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Do learning disability nurses adhere to zero tolerance of patient abuse?

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This focus group study explored the extent to which health care adhered to best practice in relation to zero tolerance of abuse in learning disability services

Key points

  • Systemic and individual influences result in a 'hierarchy of abuse'.

  • Failure to address these issues could lead to a disjointed and inconsistent response to tackling abuse from the nursing profession.

  • All nurses need to debate how workable zero tolerance is in the complex area of abuse.

  • Zero tolerance policies and professional codes do not appear to equate to zero tolerance in practice.

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This study explores the concept of 'zero tolerance' to abuse in the care of people with learning disabilities. The NMC published a policy of zero tolerance to abuse of clients in 2002.

The authors point out that, while zero tolerance implies 'non-negotiability', there is diversity in interpretation. They stress that while zero tolerance does have some difficulties, nurses working with people with learning disabilities have a professional responsibility to prevent and report all abuse.

The study

The study aimed to address the following question: to what extent is best practice in relation to preventing, identifying and responding to the abuse of people with learning disabilities evident in Wales?

This study was part of a larger one that used a multiphase, multimethod approach. The results here relate to the focus group stage. A series of focus groups involved 70 participants who worked as direct care staff with people with learning disabilities or as investigators of abuse. The groups explored staff attitudes to practice issues.

Key findings

Staff expressed attitudes in focus groups that appear to support the suggestion that zero tolerance policies are not interpreted as unequivocal guidance.

Recurrent themes indicated that individual and systemic themes affect responses. Individual themes are factors in the individual worker that influence their response to abuse, while systemic ones come from a more organisational or societal perspective.

Individual themes include:

  • Ambivalence/uncertainty;

  • Positive value base;

  • Who perpetrates abuse;

  • Clients abusing other clients;

  • Unfounded allegations.

Systemic themes include:

  • Types of abuse;

  • Abusive systems;

  • Environment;

  • Whistle-blowing.

Individual themes
Participants often expressed ambivalence and uncertainty in terms of expectations on them and the best course of action. Staff often felt conflict between what they knew they should do and what they felt able to do.

Discussions included the issue of 'who abuses'. There were few mentions of staff abusing clients. More commonly, staff referred to abuse in the family home. While they expressed understanding of families' difficult circumstances, they acknowledged difficulties for staff when uncovering and responding to abuse at home.

A further difficulty is when a client abuses another client. If both are cared for in the same service, staff can experience conflict
in maintaining a duty of care to both clients while making sure the victim is protected.

Systemic themes
Some organisations appear to be more aware of certain types of abuse (such as sexual abuse) and therefore show greater clarity in how they would respond to these.

Often there was greater confidence in reporting types of abuse where evidence could be gathered more easily, such as in the case of physical abuse. Some staff were aware of the less obvious types of abuse.

Several participants acknowledged the existence of 'abusive systems', relating to the wider context of life in institutions. Staff also acknowledged the individual staff member's responsibility for whistle-blowing. They felt that whistle-blowing needed to be encouraged and facilitated by the service.


The study found that a 'hierarchy of abuse' existed among staff working with people with learning disabilities. Staff seemed to weigh up what they considered as serious abuse before reporting concerns, in contrast to the ethos of zero tolerance. However, by focusing on types of abuse perceived as the 'most severe', nurses can seek to distance themselves and their profession from these acts.

Some staff held a strong 'abuse is abuse' standpoint, in line with zero tolerance, while others distinguished physical and sexual (and in some cases financial) abuse from other forms in terms of severity and response required.

Jenkins et al (2008) stress the need for a consistent approach to abuse, highlighting that nurses need training to gain confidence in their role in preventing, identifying and responding to abuse of clients.

The authors conclude that, currently, zero tolerance outlined in codes and policies does not appear to equate to zero tolerance in practice.


Jenkins, R. et al (2008) Zero tolerance of abuse of people with intellectual disabilities: implications for nursing. Journal of Clinical Nursing; 17: 22, 3041-3049.

To read this study in full click here.

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