Chapter 5: Communication, psychological wellbeing and safeguarding
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Source: Adapted from DfE ([65]).
Source: Adapted from the London Child Protection Procedures ([154]).![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f018.gif@B)
![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f019.gif@B)
Source: Adapted from ADASS ([2], p.13).
![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f020.gif@B)
Source: Adapted from NHS England North ([199]).
Safeguarding, mental capacity and the Mental Health Act
Safeguarding
Definition
The Department of Health and Social Care defines safeguarding as follows:
Safeguarding means protecting an adult's right to live in safety, free from abuse and neglect. It is about people and organizations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult's wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. This must recognize that adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances.(DH [81], para. 14.7)
Safeguarding duties apply to an ‘adult at risk’ (which has replaced the term ‘vulnerable adult’), who is defined as an adult who ‘has needs for care and support; is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect’ (DH [81], para. 14.2).
Similarly, safeguarding children and young people consists of action taken to ‘protect children from maltreatment; prevent impairment of children's health or development’, ensure children grow up ‘in circumstances consistent with the provision of safe and effective care’ and enable ‘all children to have the best outcomes’ (DfE [65], p. 102).
Safeguarding is a key focus for all nurses, healthcare practitioners and organizations. Although this manual is for nurses working in adult contexts, it is imperative that all nurses consider safeguarding in the context of families, as they will work with adults who are in contact with children who require safeguarding.
Related theory
Types of abuse and neglect
The statutory guidance on the Care Act ([42]) (DH [81], paras. 14.17–14.33) describes different forms of abuse and neglect: physical, sexual, psychological, discriminatory, domestic and financial, as well as organizational abuse and modern slavery (Box 5.18). Further adult safeguarding concerns include female genital mutilation, forced marriage, honour‐based violence, hate crime, human trafficking, sexual exploitation and mate crime (Box 5.19) (Gov.uk n.d., [110], [111]).
Within the child safeguarding arena, there are four identified types of abuse and neglect: physical, psychological, sexual and neglect (DfE [65]) (Box 5.20). The London Child Protection Procedures (London Safeguarding Children Board [154]) provide guidance in relation to safeguarding children in specific circumstances, including children with disabilities and those with fabricated or induced illness (Box 5.21).
Box 5.18
Physical abuse | |
Physical abuse includes assault, hitting, slapping, pushing, misuse of medication, restraint and inappropriate physical sanctions. |
Possible indicators
|
Sexual abuse | |
Sexual abuse includes rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, indecent exposure, and sexual assault or sexual acts to which the adult has not consented or was pressured into consenting. | Possible indicators
|
Psychological abuse | |
Psychological abuse includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, cyber bullying, isolation, and unreasonable and unjustified withdrawal from services or supportive networks. | Possible indicators
|
Neglect and acts of omission | |
Neglect and acts of omission include ignoring medical, emotional or physical care needs; failure to provide access to appropriate health, care and support or educational services; and withholding the necessities of life, such as medication, adequate nutrition and heating. | Possible indicators
|
Self‐neglect | |
Self‐neglect is defined as a wide range of behaviours including neglecting to care for one's personal hygiene, health or surroundings. It includes behaviours such as hoarding. | Possible indicators
|
Discriminatory abuse | |
Discriminatory abuse is discrimination on the grounds of protected characteristics (Equality Act [93]), such as race, faith or religion, age, disability, gender reassignment, sexual orientation, relationship status or pregnancy, along with racist, sexist, homophobic or ageist comments or jokes, or comments or jokes based on a person's disability or any other form of harassment, slur or similar treatment. Excluding a person from activities on the basis that they are ‘not liked’ is also discriminatory abuse. | Possible indicators
|
Domestic abuse | |
Domestic abuse (or domestic violence) is defined as any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between individuals aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality (DH [78]). It includes psychological, physical, sexual, financial and emotional abuse, and so‐called ‘honour’‐based violence. | Possible indicators
|
Financial or material abuse | |
Financial or material abuse includes theft; fraud; internet scamming; coercion in relation to an adult's financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions; and the misuse or misappropriation of property, possessions or benefits. | Possible indicators
|
Modern slavery | |
Modern slavery is defined as slavery, servitude and being forced into compulsory labour (Modern Slavery Act [190]). A person commits an offence if:
All disclosures of modern slavery must be reported to the National Referral Mechanism by an identified first responder agency. | Possible indicators
|
Organizational abuse | |
Organizational abuse includes neglect and poor care practice within an institution or specific care setting (e.g. hospital or care home) or in relation to care provided in the person's own home. This may range from one‐off incidents to ongoing ill‐treatment. It can occur through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organization. | Possible indicators
|
Box 5.19
Further safeguarding concerns for adults
Female genital mutilation (FGM)
FGM is any procedure that is designed to alter or injure a girl's (or woman's) genital organs for non‐medical reasons. It is sometimes known as ‘female circumcision’ or ‘female genital cutting’. It is mostly carried out on young girls. The Female Genital Mutilation Act ([101]) makes it illegal to practise FGM in the UK or to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in another country (Gov.uk [111]).
