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How does leadership contribute to safeguarding vulnerable adults within healthcare organisations? A review of the literature

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Purpose – The purpose of this paper is to identify aspects of leadership and evaluate their contribution to safeguarding vulnerable adults in healthcare organisations through conducting a critical review of literature. To identify or adapt a leadership framework to contribute to safeguarding vulnerable adults in healthcare organisations through analysis of the literature. Design/methodology/approach – The methodology was qualitative and inductive. It was based on constructivism and an interpretive theoretical perspective, beginning without hypothesis. Themes emerged during the process. A critical review of literature was undertaken to answer the research question. Literature was sourced from a variety of health and social care databases and grey literature. All inclusions underwent rigorous critical appraisal and a total of 18 papers were explored. Findings – The importance of clear leadership and direction was a common theme across the majority of sources. Aspects of leadership that can safeguard vulnerable adults in health care organisations include organisational culture, implementation of policies, procedures and frameworks, and reinforcing strong values and ethics around empowering individuals and delivering person-centred care. Through the meta-synthesis of findings, a model of leadership emerged. Research limitations/implications – The critical review utilised only one reviewer and the proposed leadership framework has not been empirically tested. Practical implications – The paper proposes a leadership framework that can be applied within healthcare organisations to safeguard vulnerable adults. Originality/value – This paper fulfils the need for evidence that supports the belief that strong leadership can safeguard vulnerable adults. It provides a comprehensive review of existing literature in this area. Keywords Leadership, Health, Management, Empowerment, Safeguarding, Vulnerable adults Paper type Literature review
The Journal of Adult Protection
How does leadership contribute to safeguarding vulnerable adults within healthcare organisations? A
review of the literature
Emma L Stevens
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To cite this document:
Emma L Stevens , (2015),"How does leadership contribute to safeguarding vulnerable adults within healthcare
organisations? A review of the literature", The Journal of Adult Protection, Vol. 17 Iss 4 pp. 258 - 272
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How does leadership contribute to
safeguarding vulnerable adults within
healthcare organisations? A review
of the literature
Emma L. Stevens
Emma L. Stevens is a
Safeguarding Adults
Practitioner at City Health Care
Partnership CIC, Hull, UK.
Abstract
Purpose The purpose of this paper is to identify aspects of leadership and evaluate their contribution to
safeguarding vulnerable adults in healthcare organisations through conducting a critical review of literature.
To identify or adapt a leadership framework to contribute to safeguarding vulnerable adults in healthcare
organisations through analysis of the literature.
Design/methodology/approach The methodology was qualitative and inductive. It was based on
constructivism and an interpretive theoretical perspective, beginning without hypothesis. Themes emerged
during the process. A critical review of literature was undertaken to answer the research question. Literature
was sourced from a variety of health and social care databases and grey literature. All inclusions underwent
rigorous critical appraisal and a total of 18 papers were explored.
Findings The importance of clear leadership and direction was a common theme across the majority of
sources. Aspects of leadership that can safeguard vulnerable adults in health care organisations include
organisational culture, implementation of policies, procedures and frameworks, and reinforcing strong values
and ethics around empowering individuals and delivering person-centred care. Through the meta-synthesis
of findings, a model of leadership emerged.
Research limitations/implications The critical review utilised only one reviewer and the proposed
leadership framework has not been empirically tested.
Practical implications The paper proposes a leadership framework that can be applied within healthcare
organisations to safeguard vulnerable adults.
Originality/value This paper fulfils the need for evidence that supports the belief that strong leadership can
safeguard vulnerable adults. It provides a comprehensive review of existing literature in this area.
Keywords Leadership, Health, Management, Empowerment, Safeguarding, Vulnerable adults
Paper type Literature review
Hospital [] should do the sick no harm (Nightingale, 1859, p. iii).
Background
Many government health publications indicate that strong leadership is essential to safeguard
vulnerable adults (Department of Health (DoH), 2010, 2011a, 2012, 2013). Learning from serious
case reviews (Orchid View, West Sussex Adults Safeguarding Board, 2014) and serious incidents
recorded in healthcare organisations also suggest that the absence of leadership can result in poor
practice. The Francis (2010, 2013) reports into failures at Mid-Staffordshire hospitals also indicate
that leadership was inadequate and this impacted on the Trusts ability to maintain safe services.
Received 1 September 2014
Revised 25 November 2014,
22 December 2014
Accepted 4 February 2015
Many thanks to Gill Fieldsend for
her support during the process of
this research.
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As there is this widespread belief that effective leadership results in safeguarding vulnerable
adults (or that a lack of leadership results in a lack of protection), this study aims to uncover
the existing evidence-base that leadership can safeguard vulnerable adults in health care
organisations. It provides a timely study as failures in health care (Mid-Staffordshire hospitals,
Winterbourne View) have received a lot of media attention and it must now be a priority to seek
improvements in healthcare systems and for the vulnerable adults that they serve.
The method undertaken by this study was a critical review of literature. This was selected in order
to gain an informed analysis (based on a variety of perspectives) to influence professional
practice. The knowledge from the literature review has subsequently been utilised to propose
a framework for leadership that can be applied in practice within healthcare organisations. This
framework also has relevance for organisations working across wider safeguarding adults
partnerships.
