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Safeguarding children: providing nursing staff with supervision

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Safeguarding children is challenging and emotionally draining, so safeguarding supervision needs to be built into daily practice. This article comes with a handout for a journal club discussion

Abstract

Safeguarding children is a duty of all health professionals, no matter where they work. Nurses are a crucial part of the multi-agency safeguarding systems in place to protect children and young people. However, safeguarding children is challenging work, so nursing staff need regular and protected supervision time at work with a trained, skilled, experienced and knowledgeable supervisor. This article explains the role of nurses in safeguarding children, what safeguarding supervision is, the roles and responsibilities of supervisors and supervisees, the process of reflective supervision and the key functions of supervision.

Citation: Smikle M (2018) Safeguarding children: providing nursing staff with supervision. Nursing Times [online]; 114: 12, 36-40.

Author: Marcia Smikle is head of safeguarding children, safeguarding children team, Homerton University Hospital Foundation Trust.

Introduction

Many health professionals, including nurses, will at times feel challenged or overwhelmed by their role in keeping children and young people safe. How Safe Are Our Children? published by the National Society for the Prevention of Cruelty to Children (NSPCC) (Bentley et al, 2018) reported that, in the previous five years, there had been an increase in the number of recorded offences of cruelty towards, and neglect of, children aged under 16 years by a parent or carer in England, Wales and Northern Ireland. In 2016/17 there were 98 child homicides in England and Wales and suicide rates among 15-19-year-olds had risen (Bentley et al, 2018). In addition, the rate of recorded sexual offences against children aged under 16 in the UK had doubled since 2005/06, with 2016/17 seeing the highest number in the past decade measured mid-year (Bentley et al, 2018).

The Care Quality Commission (CQC, 2015) requires that service users are safeguarded from abuse while receiving care or treatment. It is therefore essential that healthcare staff are able to recognise when young service users have experienced (or are experiencing) neglect or emotional, physical or sexual abuse, and take the appropriate action. It may be an overused phrase, but safeguarding children is everyone’s responsibility.

Nurses and other healthcare staff, wherever they work, are key members of the national and local multi-agency safeguarding systems in place to protect children and young people. Keeping children safe can be challenging work and emotionally draining so, to be able to fulfil their safeguarding role, nursing staff need appropriate support in the form of safeguarding supervision.

What is safeguarding?

The word ‘safeguarding’ is an umbrella term covering a wide spectrum of situations and interventions, from early identification, intervention and support for vulnerable children and families, to situations where immediate action is needed to protect a child. The Department for Education (HM Government, 2015) defines safeguarding as:

  • Protecting children from maltreatment;
  • Preventing the impairment of children’s health or development;
  • Ensuring that children grow up in circumstances consistent with the provision of safe and effective care;
  • Taking action to enable all children to have the best possible outcomes.

Child protection is the protection of children who have been identified as experiencing, or likely to experience, significant harm to their health and wellbeing.

Role of nurses

Nurses are in constant contact – directly and indirectly – with adults and children in a variety of settings (such as hospital wards, outpatient departments, schools and family homes) where they undertake a range of activities, such as conducting health assessments (including assessment of risks), providing and evaluating care of the sick, and promoting good health in the well population. Nurses are also expected to intervene early and take action when things seem to be going wrong.

All nursing staff – not just those with child protection caseloads such as health visitors and school nurses – have an active role to play in the prevention of harm and the early identification of children and young people at risk of harm or who have been harmed. This includes:

  • Advocating on behalf of the child or young person;
  • Keeping them in a place of safety;
  • Making timely referrals to appropriate support services (for example, children’s social care);
  • Attending case conferences;
  • Helping to develop and deliver multi-agency protection plans.

As a nurse, it does not matter whether you work in adult or children’s services: safeguarding children is your responsibility. If you work in adult services and are concerned about the behaviour or mental state of an adult who has a child in their care, then your mantra should be: “If you are concerned about the adult, be concerned about the child”.

