Nursing and Child Protection Essay

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.Nursing and Child Protection Essay.

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.

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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. Nursing and Child Protection Essay. 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. Nursing and Child Protection Essay.

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. Nursing and Child Protection Essay. 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). Nursing and Child Protection Essay.

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.

Nurses face many issues involving their client’s wellbeing. Confusion relating to the balance of a clients need for autonomy with family members responsibilities and clients wellbeing can make some decisions difficult. Protecting the nurse’s own standards of care and an orgnaistations /employers policies while supporting clients and family members can lead to distress for not only the clients but also the Nurse. By utilising an ethical decision-making tool, I will attempt to tackle some of the legal, ethical and social aspects of child abuse and mandatory reporting faced in nursing (State Government of Victoria, Department of Human Services 2010).

THE PROBLEM

Physical child abuse is characterised by physical injury resulting from hitting, punching, kicking, biting, burning, shaking or otherwise harming a child. Certainty that injury or condition was caused by neglect or by non-accidental means is not a necessity, ‘reasonable cause’ to entertain the possibility of abuse is all that is required, to meet the criteria of mandatory reporting (Funnell, Koutoukidis, Lawrence 2009).

Most children know that negative consequences can result if they break the silence about abuse, and become reluctant to report any abuse for fear of the consequences.Nursing and Child Protection Essay.  Therefore, abuse may continue for months and even years, particularly if the abuser is someone close to the child. Disclosure of abuse with string attached such, as “you have to promise not to tell anyone” can also be distressing for a nurses as there is a legal, ethical and social obligation report such cases to Child Protection or the new Child FIRST intake service (Department of Human Services Child Protection 2010)

Sections 182(1) a-e, 184 and 162 c-d of the Children, Youth and Families Act 2005 (Vic.) states registered nurses are legally required to report cases of child abuse if there is a “belief on reasonable grounds that a child is in need of protection on a ground referred to in Section 162(c) or 162(d), or formed in the course of practicing in his or her office, position or employment. A nurse has a duty to all clients to act as a patient advocate, whilst encompassing the ethical principles of Beneficence (active well doing), Non Maleficence (to do no harm), Justice (fairness and equality), and Autonomy (liberty, free will, rights and self determination) (Australian Government, Australian Institute of Family Studies 2011).

In some cases, this may be against the wishes of the client and pose further dilemmas, and conflicts for the nurse and client.

FACTS

Christine, a 12-year-old girl. has been admitted for observations and investigation of a recent and severe episode of abdominal pain. Shortly after Christine’s admission, whilst assisting her to have a shower, the nurse notices bruising on her arms and back. Christine tells the nurse that her mother beats her regularly. She also says that the bruises on her arms and back are the result of a particularly vicious beating her mother had given her recently using a wooden coat hanger. Christine also discloses that some weeks earlier she had taken an overdose of panadol to ‘try and make her mother stop beating her’ but that all her mother had done at the time was to laugh at her and tell her ‘how stupid she was’ and sent her to her room to ‘sleep it off’. Christine then begs the nurse not to tell anyone pleading ‘If my mother finds out that I’ve told anyone she will beat me up I will be much worse for me’. The nurse reassures Christine that she won’t tell any-one. As soon as Christine is settled in her bed the enrolled nurse who is concerned for Christine’s welfare informs the registered nurse about the beatings and drug overdose

Christine, a 12-year-old girl has been admitted for observations and investigation of a recent and severe episode of abdominal pain. Whilst assisting her shower, bruising on her arms and back was noticed. Nursing and Child Protection Essay. Christine claims her mother beats her regularly. Christine also disclosed that some weeks earlier she had taken an overdose of Australian and Nursing Midwifery Council 2008 done at the time was to laugh at her and tell her ‘how stupid she was’ and sent her to her room to ‘sleep it off’. Christine has pleading ‘If my mother finds out that I’ve told anyone she will beat me up, It will be much worse for me’ and has requested not to tell anyone this information (Gault 2011).

THE FUNDAMENTAL ETHICAL PRINCIPLES AND THEIR IMPACT

Ethics in nursing focuses on the virtues that make a good nurse, and obligations to respect the human rights of the patient. This is reflected in a number of professional codes for nurses . The fundamental principles are:

Autonomy: the ability to function independently and retain control over decision making in all aspects of health care (Guilt 2011).

Beneficence: an act of doing something good that has a benefit for others, such as care giving, empathy, compassion, kindness and sympathy (Guilt 2011).

Non-Maleficence: avoiding all unjust suffering, injuries and harm (Guilt 2011).

Justice: the use of equality, fairness, harmony, mercy whilst encompassing current and appropriate legislation and guidelines (Guilt 2011).

Duty of Care: The moral and legal obligation and responsibility to provide health care to the best of health care workers and organizational capabilities, encompassing guidelines and legislation (Guilt 2011). Nursing and Child Protection Essay.

HOW THE PROBLEM MAY LOOK FROM ANOTHER PERSPECTIVE

Although cases present challenging ethical problems, Nursing Medical advances, economic pressure, and social demands make it inevitable that even more difficult ethical dilemmas will be seen in the future.