This paper poses the research question:
RQ1. How does leadership contribute to safeguarding vulnerable adults within healthcare
organisations?
Definitions
In order to answer the research question it is first important to define key terms.
Leadership
Grint (2000) believes leadership is a contested subject and Stogdill (1974) states there are many
definitions of leadership. Many people also attempt to differentiate leadership from management
(Bennis, 2009; Rost, 1991; Kotter, 1990; Northouse, 2010).
As leadership is not universally agreed, the definition of leadership that this study utilises was
deliberately kept broad to encompass many traits, qualities and skills and is therefore defined as
showing the way(Sturmberg and Martin, 2012, p. 18).
Safeguarding
The definition of safeguarding that this paper utilises is taken from the Department of Health,
as follows:
Safety from harm and exploitation is one of our most basic needs. Being or feeling unsafe undermines
our relationships and self-belief. Safeguardingis a range of activity aimed at upholding an adults
fundamental right to be safe (DoH, 2010, p. 7).
Vulnerable adult
Vulnerable adulthas been selected as a search term. As safeguarding adults practice works to
the definition of vulnerable adult contained within No Secrets (Department of Health (DoH), 2000),
this phrase assists in focusing the search so that it does not incorporate all adults. Therefore, this
paper adopted the No Secrets definition of vulnerable adult as a person aged over 18 []:
[] 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 (DoH, 2000, pp. 8-9).
Objectives
The objectives of the study were to:
identify aspects of leadership in healthcare organisations and evaluate their contribution to
safeguarding vulnerable adults through conducting a critical review of literature; and
identify or adapt a framework or model of leadership to contribute to safeguarding vulnerable
adults in healthcare organisations through analysis of the literature.
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Qualitative methodology
This paper does not seek to provide any evidence of an objective reality, as the ontological
position does not assume there is an absolute truth to be discovered.
The perspective of this paper has been influenced by the authors experience, skills and
knowledge from employment as a safeguarding adults practitioner within a healthcare provider
organisation. As sole researcher it must be recognised that the paper reflects the authors values
and biases. These are explicitly acknowledged, not as a limitation to the paper, but as an
experience-led, influencing factor that has enhanced a reflexive research process.
This paper did not have a starting hypothesis. It began from the premise that existing evidence
indicates that leadership could safeguard vulnerable adults and it aimed to uncover how it would
do so. The proposed model of leadership that emerged (objective 2) was constructed through
the authors interpretation of the presented evidence. Thus, it is not presented as an objective
reality, but as an interpretive construct.
Design
A critical review of literature was undertaken in order to answer the research question. Although
this paper took a systematic approach to sourcing literature, it did not conform to principles of a
systematic review as it did not utilise the full resources required for a systematic review (such as
utilising two reviewers).
In the pedagogical field of leadership and management, a wide range of theories from different
professional disciplines are relevant. Therefore, diverse literature sources were used (including
grey literature) to produce a meta-synthesis of findings. Grey literature has been defined as that
which is produced [] but which is not controlled by commercial publishers(Grey Literature
Report, 2014).
Search strategy
Inclusion criteria involved publication between 2005 and 2013. Databases used were: CINAHL
Plus with full text, Medline (Proquest), Health Source: Nursing/Academic Edition, British Nursing
Index, Health Business Elite, Health Management Information Consortium, ASSIA, Scopus and
Psych. Info.
Grey literature was sourced through: World Health Organisation, Nursing and Midwifery Council,
NHS Evidence, Royal College of Nursing, General Medical Council and the Social Care Institute
for Excellence.
Search terms were:
leader* and safeguard* or protect* and vulnerable adult not child*.
All search terms were found in the title or abstract.
Any papers that related to child* were excluded from this review as there is sufficient pedagogy
focusing on adults.
Healthcarewas not included as a search term as it was anticipated that there may be
transferable learning from non-healthcare organisations.
Quality appraisal
The critical review process can be seen in Figure 1. Following the database search,
Cronin et al. (2008) advise authors to undertake an initial screening. This was undertaken through
analysis of the abstract/summary to determine whether the source was worthy of further
consideration. Following the initial inclusions and exclusions, there were 148 sources that
remained included for critical evaluation of their full content through utilising a critical appraisal
framework.
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Critical appraisal, data analysis and meta-synthesis
Dixon-Woods et al. (2004) highlight that appraising qualitative research is needed, but there is no
consensus of how to do this. Katrak et al. (2004) undertook a systematic review into critical
appraisal tools and note that researchers should select the most appropriate critical appraisal
tool for their needs as there is no gold standardtool.
As there is no single critical appraisal tool that is evidenced to be the most effective, knowledge
was combined from both Mays and Pope (2000) and Letts et al. (2007) to devise a data
extraction/critical review form which was used to review all of the selected literature. The
credibility, trustworthiness and ethical integrity of the research was considered. Shortcomings
in one of the criteria did not automatically negate the value of the paper and, thus, the author
worked reflexively through the criteria.
Use of the critical appraisal framework facilitated the inclusion and exclusion process until
finally 18 sources remained.
In order to assist with the formation of themes, a thematic matrix was then utilised to uncover the
themes and enable cross-referencing of materials. The thematic matrix contained 20 themes and
in order for it to be considered a theme, the issue had to be identified within a minimum of two
sources. The author then worked reflexively to combine learning from the most compelling
arguments and the most frequently cited themes. The materials were meta-synthesised during
Figure 1 Process/method
Initial sources identified via
searches on health databases
(n= 262) and social care
databases (n= 235). Total number
of sources n= 497.