Wellbeing of nursing staff

Healthcare organisations are responsible for ensuring their workforce can safeguard children effectively (Department for Education, 2018). There is growing evidence of a link between the health and wellbeing of staff and the quality of the services they provide. Poorer staff health and wellbeing can adversely affect care quality, patient experience and patient safety – which, in turn, can lead to poorer health outcomes for patients (Dawson, 2014; Aitken et al, 2012; Maben et al, 2012; Boorman et al, 2009). It is therefore sensible and cost-effective to provide nursing staff with adequate support.

The NHS is currently affected by major social and political changes that have created workforce challenges. Along with well-known factors, such as Brexit, for example, also included are the technological and medical advances that enable people to live longer with complex long-term conditions and comorbidities. These workforce issues affect the everyday working lives of nursing staff.

Nurses may sometimes feel overworked and overstretched in a relentless and difficult job. Work-related stress, sickness and low morale seem to be increasing, and more nursing staff are leaving the NHS than joining it: there was an estimated shortfall in nursing staff of approximately 8.9% in March 2015 and it is predicted that the figure could rise to 11.4% by 2020 (NHS staffing numbers). This means the remaining staff are carrying the workload of those who have left, as well as their own.

Trusts have been asked to come up with plans to improve the health and wellbeing of their workforce (The NHS in 2017; Royal College of Nursing, 2016). In the meantime, it is important that staff feel supported and well cared for.

Need for safeguarding supervision

When it comes to safeguarding and protecting children, embedding lessons from serious case reviews remains an ongoing challenge. The NSPCC (2015) has highlighted that:

  • Many of the children and young people who experienced significant harm and/or died had recently had contact with healthcare staff and so opportunities to safeguard them had been missed;
  • Staff were often focused on meeting organisation performance targets and, therefore, spent less time on reflection, critical thinking and the review of complex safeguarding and child protection cases.

Nurses need to move from a task-oriented focus to taking a reflective and analytical approach to the care they provide, as this will enable them to make good, patient-focused decisions (Nordbøe and Enmarker, 2017). They also need appropriate safeguarding supervision. However, there is evidence that this is often lacking, both in terms of quality and frequency (Brandon et al, 2009).

To develop and maintain the competence of nursing staff in safeguarding children, healthcare organisations need to commit to provide staff with:

  • Training that will enable them to acquire the right knowledge, skills and attitudes to identify children and young people at risk of harm or who have been harmed (Royal College of Paediatrics and Child Health, 2014).
  • Regular and protected supervision time at work with a trained, experienced, skilled and knowledgeable supervisor.

These two essential factors will facilitate nurses’ critical thinking on how safeguarding knowledge is to be applied in clinical practice.

What is safeguarding supervision?

As previously mentioned, keeping children safe can be challenging, overwhelming and draining, which can, in turn, adversely affect nurses’ wellbeing. It is therefore important that safeguarding supervision is provided to nursing staff, particularly to those, such as health visitors, who are responsible for the case management of vulnerable children and families.

Safeguarding supervision provides a safe, confidential space in which supervisor and supervisee can reflect on challenging cases and difficulties encountered in practice. It needs to be provided in an environment in which staff can speak freely about the difficulties they have experienced (or are still experiencing) and receive emotional support from their supervisor.

It has been argued that health and social care organisations should view the provision of safeguarding supervision as part of their duty of care to staff and as a way of ensuring staff are competent (Social Care Institute for Excellence, 2013). Key benefits of safeguarding supervision for nursing staff are listed in Box 1.

Box 1. Safeguarding supervision: key benefits

  • Improved confidence in safeguarding practice
  • Sense of clarity, including on action required
  • Time to ‘blow off steam’
  • Learning from experience

Roles of supervisor and supervisee

Successful safeguarding supervision requires staff to be properly prepared for it and to understand the roles and responsibilities of supervisor and supervisee.

The supervisor’s role includes:

  • Reviewing risk assessments;
  • Ensuring the nurse’s responsibilities in delivering protection plans are clear;
  • Being a source of emotional support.

