Nursing professionals have a distinct contribution to make to the safeguarding of adults. Nurses are required to make patient care their primary concern and ensure that protecting vulnerable adults is an integral part of everyday nursing practice. They need to be aware of adults in their care who could be vulnerable to and at risk of abuse and take all reasonable steps to prevent harm from occurring.
What is safeguarding?
Safeguarding adults is an integral part of patient care. Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. Nurses have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients are required by professional regulators and service regulators and are supported by law.
Safeguarding adults at risk means protecting their right to live in safety and free from abuse and neglect.
- Has needs for care and support.
- Is experiencing, or is at risk of, abuse or neglect.
- 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.
Safeguarding also means that individuals are adequately supported to access care and support where this is needed, so that they are able to stay well and maintain a high quality of life. This is achieved by different organisations working effectively together to prevent and stop both the risk and experience of abuse or neglect. Safeguarding aims to balance the right to be safe with the right of the individual to make informed choices and to have their wellbeing promoted at all times.
Safeguarding adults is shaped by six principles:
- Principle 1 – Empowerment – presumption of person-led decisions and consent
- Principle 2 – Protection – support and representation for those in greatest need
- Principle 3 – Prevention – prevention of harm and abuse is a primary objective
- Principle 4 – Proportionality – proportionality and least intrusive response appropriate to the risk presented
- Principle 5 – Partnerships – local solutions through services working with communities
- Principle 6 – Accountability – accountability and transparency in delivering safeguarding
What risk factors make someone more likely to experience abuse?
Abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health
- Be physically dependent on others
- Have a sensory impairment
- Have a learning disability
- Suffer from drug or alcohol problems
- Have low self-esteem
- Be unable to make their own decisions
- Have a previous history of abuse
- Have negative experiences of disclosing abuse
- Be of increasing age
- Be frail
- Have experienced a lack of access to health and social services or high-quality information
This list is not exhaustive, and other people might also be considered to be adults at risk.
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
These are:
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, or withholding medication, adequate nutrition and heating.
- Discriminatory abuse – including racist, sexist or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.
What adult safeguarding issues do nurses need to be aware of?
Abuse and neglect can take many forms, ranging from exploitation and disrespectful treatment to physical harm. It can be at a low level, and take place over a long time, or it can take place over a short time and be more extreme. It is all abuse.
Organisations and individuals should not be constrained in their view of what constitutes abuse, neglect or harm and should always consider the circumstances on a person-centred basis. Adult safeguarding concerns vary according to the nature of harm, the circumstances it arose and the people concerned.
Nurses often see patients in times of distress and difficulty. It is likely that you may come into contact with someone who is at risk or suffering from abuse or neglect. The abuse or neglect can be deliberate, or the result of ignorance or a lack of proper training. Recognising abuse or neglect is crucial.
It may:
- Be a single act or repeated acts.
- Cause harm temporarily or over a period of time.
- Occur when a person is persuaded to enter into a transaction to which they have not consented to, or cannot consent to.
- Be an act of neglect or an omission to act.
- Occur through deliberate targeting/grooming.
- Occur in any relationship.
- Be perpetrated by an individual or as part of a group/organisation.
- Be the result of deliberate intent, or be unintentional, through negligence or ignorance.
- Involve several abusive acts which are crimes, and informing the police must be a key consideration.
Who may abuse or neglect? In short, anyone.
This may include but is not limited to:
- Spouses/partners
- Other family members
- A relative or unpaid carer
- Neighbours, friends
- Paid staff including professionals such as nurses
- Volunteers
- Another adult at risk
- People who deliberately exploit adults they perceive as vulnerable to abuse
- Children
- Strangers, that is members of the public not known to the abused
The roles and responsibilities of a nurse in regard to safeguarding adults
All nursing staff will have an individual responsibility to safeguard people; to identify and respond to allegations of abuse and neglect. Health services have a duty to safeguard all patients, but provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding adults covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is a concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A nurse’s role in adult safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
Nurses have a duty to make sure that:
- Safeguarding concerns are dealt with promptly and appropriately and are reported in a secure and responsible way to all relevant agencies.
- Steps are taken to escalate or alert those able to protect patients and/or other adults at risk from harm and minimise the risk of abuse.
- Appropriate and proportionate measures are in place to protect from harm all those who work for, or with them, or come into contact with them.
Nursing practitioners may find it difficult to accept the patient’s choices such as declining services or acting against advice about how to manage their safety. They may be concerned that they are failing in their duty of care and that they could be found to be reckless or negligent. A duty of care is a requirement placed on an individual to exercise a reasonable standard of care while undertaking activities or omissions that could foreseeably harm others. However, duty of care also includes respecting the person’s wishes and protecting and respecting their rights.