All abstracts reviewed; inclusion criteria applied and initial exclusions made
(n= 755). Remaining papers n= 148.
Critical appraisal framework applied to remaining inclusions.
Data extraction forms utilised (n= 144).
Initial sources identified via
grey literature search (n= 406);
Sources excluded following application of critical appraisal (n= 126).
Studies remaining included following application of critical appraisal
framework (n= 18).
Final inclusions remaining for thematic review and transferred into thematic
review matrix (n= 18).
Articles not retrievable n= 4 (either unavailable in English
language or unavailable from British Library).
Articles for initial inclusion (n= 903).
Source: Author’s own
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the thematic analysis. This process enabled comparison of work and identification of
concordance and dissonance between studies. The author worked reflexively to analyse and
interpret the information.
Themes
Five themes were explored where strong and compelling arguments were made within the
literature.
Leadership
A common theme across many studies is the need for strong and clear leadership (Arya and
Callaly, 2005; Department of Health and Children (DoHC), 2008; Department of Health (DoH),
2011b; Humphries, 2011; Souba, 2011), however, many sources fail to adequately define what
this leadership would look like at a practical level. Conversely, Torjesen (2008) holds a different
view by emphasising the desirability of lead posts to safeguard vulnerable adults within healthcare
organisations. In Ireland, the DoHC (2008) also recommend that healthcare organisations ensure
that there is a named lead person to liaise with patients, their advocates and families. This person
should be identified to receive feedback in relation to care and then respond to service-users so
that they know that their views are being addressed.
Importantly, Bell et al. (2005) recognise the difficulty for vulnerable adults to make their views
known. Similarly, in their study, Rudolfsson et al. (2007) found that nurse leaders ensured
everybody had an opportunity to express their opinions and be listened to, and they considered it
their responsibility to create a friendly atmosphere in the team. They also emphasise the
importance nurse leaders place on being trustworthy. This includes not placing higher demands
on their nurses than on themselves, being genuine and honest and helping to create trust. They
also recognise the importance of role modelling as they describe a leader as someone who rules,
guides or inspires others.
Implicitly, Calcraft (2007) also recognises the importance of role modelling as she notes that
managers may perpetuate the tolerance of abuse and bad practice by failing to deal with
concerns. She asserts that it is important for managers to be willing to challenge powerful
individuals. If managers fail to challenge powerful individuals, they become complicit in the abuse
and many whistleblowers from her study felt that it would have been useful to have an
independent person whom they could talk to. Mayer and Cronin (2008) recognise that leaders are
responsible for determining actions following adverse events and leadership should not accept
any practices or attitudes that may result in abuse or neglect (Grimshaw, 2012).
Although leadership is often related to staff that are hierarchically placed in leadership and
management positions, Agnew et al. (2012) were one of the few studies that acknowledge that
committed leadership was required at all levels. They also recognise that although the
government indicate that ward rounds could monitor patient care, rounds in themselves are not a
substitute for poor leadership or inadequate staffing. They cite that other high-risk industries
recognise leadership as an essential component of safety management, resulting in specific
leadership safety training programmes.
Edwards et al. (2012) believe focused leadership is required from those responsible for safety,
which should be visibly conveyed as a priority by people in charge. This may be valid for their
study (specifically relating to healthcare manufacturing organisations); however when working in a
healthcare provider organisation, safety should not be prioritised over listening to what the patient
wants, which (for capacitated adults), may involve practitioners empowering them to take
risky or unwise decisions in accordance with the Mental Capacity Act 2005 (Stevens and
Hebblewhite, 2014).
Although service-users are lawfully allowed to make unwise decisions under the Mental Capacity
Act, the DoHC (2008) note that leadership and accountability are fundamental to delivering a safe
system; including maintaining the accountability of staff whose performance has fallen below
what might reasonably be expected of them. Agnew et al. (2012) note that relationship-orientated
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behaviours of nurse leaders (such as being approachable and giving feedback) were related to
reduced adverse incidents. Humphries (2011) notes that significant progress has been made as a
result of strong leadership and the next development may be to utilise transformational change
and a shared model of leadership (straddling inter-agency boundaries). Despite this, he also
believes there is still the need for clearer clinical leadership (which was also recognised by
Grimshaw, 2012).
Rather than focusing on clinical aspects of leadership, Souba (2011) examines leadership
through exploring both ontology (the nature of being a leader) and axiology (values and ethics of
leadership). He acknowledges that leadership occurs within a context of hidden frames of
reference and assumptions that shape the way for leaders. He acknowledges that good
leadership enables people to recognise their blind spots or filters by sharing insights that enable
revisions of their mental maps. Mayer and Cronin (2008) also recognise at risk behaviour
occurs when staff may have impaired or lost their perception of risk attached to everyday
behaviours. Therefore, reflecting on individualsmental maps may encourage meaningful
personal change because when staff are willing to challenge habitual behaviours or deeply held
assumptions there is a real chance of transformation.
