Art & science | safeguarding children
Role of effective documentation in emergency departments Joyce Forge offers findings from a literature review and staff opinion survey about whether the use of documentation safeguards children adequately Correspondence [email protected] Joyce Forge is a member of the RCN National Pensioners Convention national council and former specialist health visitor in paediatric liaison Date submitted March 13 2014 Date accepted May 7 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Lord Laming’s report into the death of Victoria Climbié highlights shortcomings in the safeguarding of children, in part due to poor record keeping and information sharing (House of Commons Health Committee 2003). This article presents findings from a survey of emergency department staff opinions about whether keeping records on children aged between birth and 16 years can safeguard them from harm. Staff members said that, while written records generally aid communication, the records they use did not focus satisfactorily on the children concerned and did not take into account some risks factors. The study led to a redesign of the record-keeping system. Keywords Safeguarding children, records, staff perspectives SEVERAL RECENT reports on cases of child neglect, including those of Victoria Climbié (House of Commons Health Committee (HCHC) 2003), Peter Connelly (Local Safeguarding Children Board (LSCB): Haringey 2009), Daniel Pelka (Coventry Safeguarding Children Board 2013), Hamzah Khan (Bradford Safeguarding Children Board 2013) and Callum Wilson (LSCB: Windsor and Maidenhead 2014), have implicated ineffective documentation and information sharing. Lord Laming’s inquiry into the care of Victoria Climbié (HCHC 2003), his follow-up report (Laming 2009) and recent government legislation on safeguarding children, such as the Children Act 2004, show that there is an association between child deaths following emergency department (ED) attendance and poor record keeping and information sharing (Department for Education and Skills (DfES) 2004). Between publication of the two Laming
34 June 2014 | Volume 22 | Number 3
reports, communication in EDs does not appear to have improved (Laming 2009). This article describes findings from a study of staff perceptions of the use of child records in the safeguarding of children in one ED in England. According to practice in the ED, the records of all patients aged up to 16 years must be seen by a paediatric liaison health visitor (PLHV) within 24 hours of their attendance. The PLHV is expected to analyse the records each day, and then provide trust and local community professionals with accurate, relevant and timely information to ensure that vulnerable children receive appropriate support. Where necessary and appropriate, and as recommended by the Laming (HCHC 2003, Laming 2009) and Royal College of Paediatrics and Child Health (RCPCH) (1999, 2007) reports, the PLHV also exchanges relevant information with staff. However, the PLHV role has not been standardised across all EDs in England. In 2002, a critical incident concerning the availability of a child’s ED records occurred where the author used to work and was subsequently the subject of the author’s degree dissertation (Forge 2006). This article is based in part on an evaluation of the incident and study to assess how much practice in the use of records had changed at the ED. About two million children attend EDs in the UK each year (Department for Children, Schools and Families 2009). At each attendance a record is made of the child’s personal details and history, the type of injury and how it was sustained, and the relevant treatments and their rationale. In some EDs, including the one in which the author’s study was made, child records also include the method by which patients are referred to other professionals. These records are essential for the safeguarding of children. They should therefore be clear, relevant, EMERGENCY NURSE
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and appropriate in length, content and style. The sharing of ED records among different professionals should improve communication and continuity of care (DfES and Department of Health (DH) 2004). Studies of safeguarding of children tend to focus on injury types, and care standards and procedures, rather than on the children themselves. Christopher et al’s (1995) study, for example, presents some of the discrepancies found in documentation. In studies by Benger and McCabe (2001), Taitz et al (2004), Law et al (2006) and Gilbert et al (2009), however, the importance of appropriate documentation is not discussed. Sanders and Cobley (2005) focused on non-accidental injuries, which detracts from the importance of appropriate documentation. Last year the DfES and DH (2013) published a report called Good Practice in Information Sharing in the Foundation Years, yet failed to highlight poor documentation as a potential risk factor. As part of her evaluation, the author decided to undertake a literature review of information about the safeguarding of children, staff communication and the use of records in EDs. She searched several databases, including Anglia Ruskin University’s digital library, ASSIA, CINAHL, Cochrane Systematic Reviews, MEDLINE and ISI, using variations of search terms, including ‘child protection’, ‘safeguarding’, ‘communication’, ‘perceptions’, ‘record keeping’, ‘documentation and nursing’, and ‘emergency department’. She also searched journals and books from local libraries, including the British Library, and academic sources. Of the 155 books, journal articles, reports, conference literature and official publications published in English between 1991 and 2012 she found, 12 concerned the use of ED records of patients aged between birth and 16 years in EDs, and are discussed in this article.
