In this article
Community nursing, which is sometimes referred to as district nursing, plays a crucial role in the primary health care team. Community nurses visit people in their own homes or in residential care homes, providing care for patients and supporting family members. Community nurses also play a vital role in keeping hospital admissions and readmissions to a minimum and ensuring that patients can return to their own homes as soon as possible. When visiting patients in their own homes community nurses will meet all members of the family, adults and children. They are required to make patient care their primary concern and ensure that protecting vulnerable adults and children is an integral part of everyday nursing practice.
What is safeguarding?
Working in the community nursing setting by its very nature will involve working with vulnerable people. Safeguarding adults and children is an integral part of patient care. Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. Community nurses have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients and others 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.
Adults at risk means anyone aged 18 or over who:
- 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.
Child safeguarding applies to all children up to the age of 18 years whether living with their families, in state care, or living independently.
Safeguarding children is defined in Working Together to Safeguard Children as “protecting children from maltreatment; preventing impairment of children’s health or development; ensuring that children are growing up in circumstances consistent with the provision of safe and effective care.”
Child safeguarding is a set of actions that can be taken to encourage children’s welfare and protect them from harm.
- Preventing children’s health and development from being damaged.
- Making sure that children are safe and well cared for as they grow up.
- Doing things to make sure that children have the best outcomes.
- Protecting children from abuse and harm.
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 who 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?
There is no way to know which children are most vulnerable to abuse, but there are some factors for abuse and neglect risk to be aware of including, but not limited to:
- Very young children.
- Children with disabilities and health problems.
- Children who have already been, or who are currently being, abused and/or neglected.
- Parents who are young when their child is born.
- Parents who are poorly informed about parenting.
- Parents with mental health issues, especially untreated issues, for example depression, antisocial personality disorder, substance abuse and related disorders.
- Single parent households.
- Intimate-partner violence.
- Parents experiencing emotional and/or financial stress.
- Poverty, poor housing and deprivation.
- Social isolation.
- Violence in the community.
Adult 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 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.
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- 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 safeguarding issues do community 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.
Community nurses 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 and children’s safeguarding concerns vary according to the nature of harm, the circumstances it arose in and the people concerned.
Community nurses often see patients and their families at 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, and 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, be unintentional, through negligence or ignorance.
- Several abusive acts which are crimes, and informing the police must be a key consideration.
The roles and responsibilities of a community nurse in regard to safeguarding
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 also to provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A community nurse’s role in 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.
Community nurses have a duty to make sure that:
- Safeguarding concerns are dealt with promptly, appropriately and 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 them, or with them, or come into contact with them.
Community nurses 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 community 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 considerable amount of community nursing safeguarding work in people’s homes or care homes relates to the domestic abuse of people with care and support needs. There is a good deal of overlap between safeguarding and domestic abuse procedures.
- Family members who can convincingly persuade community nurses that they have authority over a patient’s affairs and yet no evidence is produced to that effect.
- A child presents with bruising which looks like it has been caused by fingers, a hand, or an object, or burns which have a clear shape, like a circular cigarette burn. Head injuries caused by a blow or by shaking.
- Presentation doesn’t fit the explanation provided.
- Living in very unclean, sometimes verminous, or harmful conditions.
- Obsessive hoarding.
- Refusing to allow access to community nurses in relation to personal hygiene and care.
- Poor personal hygiene, poor healing/sores, long toenails.
- Declining or refusing prescribed medication and/or other community healthcare support.
Where should community 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 community 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 Adults and 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.
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 the police is indicated in incidents of suspected theft and common assault, including sexual assault, and assault causing actual bodily harm. However, the 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 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.
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 community 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.
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:
- Care workers in homes
- Workers providing services in clinics or hospitals
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.
The following legislation is also relevant to community nurses in safeguarding children and vulnerable adults, but is not limited to:
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. You may need to pass on information without the consent of the family if you think it is necessary to protect the child.
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.
The Equality Act 2010 – this Act aims to protect people or groups of people who have one or more “protected characteristics”.
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 community nurses 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 individuals 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 who are at higher risk of abuse. Safeguarding Vulnerable Adults (SOVA) Level 3 is designed for people who are wanting more in-depth knowledge into safeguarding vulnerable adults.
Safeguarding Children Level 2 is designed for people who are working with children and teaches the skills needed to safeguard children who are at higher risk of abuse and is recommended for community nurses who have regular contact with families and children as part of their role.
Other training that is recommended to provide the skills and knowledge for effective safeguarding include, but are not limited to:
- Domestic Violence Awareness
- Substance Misuse Awareness
- FGM Awareness
- Modern Slavery Awareness
- Mental Health Awareness
- Drugs and Alcohol Awareness
- Self-Harming Awareness
Managers should evaluate changes in understanding and confidence of community nurses 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.
Managers should provide feedback through supervision and appraisals, acknowledging how the community nurses have learned from their experience of identifying, reporting and managing safeguarding concerns.
How often should community nurses renew their safeguarding training?
Managers should assess community nursing staff safeguarding knowledge annually, and run refresher training if needed. To help community nurses 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).