NIHR DC Discover

NIHR Signal Nurses lack confidence in escalating or identifying children at risk of abuse and neglect

Published on 6 December 2016

doi: 10.3310/signal-000339

On the face of it, nurses are well placed to safeguard children, but asking them about their experiences reveals barriers which hinder that role. The research points towards areas where support could help nurses fulfil their legal and ethical duties better.

In a review of published qualitative research, including surveys, interviews and focus groups, nurses say they have insufficient confidence to report child abuse issues. They often feel a need to convince other professionals, viewed as above them in the hierarchy, before taking action. Some see child protection services as unhelpful; lacking faith that they will take appropriate safeguarding action. There is also a tension between being seen as caring, compassionate and trustworthy, and watching for abuse and neglect in vulnerable families.

Current training is not enough to equip nurses with the necessary skills to confidently and effectively safeguard children. Instead, education could be tailored to specific situations.

These findings were based on international studies where child protection policies and services and the training and expectations of nurses differ. Therefore, they may not all be completely relevant to the UK context. Many were small studies, but the review raises useful questions for those responsible for nurse training and professional standards.

Share your views on the research.

Why was this study needed?

The National Society for the Prevention of Cruelty to Children (NSPCC) 2016 estimates that over half a million children are abused in the UK each year. As nurses are in frequent contact with children and families, they are well placed to identify children and young people at risk. Part of their duty of care is to act to safeguard their welfare.

However, this can be challenging despite training and education. Serious case reviews, such as those published by the NSPCC, often cite missed opportunities by medical staff, social workers and police. This review brought together the findings from different study approaches to explore nurses’ experiences and identify barriers to their role in keeping children safe.

What did this study do?

This integrative review drew on 60 international studies of nurses’ experience. They included case studies, focus groups, surveys and interviews, looking at nurses’ subjective experiences, perspectives, attitudes and knowledge.

To find reports, the authors searched five databases and grey literature. Most studies were conducted in developed counties. Over two thirds included exclusively nurses as the professional group. The studies covered a range of settings including home visits, community health centres, hospitals and adult mental health services.

Most studies were small, with under 20 participants, though some surveys included up to 930 nurses. Only 11 studies were from the UK, so as the training, policy and health service context may differ, limiting applicability of the findings to the UK.

What did it find?

  • The review identified three themes: nurses’ insufficient knowledge, need for validation of concerns and improved communication with other professionals, and balancing the conflict between monitoring and supporting vulnerable families.
  • Although, based on 7 studies, 49-86% of nurses had received some training, in 44 out of 60 studies, nurses reported a lack of knowledge and confidence to effectively respond to child abuse and neglect.
  • Because of this perception, nurses relied on other health professionals, particularly doctors, to guide them in responding to suspicions of child abuse or neglect.
  • Responses of colleagues - particularly those viewed above them in the professional hierarchy - and child protection services, regularly dissatisfied nurses.
  • Nurses were often left out of communication about the help provided for the family under concern and for the outcomes for the child.
  • There was a fundamental conflict between nurses’ engagement with families to provide healthcare, and the potential need to report abuse within those families.

What does current guidance say on this issue?

In the UK, people working in 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.

To help meet this duty, Department of Health 2015 guidance recommends all staff working in healthcare settings - including those predominantly treating adults - receive training to ensure they attain the competencies appropriate to their role and follow the relevant professional guidance.

The Royal College of Nursing 2014 advises nurses to document safeguarding or child protection concerns in order to inform relevant staff and agencies and differentiate between fact and opinion. Where appropriate, information could be shared with other teams.

Policies and services for child protection vary globally, for example reporting concerns is mandatory in Australia the US and Canada.

What are the implications?

Most nurses were aware of their obligation to report child abuse and neglect. However, many faced barriers to safeguarding children and generally ‘training’ appeared not to be enough to provide sufficient confidence and knowledge to report issues.

Nurses of any kind can encounter children suspected to be at risk of abuse, from emergency nurses to practice nurses, as well as those working directly with children (such as health visitors).

To overcome the barriers, educational programmes for nurses could be better tailored, recognising the complexity of clinical judgement, knowledge and workplace relationships with regards to safeguarding.

Citation and Funding

Lines L E, Hutton A, Grant J. Integrative review: nurses’ roles and experiences in keeping children safe. Journal of Advanced Nursing. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

Charity Commission. Policy Paper. Safeguarding children and young people. HM Government; 2014.

Compendium: Homicide. Victims aged under 16 years. Newport: Office for National Statistics; 2016.

HM Government. Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government; 2015.

Royal College of Nursing. Safeguarding children and young people- every nurse’s responsibility: RCN guidance for nursing staff. Royal College of Nursing; 2014.

 

Why was this study needed?

The National Society for the Prevention of Cruelty to Children (NSPCC) 2016 estimates that over half a million children are abused in the UK each year. As nurses are in frequent contact with children and families, they are well placed to identify children and young people at risk. Part of their duty of care is to act to safeguard their welfare.

However, this can be challenging despite training and education. Serious case reviews, such as those published by the NSPCC, often cite missed opportunities by medical staff, social workers and police. This review brought together the findings from different study approaches to explore nurses’ experiences and identify barriers to their role in keeping children safe.

What did this study do?

This integrative review drew on 60 international studies of nurses’ experience. They included case studies, focus groups, surveys and interviews, looking at nurses’ subjective experiences, perspectives, attitudes and knowledge.