Study Methodology In 2007, the author undertook a reflective qualitative case study to determine how child records were used in one hospital’s ED. The children under consideration were those aged between birth and 16 years in accordance with the PLHV’s role description, and the RCPCH (1999) and Laming (HCHC 2003) reports. The choice of age range does not imply that the welfare of children aged over 16 is not considered in the ED. The study’s methodology was informed by Berger and Luckmann’s (1967) constructivist theory, which states that people’s interactions with each other depend on what they understand about their shared environments. Purposive sampling was undertaken to maximise the richness of the data. EMERGENCY NURSE
It was intended that data collection should take place in three stages. In stage one, a purposive sample of children’s records would be analysed. In stages two and three, two focus groups, one involving ED staff members who provide child records and one involving non-ED professionals who receive the records, would be set up. Ethics Ethical approval for the study was granted by the local research ethics committee, and from the relevant research and governance departments. All participants in the focus groups provided their written informed consent. Stage one In the six months between May 1 and November 5 2007, 2,646 child records were made in the ED. The author’s sample of 378 (14.3%) child records comprised all those made during six 24-hour periods, each a different day of the week in each of the six months. This was a representative rather than statistically valid sample, from which the author could determine what was in the records and what readers did with the information. Each record was allocated to one of two categories: those in which there were no causes for concern beyond the medical needs of the children involved, and those in which there were causes for concern, such as signs of general distress, lack of interaction with parents, inconsistent histories, histories of multiple overdose and multiple attendances, that required action. Such causes of concern were found in 73 (19.3%) of the 378 records and were analysed further. Stage two In July 2007, a purposive sample of 12 members of the local operational child protection group, namely safeguarding nurses and doctors, health visitors, school health advisers, community children’s nurses, GPs and social care professionals, took part in a focus group discussion. The author asked them questions about the content and use of child records in the ED, the discussion was audio recorded and the results were transcribed later. Stage three In August 2007, a purposive sample of 12 nurses, doctors, clerical staff, healthcare assistants and managers from the ED took part in a focus group discussion. The author asked them the same questions she had asked participants in the earlier focus group, and recorded and transcribed the results. Data analysis Data analysis was guided by the research design. Significant statements extracted from analyses of the three stages of the study were June 2014 | Volume 22 | Number 3 35
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Art & science | safeguarding children organised into theme clusters and, eventually, five different but interrelated theme categories: ■■ Communication and power levels among staff. ■■ Staff passivity and disengagement from the assessment process. ■■ How records are produced. ■■ Approaches to hospital management. ■■ Imbalances in professional knowledge. An in-depth understanding of staff’s perceptions of the use of child records in the ED was reached referring continually to the original transcripts, during and following data analysis, to ensure that all relevant issues had been explored, and that the study findings were compatible with descriptions and explanations made by the participants. Such hermeneutic phenomenological research characteristically starts with data of descriptions of lived experience but allows researchers to go beyond explicit, or surface, meanings to discover implicit, or intuitive, meanings (Heidegger 1962, Colaizzi 1978), commonly known as ‘reading between the lines’. Limitations The study’s sample size was small because its findings were intended to inform an interpretation of the meaning the people in the sample place on hospital documentation about children’s safety. As such, its findings were not intended to be applicable to, but could be adapted for, other healthcare organisations. Findings The results were shared informally with participants for validation. They show that causes for concern had not been noticed in 49 of the 73 child records in which there were such causes. In addition, the dates and times of incidents that led to injury were recorded in only five of the 73 records, while patient histories were legible in only 27 of them, and were completed in only seven. Participants of both focus groups thought that written records were necessary but that those used at the ED did not include enough relevant information about the children concerned and that, as a result, risk factors were being missed. The causes for concern that had been missed in 49 child records were discovered by the author during her study, and therefore after the children had left the ED, which indicates that the needs of the children concerned may not have been fully assessed. When professionals responsible for children’s care refer their concerns to the appropriate agencies, they must ensure that documentation is accurate to avoid misunderstandings and discrepancies. Crucially, they must also ensure that the children’s parents are aware that referrals have been made, and should observe the children’s and parents’ 36 June 2014 | Volume 22 | Number 3
demeanours, levels of distress and other nonmedical indications. That complete histories had been recorded in only seven records and was legible in only 27 is problematic because, if records are illegible or incomplete, health and social care professionals will struggle to provide the appropriate care to the children concerned. That dates and times of incidents had been recorded in only five records is problematic because assessments of children’s needs may not be met if this information is not recorded in the first instance. Late presentations of injuries may indicate harm or neglect, or that the parents have accessed GP services inappropriately, and may prompt further investigations. This issue is especially important in cases, such as that of Victoria Climbié (HCHC 2003), in which children are left in then care of friends or relatives.
