The paramedics' role in safeguarding and protecting children and young people

Review of current literature

A search was conducted of the emergency nursing and paramedic practice journals, alongside Pubmed, Cochrane, and Science-Direct data bases, from 1990 to current date. The following key words were entered, both individually and in combination; ‘pre-hospital’, ‘out of hospital’, ‘paramedic’, ‘vulnerable’, ‘child protection’, ‘in need’, ‘sociology’, ‘psychology’, ‘psychosociology’ and ‘biopsychosocial’. Results relating to emergency nurses were included in this data as the author argues that there is a distinct similarity in the underpinning education and way in which emergency nurses and paramedic practice (Brady, 2011). Of the limited amount of data found the majority originated from the UK, with small amounts from America, Australia and New Zealand.

Theory vs practical, physical vs psychosocial

Congruent with much of the literature available in relation to most subjects in paramedic practice, the safeguarding of children and young people focuses primarily on their physical needs (Children's Commissioner, 2004). A textbook named Nancy Caroline's Emergency Care in the Streets (2008), the latest of six editions and often dubbed ‘the paramedics' bible’ comes close to a 1000, of which only one–and–a–half are related to child abuse; the presented definition of which this author would contest. The protection of children within this arguably best–selling paramedic text talks only in terms of injury prevention, safety guidance, home protection and other various practical approaches to protecting children from physical injury. This text's limitations are further advertised when compared to a theoretical approach to paramedicine and one would suggest a far less popular and infrequently bought academic text, Foundations of Paramedic Practice a theoretical perspective (2008). This contains an extensive chapter, albeit very instructional, on the safeguarding and welfare of children. This chapter covers legal statue, guidance, psychosociology, different constituents of child need, vulnerability and abuse and is in stark comparison both in its depth and published frequency with the lacking of any mention of child protection in older texts of previous training regimes that have only recently been retired. This comparison is made not only between these well–known texts but also between papers such as Duffin (2008), who links the paramedics' role in child protection to that of major hazardous incidents, without making any mention of other potential aspects of their role in this important and emotive subject. Perhaps most disconcertingly, articles such as Davies' (2010)How to spot a really sick child, mentions only physical needs of children and omits any reference to wider psychosocial or safeguarding perspectives. This being the case one would expect that papers such as Determining the paediatric educational needs of pre-hospital providers part one and two by Breon et al (2011) would most certainly make some reference to safeguarding children and young people; however, no such subject is mentioned with only a small reference being made to paediatric psychological assessment. This one feels exemplifies the current position of child protection and psychosociology within paramedicine as being almost cordoned off or separated to mere theoretical knowledge as opposed to the hands on practicality perceived to be of higher importance.

Identification of need, vulnerability and abuse

Sibson and Brain (2009) published a two–part piece on the paramedics' role in the protection and safeguarding of children and drew attention to the recognition of child abuse, risk factors and the obstacles and challenges facing front line practitioners. These instructional papers identified the importance of early recognition that encompasses a well–rounded biopsychosocial approach to protection and safeguarding. Well written that they are one would expect an abundance of literature similar to these examples, elaborating, investigating and sharing experiences and cases to be published. However, these two papers were the only the only two identified that were specifically related to paramedic child protection and safeguarding, and although historically are relatively recent (2009), it could be argued that in the light of the continuing financial constraints on both population and public services due to the globally recognised financial crisis, and the effects related to social determinants of health, they could be seen as somewhat dated.

In a similar vein, Hawley et al (2011) approaches the protection of children and young people from a mental health perspective. Mental health in the care of paramedics (parts 1 and 2) (2011), although far less in–depth as Sibson and Brain (2009), makes mention of the paramedics need to be aware of local guidelines and partnerships with social and child protective services. However, Brady (2012) has highlighted the negative view in which paramedics hold psychiatric cases which may inhibit the uptake of recommendations of such papers, however conversely as paramedics view children with high priority this mightn't be the case. Apart from Smart (2009) there also appears to be a lack of differentiation between that of children and young person, both of which have arguably completely different sets of risk factors, needs and levels of vulnerability further highlighting the possible miscomprehension surrounding child and young person protection and safeguarding.

UK paramedic guidelines

The Joint Royal Colleges' Ambulance Liaison committee (JRCALC) have specific guidelines available to UK practioners on the protection and welfare of children and young people, which cites previously mentioned literature. JRCALC guidelines are often unfortunately and wrongly seen as a path from which UK paramedics should never deviate, else risking deregistration or law suits. Often as much helpful as it is limiting, JRCALC guidance are now viewed by UK practioners in a light reminiscent of previously descriptive UK Institute of Health and Care Development (IHCD) training programmes, now retired.