A combination of individual, family, and socioeconomic stressors all play apart in child abuse. Nursing and Child Protection Essay. Caregivers may be suffering from issues that require treatment (Low self esteem, depression, abused as a child themselves, substance abuse and character disorders). With the appropriate services and support orientated to people in need, there is a potential for all parties involved to receive help required and make the changes necessary to keep children safe.

IDENTIFY ETHICAL CONFLICTS

Conflicts between the fundamental ethical principles, law and a nurses own moral judgment are all difficult obstacles facing a nurse during all decision making processes. Identifying and risk/benefit analysis of conflicts helps to achieve a therapeutic outcome (Gault 2011) (Australian Nursing and Midwifery Council 2008) Australian and Nursing Midwifery Council 2008 . Ethical conflicts in Christina’s case include Beneficence versus non-maleficence; reporting the abuse to child protection is aimed to benefit Christina, with the intention for her to receive protection and support that she requires. But this may also produce additional suffering and family strain as a result of possible consequences such as repercussions from her mother, or being separated from her family (Gault 2011) (Australian Nursing and Midwifery Council 2008).

Autonomy versus Non-maleficence; consent and free will is closely joined to capacity to make decisions for ones self. A 12-year cannot legally decide on a treatment plan and the act of preventing harm is of utmost importance even though it is against her wishes. The accused abuser is the primary decision maker in Christina’s life, this poses Communication constraints effecting the nurse, mother and Christina.

Confidentiality versus Non-malefience: maintaining trust and confidences are superseded by the need to avoid harm. Issues such as privacy, respecting the wishes of the child and communication with both child and parent will also be in conflict (Gault 2011) (Australian Nursing and Midwifery Council 2008). Nursing and Child Protection Essay.

CONSIDER THE LAW

The law in relation to nursing provides a framework for establishing nursing actions in the care of clients, differentiates the nurse’s responsibilities from those of other health professionals, helps establish the boundaries for independent nursing actions, and maintains a standard of nursing practice by making nurse’s accountable under the law

Relevant acts in Christine’s case include but are not limited to the Child protection Act, Nurses Act and Health Professions Registration Act. All heath care acts are devised from the Australian Charter of Health Care Rights, these include:

Access: A right to be able to access appropriate health care. Regardless of any discriminatory issues, age, sex, or location (The Australian Commission on Safety and Quality in Healthcare 2010).

Safety: A right to high quality and safe health care. Key elements in safety are attention to clients needs, ensuring clients have a complete understanding of treatments they are to receive and complying with existing safety systems, guidelines protocols and laws (The Australian Commission on Safety and Quality in Healthcare 2010).

Respect: A right to be shown respect, dignity and consideration regardless of client’s environment and background and health care that is appropriate to the client’s individual needs (The Australian Commission on Safety and Quality in Healthcare 2010).

Communication: A right to be informed on all services, treatments, options and costs in a clear and open way.  Nursing and Child Protection Essay.By being alert to signs of misunderstanding or confusion health care providers can best assess if additional arrangements for communication are required (The Australian Commission on Safety and Quality in Healthcare 2010).

Participation: A right to be included in decisions and choices about care. Discussing nature of treatment and options, rights and responsibilities, and always inviting clients consent. Health care providers should take into consideration the circumstances of the individual when providing care (The Australian Commission on Safety and Quality in Healthcare 2010).

Privacy: A right to privacy and confidentiality of provided information. Information is only to be shared with appropriate health professionals whilst ensuring sensitivity to privacy needs (The Australian Commission on Safety and Quality in Healthcare 2010).

Comment: A right to comment on care and have any concerns addressed. Health care providers must always be attentive to the concerns of patients (The Australian Commission on Safety and Quality in Healthcare 2010).

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THE ETHICAL DECISION

Kerridges model for ethical decision-making concentrates on justice, in recognition that healthcare choices are constrained by inequality in resources. The decision-making model may be applied in situations to decide on the best course of action. The following steps are necessary to the Kerridges model to achieve resolution of conflict:

â- Clearly state the problem (definition).

â- Identify the facts (listen to the patient, caregiver, and health professionals

Involved).

â- Consider the ethical principles and how they impact on the problem.

â- Consider how the problem would look from another’s point of view

â- Identify the ethical conflicts.

â- Consider the legal aspects.

â- Make the ethical decision

In executing these tasks the most important treatment priority is ensuring the health and safety of the child.

I agree with the action taken by Christine’s nurse, and if I were in this situation I would have encompassed Kerridges decision-making tool and have explained my mandatory ethical and legal obligations to report cases of abuse or suspected abuse, using appropriate communication or a 12-year-old girl.  Nursing and Child Protection Essay.Being extremely mindful to be very comforting, reassuring and to take all of her concerns on board, whilst enlisting the help of appropriate allied health care professionals, including my unit manager (Gault 2011).

CONCLUSION

Mandatory reporting of physical child abuse involves moral, legal and responsibility obligations of health care workers and organisational capabilities that must encompass guidelines and legislation. Health care workers must to take into consideration the circumstances of the individual client and needs when care.

By using a Ethical reasoning and decision making tool assists with the complex moral reasoning and systematic consideration of all aspects the situation, identifying ethical conflicts and promoting an ethical decision that ensures the protection of clients, and abides by all codes, and standards of nursing care. Nursing and Child Protection Essay.