Discussion The standard of information communicated in documentation depended to some extent on relationships between the staff producing and receiving it, which in turn depend on the five theme categories identified during the analysis. One way in which combinations of these categories can hinder good communication is illustrated by a quote from one of the participants in the non-ED professionals’ focus group, who said: ‘Sometimes, the ED doctor’s writing is hard to read. We need to be able to [understand it] to follow up on the information. The other thing that causes problems at times is the abbreviations used.’ The quote suggests that non-ED staff tend to assume that doctors have the knowledge and, due to their senior positions in the organisation, power to decide what information should be communicated. Arguably, however, differences in power and knowledge can be constraining. If junior and non‑ED staff are constrained from acting except when they are prompted to do so by the information given to them by doctors, they may become passive and disengaged with the assessment process. Thus practitioners without the necessary knowledge and support are less likely to place value on the records than practitioners who are knowledgeable and powerful. This situation can be remedied by establishing robust educational requirements to ensure that all practitioners are confident that they have the competency and authority to act in the interests of children. In-house education is not a suitable option in this regard because it can serve to perpetuate outdated behaviour rather than help staff to adopt an evidence-based approach to safeguarding. EMERGENCY NURSE
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Change in practice The main outcome of the author’s study was a change in the design of child records in the ED. During the period of the study, patient records were A5-sized leaflets of blue paper on which information was densely typed in a small font in response to a series of questions. Each record included half a page for recording critical factors concerning safeguarding, a section on treatment or operations, a section on consent to medical or dental investigations, and a section for recording the multidisciplinary team’s notes in free hand. The only information recorded on computer was demographic data, such as children’s names and addresses. During the study the author made formal and informal presentations about potential changes to the ED’s child records at meetings of ED and non-ED professionals, and a plan to improve the records was initiated when the study ended. Five members of ED staff met regularly to discuss the form and content of the new records, which were first printed in 2009. The updated records are printed on A4 format white paper. Each record allocates a page for clinical notes that address safeguarding issues and the actions taken as a result of them. The records cover adult and paediatric safeguarding concerns, including frequencies of, or delays in, attendance. To indicate whether the records concern children or adults, the appropriate capital letters are added to the top left side of the first page. On a child’s arrival at the ED, a receptionist types the child’s record and demographic details into computer software. A copy of the record is then printed for the multiprofessional team whose members enter clinical details manually. After children have been treated and either admitted or discharged,
the details are scanned and saved on the computer, and the paper documents are shredded. Practitioners have reported that the new record forms are more effective than the old ones, and an audit of their use in the ED is being undertaken to inform further improvements. Although the study findings were not intended to be generalisable, it is reasonable to assume that its findings could inform the development of records in other EDs to ensure that all children at risk are identified.
Conclusion This article is based on the author’s PhD thesis, written in 2013, about an incident in which a child’s records at the author’s former place of work had been unavailable. The article shows that, if children’s details are not recorded or recorded inaccurately by senior staff, and if junior and non‑emergency department staff do not question such ommissions and inaccuracies, the wrong or no actions may be taken. These findings have implications for workforce development, and for commissioners and providers of health services for children. Good teaching strategies are needed to improve the standard of documentation. Finally, the author’s aim for this study is to enhance the work on safeguarding children in different disciplines, and to stimulate further research on the topic.