Described as producing protocol driven quasi–regimentally fashioned practice (Brady and Haddow, 2011) that limits autonomy, IHCD courses were highly instructional and algorithmic; traits clearly seen in these (2006) JRCALC guidance on the protection and welfare of children and young people. Perhaps limiting wider thought and discussion about the paramedics' role and responsibility.

One of its key objectives is, ‘To ensure all staff are aware of, and can recognise, cases of suspected child abuse, or children at risk or significant harm’ JRCALC and while this comparably in–depth publication does highlight documentation, professional duty and responsibility, from physical, emotional, sexual, neglect, in need and vulnerability perspectives; there is very limited discussion into the wider psychosocial determinants of health, promotion, education, sexual, dietary and housing advise that this author argues vehemently are key to early recognition and prevention. These guidelines that are solely within the chapter of ‘Treatment and management of assault’, as opposed to what should be a distinctly separate social health and welfare section of JRCALC are never–the–less well written guidelines. The author encourages practioners internationally to read these ‘guidelines’ with an open mind to somewhat more autonomy, updated practice and the expansion of paramedic roles to those not mentioned within.

Emergency nursing

Similarities can be drawn from the emergency nursing profession, within which there are increased amounts of literature regarding the safeguarding and protection of children in emergency departments (Joughin, 2003; Youd, 2005; Conway, 2008; Brady, 2011); the recognition of non-accidental injuries (Murphy 2001), and the care of children who live with domestic violence (Evans 2001) and prostitution (Knight, 2002). This source of literature is perhaps not known to paramedics as there tends to be a level of professional demarcation and tribalism, resulting in paramedics viewing emergency nursing as completely separate to their work, and wrongly, dissimilar, further inhibiting the uptake of such valuable information. This article goes onto explore how paramedics are unique in their ability to enter peoples own social worlds and communities often without question, which is dissimilar to emergency nursing, however the identification of risk factors and signs of neglect and need for protection and safeguarding are arguably the same.

Perhaps the most alarming result of this research is the sheer lack of literature found actually concerning paramedics' role in the protection and safeguarding of children and young people. While this literature review does not meet Cochrane standards and due to time and financial constraints has not fully addressed the unpublished works that may be available from various ambulance services and voluntary ambulance agencies, such as Yorkshire Ambulance Services distant learning workbook on safeguarding children (as yet to be rolled out); it does, however, highlight the need for paramedics to question their attitudes, knowledge and roles. Another possible limitation is that community nursing was not included within this review; the author recognises the possible similarities between the two professions however due to their often scheduled interaction with service-users he argues that this reduces the emphases placed on paramedics ability to view a social world in its unprepared entirety. What is clear to the author is that from the limited amount of literature found the majority is very instructional. No mention is paid to how paramedics are in a unique and privileged position to be able to bridge biomedical and public health approaches for preventing disease and injury and promoting health thorough population based strategies (Rhodes and Pollock, 2006), as related to safeguarding and protection of children and young people. There appears to be a complete lacking of critical evaluation or in depth discussion of the role paramedics currently play and ought to play in the future of a profession currently battling between different concepts of role, responsibility and identity. One suggests that these limited examples validate and highlight the distinct need to investigate and address the ambiguity surrounding the role of paramedics in the safeguarding and welfare of children and young people, at local, national, university and ambulance service levels.

The paramedics' role in protection and safeguarding of children and young people

The paramedics' role in relation to the protection and safeguarding of children and young people may be seen solely as removing the child or young person from imminent danger, such as that of a road traffic collision, house fire or unstable structure; or providing immediate safety after a death of parent or carer. However as the paramedic profession and the education underpinning it continues to evolve, long–standing definitions, professional identities, assumptions, tasks and responsibilities need to evolve with it also. This can only be achieved by investigating to what extent paramedics currently view their role, in order to create an educational package designed by subject specific experts with research findings in mind.

The legal framework within which child abuse is challenged in the authors country of the United Kingdom (UK) is provided primarily by the Children Act 1989 in England and Wales, the Children (Scotland) Act 1995, and the Children (Northern Ireland) Order 1995; each of which sets out the powers and responsibilities of local authorities and the means by which they can safeguard children and promote their welfare. The author encourages readers to become familiar with mandates within their own countries that may unknowingly affect their practice and place them in a position of professional and legal responsibility. Such mandates with the UK produced the 2003 green paper Every child matters (ECM) (Department of Education (DE), 2003) which was a comprehensive report partly in response to successive failures by multiple agencies to both recognise and react to children and young people in need; Victoria Climbie, and baby P being two such landmark cases. In the resulting home office reports resulting from the tragic death of Victoria, and baby Peter, ambulance services and paramedics were only mentioned in respect to their treatment during the crisis period leading up to their deaths; however in such cases the author questions what part paramedics could play in recognising not just the physical signs of abuse and neglect but the full biopsychosocial ‘red flags’, earlier on.

