Janet Riddell-Heaney, MA, RN, RHV, DipChild Protection, Cert Ed.
Designated Nurse for Child Protection, Harrow Primary Care Trust, HarrowThis is the fifth of a five-part child protection series, safeguarding children, comprising: - January 2003: The role of health and other professionals. - February 2003: Identifying and preventing institutional racism. - April 2003: Getting to grips with culture and ethnicity. - May 2003 Needs of refugees and asylum seekers. - June 2003: Listening as part of the child- protection process Work is already well under way towards the completion of a National Service Framework (NSF) for children, currently scheduled for winter 2003/2004 (DoH, 2003a). Many health-care professionals hope this will herald a new era in the health and social care of children. The NSF will develop new national standards across the NHS and social services, to ensure better access and smoother progression in the provision of services to children, from initial contact with the NHS, via a GP surgery or NHS hospital, through to social services support.
|This is the fifth of a five-part child protection series, safeguarding children, comprising: - January 2003: The role of health and other professionals. - February 2003: Identifying and preventing institutional racism. - April 2003: Getting to grips with culture and ethnicity. - May 2003 Needs of refugees and asylum seekers. - June 2003: Listening as part of the child- protection process|
Work is already well under way towards the completion of a National Service Framework (NSF) for children, currently scheduled for winter 2003/2004 (DoH, 2003a). Many health-care professionals hope this will herald a new era in the health and social care of children. The NSF will develop new national standards across the NHS and social services, to ensure better access and smoother progression in the provision of services to children, from initial contact with the NHS, via a GP surgery or NHS hospital, through to social services support.
Some preliminary consultation documents have already been published (DoH 2003b, c, d). The framework aims to put children and young people at the centre of their care, involving them and their carers in choices and building services around their needs.
This series on child protection has examined a range of issues concerning the safeguarding of children and young people. Among them were the role of health-care professionals, how institutional racism can affect the delivery of effective child-protection practice; the need to recognise the culture and ethnicity of the children we seek to safeguard; and issues specific to asylum-seeker and refugee children and young people (Riddell-Heaney and Allott, 2003a, b, c, d).
Here, in the final part, we highlight some of the structures in place to aid us in our practice in listening to the children and young people we seek to protect. We examine how local practice may be reviewed to promote listening to children and young people in a constructive, inclusive and proactive way.
There is a strong interest within Government and research organisations - as reflected in the developments of the NSF - in understanding how children are represented within the policy process and how they are engaged within policy and practice. Children and young people are individuals with their own issues, concerns and opinions.
Why is it so important to engage them for their views and find out the factors that impact on their lives? What are the benefits of discovering their different perceptions, meanings and life experiences?
Some would say adult decision-makers know best - but do they? The answer is no. One vital reason for eliciting a child or young person's view is that health-care providers need to know what the issues are in order to plan appropriate services.
It used to be thought that if a child was in a situation where harm was occurring or about to occur, they were better off being away from it and should be removed. The logic is that as adults with decision-making abilities and health professionals, who have a greater or lesser degree of power, we know best, so therefore it is right to remove the child from the harmful environment. However, the outcome can be that neither the child or family are consulted about hugely important areas of their lives, even though any decision made will have life-long and possibly damaging effects. This is surely not helpful to anyone. Full and inclusive discussion is required to ensure that the best interests of the child are served. This necessarily involves all concerned parties to be open, honest and respecting of each other's views.
Including children's views
The Children Act (1989) [The Children (Scotland) Act (1995) and The Children (Northern Ireland) Order (1995)] introduced a 'welfare checklist' for a court to consider in child-protection proceedings, which includes a statement that the 'wishes and feelings of the child subject to the child's age and understanding' should be included for consideration by the court.
If we are to consider children's preferences in our service delivery then a decision has to be made regarding who is a competent child. The debate about the age at which a child is considered to be 'competent' is ongoing.
The Gillick case (1985) - a court case about the rights of parents in relation to medical matters concerning their children - has become a standard benchmark for assessing the competence of children in being able to contribute to decision-making. The inclusion of a statement about children's wishes and feelings was a step forward in determining the legal individuality of a child aside from legal parents or guardians. As a result of this case, if a doctor considers a child or young person to be 'Gillick competent' the doctor can only disclose information about medical treatment to the parents with the child's consent.