Forced marriage
Forced marriage is when a person faces physical (e.g. threats, physical violence or sexual violence) or psychological pressure to marry. This includes someone being taken overseas with the intention of forcing them to marry (whether or not the forced marriage takes place) and the marriage of someone who lacks the mental capacity to consent to the marriage (whether they are pressured into the marriage or not) (Gov.uk [110]).
Honour‐based violence
Honour‐based violence is a crime that is committed when families feel that dishonour has been brought on them and they respond with violence. Women are predominantly (but not exclusively) the victims and the violence is often committed with a degree of collusion from family members and/or the community. Some victims contact the police or other organizations; however, some are so isolated and controlled that they are unable to seek help.
Hate crime
Hate crime is any incident that is perceived by the victim, or any other person, to be racist, homophobic, transphobic or due to a person's religion or belief, gender, identity or disability (Law Commission [148]).
Human trafficking
Human trafficking is actively used by serious and organized crime groups in order to make significant amounts of money. Traffickers exploit the social, cultural or financial vulnerability of the victim, or their family, and place large financial and ethical obligations on them. They control almost every aspect of the victim's life with little regard for the victim's welfare and health. Human trafficking is often related to modern slavery and includes trafficking internationally as well as within the UK.
Sexual exploitation
Sexual exploitation involves exploitative situations, contexts and relationships where adults at risk (or a third person or persons) receive ‘something’ (e.g. accommodation, affection, alcohol, cigarettes, drugs, food, gifts or money) as a result of them performing (and/or allowing another or others to perform on them) sexual activities. An example could be an adult at risk being provided with an incentive (alcohol, drugs or even a place to sleep and ‘friendship’) in exchange for providing sexual activity with a person or persons. It affects men as well as women. People who are sexually exploited do not always perceive that they are being exploited.
Mate crime
‘Mate crime’ is when a person pretends to be the friend of another person who has vulnerabilities, such as a learning disability, and then takes advantage of them (Safety Net Project [249]). It may not be an illegal act but still has a negative effect on the individual. Mate crime is often difficult for police to investigate due to its sometimes ambiguous nature, but it should be reported to the police, who will make a decision about whether or not a criminal offence has been committed. Mate crime is carried out by someone the adult knows and often happens in private.
Box 5.20
Types and indicators of child abuse
Physical abuse | |
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. |
Possible indicators
|
Emotional or psychological abuse | |
Emotional abuse is the persistent emotional maltreatment of a child that causes severe and ongoing effects on the child's emotional development, and may involve:
Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. |
Possible indicators
Changes in emotions are a normal part of growing up, so it can be difficult to tell whether a child is being emotionally abused. However, signs may be perceptible in a child's actions or emotions.
