In this article
All nurses who are in contact with children and young people have a responsibility to safeguard and promote their welfare and should know what to do if they have concerns about safeguarding / child protection issues. A child-centred approach is fundamental to safeguarding and promoting the welfare of every child. A child-centred approach means keeping the child the main focus when making decisions about their lives and working in partnership with them and their families.
What is safeguarding?
Safeguarding children is a duty of all health professionals, no matter where they work – it is an integral part of patient care. Children’s nurses are a crucial part of the multi-agency safeguarding systems in place to protect children and young people.
A child means anyone aged under 18 years, or under 25 years if they have special educational needs or disability (SEND).
Safeguarding children and young people’s welfare are defined in ‘Working Together to Safeguard Children’ as:
- Protecting children from maltreatment.
- Preventing impairment of children’s health or development.
- Ensuring that children grow up in circumstances consistent with the provision of safe and effective care.
- Taking action to enable all children to have the best outcomes.
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 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 risks 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.
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if an adult or young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
What risk factors make someone more likely to experience abuse?
Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect including, but not limited to:
An adult at risk of abuse may:
- Very young children.
- Children with disabilities and health problems.
- Socioeconomic factors such as poverty, poor housing and deprivation.
- Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation.
- The parent or carer does not engage with services.
- There have been one or more previous episodes of child abuse or neglect.
- The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
- There is chronic parental stress.
- The parent or carer experienced abuse or neglect as a child.
- A family history of maltreatment.
- Being in care, a looked-after child.
- A history of offending, either parent or child.
These lists are not exhaustive, and other people might also be considered to be children at risk.
The types of abuse children can encounter
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this 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 penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, 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 or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment.
– Protect a child/young person from physical and emotional harm or danger.
– Ensure adequate supervision, including the use of inadequate caregivers.
– Ensure access to appropriate medical care or treatment also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs.
What safeguarding issues do children’s nurses need to be aware of?
Abuse may be deliberate or as a result of lack of attention or thought, and may involve combinations of all or any of the above forms. It may be regular or on an occasional or single event basis; however, it will result in some degree of suffering to the child concerned.
Indications might include, but are not limited to:
- Physical signs such as hand-slap marks, bruising in unusual areas, bruised eyes and bite marks.
- The story provided by the adult might be inconsistent with any injuries.
- Poor physical care and inadequate hygiene, inappropriate dress.
- Failure to seek appropriate healthcare, repeated missed appointments/cancellations and failed access visits.
- Deliberate self-harm and/or drugs and alcohol misuse.
- Talking about being left home alone, with inappropriate carers or with strangers.
- Concerned for younger siblings without explaining why.
- Physical sexual health problems, including soreness in the genital and anal areas, sexually transmitted infections or underage pregnancy.
- Parents not seeking or delaying medical treatment when their children are ill or are injured.
The roles and responsibilities of a children’s nurse in regard to safeguarding
Safeguarding children and young people is every nurse’s responsibility and all nursing staff will have an individual responsibility to safeguard people, to identify and respond to allegations of abuse and neglect. Children’s nurses should act as effective advocates for the child or young person, proactively seeking the child’s views but also considering how to balance children’s rights and wishes with a professional responsibility to keep children safe from harm.
Health services have a duty to safeguard all patients, but to also provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding children 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 child 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 children 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, with, or come into contact with children.
People aged 16 or over are entitled to consent to their own treatment. Children under the age of 16 can consent to their own treatment if they are believed to have enough intelligence, competence and understanding to fully appreciate what is involved in their treatment. This is known as being Gillick competent. Children’s 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 safeguarding issues children’s 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 children’s nurses might encounter may include, but are not limited to:
- A child presents with bruising on the cheeks, ears, palms, arms and feet and on the back, buttocks, tummy, hips and backs of legs; multiple bruises in clusters, usually on the upper arms or outer thighs; or bruises which look like they have been caused by fingers, a hand, or an object. Burns of the backs of the hands, feet, legs, genitals, or buttocks and burns which have a clear shape, like a circular cigarette burn. Head injuries caused by a blow or by shaking.
- A child’s behaviour may indicate that they have been abused. The child may show fear of adults or a fear of certain adults when they approach them, or display aggressive behaviour, or be excessively withdrawn, fearful, or anxious about doing something wrong.
- The child may have repeatedly attended a healthcare setting with different types of injuries in a short period of time or presented in a variety of healthcare settings.
- Not wanting to change clothes in front of others or reluctance to undress for medical examination.
- Shying away from being touched or flinching at sudden movements.
- A child who presents with pain, discoloration, bleeding or discharges in genitals, anus or mouth or persistent or recurring pain during urination and bowel movements.
- An adult abandoning a child in a healthcare setting or claiming not to know a child they were previously with might be a sign an adult is involved in child trafficking.
- A girl who’s had FGM may have difficulty walking, sitting or standing and may spend longer than normal in the bathroom or toilet, and may be particularly reluctant to undergo normal medical examinations.
- A child presenting with a fabricated or induced illness.
Where should children’s nurses go with a 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 children 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 Children 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 record and monitor 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 may facilitate or be part of learning events.
If you witness or suspect that there is a risk of immediate harm to a child 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 the police is indicated in incidents of suspected theft and 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 of a child.
You should also keep an accurate record of your concerns and action 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, www.nmc.org.uk/whistleblowing.
Speaking up on behalf of the 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. Children’s nurses should not let other considerations, such as the fear of damaging relationships with adults such as parents or carers, get in the way of protecting children from abuse and neglect. If you think that referral to children’s social care is necessary, you should view it as the beginning of a process of inquiry, not as an accusation.
What legislation do children’s nurses have to follow in regard to safeguarding?
In the UK, people working in children’s health services have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions.
Working Together to Safeguard Children 2010 – the way that agencies and organisations should work together to carry out their duties and responsibilities under the 1989 Children Act and other legislation is set out in a document called ‘Working Together to Safeguard Children’.
It sets out the responsibilities of all agencies in the protection of children, and is aimed at staff in organisations that are responsible for commissioning or providing services to:
- Children, young people and adults who are parents/carers.
- Organisations that have a particular responsibility for safeguarding and promoting the welfare of children and young people.
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. 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).
GDPR and information sharing – all child healthcare professionals and agencies have a responsibility to inform child social care and to share information with other agencies if they are concerned that a child is in need or at risk of harm. Good practice shows that they should always discuss this with the parents/carers and the child, if they have sufficient understanding. However, if you are concerned that this could increase the risk to the child, you should share their information and get advice from child social care services. You may need to pass on information without the consent of the family if you think it is necessary to protect the child.
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.
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 Children Level 2, designed for people who are working with children and teaches the skills needed to safeguard children who 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 2 years and participate in continuing professional development (CPD).