Online archive
Find out more The improved child record form discussed in this article is available on the Emergency Nurse website, at rcnpublishing.com/j/forge
For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Benger J, McCabe S (2001) Burns and scalds in pre-school children attending accident and emergency: accident or abuse? Journal of Emergency Medicine. 1472, 1813, 172.
Department for Children, Schools and Families (2009) Accident Prevention Amongst Children and Young People: A Priority Review. The Stationery Office, London.
Berger P, Luckmann T (1967) The Social Construction of Reality. Penguin, Harmondsworth.
Department for Education and Skills (2004) Every Child Matters: Change for Children. tinyurl.com/o4oo9b8 (Last accessed: May 12 2014.)
Bradford Safeguarding Children Board (2013) A Serious Case Review: Hamzah Khan. Overview Report. tinyurl.com/kfnkc35 (Last accessed: May 12 2014.) Christopher N, Anderson D, Gaertner L et al (1995) Childhood injuries and the importance of documentation in the emergency department. Paediatric Emergency Care. 11, 1, 52-57. Colaizzi P (1978) Psychological research as the phenomenologist views it. In Valle R, King M (Eds) Existential-Phenomenological Alternatives for Psychology. Oxford University Press, Oxford. Coventry Safeguarding Children Board (2013) Serious Case Review: Daniel Pelka. Overview Report. tinyurl.com/osn8r82 (Last accessed: May 12 2014.)
EMERGENCY NURSE
Department for Education and Skills, Department of Health (2004) National Service Framework for Children Young People and Maternity Services. tinyurl.com/mv8m2xf (Last accessed: May 12 2014.) Department for Education and Skills, Department of Health (2013) Good Practice in Information Sharing in the Foundation Years. tinyurl.com/lv8pm5z (Last accessed: May 12 2014.) Forge J (2006) Improving services for children: sharing accident and emergency records. Community Practitioner. 79, 10, 311-312.
Gilbert R, Kemp A, Thoburn J et al (2009) Recognising and responding to child maltreatment. The Lancet. 373, 9658, 167-180. Heidegger M (1962) Being and Time. Harper and Row, New York NY. House of Commons Health Committee (2003) The Victoria Climbié Inquiry Report. tinyurl.com/ycdwmk8 (Last accessed: May 12 2014.) Lord Laming (2009) Protection of Children in England: A Progress Report. tinyurl.com/k5ol8lv (Last accessed: May 12 2014.) Law CY, Wong TW, Lau CC (2006) A study on trauma documentation in accident and emergency attendance records. Hong Kong Journal of Emergency Medicine. 13, 1, 31-37. Local Safeguarding Children Board: Haringey (2009) Serious Case Review: Baby Peter. tinyurl.com/pfklbs (Last accessed: May 12 2014.)
Local Safeguarding Children Board: Windsor and Maidenhead (2014) Serious Case Review: Callum Wilson. Redacted Overview Report. www.wamlscb.org (Last accessed: May 12 2014.) Royal College of Paediatrics and Child Health (1999) Accident and Emergency Care for Children: Report of the Multi-Disciplinary Working Party. RCPCH, London. Royal College of Paediatrics and Child Health (2007) Services for Children in Emergency Departments: Report of the Multi-Disciplinary Working Party. RCPCH, London. Sanders T, Cobley C (2005) Identifying non‑accidental injury in children presenting to EDs: an overview of literature. Accident and Emergency Nursing. 13, 2, 130-136. Taitz J, Moran K, O’Meara M (2004) Long bone fractures in children under 3 years of age: is abuse being missed in emergency department presentations? Journal of Paediatrics and Child Health. 40, 170-174.
