This paper will consider the impact of the “Working Together To Safeguard Children” child protection policy on the clinical practice of the nursing profession in a general community clinic. The current legislative framework for child protection will be considered with regard to the 1989 Children’s Act, with special reference to the obligations of health professionals working with vulnerable children and their families. Research evidence on the role of nurses in the detection of child abuse will be considered. Furthermore, the paper will discuss the implications of developing existing general practice child protection procedures to include a more active and explicit role for child protection by medical and nursing staff.
As Stower (2000) has argued, “Child protection is the term used by all agencies when there is a suspicion that a child or children (all or some of the children in a family) are at risk of being abused by any adult, family member or non-family member” (p 48). The 1989 Children’s Act was introduced to improve inter-agency cooperation between social services, health and education agencies in the provision of assessment and intervention with vulnerable children. One category of vulnerable children addressed by the legislation were children that have been subject to abuse. The central aim of the 1989 Children’s Act was to emphasis that the welfare of the child is of paramount importance at all times, and that professionals working with vulnerable families should promote cooperation and partnership where-ever possible. It afforded children the right to protection from abuse and the right to have inquiries made about their individual circumstances to safeguard them from harm. The Children’s Act 1989 raised the controversial issue of parental rights, patient confidentiality and a duty of health professionals to protect children and share information with appropriate other agencies with a view to protecting a child. In 1991, Working Together under the Children’s Act was published and it updated guidance on child protection, with an emphasis on different professional groups “working together” towards the interests of the child. This was replaced by Working Together to Safeguard Children in 1999. This policy document made it very clear that protecting the child was a higher priority than maintaining confidentiality. However, it recommended that parents should be informed when a professional was going to make a referral to social services, unless asking for permission from parents was likely to place the child ‘at risk’ of significant harm. The “Working Together To Safeguard Children” (WTSC) policy was based on the legislative framework of the Children’s Act 1989. It outlined the specific roles and responsibilities of community nurses where child protection concerns had been experienced in their clinical practice. It stated that where child abuse was suspected by nursing staff, careful records of parental attitudes and behaviours should be made. This might include reference to the grounds for suspicion, such as a delay in seeking treatment for an injury, unexplained injuries on a child or variation in parental account of how an injury occurred over time, or between parents (Benger and Pearce, 2002). WTSC recommends a non-confrontational, information gathering approach to early investigations of child abuse by community nurses staff, with a strong emphasis on discussing concerns with the child’s GP, who may have detailed knowledge on the circumstances of the child and their family. Where there are concerns that the child maybe at “at risk of significant harm”, nursing and medical staff may contact the social services department to make an official referral. It is standard practice for the GP to make a child protection referral, but “when there are conflicting opinion, either by medical, managerial or senior colleagues, if the nurse is still convinced that there is a child protection issues, she or he is individually accountable and should refer it to social services” (p 51).
However, under the current legislative framework, social services personnel may wish to contact the referral agency for further information on the child’s health and to undertake “network checks” with all the agencies involved. The GP or nurse maybe invited to an inter-agency strategy meeting attended by social services staff, the police and other relevant staff to discuss their child protection concerns and decide upon a plan of action. Furthermore, the GP or nurse maybe invited to a child protection conference that may lead to the decision to record the child on the Child Protection Register. The Child Protection Register is available to appointed child protection staff within health organisations, to check if a child is known to social services for reasons of emotional, sexual and/ or physical abuse, or neglect (WTSC, 1999). General guidelines on child protection are provided as part of the policy document. It is stated in section 1.13 that “For those children who are suffering, or at risk of suffering significant harm, joint working is essential, to safeguard the child/ ren and – where necessary – to help bring to justice the perpetrators of crimes against children” (p 3). It recommends that health professionals should be vigilant to the possibility of child abuse amongst patients and “be alert” to the potential risk that abusers “may pose to children”, and “share and help to analyse information as that an informed assessment can be made of the child’s needs and circumstances” (p 3). The WTSC policy stated that it was important that every organisation that came into contact with children had a child protection policy in place, but gave little guidance on what the child protection policy should be. It can be argued that the child protection policy should be revised regularly to take into consideration new developments within general practice, such as the introduction of electronic patient record systems, or change of staff or clinical services. Changes to policy should be undertaken collaboratively between GP’s, nurses and administrative staff that have contact with children.
