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Protecting children in the Accident and emergency department
Protecting children in the Accident and Emergency department C. Powell
Approximately one-third of patients attending Accident and Emergency departments are children and their differing needs are currently on the health care agenda. Nurses working in A & E will treat and care for children for whom a possibility of abuse or neglect may be raised. This article explores the concept of child protection and discusses the role of the nurse in relation to UK Government guidelines and legislation. These, in turn, inform local procedures and guidelines for practice. While the work of A & E departments is often crucial, most child protection work should take place in community child health settings.
INTRODUCTION Catherine
Powell BNSc
(Hans), RGN, RSCN, RHV Joint Appointee Lecturer I” Child Health Nursing, Southampton University Hospitals I-ust/Uwersity of Southampton, University of Southampton School of Nursing and Midwifery, Level B, South Academic Block, Southampton General Hospital, Southampton SO I6 6YD, UK Manuscript 1996
accepted
IS July
Based on a paper given at the RCN Accident and Emereencv Conference, Warrl”gto”,Y November I995
In the UK children under the age of 16 years make up approximately one-third of the total number of patients seen in Accident and Emergency (A & E) departments (Department of Health 1991). While the majority of these children will present with clearly defined health care problems resulting from accidents or acute illness, a significant minority may be suffering from non-accidental physical injury or neglect. For others, suspicion of maltreatment (including emotional and sexual abuse) may be raised indirectly alongside other presenting problems. This paper defines child protection within the framework of UK Government guidance and legislation. The role of nurses in the A & E
Accrdent and Emergency Nursing ( 1997) 5, 76-80 0 Pearson Professtonal I997
department in recognizing and responding to child abuse and neglect is also presented. The paper concludes by promoting the role of conrmunity-based health professionals in handling the preponderance of cases.
CHILD
PROTECTION
Child protection is the promotion of decisive action to protect children from abuse and neglect (Home OfIice et al 1991). The primacy of the concept of ‘child protection’ rather than ‘child abuse’ reflects the response to the recommendations of the public inquiries into the deaths of children at the hands of their parents and carers. In particular, it was the death of 4+-year-old Jasmine Beckford and the subsequent inquiry (London Borough of Brent 1985) that prompted the publication of government guidelines aimed at improving interprofessional and interagency working in the field of child abuse and neglect (Department of Health and Social Security 1988). These first Working Together guidelines called for changes in professional practice among those working with ‘at risk’ children from a reactive to a proactive approach, concomitant with a conception of child protection. The document provided clear direction in cases of actual or suspected child abuse for professionals from statutory and other agencies working with children. Statutory agencies include social services, the National Society for the Prevention of Cruelty to Children and the police. Others for whom the document was intended included health professionals, educational staff and probation and voluntary sector workers. The guidelines have since been updated in light of the Children Act 1989, and continue to promote the importance of interagency communication and collaboration in child protection work. In particular, they highlight the major role that health care agencies have in protecting children from abuse and neglect, and participating in interagency work (Home Office et al 1991). The underlying philosophy of the legislation and guidance promotes children’s rights as individuals, and recognizes the need to work in partnership with children and their families to ensure the best outcome for the child.
DEFINING
ABUSE
One of the difficulties in child protection work is in defining a particular situation as ‘child abuse’. Child abuse is not easily defined (or measured).
Protecting children 77
The recent publication of .I commicsioned report into the prevention of child abuse has provided a broad definition:
Acts that ~nay be constructed as .tbusive mill vary across time and culture (Rogers et aI 1992; Cloke 8.~ Naish 1992; Corby 1993). Cultural considerations arc important as different cultural groups may have varying ideas as to nhat may br considered iiidltreatni~nt of d child. Furthermore, fanlilics may not share the smle patterns of access to health and social servicrs. However. in a multicultural society such ‘15 thr UK, murkus may hcsitatc in intervening in casts of child abuse becawx of cumin espcctCltionc and beliefs about ethnic minority practices (Charles 1993). Working definitions given in the official Suidelines are not excluGve, but categorize four diffuent types of child niC~ltremiient for child protection registration purposes (Home Office c‘t al 1991): ‘nqlect’; ‘physical injury (including M~u~clx~~~sc~~‘ss)ndrome by proxy); srsu~l huse; and emotional husc. This final categor): recognircs that ,111abuse involves some cmtional nmltrcatmcnt, but 19 ~lscd ~vheii it is the Imin SOLIKC of abuse. Thcreforc, a range of cil-cumstanccs ior which protective action is needed arc indicated. Many of the 31 000 children whose ILIIIICS ww-e on Child l’rotcction Registers in England at 31 March 1994 (l)cpartment of Health 1995) mill have initially been referred to the statutory ag:encies b) health pmftssionals, including A & E staff. The ‘lnedicalization’ of nbuse is frequently nttributcd to the bvork of Kempe and his colhgues (1 %?a), who wised the tttriii ‘battered child’ in an attempt to gain Lvidesprcad publicity of the iscur of severe, sometimes fatal, injuries inflicted by parents and carcrs. The nature of these childhood injuries merittd a profwional response fi-own \vithin A 8.~ E departments. However, the ever-broadening construction of child nlaltreatment. alongside preventative uork m the community, no\v invokes multiagency work in a variety ofsettin~s.