Organisational culture and human factors
A safeguarding adults culture prioritises the quality of care, has strong leadership and employs a
competent and safe workforce (DoH, 2011b). Organisational culture can work against a culture of
raising concerns (Calcraft, 2007) and it has an influence on the prevention of abuse. Heath and
Phair (2009) assert that abuse and neglectful practice thrive when organisational culture involves
staff focusing on tasks, processes and procedures rather than service-users experiences,
choices and aspirations.
Building a positive culture requires integrating whistle-blowing into wider philosophies of good
practice, challenging poor practice before it escalates, fostering an open culture (including regular
supervision), challenging dominant individuals, effective inductions, organisational learning and
reflection from incidents of whistle-blowing (Calcraft, 2007). The importance of an open culture
was recognised by a number of authors (Grimshaw, 2012; DoHC, 2008; Humphries, 2011;
Madden, 2006; Calcraft, 2007). Grimshaw (2012) regards the active involvement of patients as
encouraging an open culture which should also support staff to advocate for patients and focus
on improving standards of care. Safeguarding adults work can develop better standards of
clinical practice when there is an open culture of reporting, good processes to escalate concerns,
and confidence in multi-agency procedures and practices (Grimshaw, 2012).
As an aspect of organisational culture, teamwork is also an important factor and Scraggs et al.
(2012) note that when teamwork is not functioning well there may be negative impacts for both
patients and staff in a healthcare environment. They also state that effective teamwork can be
challenging for some doctors who may identify themselves as natural leaders of the team.
Scraggs et al. (2012) identified that inter-professional education was helpful for improving team
working. Similarly, Torjesen (2008) notes that multi-disciplinary training on safeguarding
vulnerable adults is now being offered at a variety of levels.
When teams work within cultures of blame, staff can be fearful of raising concerns (Edwards et al.,
2012). Scraggs et al. (2012) believe that organisational culture may negatively affect standards of
care and obstruct ongoing improvement where there is a culture of accepting the non-disclosure
of errors or concerns for care quality. Tackling these challenges requires support for staff and
ensuring that they are not fearful of the consequences of their actions. Edwards et al. (2012) also
recognise that in certain societal cultures, barriers to speaking up may be a salient factor. For
example, in Asia losing faceis a powerful influence over behaviour. Thus, with the global
movement of healthcare staff across geographical borders, the societal cultures of diverse
professionals should be recognised as potentially inhibiting some peoples willingness to raise
concerns.
To prevent the need to raise concerns, a caring culture can be developed by sowing the seed of
an idea, waiting for an appropriate time to implement it and never giving up (Rudolfsson et al.,
2007). Thus triggering change to strong or dysfunctional cultures may require time and patience.
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The DoHC (2008) note that leaders can change the system (or create a new system) by
examining the current situation, recognising areas for improvement and envisioning future
possibilities. Change management is a complex process and changing organisational culture
may be a long-term goal of healthcare organisations.
Alongside the theme of organisational culture, it is important to consider human behaviour.
Mayer and Cronin (2008) recognise three types of error-behaviour: human error (unintentional
actions that could have caused harm or increased risks); at risk behaviour (unsafe habits and loss
of perception of risk attached to everyday behaviours) and reckless behaviour (understanding
the risk is substantial, yet making a conscious choice to disregard these risks). The DoHC (2008)
along with other studies (such as Edwards et al., 2012) emphasise individual accountability,
whereas Mayer and Cronin (2008) recognise that it is helpful to examine why a particular event
occurred, including the causes of organisational errors in health care (including systems factors),
which may result in a greater understanding of the predictable limits of human ability and factors
that shape behaviour. Mayer and Cronin (2008) advocate for a safety culture which is achievable
through an organisational leadership commitment to demonstrate and communicate the desire
to have a safety culture by nurturing and perpetuating cultures that value learning, reporting and
fairness. They note that a just culture means that human actions are judged fairly and considered
within the complexity of the system factors in operation; thus human error is recognised as
unintentional and does not lead to disciplinary action. Without a just culture, real progress will be
limited (Mayer and Cronin, 2008).
Mayer and Cronin (2008) note the importance of differentiating between human error, reckless
behaviour and practice that lies somewhere between the two. They understand that human error
is more likely to occur when staff have high workload conditions or are fatigued and errors
increase when nurses are distracted during medication administration. Similarly, Scraggs et al.
(2012) found that morale, workload and resources should be effectively managed to enable
doctors to make good decisions as heavy workloads affect their ability to make good decisions or
adjust their behaviour. Thus, these studies indicate that staffing levels need to be adequate and
processes should be in place to ensure staff do not make important decisions when fatigued or
distracted.
Souba (2011) acknowledges that our mental maps impose limitations upon us and our
awareness (which is one his four ontological pillars of leadership). He states that no person is fully
aware and the brain creates mental constructs (from deeply ingrained internalised beliefs and
assumptions) which influence how we behave. This concurs with Scraggs et al.s (2012) finding
that doctors utilise informal information when making decisions. Similarly Campbell et al. (2009)
who believe that when individuals make decisions, their brain utilises pattern recognitionwhich
involves making assumptions based on prior experiences or judgements and emotional tagging
which can mislead good decision making (Campbell et al., 2009, p. 62).
Campbell et al. (2009) recognise that important decisions may be flawed despite being made by
intelligent and responsible people with the best information and intentions. They state that to
safeguard against poor decision making, a simple solution is to involve another person when
making certain decisions. However, in the healthcare environment, when swift decisions are
required to save patients life, time constraints may not always facilitate this.
