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Community Based Nurses and Midwives
The deployment of nurses, health visitors and midwives working in the community differs significantly from that of their colleagues working in hospital. In the community setting the relationship between numerous agencies, general medical practice, social services, education, police and voluntary agencies, and the professional relationship of the nurse with her clients and their families have to be considered. Child protection work is an essential part of their duties. The senior nurse in child protection is an expert resource available to all practitioners.
Health visitors and school nurses working with the "well" population monitoring child health, growth and development have a unique role to play in the promotion of children's health and the protection of children from harm. Where opinions of teaching staff and school nurses conflict, the school nurse is accountable for making a referral. Practice nurses who see children should be aware of child protection issues and be alert to signs or symptoms which might give rise for concern. Community children's nurses caring for sick children in their own homes are also well placed to identify the child at risk of significant harm. All nurses working with children in the community should be aware of children who are "in need" and of children on the child protection register. All nurses should receive training, clinical supervision and updating in child protection to equip them with the additional knowledge and skills to protect children, to meet the needs of children and their families, to prevent abuse occurring and to be aware that the interests of the child are paramount.
The nurse, health visitor or midwife involved with a family where there are child protection concerns should ensure as a priority that she attends Child Protection Case Conferences, case reviews and planning meetings. Should she be unable to attend, she should submit a written report, arrange for a colleague to attend and ensure receipt of the minutes. The time taken for these activities should be recognised.
There should be reliable systems for hand-over from midwife to health visitor, and health visitors to school nurse.
District nurses, communitypsychiatric nurses, learning disability nurses, nursery nurses, therapists, nurses working in child development centres and other clinical settings in the community all meet with children in the course of their duties. The practitioner may become concerned about the well being of the child, or receive information of concern about the care of the child. For these reasons there must be clear NHS Trust guidelines about the action to be taken if there is a suspicion that the child is at risk of significant harm. These guidelines must include advice about contact with statutory agencies especially during unsocial hours.
Nurses, health visitors and midwives are responsible for ensuring that the key activities are carried out to enable the individual to practice in accordance with the UKCCguidance and to be accountable for their practice.
A review of the Nurses' Contribution to Public Health in Scotland is being undertaken in 1999, to better understand the contribution that nurses, midwives and health visitors can and should make to improving public health in Scotland. It will focus initially on the role of the health visitor, the school nurse and the practice nurse. This work is being commissioned by the Chief Nursing Officer and funded by the Chief Scientist Office of The Scottish Executive.
Health Visitors
The health visitor's role is unique because she offers a universal service to all young children and their families. Parents recognise the public health and health education role of health visitors and respond to her input into family life. Her work is largely with the "well" population with visits to families in their homes being made over a period of time. She is concerned with the family as a whole as well as the individual within it. She is trained to recognise deviation from normal in both health and relationship terms, and is ideally placed to recognise the need for and initiate action at an early stage.
The health visitor is also well placed to recognise early signs of parenting difficulties or poor attachment that will require support to enhance parenting skills. Her unique role offers her the opportunity to monitor the health of children and through regular contact, to assess growth and physical and emotional and social development. Her role in detecting post-natal depression and referring for treatment, may be crucial to the bonding and development of the baby. (National Commission of Inquiry into the Prevention of Child Abuse 1996).
Health visitors play an important role in Child Protection specifically in the identification and referral to the statutory agencies of children at risk or suffering abuse. Because of their frequent contact with children and families and their specialist training and expertise in preventive health care, they have a key role in supporting vulnerable families and children, helping parents care adequately for their child, and ensuring that everything possible is done to avert situations where a child might come to harm.
The role of the health visitor in protecting children in the community is to observe, assess, record, refer and support. It is not his or her responsibility to investigate child abuse. S/he should be vigilant to the possibility of abuse, and familiar with the procedures for making referrals to the appropriate statutory authorities. This will mean assisting in the prevention of abuse and neglect, the identification and assessment of children causing concern, and the referral for investigation of children who are at risk of or are subject to abuse or neglect.
The health visitor often continues this work when other statutory agencies have formally withdrawn, and he or she provides ongoing support for these families. His or her approach to the family should be one of partnership and long-term support.