The nurses’ role in child protection in the UK lies within the framework of legislation and govermnent guidelines for mteragrncy working. As LVChave seen, this points to a proactive
role in prevention, early detection of family dysfunction and the provision of support. The qidance document for wnior nurses, published in conjunction with the government guid&ies, suggests:
This role is personified by Herbert (1903), who acknowl+es that nurst‘s arc in J kq position to identify f,miilies under mess and children \vho are at risk of, or \vho haw suffered, abuse and neglect. Cloke K Nanh (1092) sqgcst that nurses have a role in prtwwitioii through the promotim of positiw paxnting alld by working with parents to teach thctll iioi-mdl patterns ofdevelopnicnt.
The A & E nurse The role of nurses in the A K E department is paramount in both recognizing, and responding to, situations that may bc indicative of actual, or likely. f?equent abuse or nrglect. The importance of this role has been highlighted by Wynne (1992) and l)in~wall et al (1095). lXngwal1 t‘t al (1095) also iiotc that perniancnt nursing staff working in A & E departments may have detailed knowledge of the social geography of the local conlmunity. This knolvledgc, alongside experience and skills in assessing parental dcmeanour, is contrasted with the abilities of junior doctors, who are usualI> both less experienced with families. and practismg in an A & E department ml a tm~porary, rotational basis. Such a situation reitcratrs the need for profmionals to work collaboratively ill child protection decisioll-snaking.
Named
professionals
Recent guidance on the clarification of the child protection roles and responsibilities of senior health professionals recommends that each trust identifies ‘named professionals’ (a senior nurse, midwife and doctor) with an accountability for child protection work. In sunmlar): the duty of such professionals is to offer support alld advice to staff idrnti+ training needs and facilitate clinical supervision (1)epartment of Health ct Welsh Office 1095). One example of this role may bc to help professional colleagues who arc prcpuing to (Ionferences or attend Child Protection Court. Iinportmtly, the naiiied professionals
78 Accident and Emergency Nursing
will provide a health perspective to a range of multidisciplinary and multi-agency Child Protection Committees. However, it is notable that many post-holders, chosen for their child protection experience and knowledge, undertake this role as part of a senior managerial or clinical post. The exception to this may be the growing number of ‘Child Protection Nurse Specialists’ the vast majority of whom are employed by community trusts.
Recognizing
child abuse
Accident and Emergency nurses may be the first professionals to identifji a child in need of protection. Their role is primarily to express a concern rather than ‘make a diagnosis’ (Swann 1993). A number of texts are recommended for a more detailed review (Bannister 1992; Meadow 1993; Blumenthal 1994; Powell 1995). The physical and behavioural indicators of possible abuse may include: bruising of sot? tissue, burns, multiple fractures and fractures in children under the age of three l adult bite marks 0 torn frenulum l failure to thrive l frozen watchfulness l excessive sadness 0 self mutilation l childhood overdose l indiscriminate attachment 0 precocious sexual activity l venereal disease l genital or rectal bleeding A l
The neglected child may present as dirty, smelly, obviously under weight and hungry. The ‘signs and symptoms’ are not definitive, however, and will always need to be taken in context with other factors. These may include concerns relating to the timescale in seeking help, a mismatch between injuries and explanations given, and the behaviour of the child and parents. Concerns may also embrace the frequency of attendance in the department (Royal College of Nursing 1994). It is salutary to learn that the children of Frederick West were reported to have been seen at their local hospital on 16 occasions (Gcrardian 23 November 1995). Indeed, child abuse is rarely a ‘one-off’ incident, with children who are seriously injured or killed often having a long history of frequent bruising and other injuries (Bannister 1992). In recognition of this factor many A & E departments have information systems that highlight attendees. In tandem with this it is important to have mechanisms in place that detect abusing parents and carers who ‘shop around’ for health care.
