For the purposes of this assignment the author, a Return To Practice Paediatric Nurse will consider how the practice of safeguarding children within a hospital setting has undergone appreciable change since she last practiced in the 1990s and explore how these modifications in child protection arrangements have been influenced by changes in health care policies and legislation.
The major focus of the essay will centre on the child safeguarding referral process experienced by a five year old boy (for the purposes of the assignment we will use the pseudonym Charlie) who was admitted to a general paediatric ward suffering the effects of smoke inhalation due to a house fire late at night. The report received from the emergency rescue services by the hospital staff indicated that at the time of rescue, both parents appeared to be highly intoxicated and proved difficult to rouse and thus child safeguarding concerns were raised.
The implementation of the child protection procedures by ward staff immediately triggered a series of multi-agency assessments and the co-ordination of responses through an Area Child Protection Committee. This illustrated to the author a significant change in practice which highlighted a move towards greater collaborative multi-disciplinary and interagency working.
As a result of this new experience and learning, this essay will explore the rationale behind such changes in practice, it will discuss the emergence of the ‘designated professional’ with regard to child protection and safeguarding and consider the challenges of interagency working while making reference to relevant policies and legislation. The protection and safeguarding of children and young people within the hospital setting has been given huge prominence in recent years.
Not only is it considered a fundamental issue for all healthcare professionals but as stated in The Great Ormond Street Hospital Manual of Children’s Nursing Practices (2012), a “key governance issue for the National Health Service”( p118). The paramount importance of safety and wellbeing of children in care requires recognising and understanding the issues of a child ‘in need’, in addition to knowing how to respond and refer these children to the appropriate support services that now exist in a complex and constantly changing practice environment.
This primary duty to protect and safeguard vulnerable children is enshrined in the Children Northern Ireland Order (1995) and it is also encapsulated in the Nursing and Midwifery Council Code of Practice (NMC) (2012) which emphasises that the best interest of our patients must lie at the heart of all practice. Practices and procedures for children’s nurses have been altered and shaped over time with the emergence of new evidence and subsequent changes in legislation, policies and procedures.
In many instances, the development of and changes that occur in legislation, policies, procedures and practice have been the result of recommendations from inquiries into specific cases of child abuse and neglect. These enquiries have been the key drivers towards improving collaborative approaches to working with children at risk throughout the United Kingdom. (Vincent 2009). A landmark case concerned The Laming inquiry into the death of eight year old Victoria Climbie.
The recommendations from this report had immense implications and it was considered singly responsible for significant changes being adopted into primary legislation and associated regulations, guidance and policy in England and by extension influenced much legislation and policy here in Northern Ireland. One of the key findings of Laming was the failure of the multiple agencies and services involved with Victoria to properly assess the level of risk she was under, and to communicate effectively and work strategically with each other (Laming 2003).
In the context of Charlie it was possible to experience at the clinical level how such changes impacted on contemporary nursing practice. From previous experience such guidelines, procedures and policies for multi-agency collaborative workings did not exist. Another case that drew similar conclusions of the deficiencies in interagency communication and collaboration in Northern Ireland following the Laming inquiry concerned the tragic loss of an entire family in a house fire initiated by the father.
The review of the deaths of the Mc Elhill/McGovern family in 2008 served as another unexpected reminder that multi-agency working still had difficulties with ensuring the safeguarding and protection of children. The media and public outcry that the case triggered served to remind nurses of their clear responsibilities and duties in relation to safeguarding the welfare of children at the clinical practice level. From the author’s viewpoint Charlie was deemed in many ways to be the recipient of the benefits in changes to local trust policies and procedures that ensured the immediate activation of early warning systems to protect him.
This incident alone reflected the important changes that have occurred in practice in recent times. Another influential piece of legislation that came about as the result of Lord Laming’s report in 2003 was the Green Paper entitled ‘Every Child Matters’. In this, the British government set out the five aims that it deemed necessary for the wellbeing of children and young people: be healthy, stay safe, enjoy and achieve, make a positive contribution and achieve economic wellbeing.
Each of these five themes has a detailed framework attached to them that influence current nursing practice, especially as all the outcomes require a multi-agency partnership working together. The involvement of agencies includes primary and secondary health services, schools, early years organisations, children’s social work services and children and adolescent mental health services have demonstrated a massive shift in focus to managing the holistic needs of the child and not just the medical need they present with as in Charlie’s situation.
In accordance with regional and local policy and procedure, the concern raised by Charlie’s admission to the ward, prompted a formal referral by the medical and nursing staff not only to the duty social worker but also to the Named Child Protection Nurse Specialist (CPNS), both of whom are key members of the Local Area Child Protection Committee.