School Nurses
Identification
School nurses may identify child abuse and child protection issues in several ways:
The Scottish Council for Independent Schools in Scotland have produced a very useful guide on child protection, written by Kathleen Marshall which will be of use to school nurses.
District Nurses and Clinic/Treatment Room Nurses
In the course of work with patients, the district nurse and clinic/treatment room nurses may be in a position to notice that relationships within a family are dysfunctional. Concerns may be expressed about the well-being of the child or the parent may confide in the nurse about the care of a child. Because of the nature of her work, the district nurse may not normally have experience of child abuse, and it is important that she understands that the protection of the child is paramount. The district nurse and clinic/treatment room nurse must have clear guidelines about the action to be taken if there is suspicion that a child is at risk of potential or actual abuse or neglect. These guidelines must include advice and updated information about contact points and, especially out of office hours, how, in liaison with her clinical manager, to contact the social work duty officer.
District nurses are likely to be the first to be aware of the contribution of young people to the care of sick or disabled parents or other siblings within the home setting. They should ensure that the contribution given by children is appropriate, willingly given and not onerous to them. They should refer children to the local authority for assessment of their needs as children 'affected adversely by the disability of another family member' under the Children (Scotland) Act 1995 and ensure that they have adequate support and respite consistent with their needs and rights.
Practice Nurses
Practice nurses are employed by the GP, but are accountable for their own professional practice. Working in a GP practice they have opportunities to interact with families and should be alert to signs and symptoms which might give rise to concerns about abuse. The General Practitioner has responsibilities that need to be met, especially for training of practice nurses on child protection, liaising and supervision.
Midwives
Midwives have a significant role in identifying risk factors to the child during the mother's pregnancy, birth of the child and in the post-natal period both in the hospital and community. During this period the midwife has the opportunity to participate in preparing the couple or single mother for parenthood and, using their knowledge of community resources, can assist in the early resolution of problems or provide support (RCM 1998). These can range from issues of poverty and poor diet, to social security benefits and problems with drug-taking, support for those with disabilities including learning disabilities and others with HIV. When a teenager is pregnant the midwife should consider whether they may need more intensive support and the possibility that the very young mother will have particular difficulties in coping with the demands of a new baby. They are in an ideal position to observe unusual attitudes and behaviour in pregnancy and early parenthood which may the first indication of future difficulties.
Midwives involved in child protection cases, will need to liaise with their clinical manager and have access to advice from the senior nurse for child protection matters, to know what the policies are to which midwives can refer and have access to adequate training, support and clinical supervision in order to carry out this role. Time will be needed to participate and prepare for inter-agency decision making, planning meetings and follow-up action.
Pre-birth Case Conferences
Agencies should consider asking the social work services to convene a child protection case conference concerning an unborn child if there appears to be a risk of significant harm to the child when he or she is born. This case conference will have the same status and form as any other. Parents or carers should be invited to a pre-birth conference, and should be fully informed and involved in planning for the child's future, unless this would increase the risk of harm to the unborn child, for example by prompting the family to avoid contact with ante-natal services, or move out of the area to avoid detection. The case conference may decide that the child's name should be placed on the Child Protection Register when he or she is born, and agree an Inter-agency Child Protection Plan. The conference may recommend that the local authority seek a Child Protection Order at birth. The plan may include the tasks to be undertaken by agencies to support and prepare parents before the child's birth. The social work service should identify a keyworker to co-ordinate the plan.
Adult Mental Health Services
Health professionals working with adults with mental health problems or more severe mental illness should always be aware of how the parents' mental state impacts on any children in the family. They need to be aware that adult mental illness has been a factor in some cases of child abuse and neglect. They should liaise with colleagues in children's services if they have concerns that their patient is unable to provide adequate emotional support or physical care for the children.
