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Chapter 1
Safeguarding, vulnerability and abuse
Understanding the context
NMC Standards for Pre-registration Nursing Education
This chapter will address the following competencies:
Domain 1: Professional values
2. All nurses must practise in a holistic, non-judgemental, caring and sensitive manner that avoids assumptions; supports social inclusion; recognises and respects individual choice; and acknowledges diversity. Where necessary, they must challenge inequality, discrimination and exclusion from access to care.
Domain 3: Nursing practice and decision-making
1. All nurses must use up-to-date knowledge and evidence to assess, plan, deliver and evaluate care, communicate findings, influence change and promote health and best practice. They must make person-centred, evidence-based judgements and decisions, in partnership with others involved in the care process, to ensure high quality care. They must be able to recognise when the complexity of clinical decisions requires specialist knowledge and expertise, and consult or refer accordingly.
9. All nurses must be able to recognise when a person is at risk and in need of extra support and protection and take reasonable steps to protect them from abuse.
NMC Essential Skills Clusters
This chapter will address the following ESCs:
Cluster: Organisational aspects of care
10. People can trust the newly registered graduate nurse to safeguard children and adults from vulnerable situations and support and protect them from harm.
By the first progression point:
i. Acts within legal frameworks and local policies in relation to safeguarding adults and children who are in vulnerable situations.
By entry to the register:
ix. Supports people in asserting their human rights.
x. Challenges practices which do not safeguard those in need of support and protection.
Chapter aims
By the end of this chapter you will be able to:
ā¢ identify the core values of nursing and safeguarding vulnerable people;
ā¢ discuss the common themes that have emerged from historical abuse inquiries;
ā¢ recognise the implications for nursing practice.
Introduction
The evidence is growing that vulnerable adults may be more at risk from abuse and poor practice compared with the general population. Hardly a week goes by now without some abuse or poor practice scandal making news on the television or in national newspapers. It often involves a range of vulnerable adults, but certain groups of people, such as older people or those with a learning disability or mental health need, make up a large proportion of cases. It may seem that this is a new development as we are often not made aware of past failings. However, the abuse of those deemed in need of additional support has been going on for thousands of years. Sadly, some of these abuses have been carried out by nurses, either intentionally, unintentionally or as part of an abusive culture of care.
Angels of death
In 1993, nurse Beverley Allitt was given 13 life sentences for the murder and abuse of children in her care while working at a hospital in Lincolnshire. In 2015, male nurse Victorino Chua was jailed for life for murdering two patients and was also convicted of poisoning or attempting to poison 22 patients at Stepping Hill Hospital by deliberately injecting insulin into saline bags and ampules back in 2011. Both these killers will be required to serve a minimum of 30+ years in prison for their crimes.
The two cases above are thankfully still very rare events, but they do illustrate the evil intents of some nurses who choose to abuse and murder vulnerable patients in their care. This chapter will help you to develop an understanding of the term ānursingā and explore some of the abusive and questionable practices that have arisen from previous and recent failures in care. It will also require you to examine critically the extent to which such practices have been deemed abusive and to understand the relevance to modern-day nursing practice. A number of common themes will be highlighted and explored that have arisen from a number of abuse inquiries. Some useful recommendations made to address the shortcomings highlighted in abuse investigations, at inquiries and in the media will be presented. Nurses as perpetrators, witnesses and receivers of disclosures concerning abuse and neglect will be discussed. Finally, the issues discussed in this chapter will also help you to examine your own personal values and attitudes in order for you to enhance the service of people in your care.
Nursing vulnerable people
Before discussing safeguarding issues related to nursing it would be sensible to start off by exploring what we understand by the term ānursingā. Nursing is a diverse and complex activity with many facets. The Royal College of Nursing (RCN) defines nursing as
the use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.
(2003a, p3)
The RCN acknowledged the limitation of a single definition and also included six defining characteristics that should be used in conjunction with each other to capture the full breadth of what it believes nursing entails (see Table 1.1).
Activity 1.1 Critical thinking
ā¢ Consider the above definition and the unique characteristics of nursing developed by the RCN. Can other professionals lay claim to some or all of the elements of nursing?
ā¢ Highlight some of the main features and values of nursing. Pay particular attention to the safeguarding role of nursing.
You may find some other ideas you have not thought of in the discussion below and in the outline answer at the end of the chapter.
