| Description | Prevention of abuse towards vulnerable patient population. |
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| ISBN | (Web Only) |
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| Official Print Publication Date | |
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| Website Publication Date | December 10, 1999 |
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Protecting the Vulnerable: Caring Enough?
Guidance for Nurses, Midwives and Health Visitors
1. As a result of concerns raised by the Committee, the Chief Nursing Officer commissioned the National Nursing, Midwifery and Health Visiting Advisory Committee, (NNMHVAC), to consider vulnerable patients with a view to 'establishing guidance for nurses, midwives and health visitors involved in the care of vulnerable patient populations so that the potential for inappropriate attitudes and behaviours is recognised and appropriate action taken.'
2. The Working Group was drawn from the Committee membership and other members were co-opted as appropriate (see Appendix I).
3. Over the past few years, several reviews have been undertaken which have focused on various aspects of vulnerability 1,2,3 . Reports have been published and these have been acknowledged in discussions within the Working Group. A selective review of published and unpublished literature was carried out and a reading list is given in Appendix II.
4. Since the working group was first established, a number of papers have been published including the White Paper Designed to Care4, the White Paper Towards a Healthier Scotland, and the Human Resources Strategy document Towards a New Way of Working6 . This guidance incorporates the principles embodied within those documents.
5. The group has chosen to highlight common themes that could apply in different care areas and throughout the range of age groups, as several reports exist to inform focused debate within individual specialty areas 7,8,9.
6. Whilst vulnerable patient groups are the key focus of this document, it is recognised that nurses are themselves vulnerable to abuse within the workplace and this area should not be overlooked. Issues relating to bullying and harassment have been excluded from this report as these areas have been covered elsewhere 10,11,12.
7. The guidance in this report takes the form of general principles that apply throughout different care areas. It focuses on:
- generating a definition
- identifying potentially vulnerable patient populations
- identifying issues raised as a result of breaches of care
- making recommendations
- stimulating debate and raising awareness.
8. For the purposes of this document, vulnerability is operationally defined as 'the potential risks associated with the physical and mental status of an individual which might reasonably be anticipated irrespective of the context in which care is provided'.
9. Increasingly, vulnerability is being described in terms of potential for exposure to deliberate maltreatment (active) and unintentional or thoughtless acts (passive) 13. There are many risks involved which mean that the potential for a breach of care is always present and is not restricted to specific care contexts.
10. Some indications of abuse have also been given but are not meant to convey the full range of possible warning signs. Equally, some may exist for quite legitimate reasons and are thus only indicators.
Type of Abuse | Definition | Warning Signs |
physical abuse | action or inaction by others which results in discomfort, pain or injury | unexplained or frequent injury |
verbal abuse | verbal comments by others which cause distress | low levels of esteem |
emotional abuse | action or inaction by others which results in mental anguish | changing sleep patterns, loss of appetite, poor social behaviour, fear |
violation of rights | failure to recognise individuality and choice failure to ensure advocacy | denial of involvement in care planning, seeking agreement for care, failure to communicate effectively, delivering or withholding medication |
sexual abuse | coercion or force to take part in a sexual act | injury or distress |
financial abuse | misuse of money, valuables or property | inability to pay bills, sudden withdrawals of money, failure to meet Incapax requirements |
information abuse | failure to adhere to relevant data protection guidance and lack of appropriate information about care | dissatisfaction and /or complaints |
care omission | failure to respond to identified care needs - either your own failure or the recognition of others' failure to meet this duty of care | patients left soiled or other lack of identified care deficient service provision |
11. All people are potentially vulnerable but, by concentrating on those groups considered to be most at risk of abuse and on raising awareness about vulnerability amongst all carers, it is anticipated that all population groups will benefit. Individuals in the following population groups are considered to be at greatest risk. They apply across all care settings, including the home, and are relevant irrespective of age and/or severity.
- people with limited physical mobility
- people with impaired mental function
- people with learning disabilities
- people with impaired communication
- people with reduced levels of consciousness
- people participating in research
- people with a heightened emotional state
- people caring for individuals in any of the above groups.
12. The above categories are not mutually exclusive and it is possible that an individual may belong to more than one grouping, even if only temporarily.
13. A key feature of nursing practice is the close and sometimes continuous relationship with people who are both vulnerable and dependent. Factors such as workload, the emotional aspects of caring and the ability of the patient to communicate, often interrelate in such a way that it becomes difficult for the nurse to manage effectively. Failure to recognise and act on emerging stress factors will, over time, increase vulnerability.
14. It may be assumed that abuse occurs most frequently between patient and carer but any dependent relationship is fragile and carries a degree of vulnerability.
15. The Professional Code of Conduct published by the UKCC 14 underpins all professional practice. In addition various professional bodies, statutory authorities and professional groups have recognised the need to provide advice to staff on issues associated with vulnerability. Several useful documents 15,16,9 have been published, or are being planned, which address specific care areas and/or issues.
16. A number of common themes run through these documents.
Poor policies at local level
Policies may not exist or may require review to ensure that the organisation is meeting minimum standards of human resources and professional policies and procedures.
Lack of awareness of staff
People are often unaware of the issues associated with the vulnerability of patients and professional groups. They may also be unaware of how to conduct risk assessments and/or critical reviews of environment and practice or how to monitor outcomes.
Lack of appropriate education and training
There is a lack of appropriate education and training introduced at the pre-registration stage and developed at post-registration levels. There is a lack of consistency of programmes within education and within organisations where prevention of abuse has not been a priority.
Unsuitability of staff for practice
Poor selection and screening procedures may result in staff being employed who are either unsuitable for practice or who are unsuitable for a specific specialty care area. Early identification and ongoing support of vulnerable staff is related to the provision of occupational health services.
Lack of support or supervision
Inadequate managerial support is identified by staff as a contributory factor which, coupled with poor clinical supervision, will adversely affect patient care.
Cost to the individual and the organisation
The estimation of cost to an individual is measured in terms of the injury and damage caused as well as any financial loss. There may be a cost to any members of staff involved in abuse as well as to the organisation.
Lack of independent advocacy
The absence of a system of independent advocacy has on some occasions led to a violation of individuals' rights.
17. Without an explicit statement of intent manifest in a positive strategy towards the minimisation of the possibility of abuse, organisations will not be able to provide evidence that they have addressed these issues. Each organisation must develop a culture of care that outlaws abuse and ensures positive support and supervision for staff.
18. An audit tool and models for risk management are set out in Appendices III and IV. They are intended to guide those who do not have an established strategy towards positive action.
19 Towards a New Way of Working6 gave a commitment to develop a comprehensive and inclusive Occupational Health and Safety Service (OHSS) for NHS staff. An expert Short Life Working Group was formed and a draft OHSS Strategy prepared. The strategy recognises that staff must be provided with access to an inclusive and comprehensive OHSS service which is fully integrated within an organisation's HR strategies and policies.
20 Organisations should already have policies to reduce accidents and injuries to staff and patients. These policies can only enhance the capacity of staff to work effectively and thus improve patient care. Staff and their representatives will be involved in determining the standard and provision of occupational health and safety at a local level. OHSS strategies will be benchmarked and audited to ensure that employers provide at least the minimum standard of service, encourage the spread of good practice and strive to attain the best standard of service for staff.
21 Some organisations may already have effective systems of risk management which pay attention to the vulnerability of patients in specific services. Staff can learn from such templates although all systems must be regularly reviewed.
22. The principles of clinical governance enhance the opportunity to raise clinical issues at all levels within an organisation and ensure a multi-professional focus to the protection of the vulnerable. Non-compliance with these principles is not acceptable.