures 1 and 2), with many staff stating that the session is meaningful and relevant to their practice. Evaluation forms are completed at the end of the session; positive comments are often recorded from all levels of staff, as well as via e-mail post attendance. Ad-hoc sessions continue to be delivered to employed staff, and levels one and two safeguarding training is delivered at corporate induction. A total of 2,110 forms were completed by 2,397 participants between April 2013 and March 2014. Overall, the evaluations were positive as indicated (Figure 1). The feedback forms ask participants to give three examples of information gained and how this will change their practice. Figure 2 summarises their responses. Combining the safeguarding message for children and adults has engaged staff in the safeguarding process, raised awareness of the importance NURSING CHILDREN AND YOUNG PEOPLE
Understanding of information sharing
Know what to do about child abuse
Know what to do about adult abuse
Did you find the session useful?
n/a
Figure 2 Summary of responses from evaluation forms 1,000 Number of responses
0
800 600 400 200 0 fe
Sa
g
in
rd
a gu
l , s n n d d … ta ce te s re rie tio tio nd nt are ervi t… Men Act go use pec ath ma ring nta a e e c h c s r a x e t b e t rig nt/ city do nt Ca of a Une d Info sh um o e a igh c tie tt R o ns ap a a D P h Co C W
of assessing the carers/parents, the strength and relevance of good, accurate and concise documentation. The safeguarding team monitor children’s safeguarding referrals and have noted an improvement in relevant referrals to children’s social care services. The monitoring process has also highlighted that further training is needed in some departments to support staff with making a good quality referral. A well-written referral enables social care services to prioritise the safeguarding assessment of healthcare staff. A short three-minute DVD has been produced with information on what makes a good quality referral. This was a joint project with Birmingham Children’s Safeguarding Board, who provided the funding for filming. The engagement of the adult workforce with children’s safeguarding concerns has also improved. April 2015 | Volume 27 | Number 3 25
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
Art & science | professional issues There has been an increase in contacts for advice and support received by the children’s named nurse from the adult workforce. The ‘Think Family’ message (Department for Children, Schools and Families 2009) is visible through the number of referrals made due to concerns about parental capacity (Figure 3). These are initiated by the adult and children’s workforce. To assess staff’s understanding and application of safeguarding knowledge and skills, HEFT senior personnel undertake walkabouts, during which clinical staff are interviewed at random to assess their safeguarding knowledge and understanding. This process will continue to be developed, so that safeguarding knowledge and skills can be monitored. This will ensure that future learning resources are developed to address gaps and develop strengths. The results are positive, demonstrating greater awareness and understanding. This evaluation process needs to be refined by tailoring the interview questions to reflect the roles and responsibilities of different grades of staff. Post-training evaluations will be developed when the NHS trust’s new training database has been implemented this summer. This will allow for an automated e-mail to be sent to participants three months after training. This will contribute to the information of knowledge and skills obtained through the walkabouts and other audit processes, such as the review of patient records to monitor understanding and application of safeguarding knowledge and skills.
Maintaining compliance Safeguarding levels one and two continue to be delivered at weekly corporate induction; this will ensure that the compliance rates are maintained with newly appointed staff. Ad-hoc sessions across the three sites continue to be provided for employed
Figure 3 Parental problems identified 123
Domestic abuse
188
Mental health
48
Substance misuse History of child removed
14
Previous involvement 2 as a child
Discussion 45
Other
0
untrained staff who are notified individually and through line managers of the requirement to be trained. There is support and engagement with this process from heads of service, line managers, clinical leads and educators. Research shows that learning is more effective when delivered through blended learning (De Ciccio and Kennedy 2012), which combines face-to-face and computer-aided activities. The HEFT education faculty encourages educators to develop blended learning, to ensure that learning objectives are met. The competency framework (RCPCH 2014) acknowledges that different methods of learning are required to improve safeguarding knowledge, understanding and skills. Safeguarding training in HEFT involves face-to-face learning, e-learning, supervision, group discussions, experiential learning, action learning and reflective practice. Safeguarding training resources include the level one DVD; the level two update e-learning programme also includes sections from the DVD. Two short videos on ‘managing challenging behaviour’ and ‘how to make a good quality safeguarding children’s referral’ are viewed in the taught sessions and are also available to watch on smartphones and other mobile devices. HEFT staff access e-learning through a Moodle site – an open source interactive environment used by educational institutions to deliver course content online. The online system enables the clinical leads for the modules to monitor participants’ activities, such as the learning resources accessed or ignored. It also captures responses to assessment questions; module leads can analyse the data, which is recorded in the organisation’s training database, and identify participants’ gaps in knowledge and strengths to inform the development of learning resources. Taught sessions will continue to be provided for the level three workforce, alongside developments in e-learning resources. As the level three adult workforce is trained and their knowledge, understanding and skills develop, they will support the safeguarding leads in delivering new safeguarding recommendations. This approach will provide the organisation with an opportunity to deliver face-to-face sessions within mandatory training days, delivering service-specific safeguarding messages to develop knowledge, understanding and skills for that service or department.