The RCN recognised that many other professions may lay claim to particular aspects of nursing highlighted in both the core definition and characteristics. However, it points out that the uniqueness of nursing lies in the totality of all parts not just particular aspects. It is the combination of all the elements that gives nursing its distinctiveness and the definition expresses the common core of nursing, which remains constant (RCN, 2003a). The core definition has three key areas: the use of clinical judgement, concern for health and enhancing quality of life. This in itself sets nursing apart from other professions, although most health professionals would argue that they use clinical judgement in their practice. There is also an expectation that nurses need to empower individuals, which inevitably means that they do more than just concern themselves with physical aspects of care such as mobility. They also have to deal with families and communities and thus take on elements of a social dimension.
In terms of safeguarding, people need to feel safe and trust nurses with their health and well- being, particularly when they feel vulnerable or at risk of harm (you will explore these issues, particularly vulnerability, in more detail in Chapter 2). When people are in need of care and support they should expect to be treated with dignity and respect by nurses (NMC, 2015a). They also expect to have support with a range of daily living activities if they are unable to do these things themselves. This support may involve assistance with feeding, bathing and dressing as well as having psychological needs being met. The level of support and personal care required varies between individuals. For example, a person with dementia or multiple sclerosis may be able to perform some self-care, such as brushing his or her teeth, but may need support with shopping. A person may be able to dress themselves one day but not the next. Essentially, some individuals may be able to live independently while others need support with everyday activities.
Table 1.1 Defining characteristics of nursing (adapted from RCN, 2003a)
The level of support or nursing care provided may be dependent on the type of service provided. There are nursing care services that deal with predominantly health needs and there are social care services that deal with social needs or personal care. The more dependent the person is, the more likely he or she will be in need of some form of residential care. Residential care can be provided in a variety of settings, such as ordinary houses, group homes, hostels, warden- controlled complexes and small or large hospital-type services. Residential care services tend to be based on the nature of the client group. So we have residential services for older people and for people with mental health problems or learning disabilities. These can be provided by both health and social services.
Activity 1.2 Critical thinking
Consider the following brief pen pictures and identify some of the likely biological, psychological and social aspects of nursing and support needs of each person.
Alexandru Constantin is a 38-year-old man who was involved in a serious road accident. He is currently in a coma, on life support, in the critical care unit of a local NHS Trust hospital.
Lily Evans is a 48-year-old woman who has not left her home for ten years due to panic attacks.
Jack Davies is an 82-year-old man who has had a fall and broken his femur and wrist.
The above pen pictures illustrate that each patient requirement is unique, but also that there may be some similar nursing and support needs. These differences and similarities can be seen in the outline answer at the end of the chapter.
Historical background to poor standards of care
The last thing people expect is to be abused by people who are being paid to care for them. There is nothing in the above definition and characteristics of nursing that suggests it is concerned with abusing people under nursing care. However, hospital inquiries and personal accounts have implicated professionals, including nurses, in abusing individuals in their care (these issues will be further explored in Chapter 10). Large residential facilities are not the sole domain of abuse as both Brown (1999) and Manthorpe (1999) argue that no settings, including small community homes or even a clientās family home, are immune from the potential of abuse.
In the past groups of individuals such as those with learning disabilities or mental health problems were cared for initially in institutions called asylums, which were renamed hospitals when the NHS was formed in 1948. During the 1960s, institutional-type care was called into question by Goffman (1961), who undertook some of the earliest research into the life of institutionalised people with mental health problems in America. He described how some of the patients were socialised into developing institutionalised types of behaviour. The negative effects of such institutional process and setting took away some of the residentsā personality, skills and choices. A type of āinstitutional neurosisā develops in which patients become overly passive and dependent on those caring for them and do not challenge inhuman or degrading treatments. It must be remembered that there is great variation between institutions and not all residents are adversely affected by their processes.
In the UK, numerous hospital scandals of the early 1970s reinforced the view that hospital care was not a suitable provision for people with learning disabilities. The first of these took place in Ely Hospital in Cardiff (Committee of Inquiry, 1969) and was exposed by the News of the World newspaper. This scandal brought home to the nation the reality that nursing staff themselves could be guilty of abusing people in their care.
Subsequent major inquiries are highlighted in Box 1.1.
Box 1.1: How abuse of those with learning disabilities came to light
ā¢ 1969 Ely: Initial complaints ignored until nursing assistant sent letter to national newspaper.
ā¢ 1971 Farleigh: Initial complaints ignored until student nurse made allegations to police.
ā¢ 1972 Whittingham: Initial complaints from student nurses suppressed until two senior managers made complaints.
ā¢ 1978 Normansfield: Initial complaints ignored until strike by nurses protesting against the consultant psychiatrist.
ā¢ 1992 Ashworth: Patient made initial allegations and then Channel 4 undertook documentary.
ā¢ 2006 Cornwall: Mencap raised concerns and a Healthcare Commission investigation was undertaken.
ā¢ 2007 Sutton and Merton: Chief executive of the NHS Trust requested ...