To find reports, the authors searched five databases and grey literature. Most studies were conducted in developed counties. Over two thirds included exclusively nurses as the professional group. The studies covered a range of settings including home visits, community health centres, hospitals and adult mental health services.

Most studies were small, with under 20 participants, though some surveys included up to 930 nurses. Only 11 studies were from the UK, so as the training, policy and health service context may differ, limiting applicability of the findings to the UK.

What did it find?

  • The review identified three themes: nurses’ insufficient knowledge, need for validation of concerns and improved communication with other professionals, and balancing the conflict between monitoring and supporting vulnerable families.
  • Although, based on 7 studies, 49-86% of nurses had received some training, in 44 out of 60 studies, nurses reported a lack of knowledge and confidence to effectively respond to child abuse and neglect.
  • Because of this perception, nurses relied on other health professionals, particularly doctors, to guide them in responding to suspicions of child abuse or neglect.
  • Responses of colleagues - particularly those viewed above them in the professional hierarchy - and child protection services, regularly dissatisfied nurses.
  • Nurses were often left out of communication about the help provided for the family under concern and for the outcomes for the child.
  • There was a fundamental conflict between nurses’ engagement with families to provide healthcare, and the potential need to report abuse within those families.

What does current guidance say on this issue?

In the UK, people working in 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.

To help meet this duty, Department of Health 2015 guidance recommends all staff working in healthcare settings - including those predominantly treating adults - receive training to ensure they attain the competencies appropriate to their role and follow the relevant professional guidance.

The Royal College of Nursing 2014 advises nurses to document safeguarding or child protection concerns in order to inform relevant staff and agencies and differentiate between fact and opinion. Where appropriate, information could be shared with other teams.

Policies and services for child protection vary globally, for example reporting concerns is mandatory in Australia the US and Canada.

What are the implications?

Most nurses were aware of their obligation to report child abuse and neglect. However, many faced barriers to safeguarding children and generally ‘training’ appeared not to be enough to provide sufficient confidence and knowledge to report issues.

Nurses of any kind can encounter children suspected to be at risk of abuse, from emergency nurses to practice nurses, as well as those working directly with children (such as health visitors).

To overcome the barriers, educational programmes for nurses could be better tailored, recognising the complexity of clinical judgement, knowledge and workplace relationships with regards to safeguarding.

Citation and Funding

Lines L E, Hutton A, Grant J. Integrative review: nurses’ roles and experiences in keeping children safe. Journal of Advanced Nursing. 2016. [Epub ahead of print].

No funding information was provided for this study.

Bibliography

Charity Commission. Policy Paper. Safeguarding children and young people. HM Government; 2014.

Compendium: Homicide. Victims aged under 16 years. Newport: Office for National Statistics; 2016.

HM Government. Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. HM Government; 2015.

Royal College of Nursing. Safeguarding children and young people- every nurse’s responsibility: RCN guidance for nursing staff. Royal College of Nursing; 2014.

 

Integrative review: nurses' roles and experiences in keeping children safe

Published on 11 August 2016

Lines, L. E.,Hutton, A.,Grant, J.

J Adv Nurs , 2016

AIM: To identify nurses' role and experiences of keeping children safe. BACKGROUND: Approaches to preventing, identifying and responding to child abuse and neglect have moved towards a multidisciplinary approach where all professionals are expected to contribute to the goal of keeping children safe. Frequently in contact with children and families, nurses well positioned to contribute to keeping children safe from abuse and neglect. Much has been published around nurses' experiences of their role in keeping children safe but this literature has not yet been synthesised to determine the challenges and potential scope of this role. DESIGN: Integrative review following an Integrative Review framework. DATA SOURCES: Studies were identified through a search of the electronic databases CINAHL, Medline, Web of Science, Scopus and Informit to identify literature published between 2005 - 2015. REVIEW METHODS: All the studies were critically appraised for methodological quality using the Critical Skills Appraisal Programme. Data from each study was extracted and categorised according to the review aims and the study's major findings. RESULTS: Inclusion criteria were met in 60 studies. Three main findings were identified including nurses' insufficient knowledge, need for validation and improved communication and balancing surveillance and support for vulnerable families. CONCLUSIONS: Nurses have many roles and experiences in keeping children safe but often felt they did not have the knowledge, skills and support to take action in this area. Further research is needed to understand why nurses feel inadequate and disempowered to advocate and intervene on the behalf of children at risk of abuse or neglect. This article is protected by copyright. All rights reserved.

According to a Charity Commission policy paper published in 2014,

“Safeguarding is a term which is broader than ‘child protection’ and relates to the action taken to promote the welfare of children and protect them from harm. Safeguarding is everyone’s responsibility. Safeguarding is defined in Working together to safeguard children 2013 as:

  • protecting children from maltreatment
  • preventing impairment of children’s health and development
  • ensuring that children grow up in circumstances consistent with the provision of safe and effective care and
  • taking action to enable all children to have the best outcomes”

Expert commentary

The responsibility of keeping children safe should be the responsibility of all health care professionals. Nurses, as the patients advocate, are well placed for ensuring that safeguarding policies and practices are understood, implemented and followed. Key to this is education that translates principles into practice; understandable policies with key messages; easy to follow processes, including escalation. There have been too many instances where a lack of knowledge, policy or action has adversely affected a child’s life; nurses have a professional, moral and statutory responsibility to ensure that they understand their role and that the actions they take safeguard the child.

Angela Thompson, Improvement Director (Nursing), NHS Improvement