Mental illness in parents may affect their children in diverse ways. People who are depressed may be unable to provide adequate levels of care particularly to younger children. Post-natal depression may have an immediate impact on the child's welfare or safety or a longer term impact through emotional unavailability to the child. Adults with personality disorders may themselves have experienced abuse or deprivation and have poorly developed parenting skills. This may lead to emotional abuse. Children may also become caught up in the process of other mental disorders in their parents - for example in the delusional systems of patients with psychotic illness or be drawn into the process of obsessive compulsive disorders.
The children of parents with chronic illness may become the parent's main carer. The nature of the parent's illness may lead to social isolation and lack of "warmth", and children of such parents may well experience emotional abuse or neglect. Some parents may display aggressive behaviour and may be either verbally or physically abusive to their children.
Failure to address the needs of such children who are affected by mental illness in their parents can result in inappropriate and even dangerous situations arising for the children. When a parent's behaviour or mental state poses a risk of abuse or neglect of the child, professionals need to take action to protect the child by referring them to a statutory agency.
In the course of their work with adults, disclosures of abusive behaviour may be made to mental health professionals. They will therefore need to be aware of their role in protecting children, familiar with local CPC procedures and able to receive appropriate child protection training. Clear lines of communication should be established with other agencies. Those mental health professionals who work in community settings, particularly people's homes, should ensure that the welfare of any children in those settings is paramount. Liaison with other health service professionals who may be involved in the care of the children and families is essential. Adult mental health services may be involved in assessing and treating actual or suspected adult abusers and it is therefore vital that appropriate liaison takes place with other health services and relevant agencies. Although the Adult Mental Health Service may be involved primarily in treating the adult, the child's welfare must remain in focus. Mental health professionals assessing or treating actual or suspected abusers should ensure that reports written for another agency or Child Protection Case Conference make a clear statement of risk to any child with whom the abuser has contact regardless of diagnosis of treatability.
Where patients, who are parents or carers of children, are misusing drugs or alcohol the nurse should establish contact with other professionals known to the family.
Awareness of the possible reluctance of those working in the field of mental health to break their confidentiality with their clients should be recognised. However, they must be reminded that the protection of the child is of paramount importance and nurses are referred to the United Kingdom Central Council paper on confidentiality in Guidelines for Professional Practice (1996).
Adult mental healthstaff should monitor the appropriateness of either children visiting adults in their care or those adults visiting children in hospital or care. A vetting procedure including risk assessment and management may be appropriate.
Child and AdolescentMental Health Services
Children and young people with emotional and behavioural problems may be particularly vulnerable by virtue of both their past experiences and the circumstances under which they are being looked after. Child and AdolescentMental Health Teams have a clear role in the follow-up of abused children. It should be recognised that all forms of abuse includes an element of emotional abuse and this applies particularly to all cases of intra familial abuse where there has been a significant failure to maintain basic trust between the child and their primary care givers. This failure is likely to give rise to significant psychological sequelae and to affect the child's emotional and psychological development. These problems may emerge in later years in the form of mood disorder, acts of self harm, eating disorder, or disturbed personality development. Those who work in child and adolescentmental health services may recognise, or come to suspect, that a child has suffered or is at risk of suffering significant harm. They will need to be fully conversant with local child protection procedures and receive regular training and updating concerning these procedures.
Should a child make an unsolicited disclosure this should be reported to social work services, who will determine if there are sufficient grounds to undertake child protection inquiries or a joint investigation with the police. These should be carried out in accordance with the local child protection procedures.
Child and AdolescentMental Health Services will need to focus on the needs of the child and on those of the parents. However, it is the welfare of that child and of any other children in the family which should be paramount at all times. The Child and AdolescentMental Health Service may also have a role in the assessment of the alleged abuser if that abuser is a child or adolescent. Liaison should be established with other services providing treatment for abusers. Those working in Mental Health Services assessing actual or suspected abusers should ensure that any report produced, particularly for another agency or child protection conference makes a clear statement of assessment of risk to any child with whom the abuser has contact regardless of diagnosis or treatment.
Substance Misuse
The emphasis for those working in this field is on the early detection of parents who are misusing drugs or alcohol, so that they can establish contact with other professionals involved in working with pregnant women and parents of young children.