June 2014 | Volume 22 | Number 3 37
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Role of effective documentation in emergency departments Joyce Forge offers findings from a literature review and staff opinion survey about whether the use of documentation safeguards children adequately Correspondence [email protected] Joyce Forge is a member of the RCN National Pensioners Convention national council and former specialist health visitor in paediatric liaison Date submitted March 13 2014 Date accepted May 7 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Lord Laming’s report into the death of Victoria Climbié highlights shortcomings in the safeguarding of children, in part due to poor record keeping and information sharing (House of Commons Health Committee 2003). This article presents findings from a survey of emergency department staff opinions about whether keeping records on children aged between birth and 16 years can safeguard them from harm. Staff members said that, while written records generally aid communication, the records they use did not focus satisfactorily on the children concerned and did not take into account some risks factors. The study led to a redesign of the record-keeping system. Keywords Safeguarding children, records, staff perspectives SEVERAL RECENT reports on cases of child neglect, including those of Victoria Climbié (House of Commons Health Committee (HCHC) 2003), Peter Connelly (Local Safeguarding Children Board (LSCB): Haringey 2009), Daniel Pelka (Coventry Safeguarding Children Board 2013), Hamzah Khan (Bradford Safeguarding Children Board 2013) and Callum Wilson (LSCB: Windsor and Maidenhead 2014), have implicated ineffective documentation and information sharing. Lord Laming’s inquiry into the care of Victoria Climbié (HCHC 2003), his follow-up report (Laming 2009) and recent government legislation on safeguarding children, such as the Children Act 2004, show that there is an association between child deaths following emergency department (ED) attendance and poor record keeping and information sharing (Department for Education and Skills (DfES) 2004). Between publication of the two Laming
34 June 2014 | Volume 22 | Number 3
reports, communication in EDs does not appear to have improved (Laming 2009). This article describes findings from a study of staff perceptions of the use of child records in the safeguarding of children in one ED in England. According to practice in the ED, the records of all patients aged up to 16 years must be seen by a paediatric liaison health visitor (PLHV) within 24 hours of their attendance. The PLHV is expected to analyse the records each day, and then provide trust and local community professionals with accurate, relevant and timely information to ensure that vulnerable children receive appropriate support. Where necessary and appropriate, and as recommended by the Laming (HCHC 2003, Laming 2009) and Royal College of Paediatrics and Child Health (RCPCH) (1999, 2007) reports, the PLHV also exchanges relevant information with staff. However, the PLHV role has not been standardised across all EDs in England. In 2002, a critical incident concerning the availability of a child’s ED records occurred where the author used to work and was subsequently the subject of the author’s degree dissertation (Forge 2006). This article is based in part on an evaluation of the incident and study to assess how much practice in the use of records had changed at the ED. About two million children attend EDs in the UK each year (Department for Children, Schools and Families 2009). At each attendance a record is made of the child’s personal details and history, the type of injury and how it was sustained, and the relevant treatments and their rationale. In some EDs, including the one in which the author’s study was made, child records also include the method by which patients are referred to other professionals. These records are essential for the safeguarding of children. They should therefore be clear, relevant, EMERGENCY NURSE
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and appropriate in length, content and style. The sharing of ED records among different professionals should improve communication and continuity of care (DfES and Department of Health (DH) 2004). Studies of safeguarding of children tend to focus on injury types, and care standards and procedures, rather than on the children themselves. Christopher et al’s (1995) study, for example, presents some of the discrepancies found in documentation. In studies by Benger and McCabe (2001), Taitz et al (2004), Law et al (2006) and Gilbert et al (2009), however, the importance of appropriate documentation is not discussed. Sanders and Cobley (2005) focused on non-accidental injuries, which detracts from the importance of appropriate documentation. Last year the DfES and DH (2013) published a report called Good Practice in Information Sharing in the Foundation Years, yet failed to highlight poor documentation as a potential risk factor. As part of her evaluation, the author decided to undertake a literature review of information about the safeguarding of children, staff communication and the use of records in EDs. She searched several databases, including Anglia Ruskin University’s digital library, ASSIA, CINAHL, Cochrane Systematic Reviews, MEDLINE and ISI, using variations of search terms, including ‘child protection’, ‘safeguarding’, ‘communication’, ‘perceptions’, ‘record keeping’, ‘documentation and nursing’, and ‘emergency department’. She also searched journals and books from local libraries, including the British Library, and academic sources. Of the 155 books, journal articles, reports, conference literature and official publications published in English between 1991 and 2012 she found, 12 concerned the use of ED records of patients aged between birth and 16 years in EDs, and are discussed in this article.