Responding At the early stage of identification of a child who may have been abused it may be helpful for A & E staff to seek advice and support from the ‘named professionals’ who have an expertise in child protection. When a child presents with signs of possible abuse or neglect it may also be useful for A & E staff to gather information from community staff such as health visitors, school nurses and general practitioners. The liaison health visitor may be able to give support in facilitating this. The child should be examined by a paediatrician experienced in child protection. Repeated examinations are to be avoided and may well be construed as further abuse by an already distressed child. The statutory agencies may also offer advice and support at this early stage, particularly where a search of records shows earlier concern within the family. The child’s or a sibling’s name may have been previously entered on the local ‘Child Protection Register’. Many A & E departments have direct access to the names of children on the Register. A need for protection has already been identified for such children and early communication with the key worker is essential. Through the discussion of concerns with appropriate colleagues, a decision may be made to make a formal child protection referral to the local Social Services Department. The precise mechanisms for achieving this will vary according to local guidelines and procedures. As the Working ‘l@ether document (Home Office et al 1991) identifies, the responsibility for the provision of multi-agency guidelines lies with Area Child Protection Committees (ACPCs). Individual agencies will usually have their own procedures that are commensurate with the ACPC guidelines. The processes may involve a strategy discussion, investigation and child protection conference. Criminal or care proceedings may follow. Accident and Emergency staff may be called upon to contribute at all stages. It is particularly important that clear, contemporaneous records are kept. As with any other child patient, parents or carers need to be supported and involved in the immediate care and treatment. However, there may be occasions when parents or carers present a threat to the child by removing the child from the department before treatment and investigations are completed. In an urgent situation such as this, Section 46 of the Children Act (1989) ‘Police Protection’ allows the police to prevent removal of a child for up to 72 hours if they believe that a child would otherwise suffer significant harm.
Protecting children 79
Confidentiality While the key to protecting children is interagency conmm~ication and collaboration, medical and nursing staff may feel sensitive to the notion of confidentiality. In child protection work:
1)isclosure of inforinatioii in relation to child protection by medical or nursing staff is considered a matter of public interest and \vill therefore norniall~ be justified (United Kingdom Central Council 1 Y87; IIepartnlent of Health et al 1001). Child abuse and neglect at-e emotive issues and staff support and debriefinS are essential. In recognition that retrospective studies have sugbcrested high < levels of undetected and prcviousl) unrccord~d childhood abuse (Taylor lYY3) it is important to remember that the response and i-cactioils of staff may reflect adverse personal espcrienccs. The excellent R(:N pamphlet I+c)fcrtir~~~Clriltlwrr (1 YO4) provides d list of national helplines that m,l): be a starting pomt for distressed staff a5 dell as a source of help for f;iniilics. These could, therefore, be publicized \\,ithin the l~epartnicnt.
-,._
ii:,
,.
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_
CARE AND TREATMENT IN THE BEST INTERESTS OF THE CHILD In contrast to the images of serious and fatal childhood InJuries presented by Kempe et al (1062), the majority of- cases of physical injury investigated by the statutory agencies today are those of relatively minor physical harm (Herbert lYO3). Thus, the centrality of the A &. E department in de&g with child matreatment has become of less importance as LVVC respond to these cases and the other forms of abuse outlined above. This section puts forlvard the arguments for coiiiliiuiiity-hased assessinent of children who arc suspected of suffering from abuse or neglect.
Care of children
in hospital
Although there have been numerous initiatives to make all hospital environments ~nuch more ‘child friendly’, children are particularly vulnerable to the effects of hospitalization (Department of Health IYYI). Indeed, it is interesting to compare the behavioural indicators of child abuse with soll~e of the historic reports of hospitalized children’s reactions
(Robertson 1958). In an attempt to provide high quality services to children, some hospitals provide a separate paediatric A & E department, while many more have children’s waiting and treatment areas. Nevertheless. in some hospitals it rn~y be more appropmte to admit children who present with a possible child protection problem to a paediatrlc mrard area f& assewnent by a paediatrician. The provision of child and f&nily-centrcd facilities m A K E departments is supported b) the latest Patient C:harter initiative (I~epartmcnt of Health 1YY6) This docunlent adds Lveight to the previous calls for staffing to reflect the diff>reiit needs of children. While recognizing the speciahst preparation of A K E practitioners, there is cle,lr ju\tificatioii to support the presence of paediatric staff (including ilurses \vith the Kegistered Sick Children’s Nurse/ Registered Nurse - Child qualification) iu ,111 areas that cdrc for children (l)ep,lrtiiient of Health 1 OY1 ; Clothier ct al 1004; I?epartmrnt of Health lYY6). In additioil, Wynnc (lc102) suggests that prevcntatiw work in child protection is dependent upon knowledge and undcrstandmg of a child’s needs and rights as ‘111 individual. Study of such concepts is central to the preparation of children’s nursing practitiow ers. The ideal must be the duality of a children’s qualiticatlon coupkd with the specialist A & E certificate. To ensure that children are not harmed b) to recognize and their experience\. LVK need address the possibility that A & E services ma) not ,~l\vays be responsive to the needs of children (Gay IOY I). Furthermore, we need to question the 3pI”“l)riateness of referrals of children to A K E departments for investigation 01 awsment ofnmor physical injuries or possible ses~d &LIS~‘. As Wynne (1003) points out, the A 8, E department may not be a suitable envii-onnicnt in M-hich to assesscases oiabuse, as it is often noisy and lacking in privq and space.