Clinical governance, accountability, quality and performance
Poor governance structures are a major contributory factor in adverse incidents (DoHC, 2008;
Arya and Callaly, 2005) and a change in organisational culture is required for continuous quality
improvement (Arya and Callaly, 2005). The government also requires that safeguarding is
integrated with patient safety and clinical governance (DoH, 2011b) and through the study by
Braye et al. (2012) a complex system and pattern of governance arrangements were revealed,
with Safeguarding Adults Boards having a key role in fulfilling these.
Practical governance strategies were discussed by various authors, such as the use of audit as
an effective tool (Bell et al., 2005; DoHC, 2008). The DoH (2011b) noted that standards are
fundamental to preventing neglect, harm and abuse. Setting standards and measuring how they
are achieved in day-to-day care, allows services and practitioners to identify concerns about
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individual patients and give early warning indicators of possible poor care within a service.
Edwards et al. (2012) also recognise that the NHS uses whistle-blowing as a practical
governance tool to deter wrong-doing and raise safety and quality standards. The belief that
whistle-blowing may deter wrong-doing implies that staff deliberately partake in wrong-doing and
this can be prevented by robust whistle-blowing policies. However, although it is likely that
a minority of professionals enter a job with access to vulnerable people with intent to harm others,
the majority of healthcare staff are actually likely to enter their professions with the intention of
doing a good job. Any wrong-doing on their part might be reflective of inadequacies in the system
in which they are functioning (concurring with Mayer and Cronin, 2008) or poor training and not
always a symptom of a deliberate action to harm.
Arya and Callaly (2005) believe that clinical governance provides a framework through
which health organisations are accountable for their continuous improvement of quality. Although
their study is specifically aimed at mental health services, the learning is transferable to other
settings. A clinical governance framework should clarify concepts of accountability, clinical
practice improvement, management of clinical risks and monitoring or evaluation of
clinical standards and quality improvement. Continuous monitoring assists services to
recognise problems, deficits and gaps and a clinical governance framework will remedy a lack
of measurement which can allow staff to believe that practices are done well, deflecting
responsibilities for any failures (Arya and Callaly, 2005). Humphries (2011) notes that there is need
for stronger engagement by NHS clinicians (especially the GP consortia) to maintain
improvements in quality.
The DoHC (2008) note that poor governance structures have been identified as major
contributory factors in the analysis of many adverse incidents. They agree that governance
provides a framework (composed of many elements) to drive a culture of continuous
improvement in safety and quality. A key principle of good governance is clear lines of
accountability at individual, team and system levels, including accountability to employers,
professional bodies, patients and the public.
Training, procedures and policy
Safeguarding policies and procedures are important in steering staff into appropriate actions to
take if abuse is suspected. As training staff in these protocols is essential, the three aspects were
linked together during the thematic review.
Grimshaw (2012) notes that policies and procedures to protect vulnerable adults should ensure
that safeguarding concerns are identified and managed safely, and that practitioners are
supported to empower and protect individuals. She recognises that it is essential to maintain high
standards of care delivered by well-trained staff who are supported to recognise and deal with the
needs of vulnerable adults. Torjesen (2008) notes that many Trusts increase their emphasis on
safeguarding by developing policies and procedures, and introducing training for all staff. Staff
may lack knowledge about what constitutes abuse and may not be able to differentiate between
abuse and poor practice and, thus, may not raise concerns (Calcraft, 2007). Therefore, induction
and training can address such issues. Heath and Phair (2009) acknowledge that the training
and education of health and social care professionals can emphasise the specialist practice of
prevention and support for vulnerable people.
Bell et al. (2005) also note that professionals may require training in the recognition and
management of complaints from vulnerable adults, although they acknowledge that it may be
difficult to determine what the most appropriate training comprises of. Related to this, Madden
(2006) outlines that people with learning disabilities should also be offered specific programmes
to encourage assertiveness and prevent abuse. Thus, a twofold approach of training both staff
and vulnerable adults might provide an effective preventative intervention.
The DoHC (2008) strongly supports education, training and research on patient safety as a
priority. It also recommends that all bodies responsible for the education and continuing
professional development of healthcare staff should review their training to ensure that both
technical and human factors, in relation to safety and quality, are incorporated into their training at
undergraduate and postgraduate levels. They recommended that healthcare organisations
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provide mandatory induction training for all staff, specifically including patient safety (including
reporting adverse incidents) and refresher training should be provided on a regular basis.
The DoHC (2008) recommends that service-users and carers should influence policy
development, service delivery and health service development and evaluation. Mayer and
Cronin (2008) cite research that indicates that policies and procedures created to safeguard the
patient can inadvertently contribute to adverse incidents. Humphries (2011) believes that
approaches that empower service-users through the safeguarding process are likely to
be key priority for the next stage of policy development. However, he misses the opportunity
to focus on the application of empowerment at a practice level through mainly focusing on the
policy level.
It is interesting that none of the reviewed literature identifies specific training issues pertaining to
the application of the Mental Capacity Act 2005 into practice. This is a hugely significant piece of
legislation to support vulnerable adults in England and Wales and yet it has been recognised that
healthcare staff require a better understanding of the law (Stevens, 2013) and adherence to the
Act is poor (Heslop et al., 2013). Despite this, the reviewed literature failed to identify this as a
training need in healthcare organisations.