There are many structures and projects in place to assist children's and young people's participation. Wales has a Children's Commissioner. Northern Ireland and Scotland are soon to appoint to this post. However, in England, although there is a minister for children, there are no known plans to appoint a children's commissioner. This is despite repeated requests for this, most recently in the Laming report into the circumstances surrounding the death of Victoria Climbie (Laming, 2003).
Empowering young people
A number of projects have sprung up to empower children and young people. These take a variety of forms, such as published personal stories, the Children's Express (a national news agency run by and for children), surveys and interviews undertaken by voluntary bodies such as ChildLine, the National Society for the Prevention of Cruelty to Children (NSPCC), the National Children's Bureau, and the Children's Society, among others. These organisations continually strive to include the views of children and young people at every point of their policy development. Article 12 is an organisation run by young people for children and young people and offers advice on a whole range of issues in child-friendly language. It requires dedicated workers to develop initiatives that are child friendly - it may well involve adapting processes for being in touch with children and young people such as internet publications, mobile phones and text messaging.
The National Service Framework for Children
The 2000 NHS Plan hardly mentioned children and young people (DoH, 2000a). But on 28 February 2001 the Government announced a new children's National Service Framework, to be based on values spelt out in the NHS Plan - of modernisation, breaking down professional boundaries and partnership between agencies (DoH, 2003a).
The Government has already published the first module of the NSF, called Standard for Hospital Services (2003c); Emerging Findings (DoH, 2003b), a consultation document setting out the direction of travel for the whole NSF; and guidance on the core principles for providing a friendly environment for children or young people accessing health-care facilities (DoH, 2003d). A Children's Taskforce is overseeing the development of the whole NSF, with the main document scheduled to be published in the winter of 2003/2004.
The new national standards across the NHS and social services for children will hopefully ensure better access for all children from the first point of contact with the health service. The children's NSF is about putting children and young people at the centre of their care and building services around their needs.
The Department of Health also has a Quality Protects co-ordinator specifically for children and young people's participation. The co-ordinator has established a Quality Protects young people's reference group that meets regularly to discuss policy initiatives.
During the course of the Quality Protects (DoH, 1998) programme several events have enabled children and young people to be heard through workshops, drama, and other activities. The Department of Health has published an action plan on the 'core principles for the involvement of children and young people' (DoH, 2002a). It recognises that child health and social needs are different to adult ones, and provides an overview of current and future measures.
The NSPCC (1997), in conjunction with Chailey Heritage and the Department of Health, has produced Turning Points, which is a helpful training resource for use with children and young people.
The standard of advocacy that children and young people may receive is an important issue.
Again, the Department of Health has issued guidelines on good advocacy practice - National Standards for the Provision of Children's Advocacy Services (DoH, 2002b) - as part of the Quality Protects initiative (see Box 1). The standards have been written in consultation with children's and young people's advocacy groups such as the National Children's Bureau and NSPCC. They mirror the principles of the United Nations Convention on the Rights of the Child (1991) Working Together to Safeguard Children (DoH et al, 1999) and the Children Act (1989).
The standards state that 'advocacy is about empowering children and young people to make sure that their rights are respected and their views and wishes are heard at all times'. The role of the advocate encompasses more than just speaking for and representing children and young people. It also includes supportive, advisory and informing roles in children's lives.
According to the Department of Health standards the role must have a formal management structure and be open to scrutiny, while maintaining client confidentiality. Interestingly, these standards cover children and young people up to the age of 21 years, in contrast to the definition of when a child stops being a child, which is 18 years.
In Learning the Lessons, the Government's Response to Lost in Care (DoH, 2000b), a great deal of evidence was gathered from people who were victims of child abuse within the care system. The document makes difficult reading and highlights the problems that people had when trying to report child abuse. Since then, in the care system there are efforts to build policy from the bottom up, through consultation with the children and young people who receive services.
Several authorities fund advocacy projects and there is now money available for similar projects. In England, a £450 million Children's Fund, administered by social services, has been established to develop good practice for services for vulnerable children aged 5-13 years; with £70 million earmarked for distribution to local community groups. The UK has never had to consider what to do with the views of empowered young people before. It could be disconcerting to professionals, and will add time to child-protection assessments/reviews/conferences.
Before children are encouraged to become spokespeople for their experience of the care system, it is important to consider how the process will affect them. Engaging children at a younger age - six or seven years - would appear to be more appropriate. This will allow children to develop skills for being able to express themselves clearly. It requires more creativity, staff support and resources. Listening to this age group will cut right to the heart of persistent attitudes to children as powerless or too young to have an opinion.