Study Methodology In 2007, the author undertook a reflective qualitative case study to determine how child records were used in one hospital’s ED. The children under consideration were those aged between birth and 16 years in accordance with the PLHV’s role description, and the RCPCH (1999) and Laming (HCHC 2003) reports. The choice of age range does not imply that the welfare of children aged over 16 is not considered in the ED. The study’s methodology was informed by Berger and Luckmann’s (1967) constructivist theory, which states that people’s interactions with each other depend on what they understand about their shared environments. Purposive sampling was undertaken to maximise the richness of the data. EMERGENCY NURSE
It was intended that data collection should take place in three stages. In stage one, a purposive sample of children’s records would be analysed. In stages two and three, two focus groups, one involving ED staff members who provide child records and one involving non-ED professionals who receive the records, would be set up. Ethics Ethical approval for the study was granted by the local research ethics committee, and from the relevant research and governance departments. All participants in the focus groups provided their written informed consent. Stage one In the six months between May 1 and November 5 2007, 2,646 child records were made in the ED. The author’s sample of 378 (14.3%) child records comprised all those made during six 24-hour periods, each a different day of the week in each of the six months. This was a representative rather than statistically valid sample, from which the author could determine what was in the records and what readers did with the information. Each record was allocated to one of two categories: those in which there were no causes for concern beyond the medical needs of the children involved, and those in which there were causes for concern, such as signs of general distress, lack of interaction with parents, inconsistent histories, histories of multiple overdose and multiple attendances, that required action. Such causes of concern were found in 73 (19.3%) of the 378 records and were analysed further. Stage two In July 2007, a purposive sample of 12 members of the local operational child protection group, namely safeguarding nurses and doctors, health visitors, school health advisers, community children’s nurses, GPs and social care professionals, took part in a focus group discussion. The author asked them questions about the content and use of child records in the ED, the discussion was audio recorded and the results were transcribed later. Stage three In August 2007, a purposive sample of 12 nurses, doctors, clerical staff, healthcare assistants and managers from the ED took part in a focus group discussion. The author asked them the same questions she had asked participants in the earlier focus group, and recorded and transcribed the results. Data analysis Data analysis was guided by the research design. Significant statements extracted from analyses of the three stages of the study were June 2014 | Volume 22 | Number 3 35
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Art & science | safeguarding children organised into theme clusters and, eventually, five different but interrelated theme categories: ■■ Communication and power levels among staff. ■■ Staff passivity and disengagement from the assessment process. ■■ How records are produced. ■■ Approaches to hospital management. ■■ Imbalances in professional knowledge. An in-depth understanding of staff’s perceptions of the use of child records in the ED was reached referring continually to the original transcripts, during and following data analysis, to ensure that all relevant issues had been explored, and that the study findings were compatible with descriptions and explanations made by the participants. Such hermeneutic phenomenological research characteristically starts with data of descriptions of lived experience but allows researchers to go beyond explicit, or surface, meanings to discover implicit, or intuitive, meanings (Heidegger 1962, Colaizzi 1978), commonly known as ‘reading between the lines’. Limitations The study’s sample size was small because its findings were intended to inform an interpretation of the meaning the people in the sample place on hospital documentation about children’s safety. As such, its findings were not intended to be applicable to, but could be adapted for, other healthcare organisations. Findings The results were shared informally with participants for validation. They show that causes for concern had not been noticed in 49 of the 73 child records in which there were such causes. In addition, the dates and times of incidents that led to injury were recorded in only five of the 73 records, while patient histories were legible in only 27 of them, and were completed in only seven. Participants of both focus groups thought that written records were necessary but that those used at the ED did not include enough relevant information about the children concerned and that, as a result, risk factors were being missed. The causes for concern that had been missed in 49 child records were discovered by the author during her study, and therefore after the children had left the ED, which indicates that the needs of the children concerned may not have been fully assessed. When professionals responsible for children’s care refer their concerns to the appropriate agencies, they must ensure that documentation is accurate to avoid misunderstandings and discrepancies. Crucially, they must also ensure that the children’s parents are aware that referrals have been made, and should observe the children’s and parents’ 36 June 2014 | Volume 22 | Number 3
demeanours, levels of distress and other nonmedical indications. That complete histories had been recorded in only seven records and was legible in only 27 is problematic because, if records are illegible or incomplete, health and social care professionals will struggle to provide the appropriate care to the children concerned. That dates and times of incidents had been recorded in only five records is problematic because assessments of children’s needs may not be met if this information is not recorded in the first instance. Late presentations of injuries may indicate harm or neglect, or that the parents have accessed GP services inappropriately, and may prompt further investigations. This issue is especially important in cases, such as that of Victoria Climbié (HCHC 2003), in which children are left in then care of friends or relatives.