Babies and pre‐school children may:
Older children may:
|
Sexual abuse | |
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities (not necessarily involving a high level of violence), whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (e.g. rape or oral sex) or non‐penetrative acts (e.g. masturbation, kissing, rubbing or touching outside clothing). Sexual abuse includes non‐contact activities, such as children looking at (including online) or being involved in the production of pornographic materials; children watching sexual activities; encouraging children to behave in sexually inappropriate ways; or grooming a child in preparation for abuse (including via the internet). In addition, sexual abuse includes abuse of children through sexual exploitation. |
Possible indicators
Staying away from certain people:
Showing sexual behaviour that is inappropriate for their age:
Physical symptoms:
|
Neglect | |
Neglect is the persistent failure to meet a child's basic physical and/or psychological needs. It is likely to result in serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance misuse, maternal mental ill health or learning difficulties, or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected. Once a child is born, neglect may involve a parent failing to:
It may also include neglect of, or unresponsiveness to, a child's basic emotional, social and educational needs. |
Possible indicators
Poor appearance and hygiene. They may:
Health and development problems. They may:
Housing and family issues. They may:
|
Box 5.21
Specific child safeguarding risks
Children with disabilities | |
Any child with a disability is by definition a ‘child in need’ under Section 17 of the Children's Act ([47]). The available UK evidence on the extent of abuse among disabled children suggests that disabled children are at increased risk of abuse and that the presence of multiple disabilities appears to increase the risks of both abuse and neglect. |
Specific risks
Looked‐after disabled children are not only vulnerable to the same factors that exist for all children living away from home but are also particularly susceptible to abuse because of their additional dependency on residential and hospital staff for day‐to‐day physical care needs. Specific risks include:
|
Fabricated or induced illness | |
Fabricated or induced illness is a condition where a child has suffered, or is likely to suffer, significant harm through the deliberate action of their parent and that is attributed by the parent to another cause. There are three main ways of a parent fabricating or inducing illness in a child:
| Possible indicators
|
Prevalence of abuse and neglect
As abuse usually occurs in secret, it is not possible to accurately state the number of people who are abused in the UK. Abused individuals may not know that they are being abused, or may be too frightened or ashamed to tell others what they are experiencing. Further, ‘observers’ of abuse may not recognize the signs of abuse and therefore fail to identify and report it.
Nonetheless, there are a number of sources of data that can be drawn upon to provide a sketch of the level of abuse, for example, government (Figure 5.18), social services and charities such as the NSPCC (Figure 5.19). It is accepted that actual levels of abuse and neglect are higher than the number of reported incidents.
![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f018.gif@B)
Figure 5.18 Findings from the Safeguarding Adults Collection for 1 April 2017 to 31 March 2018.
Source: NHS Digital ([195]).
![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f019.gif@B)
Figure 5.19 Prevalence of child abuse and neglect.
Source: Bentley et al. ([17]).
Contextual safeguarding
People are usually abused by someone they know, for example a spouse, parent or other family member, as well as friends, neighbours, professionals and volunteers. This is not to say that strangers cannot be the perpetrators of abuse. Neglect, by definition, can only be carried out by someone who has a personal or professional relationship with the neglected person. Extra‐familial threats can arise in educational, work or healthcare establishments; from within peer groups; or from the wider community (including online). Thus, nursing assessments must include an awareness and understanding of the context in which a child or adult exists to enable them to prevent and manage safeguarding risks.
Evidence‐based approaches
Rationale
Safeguarding aims to protect people from harm and abuse while concurrently promoting individual (and thereby societal) wellbeing so that everybody can live a healthy life to their fullest potential.
Government safeguarding principles
Government and healthcare guidance includes safeguarding principles that underscore the need for relevant systems to be
developed and applied in a robust and appropriate manner. When nurses adhere to the principles outlined below, they can provide an appropriate and personalized approach to safeguarding.
The Care Act ([42]) and statutory guidance (DH [81]) define six key principles that underpin all adult safeguarding work. These are the prevention of abuse and neglect, the empowerment and protection of people, the delivery of accountable and proportionate safeguarding responses, and partnership work with other agencies (Table 5.22). These principles are embraced by the nursing profession, which clearly states that safeguarding is a core component of the nursing role:
Table 5.22 Safeguarding principles as outlined in the Care and Support Statutory Guidance
Principle | Description | Example |
---|---|---|
Prevention | Strategies are developed to prevent abuse and neglect that promote resilience and self‐determination. | I provide my patients with easily understood information about what abuse is, how to recognize it and what they can do to seek help. |
Empowerment | Adults are provided with support, information and encouragement to make their own decisions. This is particularly pertinent in healthcare, as people are often asked to hand over control and power to professionals. | I ensure that my patients are sufficiently informed and consulted about the outcomes they want from the safeguarding process and these directly inform what happens. |
Protection | Adults are offered ways to protect themselves, and there is a co‐ordinated response to adult safeguarding. | I provide my patients with help and support to report abuse and to take part in the safeguarding process to the extent to which they want and are able. |
Proportionate | Safeguarding responses will be the least restrictive possible and appropriate to the risk(s) identified and their context. | I will only get involved as much as is needed and will provide advice and support to my patients consisting of suitable options related to the identified concerns. |
Accountable | Accountability and transparency are employed in delivering a safeguarding response. | I ensure that the patient and all those involved in the patient's life understand their roles and responsibilities. |
Partnerships | Local solutions are provided through services working together within their communities. | I ensure patient information is appropriately shared in a way that takes into account its personal and sensitive nature and will work with agencies to find the most effective responses to the situation. |
You put the interests of people using or needing nursing or midwifery first. You make their care and safety your main concern and make sure that their dignity is preserved and their needs are recognised, assessed and responded to. You make sure that those receiving care are treated with respect, that their rights are upheld and that any discriminatory attitudes and behaviours towards those receiving care are challenged. (NMC [212], p.6)
The Royal College of Nursing more specifically states that nurses must take both individual and collective responsibility to safeguard others:
Safeguarding is everyone's responsibility; for services to be effective each professional and organisation should play their full part [and] professionals and organisations must work in partnership to protect children and adults in need. (RCN n.d.)
