Protection of Vulnerable Adults
Article Outline
We use the term ‘vulnerable’ in a vast range of contexts, whether talking about patients, systems or, indeed, whole populations. The central meaning is the same, i.e. being at risk of abuse, or injury, or damage. If we think of the populations living on flood plains or fault lines, whole communities are vulnerable to massive devastation, and change at a global level. If national intelligence systems are vulnerable, the data of individuals and populations will at risk of abuse. As emergency nurses these global vulnerabilities are rarely our major concern, but the authors of our guest editorial very clearly demonstrate just how important recognition of, and action against, vulnerability is when it comes to the patients we meet every day.
Protection of adults at risk of injury or abuse is highlighted strongly in the case used by Dr. Hale, and Ms. Tippett. Currently, the UK is introducing its most robust system to date for the Protection of Vulnerable Adults (DH, 2009), by establishing of a list of individuals who will be unable to work with patients or clients in any care setting. The definition of vulnerable used to guide legislation and regulation is of a person:
‘who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.’
(Lord Chancellor’s Department, 1997).
This definition gives a clear image of the patient/client who is in long term care whether for physical or mental illness/disability, or due to their age or chronic needs. They may live within a specific facility or in their own home, and it refers specifically to the community care setting. In emergency care, we have probably all cared for a patient who has come from a care facility, and who has raised our concerns as they look neglected, or have sustained injury.
However, it is now generally recognised that vulnerability in healthcare spans all sectors of the service and the emphasis on the community setting has been dropped in many of the working documents. If we explore the definition further we begin to understand the true extent of vulnerability in healthcare, and especially in emergency care.
Most of the patients we see, day to day, have taken a conscious decision that they cannot look after their illness or injury by themselves. As such, it could be argued that they immediately become vulnerable – they are dependent on us for advice, treatment, or care. A previously independent, articulate individual will defer responsibility for decisions, often very important ones, to healthcare professionals, creating a dependent or power-based relationship. This environment fosters vulnerability, and is the basis of many abusive situations. However, most patients will continue to retain some level of autonomy, and to participate in their care, whether in front of us, or whenever they go home! One of the simplest ways to reduce vulnerability in our day-to-day practise is surely to create a culture where patients are seen as partners in their care, and treatment plans are agreed with them.
It is when the individual is unable to defend themselves that they become truly vulnerable. This may be due to their long-term needs, or it may be a very acute loss of capacity, for example the patient who has sepsis, or who has had a stroke. Some may become vulnerable long-term due to their condition, whilst others will regain their independence quickly.
Vulnerability is easy to recognise in some patients, such as those in care with significant physical disabilities, but in others it is much more difficult. The young woman repeatedly coming to the emergency department for minor problems and asking for food, may be homeless or in prostitution, and as such at significant risk of abuse. Equally, many of our patients create their own vulnerability through the use of alcohol or drugs, placing themselves in potentially violent or abusive situations. How many times have you tried to persuade an intoxicated patient to get a taxi home rather than walk, at 4am?
It is not always these patients that we think of when we discuss vulnerability, but the potential for harm, whether transient or long-term, is still evident.
The word ‘harm’ in itself is significant in this definition. It would suggest a conscious decision to cause harm, though this is not always the case. Harm may equally be caused by omission, whether through negligence, or ignorance (DH, 2000). Equally, harm or abuse can happen in any setting, whether within a care facility, on the streets, or in a patients’ own home. The POVA scheme (DH, 2009) concentrates on regulation of healthcare workers, and ensuring that those in care are not put at risk, but we also need to be aware of how the care we provide, and our systems and processes, might increase patient vulnerability. Do we truly involve our patients in their care and do our systems really promote independence? At the same time, we need to be alert to those individuals who are not in a care setting, and whose presentation at the emergency department may be the only opportunity for recognition of abuse. Domestic violence is a classic example of this. It is essential that as emergency nurses we have the skills and the confidence to ask the difficult questions, and be prepared to offer support or intervention. And we must also have robust reporting mechanisms in place if we have concerns about care or about patients at risk, whatever the setting.
I am certain that abuse of patients within care settings, whether emotional, physical or sexual, is nothing new, and will continue to horrify both the public and professionals. In the last few months alone in the UK we have seen a mental health nurse and a social worker struck off their respective registers for having relationships with their patients, and one for killing patients in his care. In contrast, another nurse lost her registration for reporting abuses in care (due to confidentiality). Our professional code of conduct clearly states that as nurses we should safeguard patients, and act as advocates for them (NMC, 2008). As such, we are clearly accountable for our behaviour towards patients and have an explicit responsibility to identify and act on any concerns we have about their care.
In examining vulnerability it is the diversity that strikes me most – in terms of the groups at risk, and the environments in which harm might occur. Emergency nurses cope well with diversity, we are good at assessing a situation on the information received, but also using our intuitive knowledge to identify risk – the risk of someone waiting, the risk of letting them go home, the risk of them deteriorating. It is exactly these skills that we use when we hear a history, or see a pattern of injury, that ‘just doesn’t fit’, and that Dr. Hale and Ms. Tippett are asking us to use in recognising and dealing with vulnerable adults in our care.
References
- . No secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse. London: DH; 2000;
- . Protection of Vulnerable Adults Scheme. London: DH; 2009;
- Lord Chancellor’s Department, 1997. Who decides: making decisions on behalf of mentally incapacitated adults. Cm 3803. Stationary Office.
PII: S1755-599X(09)00032-9
doi:10.1016/j.ienj.2009.05.002
© 2009 Elsevier Ltd. All rights reserved.