Community
paediatrics
Wynne (lYY3) supports the role of the ~~~IIIILIniy paediatrician in assessing abused children in outpatient departments or local health clinics where an appointment can be planned. Here the child is not competing with the needs of acutely ill patients or accident victims. It is suggested that such an appointment is likely to be less distressing for the child and family. The inost recent guidance from the IIepartiixnt of Health and Welsh Office (1 YY5) states that conmunity child health staff, under the direction of a consultant community paediatrician, are uniquely placed to develop high levels of espertise in child protection. Such expertise includes examination, assrssincnt and tredtnient.
80 Accident and Emergency Nursing
The moves to assess the majority of child protection cases in the community fit well with the current notion of a ‘Primary Care Led National Health Service’. While the general practitioner is often the key to specialist referral, practice nurses, health visitors, community children’s nurses and school nurses are likely to possess extensive knowledge of vulnerable children and their families. Such professionals are well placed to discuss concerns and facilitate referral to the community paediatrician. Where possible, therefore, all but the ‘critically injured’ child, for whom there is a child protection concern, should be examined by a community paediatrician. The referral for medical assessment and examination will usually follow the initial referral by the practitioner concerned to the local statutory services (Social Services or the NSPCC), as it is these agencies who take the lead in the assessment and investigation of such cases.
CONCLUSION Accident and Emergency departments treat and care for a large number of children and their families. While some children will attend following non-accidental injury or other forms of abuse, others may be suffering from abuse or neglect in addition to their presenting problem. Accident and Emergency nurses need to be able to recognize and respond to cases of possible abuse. Specific government guidelines have been issued to assist in this process. Nurses should be aware of local procedures as well as local sources of advice and help. Nurses experienced in the care of children may be able to help prevent abuse by providing education and support to parents and carers. While the current initiatives to support the creation of separate paediatric A & E facilities are to be welcomed, the majority of child abuse and neglect cases may be better served by community child health services.
REFERENCES Bannister A 1992 Recognising abuse. In: Rogers et al (eds) Child Abuse and Neglect: Facing the Challenge. Open University Press, Milton Keynes: 165-170 Blumenthal I 1994 Child Abuse: A Handbook for Health Care Practitioners. Arnold, London Charles M 1993 Child Protection Conferences: maximising their potential. In: Owen H, Pritchard J (eds) Good Practice in Child Protection. Jessica Kmgsley, London: 150-I 64 Cloke C, Naish J (eds) 1992 Key Issues m Child Protection for Health Visxors and Nurses. Longman, Harlow Clothier C, MacDonald AC, Shaw DA 1994 The Allitt Inquiry. HMSO, London
Corby B 1993 Child Abuse: Towards a Knowledge Base. Open University Press, Milton Keyner Department of Health and Social Security 1988 Working Together: a guide to interagency co-operation For the protection of children from abuse. HMSO, London Department of Health 1991 Welfare of Children and Young People in Hospital. HMSO, London Department of Health 1992 Child Protectmn: Guidance for Senior Nurses, Health Visitors and Midwives (2nd edn). HMSO, London Department of Health, British Medical Association, Conference of the Medical Royal Colleges 1994 Child Protection: Medical Responsibilities. Department of Health, London Department of Health and Welsh O&e 1995 Child Protection: Clarification ofArrangements Between the NHS and Other Agencies. Department of Health, London Department of Health 1995 Children and Young People on Child Protection Registers; Year Ending 31 March 1994, m England. Department of Health, London Department of Health 1996 The Patient’s Charter: Services for Children and Young People. Department of Health, London Dingwall R, Eeklaar J, Murray T 1995 The Protection of Children (2nd edn). Avebury, Aldershot Gay J 1991 Caring for children in accident and emergency: Paedlatric Nursing 3(7): 21-23 Herbert M 1993 Working with Children and the Children Act: A Practical Guide for the Helping Professions. British Psychological Society, L&ester Home O&e, Department of Health, Welsh Oflice et al 1991 Working Together Under the Children Act 1989: A guide to arrangements for interagency cooperation for the protection of children from abuse. HMSO, London Kempe CH, Silverman FN, Steele BF et al 1962 The battered child syndrome. Journal of the American Medical Association 181: 17-24 London Borough of Brent 1985 A Child in Trust: The report of the panel of inquiry into the circumstances surroundmg the death ofJasmine Beckford. London Borough of Brent Meadow R (ed.) 1993 ABC of Child Abuse (2nd edn). BMJ Publishing Group, London National Commission Inquiry into the Prevention of Child Abuse 1996 Childhood Matters. The Stationery Offlice, London Powell C 1995 Health problems of young children. In: Campbell S, Glasper EA. (eds) Whaley and Wag’s Children’s Nursing. Mosby, London: 278-301 Robertson J 1958 Young Children London
in Hospital.