The adult safeguarding issues nurses may come across
Understanding what abuse and neglect might look like and how to recognise warning signs is an important aspect of safeguarding.
Some examples nurses might encounter may include, but are not limited to:
- A nurse in an Accident and Emergency department identifies that a patient is developing a pattern of repeat attendance and triggers a further assessment to determine if the person is in need of additional support.
- The admission assessment of a person with advanced dementia shows signs of self-neglect and flags the need for additional support in eating and drinking.
- A series of complaints or comments from patients about staff attitudes on the wards.
- Family members who can convincingly persuade staff that they have authority over a patient’s affairs and yet no evidence is produced to that effect.
- Self-harming – there are lots of different forms of self-harming including, for example, a patient not eating, over-eating, or forcing themselves to throw up.
- A colleague not complying with procedures to meet safeguarding needs.
- Issues to do with the health of a colleague, which may affect their ability to practise safely.
- Bullying – this is behaviour, usually repeated over time, that intentionally hurts another individual or group, physically or emotionally. Bullying differs from banter because there is a deliberate intention to hurt or humiliate. There is usually a power imbalance that makes it hard for the victim to defend themselves. It may happen between staff and patients, or colleagues, or colleagues and managers.
- Danger or risk to health and safety, such as where health and safety rules or guidelines have been broken.
- Issues to do with care in general, such as concerns over resources, products, people, staffing or the organisation as a whole.
You don’t need to have all the facts to prove your concern, but you must have a reasonable belief that wrongdoing is either happening now, took place in the past, or is likely to happen in the future.
Where should nurses go with an adult safeguarding concern?
Some concerns may be minor in nature but provide an opportunity for early intervention, for example, advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
Immediate concerns about abuse or neglect should be dealt with under local safeguarding procedures first. The person who raises a safeguarding concern within their own organisation should follow their organisation’s policy and procedures. This concern may result from something that you have seen, been told or heard.
As a nurse, you have a professional duty to report any concerns from your workplace which put the safety of the people in your care or the public at risk. Normally you will be able to raise your concern directly with the person concerned or your line manager and, in many instances, the matter will be easily dealt with. However, there may be times when this approach fails and you need to raise your concern through a more formal process.
Where possible, you should follow your employer’s policy on raising concerns or whistleblowing. This should provide advice on how to raise your concern and give details of a designated safeguarding lead who has responsibility for dealing with concerns in your organisation.
All NHS services are required to have a Safeguarding Adult Lead as part of their organisational structure. Hospitals and community services are additionally required to appoint a Named Doctor, a Named Nurse or a Named Midwife (Senior Nurse/Senior Midwife) where those services are provided, to take the professional lead on all safeguarding matters. The designated safeguarding lead will normally be someone who has been given special responsibility and training in dealing with employees’ concerns.
The role includes:
- Making sure appropriate systems for raising concerns are in place and that all staff can access them.
- Making sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded.
- Investigating concerns promptly and including a full and objective assessment.
- Taking action to deal with the concern and, recording and monitoring this action.
- Keeping the employee who raised the concern up to date with what is happening.
- Having processes in place to support employees raising concerns.
- Having a role in highlighting learning and perhaps facilitating or being part of learning events.
If you witness or suspect that there is a risk of immediate harm to a person in your care, you must act straight away to protect their safety. You should report your concerns to the appropriate person or authority immediately; this may be the police in some situations. Involvement of police is indicated in incidents of suspected theft, common assault, including sexual assault, and assault causing actual bodily harm. However, police may also be involved in other patient safety incidents such as wilful neglect for a person lacking capacity.
You should also keep an accurate record of your concerns and actions that you have taken, and you should always inform the designated safeguarding lead of your actions.
If you have raised your concern internally but feel it hasn’t been dealt with properly, or if you feel unable to raise your concern at any level in your organisation, you may want to get help from outside your place of work. You can raise your concerns through the NHS Whistleblowing Helpline 08000 724 725. The Nursing and Midwifery Council have a page on their website dedicated to whistleblowing.
Speaking up on behalf of people in your care is an everyday part of your role. Just as raising genuine concerns represents good practice, doing nothing and failing to report concerns is unacceptable. Failure to report concerns may bring your fitness to practise into question and put your registration at risk.
What legislation do nurses have to follow in regard to adult safeguarding?
The Care Act 2014 sets out statutory responsibility for the integration of care and support between health and local authorities. NHS England and Clinical Commissioning Groups are working in partnership with local and neighbouring social care services. Local authorities have statutory responsibility for safeguarding, and in partnership with health they have a duty to promote wellbeing within local communities.