The concept ‘making safeguarding personal’ (MSP) (LGA [152]) is an important approach to adult safeguarding that encourages all staff to take personal responsibility for safeguarding patients and their families. This approach was implemented to end a culture of passing safeguarding concerns and responsibilities to others. Thus, MSP encourages staff to see themselves as key to both raising concerns and to implementing appropriate safeguarding responses. Nurses need to have conversations with patients that enhance patient involvement, choice and control as well as improving quality of life, wellbeing and safety. MSP frames people as experts in their own lives and supports staff to work alongside them to enable them to reach a better resolution of their circumstances and recovery.
Partnership working
While it is parents and carers who have primary care for their children, local authorities, working with partner organizations and agencies, have specific duties to safeguard and promote the welfare of all children in their area. Local authorities have statutory responsibility for adults in their area. Local authorities can only do their job effectively if there is appropriate partnership work between health, social care and other key support agencies. Co‐operation between agencies is important to reduce the risk of cases slipping through the safeguarding system and stopping abuse at an early stage or preventing it from happening in the first place.
In order for organizations, agencies and practitioners to collaborate effectively, it is vital that nurses working with adults, children and families understand the role they should play and the roles of other practitioners (Box 5.22). Nurses should be aware of, and comply with, the published arrangements set out by their local safeguarding partners.
Box 5.22
The nurse's safeguarding roles and responsibilities in partnership with colleagues and organizations
Nurse roles and responsibilities
- Nurses must be aware of the signs of abuse and neglect and keep people safe.
- Nurses can escalate their safeguarding concerns by raising these with the patient (unless this might increase the risk of harm), their line manager and their organization's safeguarding team.
- Nurses must clearly and accurately document any signs of abuse and neglect as well as their actions, the actions of others, and the patient's response and wishes.
Safeguarding lead
-
All hospitals must have a named safeguarding lead who is responsible for:
- ensuring the organization has safeguarding policies and procedures in place and has a programme of training
- consulting with hospital staff so that all employees within the organization can fulfil their own safeguarding responsibilities – it is rare that the safeguarding lead will have direct contact with a patient.
- If a safeguarding allegation is made against a staff member, the safeguarding lead may have direct contact with the patient.
- The safeguarding lead will help staff to escalate safeguarding concerns to a local authority and may continue to liaise with the local authority regarding their response.
Local authority
- Local authority structures vary and not all have safeguarding teams. However, all local authorities have social workers, who will lead the response to a safeguarding enquiry.
- A local authority social worker will screen a safeguarding concern or referral reported on the telephone or by email.
- Nurses can expect to receive a telephone call from the local authority to discuss immediate risks and safety concerns, and to seek clarity or further information (e.g. contextual information such as medical or social factors and needs). The urgency of the return call will depend on the nature of the safeguarding concern.
- Nurses may be invited to attend a case conference. The timing of these varies according to the urgency of the concern reported.
- When a concern is escalated to the local authority, it will contact the person reportedly at risk to better understand the concerns and risks and to identify their preferred outcome of any intervention.
- With respect to a child safeguarding concern, the local authority will normally contact the parents or carers; however, they may not do this if they feel this would increase the level of risk. Additionally, they may approach young people away from home (e.g. at school) to discuss the concerns raised with them away from family members.
- When nurses are advised to liaise with a local authority by their safeguarding lead, nurses need to both share their safeguarding concerns with the relevant local authority and work with it to formulate and implement an appropriate safeguarding response.