The importance of health care systems in the protection of children has been made clear in recent years, and lead to legislative changes that are presently being implemented as part of the 2004 Children’s Bill. Victoria Climbie died in February 2000 as a result of severe and repeated physical abuse and neglect by her caregivers that amounted to 128 separate physical injuries being recorded at the time of her death. The appauling circumstances of her death trigged a public inquiry, led by Lord Laming (2003), who identified 12 opportunities by health, police and social services agencies to protect this eight year old girl from many months of brutal abuse and neglect. One source of criticism in the Climbie report was directed at the health care system, in particular Accident and Emergency departments, that had misdiagnosed her physical injuries of scratches and bruises as being the result of scabies in June 1999. Social services were not notified of any child abuse concerns by doctors at this time. In July 1999, Victoria Climbie was readmitted to hospital for treatment of burns, but due to poor communication between health professionals, social services and the police no full assessment of the child was ever made (Hall, 2003). The Lord Laming report recommended that agencies work more closely together, with better training and interagency cooperation to prevent child abuse. As Hall (2003) argues, “Amid the justifiable horror at the death of Victoria Climbie and the focus on violent physical abuse, we must not neglect the opportunities for prevention. This too is the responsibility of all who work with children, but in the health service it particularly falls on primary care staff, including midwives, health visitors, school nurses, and on those working with mentally ill adults and drug misusers” (p 294). Lord Lamings recommendations were reflected in the 2004 Children’s Bill that aims to set up a central electronic record for every child in the country that would contain sensitive information on professionals who were involved with them. It is believed that such a system would make it easier for appropriate professionals to make ‘informed judgements’ about the safety of children, based on information gathered from other agencies with an interest in the child. However, the new legislation is controversial because of concerns about civil rights, and the Government are currently in consultation with local education authorities with a view to piloting the electronic record system.
In the UK, four types of child abuse are currently recognised under the legislative framework. These can be classified as neglect, physical injury, emotional abuse and sexual abuse. Physical abuse and neglect maybe the most often encountered type of child protection problem in community practice, but it is easy to mistake physical abuse for accidental injury (Breslin and Evans, 2004). The estimated burden of physical child abuse in the UK population is 2.7 children per 1000 per year, according to the NSPCC (Breslin and Evans, 2004). This means that every general practice in the country could include a sizeable minority of families registered with them where physical child abuse is occurring at home.
When children attending Accident and Emergency departments for treatment, it is standard practice to send a notification of attendance and reason for attendance to the GP. When medical staff have suspicion of child abuse, a careful examination of the medical records may show that a child has a history of injury. Shrivasta (1988) found that 22 out of 108 children (20.4%) had one or more admission to hospital for non-accidental injuries over the 5 year period of the study. Furthermore, Fryer and Miyoshi (1994) have shown that abused children are ‘at risk’ of being re-abused over a relatively short period of time. In their study, 69.2% of children that suffered from a reoccurrence of abuse, did so within 360 days of the prior abuse event. Furthermore, in their study 9.34% of children were re-abused in the four year period of the study, and the risk of multiple reoccurrences increased after every abuse event. Therefore, it is not possible for health professionals to discount evidence of child abuse as being a ‘one off’ episode that is unlikely to happen again, without a full investigation of the child’s needs. It is possible to check if a child is registered with social services on the Child Protection Register. However, this is a poor measure of risk because only the most serious cases of child abuse will ever be registered, and children rarely stay on the Child Protection Register for more than two years due to current social services policy. Greenfields and Statham (2004) have shown that the decision of health agencies to act on suspicious injuries is affected by knowledge of whether they are registered on the Child Protection Register or not and social/ circumstantial factors related to the child and their family, as opposed to the clinical characteristics of the case. Indeed, a third of child protection register custodians felt that health professionals gained a false sense of security from knowing a child was on the register, and did not intervene as much as where the child was not already known to social services.
Research has shown that abused children who live with the perpetrator are sixteen times less likely to receive medical care for their injuries, as opposed to abused children where the perpetrator is not resident (Ezzell, Swenson and Faldowski, 1999). Furthermore, retrospective studies of adults reporting that they were abused as children are much higher than official statistics would suggest (Cawson et al, 2000). This suggests that a considerable degree of child abuse is ‘hidden from view’ and community nurses may be in a unique position to befriend families through the delivery of standard health care, such as immunisation, and be vigilant to child protection issues at this time. Furthermore, since research has shown that children at risk of abuse and neglect may not be registered with a GP (Taylor, 2004), the provision of general health checks such as the cervical smear clinic or diabetic annual review provide an opportunity for nurses to enquire after any children in the home that may not be registered at the practice. As the WTSC policy emphasises inter-agency partnership, it is possible for community nurses to contact duty social workers, health visitors and youth workers to facilitate information exchange about vulnerable young people in the area. This also provides an opportunity for information and training about the respective professional disciplines.
