Being safe not sorry: training to protect... December 2012

The White Paper for Vulnerable Children was a major new policy plank for 2012 and training all ‘front line professionals’ in detecting child abuse and neglect is one of its key aims. FIONA CASSIE finds out more about why child protection training is important for nurses.

“What if I’m wrong?” “What if I make things worse?” “What if the family turns on me?”

It is uncertainty and fear that can hold back a nurse from voicing concern that a child is being abused or neglected.

“But what if you’re right?” is the question that Anthea Simcock, chief executive of Child Matters, asks back. The headlines, photos, and names of abuse victims in the country’s roll of shame are there to haunt us all.

Training and education is a key to reducing child abuse, believes Simcock, the founding CEO of the child abuse prevention advocacy and training organisation. So people working with children, like nurses, have the skills to know what to look for, the knowledge to know what to do, and the confidence to take the appropriate action.

It is a view shared by the recent White Paper for Vulnerable Children, which has opted for mandatory training rather than mandatory reporting.

Many nurses have already received training in child protection, but by the end of 2015, all front line professionals working with children are to be trained in detecting child abuse. Legislation will also require all organisations working with children to have child abuse policies and reporting systems in place (see White Paper sidebar).

Ducking for cover

Education or mandatory training is no “quick fix” for child abuse, says paediatric nursing group, Nurses for Children and Young People of Aotearoa (NCYPA).

But Becky Conway, chair of the NCYPA section of NZNO, says her members believe that if nurses have the appropriate training and skills to identify and intervene, the incidence of abuse and neglect can be significantly reduced.

Because talking to parents in a suspected abuse case is “extremely uncomfortable” and if a nurse lacks the skills, the temptation is there to “duck for cover” and even avoid reporting the abuse.

As one member recalls: “When it came to reporting this case, everyone ducked for cover, didn’t want to do the paperwork, didn’t want to make the decisions, so I got to tell mum that we had concerns and that it was necessary for me to notify CYF. Reassuringly, she just said ‘Okay, I have nothing to hide’, a big relief for me.”

Conway says, as a group, NCYPA is undecided on the merits of (legislated) mandatory reporting but believe it would have been unlikely to make a significant difference without supporting education and policy. (She says that to the group’s knowledge all DHBs, and many community health organisations, have already adopted policies of compulsory reporting for their workplaces.)

For herself, a nurse educator working in paediatrics for almost two decades, she says child protection training gave her a heightened sensitivity and awareness of why child protection screening is needed. “If you don’t think you might see it, you probably won’t.”

So while nurses don’t expect to come across abuse every day, it does become part of their daily consciousness – particularly when taking a child’s history on admission to hospital for any form of accidental injury.

“I guess that’s a good example of how every professional working with children is always second guessing whether a child has suffered something that is non-accidental,” says Conway.

Training to detect abuse is the first step, but having a clear child protection policy and reporting process is also incredibly important, in Conway’s book, to encourage nurses to feel confident to take the second step and act on suspected abuse.

“What is the next step is what everybody needs to know and wants to know – ‘now I have this information what am I going to do with it?”

Referrals to Child, Youth & Family 2011-2012

Care & Protection Notifications (CPN)

Education (1)

Total 9,447 - FAR* 7,232

Health (2)

Total 10,767 - FAR* 7,234

GP

Total 552 - FAR* 348

Plunket

Total 935 - FAR* 552

Family

Total 10,282 - FAR* 6,398

Anonymous

Total 5,990 - FAR* 3,932

Police (3)

Total 62,678 - FAR* 9,626

In all there were 152,800 referrals made from 40 different professional groupings, agencies and concerned parties involving 95,532 children and in 61,074 of those cases ‘further action was required’ (FAR*)

(1)school & early childhood (2) hospital staff, public health nurse etc

(3) CPN & family violence referrals

Changing attitudes

Responding to child abuse does not always “come naturally” says Simcock, but doing nothing is not an option.