Tavistock,
Rogers S, Hevey D, Roche J, Ash E 1992 Child Abuse and Neglect: Facing the Challenge. Open University Press, Milton Keynes Royal College of Nursmg 1994 Protecting Children. RCN, London Swan” A 1993 Recognising abuse. In: Owen H, Pritchard J (eds) Good Practice in Child Protection. Jessica Kingsley, London: 39-55 Taylor S 1992 How Prevalent is It? In: Rogers et al Child Abuse and Neglect: Facmg the Challenge. Open Universay Press, Milton Keynes: 40-49 United Kingdom Central Council 1987 Confidentiality. UKCC, London Wynne J 1992 The Construction of Child Abuse in the Accident and Emergency Department. In: Cloke C, Naish J (rds) Key Issues XI Child Protection for Health Visitors and Nurses. Longman, Harlow: 75-87
Approximately one-third of patients attending Accident and Emergency departments are children and their differing needs are currently on the health care agenda. Nurses working in A & E will treat and care for children for whom a possibility of abuse or neglect may be raised. This article explores the concept of child protection and discusses the role of the nurse in relation to UK Government guidelines and legislation. These, in turn, inform local procedures and guidelines for practice. While the work of A & E departments is often crucial, most child protection work should take place in community child health settings.
INTRODUCTION Catherine
Powell BNSc
(Hans), RGN, RSCN, RHV Joint Appointee Lecturer I” Child Health Nursing, Southampton University Hospitals I-ust/Uwersity of Southampton, University of Southampton School of Nursing and Midwifery, Level B, South Academic Block, Southampton General Hospital, Southampton SO I6 6YD, UK Manuscript 1996
accepted
IS July
Based on a paper given at the RCN Accident and Emereencv Conference, Warrl”gto”,Y November I995
In the UK children under the age of 16 years make up approximately one-third of the total number of patients seen in Accident and Emergency (A & E) departments (Department of Health 1991). While the majority of these children will present with clearly defined health care problems resulting from accidents or acute illness, a significant minority may be suffering from non-accidental physical injury or neglect. For others, suspicion of maltreatment (including emotional and sexual abuse) may be raised indirectly alongside other presenting problems. This paper defines child protection within the framework of UK Government guidance and legislation. The role of nurses in the A & E
Accrdent and Emergency Nursing ( 1997) 5, 76-80 0 Pearson Professtonal I997
department in recognizing and responding to child abuse and neglect is also presented. The paper concludes by promoting the role of conrmunity-based health professionals in handling the preponderance of cases.
CHILD
PROTECTION
Child protection is the promotion of decisive action to protect children from abuse and neglect (Home OfIice et al 1991). The primacy of the concept of ‘child protection’ rather than ‘child abuse’ reflects the response to the recommendations of the public inquiries into the deaths of children at the hands of their parents and carers. In particular, it was the death of 4+-year-old Jasmine Beckford and the subsequent inquiry (London Borough of Brent 1985) that prompted the publication of government guidelines aimed at improving interprofessional and interagency working in the field of child abuse and neglect (Department of Health and Social Security 1988). These first Working Together guidelines called for changes in professional practice among those working with ‘at risk’ children from a reactive to a proactive approach, concomitant with a conception of child protection. The document provided clear direction in cases of actual or suspected child abuse for professionals from statutory and other agencies working with children. Statutory agencies include social services, the National Society for the Prevention of Cruelty to Children and the police. Others for whom the document was intended included health professionals, educational staff and probation and voluntary sector workers. The guidelines have since been updated in light of the Children Act 1989, and continue to promote the importance of interagency communication and collaboration in child protection work. In particular, they highlight the major role that health care agencies have in protecting children from abuse and neglect, and participating in interagency work (Home Office et al 1991). The underlying philosophy of the legislation and guidance promotes children’s rights as individuals, and recognizes the need to work in partnership with children and their families to ensure the best outcome for the child.
DEFINING
ABUSE
One of the difficulties in child protection work is in defining a particular situation as ‘child abuse’. Child abuse is not easily defined (or measured).
Protecting children 77
The recent publication of .I commicsioned report into the prevention of child abuse has provided a broad definition:
Acts that ~nay be constructed as .tbusive mill vary across time and culture (Rogers et aI 1992; Cloke 8.~ Naish 1992; Corby 1993). Cultural considerations arc important as different cultural groups may have varying ideas as to nhat may br considered iiidltreatni~nt of d child. Furthermore, fanlilics may not share the smle patterns of access to health and social servicrs. However. in a multicultural society such ‘15 thr UK, murkus may hcsitatc in intervening in casts of child abuse becawx of cumin espcctCltionc and beliefs about ethnic minority practices (Charles 1993). Working definitions given in the official Suidelines are not excluGve, but categorize four diffuent types of child niC~ltremiient for child protection registration purposes (Home Office c‘t al 1991): ‘nqlect’; ‘physical injury (including M~u~clx~~~sc~~‘ss)ndrome by proxy); srsu~l huse; and emotional husc. This final categor): recognircs that ,111abuse involves some cmtional nmltrcatmcnt, but 19 ~lscd ~vheii it is the Imin SOLIKC of abuse. Thcreforc, a range of cil-cumstanccs ior which protective action is needed arc indicated. Many of the 31 000 children whose ILIIIICS ww-e on Child l’rotcction Registers in England at 31 March 1994 (l)cpartment of Health 1995) mill have initially been referred to the statutory ag:encies b) health pmftssionals, including A & E staff. The ‘lnedicalization’ of nbuse is frequently nttributcd to the bvork of Kempe and his colhgues (1 %?a), who wised the tttriii ‘battered child’ in an attempt to gain Lvidesprcad publicity of the iscur of severe, sometimes fatal, injuries inflicted by parents and carcrs. The nature of these childhood injuries merittd a profwional response fi-own \vithin A 8.~ E departments. However, the ever-broadening construction of child nlaltreatment. alongside preventative uork m the community, no\v invokes multiagency work in a variety ofsettin~s.