Nurses in community settings have a potentially high level of contact with abused children and the opportunity to form ‘trusting relationships’ with children and families (Nayda, 2002). It is necessary to formulate general practice child protection policies that make best use of nursing expertise, and facilitate ‘working together’ ideals within practice between nurses, GP’s and other professionals as much as ‘working together’ with external organisations. This means that any child protection policy should include time at a weekly practice meeting where staff can exchange information about children thought to be ‘at risk’, and discuss best child protection practice. Opportunities for information exchange and inter-agency cooperation in child protection enquiries are particularly important since nurses, in one study, felt that other professionals were keen to ‘pass the buck’ rather than engaging in equal professional consultation (Nayda, 2002). Furthermore, the nurses in this study suspected child abuse on a regular basis, but only reported it when there were no repercussions of reporting; “Their concerns were not only for the children and their families but also for themselves. One nurse stated that if her own safety was uncertain she would not report a situation where a child was at risk. However, most were concerned about the consequences of reporting for the family” (p 172). Furthermore, the decision to report about child abuse was partly informed by past experience of dealing with the child protection welfare system. As such, “some of the nurses did not report all cases of suspected abuse, knowing that reporting their suspicions did not necessarily result in action” (p 176). The nurses reported that they were reluctant to report families for child abuse because they felt it destroyed the relationship that they had developed with the families, and reporting child abuse was very much identified as a last resort when all other intervention options had failed. Through this study, it is clear that the ‘ideological’ values underpinning the WTSC policy may not be applied in practice due to difficulties contacting other professionals, and personal confidence and sense of security when making a decision about child protection. As Stower (1999) argues, there is some confusion amongst the nursing profession about their responsibilities under the Children’s Act 1989. The area of parental responsibility is not clearly defined in the legislation, and the term ‘at risk of significant harm’ is open to subjective interpretation. However, Stower (1999) suggests “This will depend on the degree of the type of abuse, the effect on the child and the circumstances surrounding the event. It must be remembered that single bruises in certain circumstances, for example, a disabled child or very young baby, could be significant and should not be disregarded” (p 49)
In conclusion, research has shown that child abuse is a common problem and one that nurses may encounter as part of their clinical practice. Research shows that community nurses are in a good position to build relationships with families, and to detect child abuse as part of their routine health screening duties. Furthermore, the new child protection policies insist that nurses report child protection concerns, and exchange information with other relevant agencies. However, in a Scottish study of training and supervision in child protection for nurses, it was observed that there was a lack of uniform availability of training opportunities; a situation aggravated by a professional resistance to clinical supervision by nurses who ‘avoided it like the plague’ and a resistance to child protection training that was perceived as not relevant to some nurses practice. “However, it is important to recognise that supervisors of these nurses may have little or no expertise in child protection issues, therefore the ability to access a specialist child protection worker in relation to specific pieces of work may be critical” (Lister and Crisp, 2005, p 67). Therefore, effective training and clinical supervision programmes, that meet nurses’ needs, may be central to their increased involvement in child protection screening and referral in general practice.
Benger J and Pearce A (2002) Quality improvement report: Simple intervention to improve detection of child abuse in emergency departments. BMJ 324, pp 780 – 782
Breslin R and Evans H (2004) Key child protection statistics. Retrived from: http://www.nspcc.org.uk/inform/Statistics/KeyCPstats/1.asp : 16th June 2005
Cawson P, Wattam C, Brooker S and Kelly G (2000) Child maltreatment in the United Kingdom (NSPCC, London)
Department of Health (1999) Working Together to Safeguard Children (HMSO, London)
Ezzell C, Swenson C, Faldowski R (1999) Child, family and case characteristics. Child and Family Studies 8.3 (pp 271- 284)
Fluke J; Yuan Y; Edwards M (2005) Recurrence of maltreatment. Child Abuse & Neglect 23.7 (pp 633 – 650)
Greenfields M and Statham J (2004) The use of child protection registers (Thomas Coran Research Unit, Institute of Education)
Hall D (2003) Child protection. BMJ 326: 293 – 294
Keshavarz R, Kawashima R and Low C (2002) Child abuse and neglect presentations to a pediatric emergency department. Journal of Emergency Medicine 23.4, pp 341-345
Lister P and Crisp B (2005) Clinical supervision in child protection for community nurses. Child Abuse Review 14, pp 57 – 72
Lord Laming (2003). Inquiry into the death of Victoria Climbie. London: Stationery Office, 2003. Retrieved from: www.victoria-climbie-inquiry.org.uk :18 June 2005
Nayda (2003) Influences on Registered Nurses’ decision making in cases of suspected child abuse. Child abuse review 11, pp 168 – 178
Prescott A, Bank L, Reid J, Knutson J, Burraston B and Eddy J (2000) The veridicality of punitive childhood experiences reported by adolescents and young adults. Child Abuse & Neglect 24.3, pp 411-423
Shrivastava R (1988) Non-accidental injuries (Unpublished thesis at University of Liverpool)
Stower S (2000) The principles and practice of child protection. Nursing Standard 14, pp 48 – 55
Taylor (2004) Integrating community child health and hospital information for communication and early warning (Royal Free Hospital Report, London)
The Children’s Act 1989 http://www.opsi.gov.uk/acts/acts1989/Ukpga_19890041_en_1.htm