Values and ethics (empowerment, person-centred care)
Although policy and practice can safeguard vulnerable adults in health care organisations, it is
also important to consider the underlying values and ethics behind the practice.
Many studies emphasise the importance of person-centred care and the effective engagement of
service-users to increase their own safety (DoHC, 2008; Scraggs et al., 2012; Heath and Phair,
2009; Grimshaw, 2012). The importance of service-user empowerment was recognised by the
DoH (2011b) and Humphries (2011). However, the only authors who explicitly recognised that it
was also important to have empowered staff and an empowered workforce were Arya and Callaly
(2005). If staff do not feel empowered there may be barriers to them empowering both staff that
they line-manage and any service-users under their care.
The study by Rudolfsson et al. (2007), found that nurse leaders considered one of their main
duties was to take care of and ensure the well-being of their staff and the respondents
emphasised that each individual nurse is different, as are their patients. This recognition of staff
as individuals is significant as sometimes the needs of individual professionals are not
recognised. In this study, nurse leaders took responsibility for the nurses well-being and
showed consideration and respect by ensuring that staff took breaks, left work at the right time
and took time off.
An important value is to promote the self-determination of service-users. Bell et al. (2005)
recognise that service-users should be able to express themselves and healthcare
organisations must develop mechanisms for vulnerable adults to complain. This is
imperative if they feel abused and they assert that a lack of complaints does not necessarily
indicate a quality service. Bell et al. (2005) note that obtaining service-user views within
the NHS is evident, however, current mechanisms are inadequate for vulnerable adults
to express their views. They argue that there are few links between complaints and systematic
quality improvement and there has been limited consideration on how to elicit or manage
complaints from service-users who are particularly vulnerable within the NHS. Through
undertaking targeted methods to gain the views of service-users that are vulnerable,
healthcare services might identify specific issues or concerns experienced by the most
vulnerable service-users accessing their services.
A related point was made by Calcraft (2007) who noted that if a victim has profound disabilities
and is unable to disclose abuse themselves, they rely on others to protect and advocate for them.
In his summary of a European Union project exploring issues of abuse of people with learning
disabilities, Madden (2006) outlines a key message that emerged across all the countries involved
in the study. This related to values and openness, as the sexual abuse of people with learning
disabilities is less likely to occur if there is a clear determination to promote their overall integrity
and it is less likely if services are open, welcoming the involvement of families, promoting
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partnerships and receive external evaluation. The DoHC (2008) state that patients, carers and
family members must be at the centre of all that is done. Their voices should be heard more
effectively and public involvement should be a requirement for all healthcare quality control and
accountability mechanisms.
It is important to note that service-users may have different priorities to the staff that are delivering
their care. Scraggs et al. (2012) found that the goals and incentives of doctors may be misaligned
with the goals of patients, particularly when doctors make assumptions about what service-users
want and need. Grimshaw (2012) also recognises that active involvement of patients, relatives
and staff in the clinical processes of assessment, care planning, evaluation of care and audit of
clinical practices can improve standards of care. The DoHC (2008) states that effective patient
and public involvement should be demonstrated in reviews of health service performance. The
document argues that the health system should develop a national framework and network of
patient advocates to work in partnership with healthcare organisations to improve patient safety
and to contribute to the education and continuing professional development of healthcare
professionals. Heath and Phair (2009) argue that preventative activity can be developed by
increasing opportunities for vulnerable people to have a voice.
The outcomes framework offered by Heath and Phair (2009) focuses on older peoples abilities,
goals and aspirations, which is conceptually more empowering than care focusing on
problems and deficits. This approach departs from viewing nursing as a series of tasks and
acknowledges the many invisibleactivities of nursing (such as listening and supporting), which
the older people involved in this study clearly said they valued. They believe that care becomes
truly person-centred when older people actively determine their priorities to the maximum extent
possible. This also supports the principles of the Mental Capacity Act 2005 which involves
professionals taking all practicable steps to help a person reach a decision (principle 2) and not
treating someone as unable to make a decision because it is an unwise choice (principle 3).
Leadership framework
As a piece of qualitative work, this study adopted an inductive approach, seeking to build up
theory from emergent information contained within the literature review. The second objective
was to identify or adapt a model of leadership to contribute to safeguarding vulnerable adults in
healthcare organisations. Through critical analysis of the literature, no clear leadership model was
presented that would fulfil this objective. Therefore the author adapted a model of leadership
which emerged through the process of meta-synthesis, in which some elements of effective
leadership were clearly identifiable from the literature. Figure 2 illustrates this framework:
(RQ1) focuses specifically on healthcare organisations. At the onset of the study, the author
was assuming that this was in provider organisations, thus there were no deliberate attempts
to explore the responsibilities of commissioners or regulators. Through the literature review,
none of the selected sources related specifically to commissioners, however many of them had
implications for those responsible for commissioning health services. In addition, one source
related to health organisations manufacturing healthcare products (Edwards et al., 2012).
Thus the proposed model (Figure 2) aims to encompass learning that is generic enough to
be applied to any health organisation regardless of whether they are a commissioner, provider
or regulator.