Safeguarding Vulnerable Groups Act 2006 and the Protection of Freedoms Bill – this Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the Disclosure and Barring Service (DBS).
The Equality Act 2010 – this Act aims to protect people or groups of people who have one or more “protected characteristics”. These protected characteristics are features of people’s lives upon which discrimination, in the UK, is now illegal.
The protected characteristics listed in the Act are:
- Age
- Disability
- Sexual orientation
- Sex
- Gender reassignment
- Marriage and civil partnership
- Pregnancy and maternity
- Race
- Religion and belief
Under the Act:
- Every individual has the right to be treated equally and fairly and not be discriminated against regardless of any “protected characteristics”.
- Every individual has the right to be treated with respect and dignity.
- Health services have a duty to ensure that services are fair and meet the needs of everyone, regardless of their background or current circumstances.
Sexual Offences Act 2003 – this Act modernised the law by prohibiting any sexual activity between a care worker and a person with a mental disorder while the relationship of care continues. A relationship of care exists where one person has a mental disorder and another person provides care.
It applies to people working both on a paid and an unpaid basis and includes:
- Doctors
- Nurses
- Care workers in homes
- Workers providing services in clinics or hospitals
- Volunteers
The Mental Capacity Act 2005 – in order to protect those who lack capacity and to enable them to take part as much as possible in decisions that affect them, the following statutory principles apply:
- You must always assume a person has capacity unless it is proved otherwise.
- You must take all practicable steps to enable people to make their own decisions.
- You must not assume incapacity simply because someone makes an unwise decision.
- Always act, or decide, for a person without capacity in their best interests.
- Carefully consider actions to ensure the least restrictive option is taken.
The Deprivation of Liberty Safeguards 2009 (DoLS), an amendment to the Mental Capacity Act 2005, provide a legal framework to protect those who lack the capacity to consent to the arrangements for their treatment or care, for example by reason of their dementia, learning disability or brain injury, and where levels of restriction or restraint used in delivering that care for the purpose of protection from risk/harm are so extensive as to potentially be depriving the person of their liberty.
The Public Interest Disclosure Act 1998 – this Act, often referred to as the Whistleblowers Act, encourages staff to report suspected wrongdoing and protects those that do against being dismissed or suffering a detriment by their employers. It also gives protection to employees against suffering a detriment or retaliation from another employee for reporting suspected wrongdoing.
Voyeurism (Offences) Act 2019 – this Act criminalises the act of “upskirting”. The Criminal Prosecution Service (CPS) defines “upskirting” as a colloquial term referring to the action of placing equipment, such as a camera or mobile phone, beneath a person’s clothing to take a voyeuristic photograph without their permission.
The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 introduced new elements to the data protection regime, superseding the Data Protection Act 1998. Practitioners must have due regard to the relevant data protection principles which allow them to share personal information. However, the GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping vulnerable adults safe.
PREVENT, section 26 of the Counter-Terrorism and Security Act 2015 – this is part of the Government’s counter-terrorism strategy. Its aim is to stop people from becoming terrorists or supporting terrorism. The strategy promotes collaboration and co-operation among public service organisations. Healthcare professionals have a key role in Prevent. Prevent focuses on working with vulnerable individuals who may be at risk of being exploited by radicalisers and subsequently drawn into terrorist-related activity. Prevent does not require you to do anything in addition to your normal duties. What is important is that if you are concerned that a vulnerable individual is being exploited in this way, you can raise these concerns in accordance with your organisation’s policies and procedures, as you would do with any safeguarding issue.
Why is safeguarding training important?
It is important that we all understand safeguarding, and know what to do should safeguarding concerns arise.
Safeguarding induction and training is essential for all staff appropriate to their role, including:
- Information on types of harm, abuse and neglect
- How to spot abuse
- How to respond to concerns
- Who to report concerns to
Training should be directly applicable to the responsibilities and daily practices of the person being trained, and to the care and support needs of the patients that they are working with. An example of appropriate safeguarding training includes Safeguarding Vulnerable Adults (SOVA) Level 2, designed for people who are working with vulnerable adults and teaches the skills needed to safeguard people that are at higher risk of abuse.
Managers should evaluate changes in understanding and confidence before and after training, assessing this:
- Immediately after the training
- In regular long-term evaluations, for example as part of supervision sessions
- Annually, for example as part of the performance management/appraisal process
Line managers should provide feedback through supervision and appraisals, acknowledging how nursing staff have learned from their experience of identifying, reporting and managing safeguarding concerns.
How often should nurses renew their safeguarding training?
Managers should assess nursing staff safeguarding knowledge annually, and run refresher training if needed. To help nursing staff increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every two years and participate in continuing professional development (CPD).