The Framework for the Assessment of Children in Need and their Families (DoH, et al, 2000) states:
- Children's own perspectives on their experiences are an important source of knowledge
- Increasingly, the validity of children's views on their lives is acknowledged in research
- Children have views about what is happening to them. They attach meaning to events
- They have wishes and feelings, which must be taken into account, and they will have ideas about the direction of decisions and the way in which those decisions are executed.
Working Together to Safeguard Children (DoH et al, 1999) endorses these statements and provides further insights by identifying:
- Children of sufficient age and understanding often have a clear perception of what needs to be done to ensure their safety and well-being
- Listening to children and hearing their messages requires training and special skills, including the ability to win their trust and promote a sense of safety
- Most children feel loyal towards those who care for them, and have difficulty saying anything against them
- Many do not wish to share confidences, or may not have the language or concepts to describe what has happened to them
- Some may fear reprisals or removal from home
- Children and young people need to understand the extent of their involvement in decisions
- They should be helped to understand how child-protection processes work, how they can be involved, and that they can contribute to decisions in accordance with their age and understanding
- However, they should understand that, ultimately, decisions will be taken in the light of all the available information contributed by themselves, professionals, their parents and other family members, and other significant adults.
Engaging and listening to children: practical advice
The difficulties health-care professionals face in engaging children and young people are varied. They range from a lack of confidence to feeling isolated and unsupported within the workplace. Many organisations have published guidance (Box 2) on how to engage children and young people and there are different ways of doing it. The broad principles are:
- Always give children and young people your undivided attention
- Tolerate - and learn to enjoy - silences. Silence allows someone to recollect and collect their thoughts and feelings
- Encourage the person to tell their story in their own words and their own time
- Be aware of 'interrogative' questions
- Do not offer advice - only information. Do not tell someone what you would do in their position
- Put yourself in the person's shoes
- Avoid making judgements and snap opinions
- Allow children and young people to say things in their own words and time - do not interrupt
- Be aware that you can empathise but you do not know how someone is feeling.
Health-care professionals need to maintain a professional boundary. Self-awareness in engaging children and young people is vital in gauging how to respond to a child or young person's conversation, views or needs. The way the health-care professional responds influences the way the personnel and the service provided are viewed.
Gaining the trust and respect of children and young people is based on the ability of the health professional to recognise outdated views or judgmental attitudes that can cause damage and hurt to children and young people.
In child protection, it is important that the child or young person knows that there may be times when you cannot promise confidentiality.
If the well-being and safety of a child or young person is at risk of or is being compromised, it is clearly identified in the Nursing and Midwifery Council's Code of Professional Conduct (NMC, 2002) that we have an obligation to pass this information on to the relevant agency. It is a difficult area, and one that can create much confusion as the boundaries with regard to confidentiality are clear. Once a concern is passed on to the relevant agency, it is important that confidentiality is maintained as much as is possible and practical. Health-care professionals who are involved with a child and family about whom there are concerns will require this information so that the most appropriate care and advice may be given. But beyond this the normal boundaries apply and child-protection concerns should be treated with the respect they deserve so that the child and family do not become socially excluded.
The new children's NSF document Getting the Right Start: National Service Framework for Children: Emerging findings (DoH, 2003a) acknowledges that confidentiality has been identified as 'something that needs further thought'. It adds:
'The Department of Health is currently consulting on proposals on confidentiality which are set out at www.nhsia.nhs.uk.confidentiality/pages/consultation. Young people aged 16 or 17 are regarded as adults for the purposes of consent to treatment and are entitled to the same duty of confidentiality as adults.
'Similarly, the duty of confidentiality owed to a person under 16 in any setting is the same as that to any other person - this is enshrined in professional codes. Under-16s can consent to their own medical treatment, without parental involvement, provided that the health professional considers them competent to fully understand the implications of any treatment and to make a choice of the treatment proposed. The health professional must ensure that the criteria known as the 'Fraser guidelines' are met. Where the young person is not judged competent to consent to his or her own treatment, the consultation should still remain confidential, in line with professional codes.'
There is much to discuss about how to gain the trust of children and young people to engage in service planning, provision and delivery. Initiatives that allow full child inclusion require wholehearted support. Other ways of engaging the child in a non-threatening way have not been discussed in this paper, such as the use of family group conferences in the child-protection process.