40
26 April 2015 | Volume 27 | Number 3
80
120
160
200
Large complex organisations that provide services mainly to the adult population may find that their staff have difficulty in understanding their roles and responsibilities in safeguarding children and NURSING CHILDREN AND YOUNG PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
young people. The merging of the safeguarding message for children and adults has improved HEFT’s training compliance rates. The clinical workforce has engaged in the process and referrals have improved, indicating greater awareness of safeguarding in relation to protecting children, young people and adults at risk of harm. It is also acknowledged that this has been achieved in a short time frame of two years, during which more than 5,000 staff have been trained, with untrained staff also frequently receiving messages about the need to attend training. About 400 staff still require level two safeguarding training. The level two update e-learning module was launched in December 2014 to staff trained before June 2012. This staff group were given an option to either complete the e-learning module or attend the taught level two children and adults session because they had not received this type of training in the past. In the first three months of the launch, 148 staff completed the level two update module and about 100 opted for the taught session. Staff are engaged with safeguarding training, which is demonstrated through the attendance rates and the queries received for information on updates and so on. In 2015/16, the focus will be the e-learning level two update module, monitoring compliance and the effectiveness of the learning resources. The level one DVD and level two training are being updated to embrace the changes in the Care Act 2014. It must be acknowledged that the approach outlined here may not be suitable for all organisations. However, to ensure that staff are
engaged in understanding their safeguarding roles and responsibilities, organisations need to provide clear, unambiguous guidance within a training strategy of individual and departmental educational requirements. This helps prevent disengagement and confusion. Safeguarding leads and educators have a responsibility to develop meaningful learning resources that are accessible and relevant to practice, encouraging independent learning. HEFT has developed e-learning materials that staff can access independently via mobile devices. Further resources will be developed to take advantage of the social media network, which help improve access for diverse staff groups, geographically dispersed with heavy workload commitments. The Moodle team has agreed to develop a safeguarding hub on the online site, so that resources can be easily identified and accessed. Learning resources will be developed to enable clinical educators in departments to share and deliver safeguarding updates. Plans include the development of short video clips of patient stories to show positive outcomes from patients who had safeguarding interventions identified by staff in the HEFT.
Online archive
Conclusion The developments outlined in this article provide opportunities for staff to develop their personal and professional safeguarding knowledge and skills, leading to better outcomes for children and young people at risk of harm.
For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Bournemouth University (2010) National Competency Framework for Safeguarding Adults. Bournemouth University, Bournemouth. Broadhurst et al (2010) Ten Pitfalls and How to Avoid Them. What Research Tells Us. tiny. cc/7sndvx (Last accessed: March 13 2015.) Care Quality Commission (2010) Guidance about Compliance. Essential Standards of Quality and Safety. tinyurl.com/pklpkle (Last accessed: March 19 2015.) De Cicco E, Kennedy S (2012) Learning in a Digital Age: Extending Higher Education Opportunities for Lifelong Learning. tinyurl. com/m4p8yh9 (Last accessed: March 13 2015.)
Department for Children Schools and Families (2009) Think Family Toolkit. Improving Support for Families at Risk. Strategic Overview. tinyurl. com/m4x9mk9 (Last accessed: March 19 2015.) Department for Education and Skills (2005) The Children’s Workforce Strategy: A Strategy to Build a World-Class Workforce for Children and Young People. DfES, London.
Her Majesty’s Government (2013) Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. Stationery Office, London. Laming WH (2009) The Protection of Children in England: A Progress Report. Stationery Office, London.
General Medical Council (2012) Protecting Children and Young People: The Responsibilities of Doctors. GMC, London.
Munro E (2011) The Munro Review of Child Protection. Interim Report: The Child’s Journey. Stationery Office, London.
Heart of England NHS Foundation Trust (2015) About Us. www.heartofengland.nhs.uk/about-us (Last accessed: March 13 2015.)
National Institute for Health and Care Excellence (2009) When to Suspect Child Maltreatment. Clinical Guideline 89. NICE, London.
NURSING CHILDREN AND YOUNG PEOPLE
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurse and Midwives. NMC, London. Office for Standards in Education, Children’s Services and Skills (2011) Ages of Concern: Learning Lessons from Serious Case Reviews. A Thematic Report of Ofsted’s Evaluation of Serious Case Reviews from 1 April 2007-31 March 2011. Ofsted, London. Royal College of Paediatrics and Child Health (2014) Safeguarding Children and Young People: Roles and Competencies for Health Care Staff. RCPCH, London.
April 2015 | Volume 27 | Number 3 27
Downloaded from RCNi.com by ${individualUser.displayName} on Jan 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