- Safeguarding responses may include ongoing monitoring, engaging in multi‐agency meetings and taking the lead on a safeguarding intervention (as the nurse may know the patient better than others).
A different form of partnership working is with the families or carers of patients. Families and carers have a wealth of information and knowledge about the person that they care for and support. As well as raising concerns, families and carers are able to support safeguarding enquiries through sharing important information. If a family member or carer speaks up about abuse or neglect, it is essential that they are listened to and appropriate enquiries are made. Families and carers can identify and mitigate risks as well as advocate for patients. Staff should also be vigilant to recognize the signs of carer stress and potential unintentional neglect; staff must address these directly with carers and discuss key agencies that can provide support.
Section 44 of the Care Act ([42]) stipulates that local authorities must conduct a safeguarding adults review (SAR) when an adult in its area with care and support needs has experienced significant harm from, or dies as a result of, abuse or neglect (whether known or suspected) and when there is a concern that partner agencies could have worked more effectively to protect the adult. The purposes of a SAR are to identify lessons to be learned from the case, to apply those lessons to future cases, and to improve how agencies work both independently and together to safeguard adults at risk. Nurses may be asked to contribute to a SAR by providing evidence and/or to participate in learning events following a SAR so that lessons learned can be embedded in health and social care practice.
A thematic review of 27 SARs completed in London identified key lessons (Braye and Preston‐Shoot [35]) (Figure 5.20). These included the need to consider risk assessment as a process (rather than a one‐off event) that is carried out in a person‐centred manner. Thus, nurses need to engage with the person at risk (and others in their system as appropriate) to elicit the history of any concerns and the person's wishes and views about these concerns and needs, bearing in mind that these may differ from the nurse's own view. Moreover, the review identified a need for services to more proficiently assess mental capacity, and, where this is deemed to be lacking, to engage in best interests decision making that incorporates the family's and/or carer's information. Furthermore, the review identified that staff need to report their concerns about services providing substandard care.
![image image](https://www.rmmonline.co.uk/media/manual/c05/image_t/c05f020.gif@B)
Figure 5.20 Key lessons from safeguarding adults reviews.
Source: Adapted from Braye and Preston‐Shoot ([35]).
The NSPCC ([214]) examined a series of safeguarding children reviews and reported a number of consistent errors, including overreliance on parental reporting and a reluctance to challenge parents’ views, a failure to flag up missed appointments, uncertainty about how to escalate safeguarding concerns, and inadequate information sharing.
Clinical governance
Confidentiality and information sharing
People have the right to expect that information shared with a nurse will be treated as confidential. However, nurses must make it clear to patients at the beginning of conversations that when they are concerned about the patient's (or another person's) welfare, they have a professional duty to share the information with someone who is in a position to take action, for example a line manager. When a nurse is concerned about safety it is important to discuss with the patient the rationale for sharing information, and how and with whom that information will be shared. Furthermore, the nurse must explain to the patient that they will record their views and wishes about what they want to happen so that these can be taken into account in so far as is possible. There may be times when it is unsafe for a nurse to share their safeguarding concerns with a patient – for example, when the nurse suspects that the patient may feel compelled to tell the alleged perpetrator due to high levels of control and coercion.
Sharing the right patient information at the right time with the right professionals is a fundamental part of safeguarding practice. Nurses can be ambivalent about sharing patient information within and between organizations for fear of breaching confidentiality or data protection guidance. However, sharing information in relation to day‐to‐day safeguarding practice is covered within common‐law duty of confidentiality, Crime and Disorder Act ([54]), the Human Rights Act ([137]), the Care Act ([42]) and the General Data Protection Regulation (GDPR) ([103]) (Box 5.23). It is important to record on the patient's notes the decision to share, or not, information and the reasons for this decision.
Box 5.23
Myth‐busting guide to information sharing for safeguarding purposes
Sharing information enables practitioners and agencies to identify and provide appropriate services that safeguard and promote the welfare of children and adults at risk. Below are common myths that may hinder effective information sharing.
1. Data protection legislation and the Human Rights Act ([137]) are barriers to sharing information
No. Legislation does not stop nurses from collecting and sharing patient personal information. Nurses need to balance the common‐law duty of confidence and the Human Rights Act ([137]) against the effect on individuals or others of not sharing the information. Data protection law provides a framework to make sure that any personal information is shared appropriately.