In her presentation on child protection to the College of Primary Health Care Nurses NZNO conference in August, she included the chilling statistics that in New Zealand 57 children a day are proven to be abused, and on average, a child is abused to death every five weeks.

Training can help to overcome the inclination to assume all parents love their child, make excuses based on culture, optimistically look for positive explanations, or deny there is a problem because your own life is already stressful enough. Training can also avert the opposite problem of automatic ‘cover your butt’ reporting that overloads Child, Youth and Family social workers.

“I think the Government got it right here – that if we just brought in mandatory reporting, then people report anything to just make sure that they are covered. And that’s not meeting what we’re trying to do.

“It means that all sorts of cuts and bruises and Mongolian spots and impetigo will get reported because people don’t know whether it’s a school sore or a cigarette burn. And the very dangerous abuse we are missing now still gets missed.”

Simcock says training should lead to better quality reporting and flow-on to a better quality response from social services because they are not so overstretched.

As a child protection advocacy group – and specialist in child protection training across the spectrum of emotional, physical and sexual abuse – Child Matters is keen to have input into the nature of that training including their recommendation it should be multidisciplinary.

“Ideally, if you can train front line professionals across sectors together, that breaks down barriers and they get to understand each other’s role in child protection.”

Training also needs to be in-depth enough to change people’s attitudes and behaviours and give them the skills to intervene earlier, respond appropriately, and report if necessary.

The basic requirement, she believes, was for the equivalent of a day’s training (around 6–7 hours) and it needed to include role play so nurses can practise how to talk to children and parents in suspected cases, know how not to put words in a child’s mouth, and know not to make promises they can’t keep.

Training experiences uneven and competency complex

Nurses currently working in ‘front line’ roles report mixed experiences in child abuse training from the very good to the very brief.

Conway says the national violence intervention programme (VIP) training on offer to district health boards (see Ministry of Health sidebar) currently consists of two four-hour sessions covering child abuse and partner abuse.

But, she says, her members report that some DHBs run very helpful two-day training workshops in family violence and child abuse, including input from Women’s Refuge and Police.

“However, in other DHBs, nurses have found training in child protection to be too brief or too inaccessible even though they are in ‘the front line’,” says Conway.

Some nurses also reported frustration at not being able to attend regular paediatrician meetings about abuse cases or being excluded from case meetings because they are not part of dedicated child protection teams.

The White Paper’s proposal to set core competencies and training requirements for the children’s workforce (see sidebar) may also not be straightforward for nursing.

“The challenge of assessing competence is very subjective and even experienced and skilled nurses may be afraid to approach the topic of abuse and neglect with families and therefore assessment and intervention does not occur,” reports Conway from member feedback. “Logistically, assessing competence of all child health workers in child protection skills would be difficult.”

She says training needs to be accessible and transparent, and the challenge for nurses was to develop a competency framework covering key “knowledge bundles” including identifying, responding, assessing, supporting, and referring; along with understanding the prevalence of abuse, socio-political influences, and the life-long impact on health.

Plunket more than weighing babies

Unfortunately, screening for family violence is a growth area for Plunket nurses going into families’ homes every day. The child health organisation’s 600-plus clinical staff made more than 930 child protection referrals to CYF in the past year.

Providing nurses with the ongoing training and tools to support Plunket nurses in their child protection role is a long-established part of Plunket training, says Merryl Ryan, Plunket’s national education manager. That role comes as a shock to some.

“A lot of people think that Well Child (nursing) is ‘nice’ – it’s weighing babies – and they don’t possibly come with the understanding, initially, that it’s looking at the family in the community and that’s the growth area – particularly when it comes to screening for family violence.”

A huge emphasis is made on communication, with the Plunket nurse right from the outset making it clear to a family that their role includes screening for family violence.

“So we take them (nurses) through how to set up the screening, the leading-in statements, and the framing of questions.”

When new Plunket nurses start their postgraduate training (the postgraduate Certificate in Well Child Primary Health Care Nursing offered in partnership with Whitereia Community Polytechnic), they write a 3000 word assignment looking at disparity within their own community, population health, and what services, like Women’s Refuge, are there to support the community.