The nurses’ role in child protection in the UK lies within the framework of legislation and govermnent guidelines for mteragrncy working. As LVChave seen, this points to a proactive
role in prevention, early detection of family dysfunction and the provision of support. The qidance document for wnior nurses, published in conjunction with the government guid&ies, suggests:
This role is personified by Herbert (1903), who acknowl+es that nurst‘s arc in J kq position to identify f,miilies under mess and children \vho are at risk of, or \vho haw suffered, abuse and neglect. Cloke K Nanh (1092) sqgcst that nurses have a role in prtwwitioii through the promotim of positiw paxnting alld by working with parents to teach thctll iioi-mdl patterns ofdevelopnicnt.
The A & E nurse The role of nurses in the A K E department is paramount in both recognizing, and responding to, situations that may bc indicative of actual, or likely. f?equent abuse or nrglect. The importance of this role has been highlighted by Wynne (1992) and l)in~wall et al (1095). lXngwal1 t‘t al (1095) also iiotc that perniancnt nursing staff working in A & E departments may have detailed knowledge of the social geography of the local conlmunity. This knolvledgc, alongside experience and skills in assessing parental dcmeanour, is contrasted with the abilities of junior doctors, who are usualI> both less experienced with families. and practismg in an A & E department ml a tm~porary, rotational basis. Such a situation reitcratrs the need for profmionals to work collaboratively ill child protection decisioll-snaking.
Named
professionals
Recent guidance on the clarification of the child protection roles and responsibilities of senior health professionals recommends that each trust identifies ‘named professionals’ (a senior nurse, midwife and doctor) with an accountability for child protection work. In sunmlar): the duty of such professionals is to offer support alld advice to staff idrnti+ training needs and facilitate clinical supervision (1)epartment of Health ct Welsh Office 1095). One example of this role may bc to help professional colleagues who arc prcpuing to (Ionferences or attend Child Protection Court. Iinportmtly, the naiiied professionals
78 Accident and Emergency Nursing
will provide a health perspective to a range of multidisciplinary and multi-agency Child Protection Committees. However, it is notable that many post-holders, chosen for their child protection experience and knowledge, undertake this role as part of a senior managerial or clinical post. The exception to this may be the growing number of ‘Child Protection Nurse Specialists’ the vast majority of whom are employed by community trusts.
Recognizing
child abuse
Accident and Emergency nurses may be the first professionals to identifji a child in need of protection. Their role is primarily to express a concern rather than ‘make a diagnosis’ (Swann 1993). A number of texts are recommended for a more detailed review (Bannister 1992; Meadow 1993; Blumenthal 1994; Powell 1995). The physical and behavioural indicators of possible abuse may include: bruising of sot? tissue, burns, multiple fractures and fractures in children under the age of three l adult bite marks 0 torn frenulum l failure to thrive l frozen watchfulness l excessive sadness 0 self mutilation l childhood overdose l indiscriminate attachment 0 precocious sexual activity l venereal disease l genital or rectal bleeding A l
The neglected child may present as dirty, smelly, obviously under weight and hungry. The ‘signs and symptoms’ are not definitive, however, and will always need to be taken in context with other factors. These may include concerns relating to the timescale in seeking help, a mismatch between injuries and explanations given, and the behaviour of the child and parents. Concerns may also embrace the frequency of attendance in the department (Royal College of Nursing 1994). It is salutary to learn that the children of Frederick West were reported to have been seen at their local hospital on 16 occasions (Gcrardian 23 November 1995). Indeed, child abuse is rarely a ‘one-off’ incident, with children who are seriously injured or killed often having a long history of frequent bruising and other injuries (Bannister 1992). In recognition of this factor many A & E departments have information systems that highlight attendees. In tandem with this it is important to have mechanisms in place that detect abusing parents and carers who ‘shop around’ for health care.