Discussion The standard of information communicated in documentation depended to some extent on relationships between the staff producing and receiving it, which in turn depend on the five theme categories identified during the analysis. One way in which combinations of these categories can hinder good communication is illustrated by a quote from one of the participants in the non-ED professionals’ focus group, who said: ‘Sometimes, the ED doctor’s writing is hard to read. We need to be able to [understand it] to follow up on the information. The other thing that causes problems at times is the abbreviations used.’ The quote suggests that non-ED staff tend to assume that doctors have the knowledge and, due to their senior positions in the organisation, power to decide what information should be communicated. Arguably, however, differences in power and knowledge can be constraining. If junior and non‑ED staff are constrained from acting except when they are prompted to do so by the information given to them by doctors, they may become passive and disengaged with the assessment process. Thus practitioners without the necessary knowledge and support are less likely to place value on the records than practitioners who are knowledgeable and powerful. This situation can be remedied by establishing robust educational requirements to ensure that all practitioners are confident that they have the competency and authority to act in the interests of children. In-house education is not a suitable option in this regard because it can serve to perpetuate outdated behaviour rather than help staff to adopt an evidence-based approach to safeguarding. EMERGENCY NURSE
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Change in practice The main outcome of the author’s study was a change in the design of child records in the ED. During the period of the study, patient records were A5-sized leaflets of blue paper on which information was densely typed in a small font in response to a series of questions. Each record included half a page for recording critical factors concerning safeguarding, a section on treatment or operations, a section on consent to medical or dental investigations, and a section for recording the multidisciplinary team’s notes in free hand. The only information recorded on computer was demographic data, such as children’s names and addresses. During the study the author made formal and informal presentations about potential changes to the ED’s child records at meetings of ED and non-ED professionals, and a plan to improve the records was initiated when the study ended. Five members of ED staff met regularly to discuss the form and content of the new records, which were first printed in 2009. The updated records are printed on A4 format white paper. Each record allocates a page for clinical notes that address safeguarding issues and the actions taken as a result of them. The records cover adult and paediatric safeguarding concerns, including frequencies of, or delays in, attendance. To indicate whether the records concern children or adults, the appropriate capital letters are added to the top left side of the first page. On a child’s arrival at the ED, a receptionist types the child’s record and demographic details into computer software. A copy of the record is then printed for the multiprofessional team whose members enter clinical details manually. After children have been treated and either admitted or discharged,
the details are scanned and saved on the computer, and the paper documents are shredded. Practitioners have reported that the new record forms are more effective than the old ones, and an audit of their use in the ED is being undertaken to inform further improvements. Although the study findings were not intended to be generalisable, it is reasonable to assume that its findings could inform the development of records in other EDs to ensure that all children at risk are identified.
Conclusion This article is based on the author’s PhD thesis, written in 2013, about an incident in which a child’s records at the author’s former place of work had been unavailable. The article shows that, if children’s details are not recorded or recorded inaccurately by senior staff, and if junior and non‑emergency department staff do not question such ommissions and inaccuracies, the wrong or no actions may be taken. These findings have implications for workforce development, and for commissioners and providers of health services for children. Good teaching strategies are needed to improve the standard of documentation. Finally, the author’s aim for this study is to enhance the work on safeguarding children in different disciplines, and to stimulate further research on the topic.
Online archive
Find out more The improved child record form discussed in this article is available on the Emergency Nurse website, at rcnpublishing.com/j/forge
For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Benger J, McCabe S (2001) Burns and scalds in pre-school children attending accident and emergency: accident or abuse? Journal of Emergency Medicine. 1472, 1813, 172.
Department for Children, Schools and Families (2009) Accident Prevention Amongst Children and Young People: A Priority Review. The Stationery Office, London.
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