Later on during live-in block courses, there is more intensive training on family violence and child protection. This is followed-up by at least 90 minutes annual ongoing training (out of the 20 professional development hours offered each year by Plunket) to update on policy or law changes, revise skills, and discuss cases.

Ryan says that while there is room for online learning further down the track, she believes it is essential for initial child protection training to be face-to-face so people can use role-play and scenarios to practise skills like leading-in statements and framing questions. So, for example, a nurse realises that asking a parent the generic question “do you feel safe?” may get the non-useful brush-off answer “Yes, I’ve got a dog”.

Plunket nurses are encouraged to work in partnership with families when initiating CYF referrals, but also to work with their clinical lead in implementing Plunket’s policy, so if they don’t feel safe they are not going through the reporting process alone.

“I don’t think you ever get used to it,” says Ryan. “They are never easy conversations to have. But to support the ‘ease’ if not the ‘easiness’, it’s important to have that ongoing relationship with families and also the ongoing training every year.”

Ready to step up to responsibility

Under the White Paper, training requirements will differ for the “core” children’s workforce like Plunket and those nurses in less frequent contact with children, but compulsory training is on its way.

“The responsibility for taking action does lie with us when children and their families come into our spheres of influence,” says Conway. “And so we need the training and the ongoing support to enable us to carry out this mandate.”

The White Paper, with its emphasis on collective responsibility for helping and protecting the country’s vulnerable children, may result in more nurses stepping up to the challenge.

WHITE PAPER FOR VULNERABLE CHILDREN

White Paper’s Children’s Action Plan Timeline for professionals working with children

By April 2013

• Agree which professions form the ‘core’ children’s workforce and ‘wider’ children’s workforce in order to prioritise and target workforce actions.

By end of 2013

• Develop cross-sector common minimum standards, core competencies, and training requirements for children’s workforce.

• Introduce legislation requiring all agencies working with children to have policies and reporting systems in place to recognise and report child abuse and neglect.

• Release “Working with Children Code of Practice” for professionals working with children.

By end of 2015

• Front line people who work with children to be trained to recognise the signs of child abuse.

• Agree minimum standards and competencies in national guidelines for inclusion in organisations’ employment, contracting and audit obligations.

Nurses not named but included …

Nurses may fail to gain a mention in the White Paper but are to be included in training development plans.

Social Development Minister Paula Bennett says the Government will work with professional groups for teachers, doctors, and nurses to develop core competencies and minimum standards for child protection skills.

Asked about the likely nature of training, Bennett points to the ‘Working Together’ child protection workshops that the Government has been funding free around the country since 2010 for local teachers, health professionals, and social service providers. The multidisciplinary workshops are a partnership between Child, Youth and Family (CYF) and training organisation Child Matters.

“By the end of June 2013, we will have reached around 4,500 professionals,” says Bennett.

She says consultation work on the competencies and developing the Working with Children Code of Practice resource will “help to identify those front line professionals who have not yet received abuse detection training and ensure they attend similar workshops from 2015”.

Ministry of Health’s Violence Intervention Programme (VIP) for DHBs

The Ministry of Health began a family violence health project back in 2001 and in 2007 launched the renamed Violence Intervention Programme (VIP) in district health boards (DHBs) covering both partner abuse and child abuse and neglect programmes.

An audit in 2011–2012 of the 20 DHBs found all had VIP systems in place to respond to child abuse and neglect, and a roll-out of staff training and VIP services was occurring across designated services (emergency, maternity, child health, sexual health, mental health, and addiction). However, the proportion of personnel in a service, including nurses, who had completed VIP training was unknown.

Fifteen of the boards had been approved to deliver the Ministry-approved standardised national VIP training package (which covers both domestic and child abuse). Two DHBs had established National Child Protection Alert Systems (NCPAS) and five DHBs were working to join NCPAS.