The emergence of the newly ‘designated professional’ and ‘named professional’ in the safeguarding of children and young people poses a significant development in the area of child protection and represents a change in clinical and nursing practice since the author practiced in the 1990s. The CPN is a designated nurse with specialist training who takes a professional lead in children’s safeguarding issues within the health trust. The development of the ‘lead professional’ at both a policy level and a clinical and nursing practice level was one of the key recommendations arising from the Laming Inquiry.
In his report Laming states: ‘All Primary Care Trusts (PCTs) should have a designated doctor and nurse to take a strategic, professional lead on all aspects of the health service contribution to safeguarding children across the PCTs area, which includes all provider. ’ This is also reinforced in the 2010 Intercollegiate Document, ‘Safeguarding Children and Young People: Roles and Competencies for Health Care Staff’ where it is stated that ‘named professionals’ have a key role in promoting good professional practice within their organisation and to provide advice and expertise for fellow professionals.
All children’s practitioners should place the interests of the child at the core of their work. For children’s nurses, and indeed all healthcare professionals having direct or indirect contact with children, there is an absolute duty and responsibility to ensure that the safety and wellbeing of the child is paramount. (Cooperating to safeguard children 2003) This duty and responsibility is underpinned in the NMC Code which states in section 5. : ‘Where there is an issue of child protection you must act at all times in accordance with national and local policies. ’ The Royal College of Nursing echo this requirement to be familiar with and act within local and regional child safeguarding protocols and it also cites the designated/ named safeguarding nurse as an important point of reference for referral, advice and guidance when it comes to safeguarding concerns. RCN 2007) As previously stated, the drive towards practical improvements of collaborative approaches to working with children at risk is a common theme of numerous inquiries over the years and a range of statutory and non-statutory guidance and legislation which suggests that there still remain many challenges and barriers to interagency and multidisciplinary working.
In response to the case of the death of Peter Connelly known as Baby Peter, a review investigating the progress made across the UK to implement effective children’s safeguarding arrangements speaks of the need for a ‘step-change’ in the arrangements to protect children from harm. In another independent review commissioned by the British government in 2010, Munro suggests that in some areas good practice thrives but that there are numerous system level challenges that are yet to be resolved (Munro 2010). This however, was not the author’s experience ith Charlie. The immediate response to implement child protection measures was prompt and proactive in minimising risk. The detailed assessments that followed demonstrated how practice has evolved in response to local policy and legislation. Without doubt practice must be continually kept under review as experience shows nurses must continually strive to enhance their practice. Martin et al. (2010) in their study sought to identify evidence of improvement in safeguarding practices since the Laming review took place.
However while acknowledging improvement in many areas in their findings they also describe a number of barriers and challenges that still remain in places towards effective multidisciplinary working. Some of the challenges cited included the lack of resources available to implement key policy changes and recommendations including recruitment of experienced staff, a lingering lack of understanding of agency and professional roles and responsibilities giving rise to issues of accountability.
The study also revealed instances were signs and symptoms of abuse and neglect were noted but not communicated to other professions and agencies. A number of agencies also stated that they often encountered a robust resistance by some families for social care support and intervention which hampered their professional ability.
Some also cited that limitations to multidisciplinary work could be effected by historical and cultural differences between professions and that some agencies were still not applying quality assurance procedures in an effective way. In his 2009 report reviewing child safeguarding procedures Lord Laming stated ‘It is evident that the challenges of working across organisational boundaries continue to pose barriers in practice, and that cooperative efforts are often the first to suffer when services and individuals are under pressure. (Laming 2009. p. 6) Having explored the literature, both long established and more contemporary, it would appear that even with changes and improvements to legislation, policies and procedures the case remains that despite our efforts as health professionals, there will always be risk and danger facing children and as a consequence there will remain challenges facing the professionals who are required to protect them. As of 30th June 2012, 1,985 children were listed on the Child Protection Register in Northern Ireland. ( DHSSPS NI Statistics and Research Agency 2012).
For the author, a salient reminder of the earnest task facing nurses in a contemporary workplace. In 2006 the Department of Health and Social Services and Public Safety, Northern Ireland (DHSSPSNI) inspection of services report entitled ‘Our Children and Young People- Our Shared Responsibility’, the need for robust structures and systems that support effective safeguarding children practice are repeatedly emphasised, as is the need for rigorous professional practice, multi-disciplinary and interagency working and service provision (DHSSPSNI 2006).
The collaborative safeguarding procedures initiated by Charlie’s hospital admission evidence a significant move towards these multi-agency requirements and for the author demonstrated a substantial positive change in contemporary nursing practice.