The supervisor is a skilled professional described by Titchen (2003) as a “critical friend” to the nurse. The supervisor will:

  • Hold the supervisee to account for their practice;
  • Ensure professional and organisational standards are maintained;
  • Scrutinise, constructively challenge and evaluate the work;
  • Ensure that a comprehensive risk assessment has been undertaken;
  • Ensure that potential protective factors for the child – for example, parenting capacity, family and social support network, external scrutiny of the child by other agencies such as school or a nursery – have been considered;
  • Ensure that potential strengths within the family – for example, parental insight and engagement with professionals and safety plans to address the identified concerns or risks, along with a willingness to make positive behavioural or attitudinal change have been explored;
  • Investigate areas for staff’s professional and personal development.

The supervisee needs to demonstrate confidence, competence and the ability to take action when things appear not to be going well. As an example, if they identify that a child is at risk of harm or has experienced harm, they would be expected to make the referral to escalate concerns. Likewise, this would also be expected if the supervisee feels that a child protection plan is not being delivered as agreed by multi-agency partnership; advice should be sought if needed. This is crucial for the effective delivery of the health component of the multi-agency protection plan that will have been put in place for a vulnerable child.

Before a supervision session, the supervisee needs to review the cases to be discussed, including:

  • Safeguarding risks;
  • Protective factors that might mitigate those risks;
  • Strengths within the family;
  • Protection plans;
  • The impact the case is having on the supervisee themselves.

They also need to ensure that enough time is allocated to their supervision session on the staff rota.

Reflective supervision

To fulfil their role in safeguarding children, nurses need to be able to:

  • Clearly articulate, and be specific about, the safeguarding concerns they have identified and the familial and extra-familial risks to the child;
  • Identify any protective factors that might mitigate the risks;
  • Understand the contents of a multi-agency plan, along with the roles that other professionals and agencies will play in delivering it;
  • Analyse the information gathered about the child and family to explain what it means in terms of keeping the child safe;
  • Consider whether there is anything they need to find out or do differently.

The nurse’s thoughts and feelings on what is working well, what is not, what they do not know and what they need to find out, as well as lessons learnt, need to be explored. This can be done through reflective supervision.

Reflective supervision is a structured guided discussion between supervisor and supervisee, who use it to look back at safeguarding concerns identified by the supervisee and the actions taken at the time. Points of discussion may include:

  • Was the action appropriate?
  • Did it have the desired outcome?
  • What could have been done differently?
  • How would the supervisee manage the case if a similar issue arose in the future?

Reflective supervision also provides the opportunity to look forward and consider how new learning can be used in future practice. Fig 1 shows a cycle of reflection-based supervision modelled on work by Gibbs (1988) and Kolb (1984).

fig 1

Functions of supervision

Richards et al (1990) identified four complementary functions of professional supervision; these are shown in Fig 2 and discussed below. A practice example is given for each.

Supportive/restorative function

Something that is ‘restorative’ has the capacity to restore health, strength and/or wellbeing. In the light of the current challenges faced by NHS staff, the restorative function of supervision is critical if we want to maintain nurses’ health and wellbeing. Employers will benefit because it will contribute to keeping children safe (see Box 2).

During supervision, nurses should be given the opportunity to:

  • Safely explore their safeguarding practice with a skilled, empathetic and non-judgemental supervisor;
  • Consider the emotional impact their work may have on them;
  • Vent frustrations;
  • Recharge their batteries;
  • Agree a clear course of action for the future.

Box 2. Restorative function: practice example

A health visitor with a challenging workload has missed two safeguarding sessions due to sickness. When she returns to work, she meets with her supervisor and tells her that she is not coping well but is too embarrassed to tell her manager because it would make her feel like a failure, as all her colleagues appear to be coping.

The supervisor explores with her the impact of not working effectively and safely may have on her, as well as on the children and families she has responsibility for. They agree that a three-way meeting with her line manager should be arranged where they will discuss how her workload can be managed more effectively and how she can be better supported.

Management/normative function

The management (or normative) function of supervision should not be confused with the supervision function of line managers, whose role includes operational responsibilities. The role of the supervisor is to hold the supervisee to account, specifically in relation to safeguarding, and ensure that standards of performance are maintained in line with organisational and local safeguarding policies and procedures. An example of the management function is illustrated in Box 3.