While clinical reports have indicated a strong connection between parental substance dependence and child maltreatment, the empirical data gives a more inconsistent picture. It is an open question whether there is a causal link or whether maltreatment of the child arises from common variables in the family such as socio-economic status or reporting bias.
Children who are misusing substances may be at risk and in need, so consideration should be given to involving social work personnel.
Working with People with a Learning Disability
Families, where cases of potential or actual child abuse involves people with a learning difficulty, may be divided into two categories: those where the child has a learning disability; and those where one or other parent may have a learning disability.
Children with a Learning Disability
Research indicates that these children are especially vulnerable to all forms of abuse. The presence of suspected or actual child abuse may be difficult to identify due, for example, to low intellect with super-imposed behavioural or communication problems and other associated physically handicapping conditions. It is important that professionals who know the child are involved in the inquiries.
The health care professionals should ensure that:
Parents with a Learning Disability
The social work services, following a multi-agency assessment, will be the lead agency for the planning and provision of a care programme to enable the child to remain with his/her parents. The social work service will also make arrangements for placement with foster parents or for adoption when a baby has one or both parents whose degree of disability inhibits adequate parenting. Parents who need help to provide adequate parenting should be supported in the community by the learning disability nurse, health visitor, social worker and other agencies as indicated.
Parents with a learning disability may need access to independent advocacy to help them participate in child protection interviews, conferences and planning.
Children Remaining in Hospital, Nursing Homes and Hospices
Children when admitted to respite care, hospital or nursing homes may show signs of abuse or disclose a history of abuse, and these should be referred to the social work services or the police under local child protection procedures.
Dental Staff in Primary Care, Community or Hospital Services
Approximately 70% of children attend a dentist annually in Scotland. Dentists are particularly well placed to identify physical injury, especially to facial and oral tissues. In addition, they may identify other forms of abuse during their contact with children and they should be aware of the signs and symptoms of such abuse through their education and training. While dentists would not normally be involved in case conferences they should be aware of the contact points within the various agencies to initiate a referral when appropriate. Dental services should be included in the circulation of material concerning these issues.
Hospital Based Professionals
Child protection in the hospital setting should occur within a framework which ensures that the rights of the child are upheld, child-centred health care is offered, the child is not harmed by the experience of hospitalisation, any significant harm is identified and the child is kept fully informed.
The Trust should ensure the safety and security of children in their hospitals, addressing physical security issues and ensuring that appropriate visiting takes place.
Professional health carers and supportstaff in many hospital departments see children in the course of their normal duties and therefore need to be aware of vulnerable children and be alert to the signs of child abuse and neglect. In wards and departments outside the children's unit where children are found there should be a children's nurse available 24 hours a day to advise and support. All these areas should have a child protection policy. The identity of the Trust's Senior Nurse/Lead Clinician Child Protection should be well publicised and staff encouraged to seek his/her advice.
In circumstances where staff believe that a child is at immediate risk of significant harm (e.g. where parents are threatening to remove the child from the ward, A&E department or out-patient clinic) they must be prepared to contact a statutory agency directly without delay. In extreme situations the police service is the agency most able to protect the child, but the relevant social work service must also be notified and a list of the relevant contacts should be available and updated on a 6-monthly basis.
Accident and Emergency Departments
Accident and Emergencystaff and emergency dental surgeons may frequently be the first contact in cases of suspected or actual child abuse and neglect. Case evidence suggests staff must be alert to carers who seek medical care from a number of sources in order to conceal the repeated nature of their child's injuries. If a child presents repeatedly, even with slight injuries, in a way that staff find worrying, further consultation and investigation should take place according to local procedures. It is essential for all children attending the department that there are arrangements for obtaining medical and nursing advice from the paediatric department and that these are covered in the guidelines.
Professionals Working in Paediatric Departments, Work Based Creches and all Areas Where Children are Cared For
Protection of the child is of paramount importance. It is the responsibility of hospitals to ensure the safety of children in their care. Open visiting and parents participating in the care of their child necessitates professionals being aware of the legal status of the child and who has parental responsibility. Attention needs to be paid to security to prevent access of strangers to children, to prevent the abduction of children and to minimise the possibilities of children leaving the ward.