2. Consent is always needed to share personal information
No. It is good practice to let a patient know the boundaries of confidentiality. For example, at the start of a conversation, let the patient know that if they share information with you that leads you to be concerned about their, or someone else's, safety, then you may need to share that information to keep people safe.
There are circumstances where it is not appropriate to seek consent: because the individual cannot give it, because it is not reasonable to obtain consent or because to gain consent would put a person's safety at risk.
When you do ask for someone's consent to share information that is not related to safety, then they need to provide this consent freely. It is good practice to have written evidence of their consent; however, it is not essential.
3. IT systems are a barrier to effective information sharing
No. IT systems, such as the Child Protection – Information Sharing (CP‐IS) project and NHS Spine, can be useful for information sharing. IT systems are most valuable when practitioners use the shared data to make more informed decisions about how to support and safeguard a child or vulnerable adult.
Source: Adapted from DfE ([65], p.18).
Legal guidance
Some legislation pertinent to safeguarding is only applicable to individual parts of the UK. It is important that nurses familiarize themselves with legislation, guidance and policy that is applicable in the country where they work. Acts of Parliament and guidance that form the legal framework for safeguarding adults are detailed in Box 5.24.
Box 5.24
Key Acts of Parliament for safeguarding adults and children
Care Act ([42])
The Care Act ([42]) and associated statutory guidance are applicable to England only (DH [81]). They provide a statutory framework and legal footing for safeguarding adults, and give guidance to professionals about how to work in partnership to support, protect and reduce the risk to adults at risk. Under the Care Act ([42]), statutory safeguarding adults duties apply to any adult at risk who:
- has care and support needs, and
- is experiencing, or is at risk of, abuse or neglect, and
- is unable to protect themselves from either the risk or the experience of abuse or neglect, because of those needs.
When concerns are identified, professionals must seek the patient's consent and consider their mental capacity. Concerns should only be shared without the patient's consent where there are identified vital or public interests in relation to the concerns raised. These may include significant risk to a vulnerable person or risk to other people.
Mental Capacity Act ([176])
Human Rights Act ([137])
The Human Rights Act ([137]) affords specific rights to all people living in the UK, such as the right to life, the right to liberty and freedom, and the right to be treated equally (without discrimination).
Equality Act ([93])
The Equality Act ([93]) aims to provide people with legal protection from ‘discrimination in the workplace and wider society’. The act includes the ‘equality duty’, which outlines the responsibilities of public sector organizations, including the provision of NHS services. The act defines nine groups of characteristics upon which people cannot be discriminated against: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation.
Counter Terrorism and Security Act ([53])
The Counter Terrorism and Security Act ([53]) requires specified authorities to have due regard to the need to prevent people being drawn into terrorism. The government's counter‐terrorism strategy CONTEST outlines four key areas, including PREVENT. PREVENT aims to safeguard and support people vulnerable to radicalization so that they do not become terrorists or support terrorism in the pre‐criminal space. PREVENT works by identifying vulnerabilities that might make people susceptible to being radicalized and ensures appropriate referral to local channel panels, so that a multi‐agency approach can be agreed to support and safeguard vulnerable people (HM Government [133]).
Principles of safeguarding
All nurses will experience times when the behaviour they witness or that has been reported to them raises safeguarding concerns. On these occasions, nurses must adhere to local policies and procedures, which will cover the recognition of abuse and neglect, how to make the individual(s) safe, how to escalate concerns and what to document. Safeguarding concerns may or may not lead to a safeguarding referral (Figure 5.21). It can be helpful for nurses to speak to their manager and their institution's safeguarding team for guidance.