Perhaps as you read this, and examine the practice points on listening to children, it is an opportune time to reflect on your own practice to see if you could enhance the quality of the communications you undertake with children and young people in the course of your professional life so that you can make a real difference in the lives of those who require your help, support and guidance.
Parental responsibility was introduced within the Children Act 1989. How does the Act define 'parental responsibility'? Consider how this is interpreted in your practice.
Study the information on the Children's National Service Framework website at www.doh.gov.uk/nsf/children/
There are six working groups. Discuss what impact the standards will have on your practice area.
Reflect on the standards required of children's advocates identified in Box 1.
Consider how your clinical practice may be altered by the introduction of some or all of these standards into your practice both at individual and at policy level.
Discuss ways in which children's participation and involvement can impact on your services.
Find out about your trust's patient advisory liaison service (PALS). Does it incorporate opportunities for children to influence discussion and bring about change in the organisation at ward/clinic level?
Access the website www.victoria-climbie-inquiry.org.uk and read the summary and the recommendations. Consider 'Could this happen here?'
Alderson, P. (2000) Young Children's Rights. Exploring beliefs, principles and practice. London: Jessica Kingsley Publications.
Brook, G. (1997) Help me make choices too! Developing and using a framework to help children, with their families, to contribute to decisions about treatment. Cascade: Action for Sick Children 26.
Brook, G. (2000) Children's competence to consent: A framework for practice. Paediatric Nursing 12: 5, 31-35.
Children's Society. (2001) Young People's Charter of Participation. London: The Children's Society.
Department of Health. (1998) Quality Protects: Principles of working with young people. London: DoH.
Department of Health. (2000a) The NHS Plan: A plan for investment, a plan for reform. London: DoH.
Department of Health. (2000b) Learning the Lessons: The Government's response to Lost in Care. London: DoH.
Department of Health. (2002a) Listening Hearing and Responding: DoH Action Plan: core principles for the involvement of children and young people. London: DoH.
Department of Health. (2002b) National Standards for the Provision of Children's Advocacy Services. London: DoH.
Department of Health. (2003a) The National Service Framework for Children. Available at: www.doh.gov.uk/nsf/children
Department of Health. (2003b) Getting the Right Start: National Service Framework for Children: Emerging findings. London: DoH.
Department of Health. (2003c) Getting the Right Start: National Service Framework for Children: Standard for hospital services. London: DoH.
Department of Health. (2003d) Improving the Patient Experience: Friendly health care environments for children and young people.. London: DoH.
Department of Health, Home Office, Department for Education and Employment. (1999) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London: The Stationery Office.
Department of Health, Home Office, Department for Education and Employment. (2000) Framework for the Assessment of Children in Need and Their Families. London: The Stationery Office.
Joseph Rowntree Foundation, Children's Society. (2000) Ask Us: A Children's Society multi-media guide to consultation. York and London: JRF/Children's Society.
Joseph Rowntree Foundation, Triangle, NSPCC. (2002) Two-Way Street Training Video and Handbook 2002: Communicating with disabled children and young people. York and London: JRF/Triangle/NSPCC.
Laming, H. (2003) The Victoria Climbie Inquiry. Report of an inquiry. London: The Stationery Office.
Morris, J. (1998) Don't Leave Us Out. Involving disabled children and young people with communication impairments. York: Joseph Rowntree Foundation.
Nursing and Midwifery Council. (2002) Code of Professional Conduct. London: NMC.
NSPCC. (1997) Turning Points: A resource pack for communicating with children. London: NSPCC.
Riddell-Heaney, J., Allott, M. (2003a) Safeguarding children: 1. The role of health and other professionals. Professional Nurse 18: 5, 280-284.
Riddell-Heaney, J., Allott, M. (2003b) Safeguarding children: 2. Identifying and preventing institutional racism. Professional Nurse 18: 6, 350-354.
Riddell-Heaney, J., Allott, M. (2003c) Safeguarding children: 3. Getting to grips with culture and ethnicity. Professional Nurse 18: 8, 473-475.
Riddell-Heaney, J., Allott, M. (2003d) Safeguarding children: 4. Needs of refugees and asylum seekers. Professional Nurse 18: 9, 533-536.
United Nations. (1991) Convention on the RIghts of the Child. London: Children's Rights Development Unit.