The framework proposes a three-tier model of transformational change. First, structural issues in
society may contribute to certain adults increased vulnerability to abuse and although this may be
difficult to challenge for individual practitioners, it needs to be recognised as the wider
environmental context within which healthcare services are delivered. Martin and Henderson
(2010) recognise that organisations operate in complex networks, consisting of three
environments (internal, near and far) and they recognise that there is a dynamic relationship
between these environments. Consideration of the societal/structural tier (the far environment)
was not evident from the literature review, as authors had failed to adequately consider
this level and how it might influence operational practice with vulnerable adults. However, the
author of this study believes it provides an essential ideological and structural context for the two
remaining tiers.
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Second, the author identified aspects for consideration by the strategic leadership of an
organisation and the culture of that organisation. These aspects should be considered by those in
senior management positions who are hierarchically the leaders of healthcare organisations and
have the power to effect strategic organisational change.
Finally, central to the proposed model is personal leadership. At the onset of the paper the author
defined leadership as showing the way(Sturmberg and Martin, 2012, p. 18) which implicitly
recognises that leadership is something that any staff member can possess. Within the realm of
personal/individual leadership, the author synthesised learning from the literature review to offer
practical suggestions that individual practitioners can begin to implement into their day-to-day
Figure 2 Leadership framework
Strategic Leadership and Organisational Culture
Visible strategic leadership for
safeguarding vulnerable adults-
includes challenging practices
and attitudes that might lead to
abuse.
Clear and visible clinical
leadership for safeguarding
vulnerable adults (this may
include lead posts).
Effective governance
arrangements that are
communicated across the
organisation.
All stakeholders are actively
engaged in processes of change.
Zero-tolerance to abuse is an
explicit value.
Safeguarding and whistle-blowing
policies are implemented and
communicated across the
organisation.
Vulnerable adults are empowered
to look after themselves– seek
and support ways to offer training
and preventative interventions for
vulnerable adults.
Commission an independent
person to support whistleblowers.
Employ specialists who are
trained specifically to engage and
support vulnerable adults during
their experience through the
healthcare journey.
Ensure arrangements for
complaints enable vulnerable
adults to utilise the process.
Ensure staffing levels are
adequate and all staff have
manageable case loads.
Involve service-users and patient
advocates at all levels.
Disseminate learning from
adverse incidents across the
organisation. Link complaints to
quality improvements
Lead a “just” culture, in which
accountability/ blame is
apportioned appropriately- adopt
a systems-based approach to
analysing adverse incidents.
Lead and encourage work across
partnerships.
Lead and support a culture that
does not place tasks and process
above the individual (that
includes staff as well as service-
users).
Regard safeguarding as
core to your practice
and the work of your
organisation. Be explicit
about this to others.
Reflect on your own
practice and challenge
yourself and others
practice and values.
Actively seek feedback
from vulnerable adults,
act on it, feedback your
learning to others.
Display a commitment
to a future greater than
yourself.
Speak up if you see
poor practice. Support
and encourage
colleagues to speak up.
Be honest when you get
something wrong and
learn from your mistake.
Avoid complacency –
look for your blind spots
and regularly reflect and
challenge your own
habitual behaviour.
Encourage an open
culture, including
adopting open and
honest communication
with others.
Give and receive
regular supervision. Do
not be afraid to seek
support and offer
support to others.
Professionally challenge
dominant individuals
and publicly support
others who
professionally challenge
dominant individuals.
Act as a role model to
others.
Support a no blame
culture – Do not be
quick to blame
individuals when
adverse incidents occur.
Consider wider
systems/ external
factors that may have
influenced decision-
making.
Take breaks from work,
encourage others to
take breaks. Ensure
you are not working
beyond your
competency and seek
support if your workload
increases to unsafe
limits.
Personal/
Individual
Leadership
Engage in mandatory
training and take
opportunities for your
continuous professional
development.
Engage in inter-
professional learning
activities and work
effectively across
professions and
partnerships.
Empower your staff,
team and service-users
to the maximum.
Work towards an open
culture within your staff
team.
Do not ask someone
else to do something
you are not prepared to
do yourself.
Familiarise yourself with
safeguarding policy and
procedures and apply
them to your practice.
Work towards
transformational change
for vulnerable adults.
Remain accountable for
your own actions,
choices, decisions and
practice. Involve other
professionals and if
appropriate, gain their
opinions when making
decisions.
Positively support
Governance
arrangements and see
quality and performance
as essential in
maintaining high
standards.
Learn from adverse
incidents/ poor decision-
making; share this
learning with others
Apply person-centred
principles to all aspects
of your practice.
Support partnership-
working with service-
users and across
teams, professional
boundaries and
agencies.
Societal Structural Issues: Socio-Political and Economic Factors; Changing
Health Environments; Local and National Policy drivers
Source: Author’s own
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working practices to support a culture of safeguarding. If every member of staff (from
administrator to doctor; bank support worker to chief executive) in a healthcare organisation
adopts these features of practice they might support and enhance a safeguarding culture.
The model is a summary and synthesis of findings from the literature review, however, without
empirical application and assessment the efficacy of the model has yet to be verified through
implementation into practice. Applying this into practice would involve change at the three levels
indicated in the model. Authors such as Iles and Sutherland (2001) acknowledge that change in
the NHS is not likely to be straightforward. Buchanan and Huczynski (2006) also suggest, that to
minimise fears and reduce opposition to change, it is important to gain involvement and
participation from those involved in the change.