Responding At the early stage of identification of a child who may have been abused it may be helpful for A & E staff to seek advice and support from the ‘named professionals’ who have an expertise in child protection. When a child presents with signs of possible abuse or neglect it may also be useful for A & E staff to gather information from community staff such as health visitors, school nurses and general practitioners. The liaison health visitor may be able to give support in facilitating this. The child should be examined by a paediatrician experienced in child protection. Repeated examinations are to be avoided and may well be construed as further abuse by an already distressed child. The statutory agencies may also offer advice and support at this early stage, particularly where a search of records shows earlier concern within the family. The child’s or a sibling’s name may have been previously entered on the local ‘Child Protection Register’. Many A & E departments have direct access to the names of children on the Register. A need for protection has already been identified for such children and early communication with the key worker is essential. Through the discussion of concerns with appropriate colleagues, a decision may be made to make a formal child protection referral to the local Social Services Department. The precise mechanisms for achieving this will vary according to local guidelines and procedures. As the Working ‘l@ether document (Home Office et al 1991) identifies, the responsibility for the provision of multi-agency guidelines lies with Area Child Protection Committees (ACPCs). Individual agencies will usually have their own procedures that are commensurate with the ACPC guidelines. The processes may involve a strategy discussion, investigation and child protection conference. Criminal or care proceedings may follow. Accident and Emergency staff may be called upon to contribute at all stages. It is particularly important that clear, contemporaneous records are kept. As with any other child patient, parents or carers need to be supported and involved in the immediate care and treatment. However, there may be occasions when parents or carers present a threat to the child by removing the child from the department before treatment and investigations are completed. In an urgent situation such as this, Section 46 of the Children Act (1989) ‘Police Protection’ allows the police to prevent removal of a child for up to 72 hours if they believe that a child would otherwise suffer significant harm.
Protecting children 79
Confidentiality While the key to protecting children is interagency conmm~ication and collaboration, medical and nursing staff may feel sensitive to the notion of confidentiality. In child protection work:
1)isclosure of inforinatioii in relation to child protection by medical or nursing staff is considered a matter of public interest and \vill therefore norniall~ be justified (United Kingdom Central Council 1 Y87; IIepartnlent of Health et al 1001). Child abuse and neglect at-e emotive issues and staff support and debriefinS are essential. In recognition that retrospective studies have sugbcrested high < levels of undetected and prcviousl) unrccord~d childhood abuse (Taylor lYY3) it is important to remember that the response and i-cactioils of staff may reflect adverse personal espcrienccs. The excellent R(:N pamphlet I+c)fcrtir~~~Clriltlwrr (1 YO4) provides d list of national helplines that m,l): be a starting pomt for distressed staff a5 dell as a source of help for f;iniilics. These could, therefore, be publicized \\,ithin the l~epartnicnt.
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CARE AND TREATMENT IN THE BEST INTERESTS OF THE CHILD In contrast to the images of serious and fatal childhood InJuries presented by Kempe et al (1062), the majority of- cases of physical injury investigated by the statutory agencies today are those of relatively minor physical harm (Herbert lYO3). Thus, the centrality of the A &. E department in de&g with child matreatment has become of less importance as LVVC respond to these cases and the other forms of abuse outlined above. This section puts forlvard the arguments for coiiiliiuiiity-hased assessinent of children who arc suspected of suffering from abuse or neglect.
Care of children
in hospital
Although there have been numerous initiatives to make all hospital environments ~nuch more ‘child friendly’, children are particularly vulnerable to the effects of hospitalization (Department of Health IYYI). Indeed, it is interesting to compare the behavioural indicators of child abuse with soll~e of the historic reports of hospitalized children’s reactions
(Robertson 1958). In an attempt to provide high quality services to children, some hospitals provide a separate paediatric A & E department, while many more have children’s waiting and treatment areas. Nevertheless. in some hospitals it rn~y be more appropmte to admit children who present with a possible child protection problem to a paediatrlc mrard area f& assewnent by a paediatrician. The provision of child and f&nily-centrcd facilities m A K E departments is supported b) the latest Patient C:harter initiative (I~epartmcnt of Health 1YY6) This docunlent adds Lveight to the previous calls for staffing to reflect the diff>reiit needs of children. While recognizing the speciahst preparation of A K E practitioners, there is cle,lr ju\tificatioii to support the presence of paediatric staff (including ilurses \vith the Kegistered Sick Children’s Nurse/ Registered Nurse - Child qualification) iu ,111 areas that cdrc for children (l)ep,lrtiiient of Health 1 OY1 ; Clothier ct al 1004; I?epartmrnt of Health lYY6). In additioil, Wynnc (lc102) suggests that prevcntatiw work in child protection is dependent upon knowledge and undcrstandmg of a child’s needs and rights as ‘111 individual. Study of such concepts is central to the preparation of children’s nursing practitiow ers. The ideal must be the duality of a children’s qualiticatlon coupkd with the specialist A & E certificate. To ensure that children are not harmed b) to recognize and their experience\. LVK need address the possibility that A & E services ma) not ,~l\vays be responsive to the needs of children (Gay IOY I). Furthermore, we need to question the 3pI”“l)riateness of referrals of children to A K E departments for investigation 01 awsment ofnmor physical injuries or possible ses~d &LIS~‘. As Wynne (1003) points out, the A 8, E department may not be a suitable envii-onnicnt in M-hich to assesscases oiabuse, as it is often noisy and lacking in privq and space.