Table 5.23 Responding to safeguarding concerns
Principle | Rationale |
---|---|
Recognition | |
Attend safeguarding training so that the signs of abuse and neglect are recognized across biological, psychological and social domains. | Early recognition of people who are at risk of, or experiencing, abuse or neglect is essential for protection (Care Act [42], C). |
Base your assessment of safeguarding concerns within the legal framework and organizational policies and procedures. Ask your manager and safeguarding team for guidance. | The Care Act ([42]) provides a legal framework for safeguarding adults. C |
Use effective communication skills during safeguarding conversations. | Discussions about safeguarding concerns can be anxiety provoking; thus, nurses need to use their communication skills to establish rapport and carry out a high‐quality assessment. E |
Engage the patient in a person‐centred conversation that enables them to fully express their concerns and needs as well as their wishes and preferences for any outcomes. | You must do everything you can to ensure that the patient is able to engage as fully as possible in the safeguarding processes (LGA 2018, C). |
Consider the patient within their social system and the potential risk (or protective) factors in relation to others, for example children or older adults. | The person at risk does not exist in isolation (LGA 2018, C). |
Do not ask probing or leading questions that may affect the credibility of the evidence. | The nurse's role is not to investigate the situation but to gain sufficient information to ascertain whether the patient is safe or not, and if or how to escalate the safeguarding concern. |
Be open and honest and do not promise to keep a secret. | The nurse's role is to keep people safe, not to keep information (Care Act [42], C). |
Immediate safety | |
When the risk of harm is assessed as high, it may be necessary to quickly implement a safety plan. | To take the necessary steps to avoid harm (Care Act [42], C). |
Link with managers and the safeguarding team for guidance on the development of a safety plan. | Nurses are not expected to work in isolation. Use the resources and support systems available to you (ADASS [2], C). |
Interventions need to be proportionate to the risk identified. | It is important that safeguarding responses are the least restrictive possible and appropriate to the risk(s) identified and their context (Care Act [42], C). |
Identify whether there are reasons to act without the patient's consent – for example, where others are at risk, where there is a need to address a service failure that might affect others, or where there are any concerns for children or young people. | Nurses have a duty to protect individuals and the public and do not need consent to share information in these circumstances (Common‐law duty of confidentiality, Care Act [42], Crime and Disorder Act [54], GDPR 2018, Human Rights Act [137], C). |
If a crime has been committed (e.g. in cases of domestic abuse), the police need to be informed. Note that the police will intervene and they may press charges, but the prosecution may collapse if the person at risk does not want to co‐operate with an investigation. | Nurses need to follow the law (Care Act [42], Female Genital Mutilation Act [101], C). |
Preserve evidence that may be required. This includes securing any patient records and notes to prevent tampering, and considering forensic requirements (e.g. medical examination). | It is important that first responders preserve forensic evidence in situations that may result in criminal or civil charges. E |
Escalation | |
Consider whether it is safe to tell the person that you have safeguarding concerns. | Some patients may feel compelled by a perpetrator of abuse or neglect to share that a safeguarding concern has been raised and this may put them in increased danger. E |
Share information without consent if it is in the vital or public protection interest in order to prevent a crime or protect others from harm (follow your own organization's policy and procedures). |
All healthcare professionals have a duty of care to protect the patient and others who may be at risk (Care Act [42], C). |
It is prudent to discuss with appropriate others (e.g. manager, safeguarding team, external organizations) what information has been elicited and your decision‐making process. | Local authorities have a statutory responsibility for adults in their area (Care Act [42], C). A lack of information sharing is repeatedly found in safeguarding children reviews (Braye and Preston‐Shoot [35], R). |
Make a clear and concise referral so that the person reading the form understands the key issues. | This makes it easy for the person reading the referral to understand what is happening and to consider how to respond. E |
Consider the needs of any other people for whom the patient may have caring responsibilities (e.g. children, older adults). | The person at risk does not exist in isolation (LGA 2018, C). |
Consider mental capacity, best interests decision making and deprivation of liberty safeguards. | If a patient has capacity in relation to safeguarding decision making and they, or others, are not at imminent danger and a crime has not been committed, they have the right for their information not to be shared. If the person is deemed to lack capacity, then best interests decisions must be made (Care Act [42], Mental Capacity Act [176], C). |
If the person is unable to advocate for themselves, ensure that someone else can do this for them, such as the Independent Mental Capacity Advocate. | The Mental Capacity Act makes provision for people to have access to independent advocates to ensure that their interests are met (Mental Capacity Act [176], C). |
Do not delay unnecessarily. | Delays in responsiveness and action may increase a person's danger. E |
Concerns about a colleague should be raised internally through your organization's policies on managing allegations against staff or whistleblowing. | Whistleblowers are given protection under the Public Interest Disclosure Act ([229], C). |
Documentation | |
Make comprehensive, accurate and factual, legible and timely notes in the patient's record; these must include the views and hopes of the adult at risk. Explain the basis of your actions or inaction. | You are accountable for your actions and omissions and must therefore document the rationale behind your decision making (Care Act [42], C). |