Limitations
Grant and Booth (2009) recognise the interpretive elements of critical reviews, which result in a
conceptual framework that is the starting point for further investigation and not an endpoint. Thus,
it is important to acknowledge that although this paper proposes a framework it has not been
empirically tested so its validity cannot be verified.
Abalos et al. (2001) note that quality evaluation should be undertaken by more than one person
independently as establishing a degree of consensus minimises errors. However, this paper only
utilised one reviewer which can therefore be noted as a methodological weakness.
Credibility and trustworthiness are terms used to describe the validity of a qualitative study
(Ritchie and Lewis, 2003). Despite the limitations discussed above, the author believes that the
credibility and trustworthiness of this study are still intact.
Summary
Although many recent publications have emphasised the importance of the relationship between
poor leadership and the occurrence of harm and abuse (DoH, 2009, 2010, 2011a, 2012, 2013;
Francis, 2010, 2013), the empirical evidence for this remains inadequate and, thus, it is clear that
further research is required in this important area.
As the definition of leadership is not universally agreed this study utilised the broad definition to
mean showing the way(Sturmberg and Martin, 2012, p. 18). The literature review concludes
that various aspects of leadership can safeguard vulnerable adults in health care organisations.
Five broad themes were considered in detail and one aspect of showing the waythat appeared
as a common theme across the literature was the importance of clear leadership and direction.
However, it is important this framework is considered relevant to all staff and not just identified
leaderswithin healthcare organisations. All staff within healthcare organisations have the duty to
show the waywhen it comes to safeguarding against the abuse of vulnerable adults.
The literature evidenced how organisational culture may influence the ability of healthcare
organisations to safeguard vulnerable adults. Abusive practice may thrive when staff focus on
tasks and procedures rather than the experiences, choices and aspirations of service-users. An
open organisational culture is essential.
Clinical quality and effectiveness will improve if organisational culture values the prevention
of harm and abuse; and challenges attitudes towards poor care (including encouraging
whistle-blowing). Effective governance structures can assist in safeguarding vulnerable adults
and it ensures the accountability of healthcare organisations.
Learning organisations recognise that mistakes happen and learning can be utilised to improve
quality. Individuals should not be unfairly blamed if their decision making has been impaired due
to inadequate systems or processes and the importance of healthcare organisations evidencing
strong values and ethics in delivering person-centred and empowering care was identified.
Leadership remains a concept that requires clarity in terms of its practical application and
therefore further research into this is essential. Thus, through the critical review of literature
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and meta-synthesis of findings, the conceptual framework of leadership that emerged now
requires empirical testing to evaluate its efficacy in practice.
In 1859, Florence Nightingale noted that hospitals [] should do the sick no harm(Nightingale,
1859, p. iii). Over 150 years have now passed and despite significant developments in medicine
and nursing throughout this period, healthcare services have not yet managed to achieve this
aspiration of doing no harm. Safeguarding vulnerable adults within healthcare organisations
remains a complex process and it requires full engagement of staff at all levels of leadership.
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Corresponding author
Emma L. Stevens can be contacted at: emma.stevens8@nhs.net
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Chapter
What evidence is there concerning the effectiveness of community-based multi-agency safeguarding of vulnerable adults? Six electronic databases were searched, which was further reduced to 39 empirical studies retained for full review. It proved difficult to draw clear conclusions about the comparative effectiveness of different approaches to safeguarding, as most studies consisted of surveys of the extent to which official guidelines were followed, or analysed reports on serious case reviews, held when safeguarding fails. A fundamental task entails ensuring that effective oversight is in place and is operational. Police services could potentially influence the emergence of a “law-oriented” model of inter-agency working. Some results supported such a way of working. There was widespread acceptance of the benefits of multidisciplinary team working, but clear evidence that supports this was sparse. Some studies supplied relevant evidence, involving specially developed centres or modes of professional liaison which showed advantages over other approaches. There are potential roles for police in enabling staff of other agencies to develop frameworks for identifying when cases should be brought to police attention and in understanding decisions about prosecution or other measures.
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Full-text available
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Whistle‐blowing is the act of speaking out about wrongdoing in the workplace. Adults with learning disabilities are particularly vulnerable to abuse, and care staff play an important role in witnessing and reporting such abuse. This paper explores the experience of whistle‐blowing on abuse in social care settings and looks at how whistle‐blowing can help to protect people with learning disabilities from abuse.
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Qualitative research can make a valuable contribution to the study of quality and safety in health care. Sound ways of appraising qualitative research are needed, but currently there are many different proposals with few signs of an emerging consensus. One problem has been the tendency to treat qualitative research as a unified field. We distinguish universal features of quality from those specific to methodology and offer a set of minimally prescriptive prompts to assist with the assessment of generic features of qualitative research. In using these, account will need to be taken of the particular method of data collection and methodological approach being used. There may be a need for appraisal criteria suited to the different methods of qualitative data collection and to different methodological approaches. These more specific criteria would help to distinguish fatal flaws from more minor errors in the design, conduct, and reporting of qualitative research. There will be difficulties in doing this because some aspects of qualitative research, particularly those relating to quality of insight and interpretation, will remain difficult to appraise and will rely largely on subjective judgement.