Community
paediatrics
Wynne (lYY3) supports the role of the ~~~IIIILIniy paediatrician in assessing abused children in outpatient departments or local health clinics where an appointment can be planned. Here the child is not competing with the needs of acutely ill patients or accident victims. It is suggested that such an appointment is likely to be less distressing for the child and family. The inost recent guidance from the IIepartiixnt of Health and Welsh Office (1 YY5) states that conmunity child health staff, under the direction of a consultant community paediatrician, are uniquely placed to develop high levels of espertise in child protection. Such expertise includes examination, assrssincnt and tredtnient.
80 Accident and Emergency Nursing
The moves to assess the majority of child protection cases in the community fit well with the current notion of a ‘Primary Care Led National Health Service’. While the general practitioner is often the key to specialist referral, practice nurses, health visitors, community children’s nurses and school nurses are likely to possess extensive knowledge of vulnerable children and their families. Such professionals are well placed to discuss concerns and facilitate referral to the community paediatrician. Where possible, therefore, all but the ‘critically injured’ child, for whom there is a child protection concern, should be examined by a community paediatrician. The referral for medical assessment and examination will usually follow the initial referral by the practitioner concerned to the local statutory services (Social Services or the NSPCC), as it is these agencies who take the lead in the assessment and investigation of such cases.
CONCLUSION Accident and Emergency departments treat and care for a large number of children and their families. While some children will attend following non-accidental injury or other forms of abuse, others may be suffering from abuse or neglect in addition to their presenting problem. Accident and Emergency nurses need to be able to recognize and respond to cases of possible abuse. Specific government guidelines have been issued to assist in this process. Nurses should be aware of local procedures as well as local sources of advice and help. Nurses experienced in the care of children may be able to help prevent abuse by providing education and support to parents and carers. While the current initiatives to support the creation of separate paediatric A & E facilities are to be welcomed, the majority of child abuse and neglect cases may be better served by community child health services.
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Corby B 1993 Child Abuse: Towards a Knowledge Base. Open University Press, Milton Keyner Department of Health and Social Security 1988 Working Together: a guide to interagency co-operation For the protection of children from abuse. HMSO, London Department of Health 1991 Welfare of Children and Young People in Hospital. HMSO, London Department of Health 1992 Child Protectmn: Guidance for Senior Nurses, Health Visitors and Midwives (2nd edn). HMSO, London Department of Health, British Medical Association, Conference of the Medical Royal Colleges 1994 Child Protection: Medical Responsibilities. Department of Health, London Department of Health and Welsh O&e 1995 Child Protection: Clarification ofArrangements Between the NHS and Other Agencies. Department of Health, London Department of Health 1995 Children and Young People on Child Protection Registers; Year Ending 31 March 1994, m England. Department of Health, London Department of Health 1996 The Patient’s Charter: Services for Children and Young People. Department of Health, London Dingwall R, Eeklaar J, Murray T 1995 The Protection of Children (2nd edn). Avebury, Aldershot Gay J 1991 Caring for children in accident and emergency: Paedlatric Nursing 3(7): 21-23 Herbert M 1993 Working with Children and the Children Act: A Practical Guide for the Helping Professions. British Psychological Society, L&ester Home O&e, Department of Health, Welsh Oflice et al 1991 Working Together Under the Children Act 1989: A guide to arrangements for interagency cooperation for the protection of children from abuse. HMSO, London Kempe CH, Silverman FN, Steele BF et al 1962 The battered child syndrome. Journal of the American Medical Association 181: 17-24 London Borough of Brent 1985 A Child in Trust: The report of the panel of inquiry into the circumstances surroundmg the death ofJasmine Beckford. London Borough of Brent Meadow R (ed.) 1993 ABC of Child Abuse (2nd edn). BMJ Publishing Group, London National Commission Inquiry into the Prevention of Child Abuse 1996 Childhood Matters. The Stationery Offlice, London Powell C 1995 Health problems of young children. In: Campbell S, Glasper EA. (eds) Whaley and Wag’s Children’s Nursing. Mosby, London: 278-301 Robertson J 1958 Young Children London
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Rogers S, Hevey D, Roche J, Ash E 1992 Child Abuse and Neglect: Facing the Challenge. Open University Press, Milton Keynes Royal College of Nursmg 1994 Protecting Children. RCN, London Swan” A 1993 Recognising abuse. In: Owen H, Pritchard J (eds) Good Practice in Child Protection. Jessica Kingsley, London: 39-55 Taylor S 1992 How Prevalent is It? In: Rogers et al Child Abuse and Neglect: Facmg the Challenge. Open Universay Press, Milton Keynes: 40-49 United Kingdom Central Council 1987 Confidentiality. UKCC, London Wynne J 1992 The Construction of Child Abuse in the Accident and Emergency Department. In: Cloke C, Naish J (rds) Key Issues XI Child Protection for Health Visitors and Nurses. Longman, Harlow: 75-87