In addition to the key activities staff should ensure that:
i. There is an agreed procedure for obtaining and recording information about the child and his/her family from other agencies, including full details about decisions on the future care of the child, who may have contact, any legal order in force, as well as the names of the social worker and health visitor.
ii. Information concerning a child admitted to the ward who is thought to have been or has been abused or neglected is given to appropriate managers.
iii. The level of knowledge or experience is continually updated and that appropriate training, support, guidance and clinical supervision is given.
Clinical Supervision
Clinical supervision is a term used to describe a formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance patient/client protection and safety of care in complex clinical situations. It is central to the process of learning and to the expansion of the scope of practice and should be seen as a means of encouraging self-assessment and analytical and reflective skills.
Clinical supervision in child protection may be undertaken by the Senior Nurse/Lead Clinician Child Protection and the clinical manager or other peer supporters. It includes discussing cases of actual or suspected child abuse and monitoring records to ensure that all the information about the child and family is reviewed. A child protection clinical supervision policy should be in place. The main types of supervision are one to one supervision, group supervision with a specified supervisor and peer group supervision. The option chosen should be appropriate to the clinical setting with particular reference to child protection issues.
Allegations of Abuse by Staff
Where staff have any concerns about other staff, they should know where and how to obtain help. Systems should be in place to protect children from abuse by staff. All staff must be clear that they have a duty to raise concerns about behaviour by staff, managers, volunteers or others which may be harmful to children in their care, without prejudice to their own position.
In order for the abuse of children by staff to be prevented, or readily discovered, it is essential that children and staff are encouraged to report their concerns. Children will require reassurance about the importance of their making such reports, and junior staff in particular will need support to access senior management to whom they can refer their concerns.
It is therefore important to have procedures in place in order that concerns can be raised outside the normal line management when they consider the manager has been unresponsive or is the subject of concern.
Children and staff making allegations should be listened to and reminded that their allegation will have to be reported and that this may mean breaking confidentiality. Action should be taken to ensure that children are protected and allegations recorded in writing without delay.
When an allegation of abuse has been made against a member of staff, whether involving children they have contact with in the course of their work, or leisure time, or their own children, the matter should be reported immediately to the Lead Clinician/Clinical Manager or, if not available, other senior members of staff.
There are obvious sensitivities to an allegation or suspicions involving a member of staff. Cases must be dealt with by following local procedures.
The Lead Clinician/Clinical Manager will initiate inquiries and, if there is a child protection issue, involve one of the statutory agencies, usually social work.
There are four possible outcomes of the inquiry:
Consideration must be given to the need for precautionary suspension of the member of staff and whether to begin disciplinary procedures. Any disciplinary action that is considered should be clearly separated from child protection inquiries or any criminal investigation, and these must take precedence over internal disciplinary procedures (see Protecting Children -A Shared Responsibility (1998) page 47 paras 6.2-6.5). Whilst the disciplinary process may be informed by the child protection inquiries, the child protection process has different objectives from the disciplinary procedure and the two should not be confused. The member of staff accused or suspected of abuse should be advised of his or her right to have union representation during disciplinary procedures and seek legal advice.
All agencies have a duty of care towards their employees who are alleged to have abused children in their care, and should treat them with consideration pending the outcome of any inquiries.
In the case of staff found guilty of offences it may be necessary to report misconduct of a nurse to the UKCC (UKCC 1996), and medical staff to the General Medical Council, in order to serve and protect the public.
Currently the Council for Professions Supplementary to Medicine (CPSM) is a federation of independent, self-regulatory statutory bodies, set up by statute in 1960 to regulate Chiropody, Dietetics, Occupational Therapy, Orthoptics, Physiotherapy, Radiotherapy, Prosthetists and Orthotists, Art Therapists as well as Medical Laboratory Scientific Officers. For professions not covered by CPSM, such as Speech Therapists and Language Therapists the professional body itself deals with cases of complaint. However, reforms are expected in Section 60 of the Health Act 1999, but this may take time before changes are in place in Scotland.
The police are required to notify the professional organisation of any member who has been convicted of a criminal offence.
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