Box 3. Management function: practice example

A school nurse constantly fails to prepare for supervision, is always late and has not delivered her part of the multi-agency child protection plan. The supervisor tries to find out whether the supervisee is having difficulty managing her workload or whether there are any other issues. The supervisee is not receptive and tells the supervisor that she is not her manager.

In view of the fact that the health component of the child protection plan is not being delivered, the supervisor explains to the supervisee that she will have to inform her line manager that there are concerns about her competence, that her clinical practice has fallen below standard and that she is potentially putting children and families at risk.

Educational function

A rewarding aspect of supervision for the supervisor is the opportunity to support nurses with their continuing professional development. For example, supervisors can help nurses to learn to use evidence to work more effectively with families. An example of the education function of supervision is outlined in Box 4.

Box 4. Educational function: practice example

An accident and emergency nurse discusses with his supervisor the case of a four-month-old baby with a head injury, which according to the parents has been sustained when the baby crawled out of bed. The X-rays showed no serious injuries and the account given by the parents has not been robustly challenged. The baby has been discharged by the doctor to the care of the parents.

The supervisor and nurse look at the evidence on developmental milestones, skills and abilities expected in a four-month-old and agree that the injury has probably not occurred in the way described by the parents, so the possibility of physical abuse by the parents has to be considered and the concern raised. The supervision session highlights the nurse’s need to be knowledgeable about normal child development, as well as to be able to challenge colleagues and/or parents if needed.

Mediation function

Mediation may not be as well understood as the other three functions of supervision. Morrison’s view is that supervision in its mediation function provides a link between the worker and the organisation (Morrison, 2006). It can be described as enabling nurses to understand how they fit into their employing organisation’s structure and what their place is in the two-way process of sharing of information with external organisations – for example, schools and children social care services (see Box 5).

Box 5. Mediation function: practice example

A nurse makes a safeguarding referral to children’s social care services for a child that he suspects has been neglected over at least 18 months, but is informed by children’s social care that no action will be taken. He contacts his supervisor for advice.

The supervisor supports the supervisee by reviewing the original referral, checking that the safeguarding concerns and actions expected from children’s social care were explicitly stated and asking the nurse to compile chronological evidence of his concerns. The supervisor also checks the referral against the children’s social care threshold documents, which outline when a ‘child in need of protection’ investigation is to be initiated. The supervisor supports the nurse to escalate the referral, in line with the local children’s board safeguarding policy.

fig 2

The voice of the child

The CQC’s (2016) report Not Seen, Not Heard concluded that the voice of the child was ‘deafeningly silent’ in safeguarding cases and inspection reports on looked-after children. Really listening to what a child is saying can make all the difference – for example, the difference between moving the child to a place of safety and leaving them in a place where they are at risk of harm. Nurses have extremely busy roles, but this should not prevent them from actively listening to what children and young people have to say.

Conclusion

No single agency or professional can keep children safe. Nurses can make a difference in safeguarding children, but they must remember that they are not alone in this. They are key members of the multi-agency safeguarding systems that are in place to protect children and young people, and their role is to advocate for vulnerable children, identify safeguarding concerns and take action in the form of timely referrals to children’s social care and specialist support services.

Working with children who are at risk of abuse or neglect, or are being abused or neglected, is challenging and will undoubtedly have an emotional impact on nursing staff, who need to develop and maintain their safeguarding competence by attending relevant training and receiving safeguarding supervision.

Safeguarding supervision is not an ‘add on’ to have only if time allows; it must be integral to practice. Preparation is key: before attending supervision sessions, nurses need to think about the cases they want to discuss with their supervisor. If nurses are not getting the right support to keep children safe or if their referrals are not followed by appropriate action, they should speak to their supervisor or manager, or escalate their concerns to their director of nursing.

Key points

  • All nurses have an active role to play in safeguarding children, which can be hugely challenging
  • Nurses need to take a reflective and analytical, rather than a task-oriented, approach
  • Nursing staff need appropriate safeguarding supervision, but this is often lacking
  • Supervisors have restorative, management, educational and mediation functions
  • Nurses should take the time to listen to children and young people
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