Whitnell (2010) argues that ECM (DE, 2003) reinforces the notion that paramedics need to pay attention to the needs of all children, and not just those already known to be in need or at risk of harm. She further puts forward that at all times paramedics are in a position to prevent a child from possibly being harmed by providing relevant information to other agencies and healthcare professionals who take over the care of the child. The paramedics' duty bound responsibility is growing in recognition, which raises questions as to whether practitioners know what actually constitutes abuse, neglect and the need to safeguard a child or young person; encouraging the need for up to date rigorous research which results in educational and career development.

Although the National Institute for Health Clinical Excellence (2009) summarise the different types of child abuse as physical, sexual, neglect, emotional and maltreatment, there is a need to differentiate between a child and young person, being abused, neglected, in need and at risk. This further highlights how inherently difficult child abuse, risk and need is to define and estimate the prevalence of (Sibson and Brain, 2009), for those practitioners who specialise in such an area let alone for paramedics who sporadically and unpredictably come into contact with children and young people.

Vulnerability is a dynamic concept with various factors such as: social status, environmental stability, psychological genetic and cultural differences. The DH (2000) defined vulnerable children as:

Some of those included in definition include: teenage parents, young carers, young substance miss-users and those living in poverty. Again all of which paramedics are likely to come into contact with, however perhaps less likely to recognise factors relating to vulnerability, due to an historical lack of psychosocial education. Vulnerability also raises questions as to what is culturally and legally acceptable in different communities and countries. The striking of a child is now illegal in some western countries (or illegal in most only if marks are left on a child's skin); however, in other countries much more than striking is the social norm and deemed acceptable, as is the marriage of young girls at the age of 14 to older men; something deemed as abusive in most western cultures. This highlights how complicated and socially, religiously and racially sensitive the subject of protection and safeguarding actually is; raising the question as to how efficient the paramedic profession is in dealing with such situations and the need for educational development.

The requirement to recognise both and/or distinguish between a child or young person in need or at risk in what often transpires to be an array of abusive, risky and neglectful factors, necessitates practitioners having some foundation knowledge and appreciation of their role within this area. This call for educational advancement and professional development into the safeguarding and welfare of children is similar to Brady (2012)Pre-hospital psychosocial care: changing attitudes, which approaches another similarly less well known area of practice in a way that does not allow perceptions, attitudes and roles to stagnate, but aims to constantly question and scrutinise them to drive forward the paramedic profession and raise the quality of patient care.

Paramedics have a professional obligation to identify and recognise areas of their practice that are perhaps less well informed than others, and to undertake forms of continual professional development and additional education, to raise these areas of knowledge to a level that ensures safe and effective practice. This itself is problematic if professionals still have a limited notion of what paramedicine entails and still believe that their job and role is predominantly the provision of emergency life threatening care and not the everyday psychosocial reality that it is (Brady, 2012). This is further compounded by the emphasis governments and individual health trusts place on response times and clinical performance indicators; and while having their strategic place within paramedicine, the proverbial poorer siblings of these financial incentivised policies perhaps lose out. This places responsibility firmly within the hands of individual professionals to approach their employers and professional bodies to encourage and assist in the progression, professional development and educational advancement of their future practice, through educational programmes and research.

Future research

Recent mandates, case reports and serious case reviews have led to a plethora of initiatives generally within social care aimed at averting and preventing similar tragic and disastrous events. The author suggests that such initiatives also have a place with paramedicine, given their unarguably unique, privileged and somewhat covert place in the recognition and prevention of harm to children and young people. One such example is the authors own doctoral research; with a current thesis title of: An investigation into paramedics own understanding and attitudes of their role in relation to safeguarding children (aged 0-18 years) and the knowledge of the psychosocial factors involved thatinform their practice.

This research aims to investigate concepts of paramedic practice, which up until now have either not been researched or only done so inadvertently and sporadically as part of larger projects. This research aims to investigate and collate information on paramedics' attitudes and thoughts regarding what they consider to be their main role in the provision of care. Furthermore, their attitudes and thoughts in relation to their role in relation to safeguarding children and young people, coupled with the related psychosocial factors that may inform their practice within this area. This mixed methodology research will employ the use of questionnaires, focus groups and vignettes with a possible sample size of 1 644 paramedics and student paramedics from an ambulance service which provides care over four disparate settings (rural, inner city, area with a large ethnic minority and an area of social deprivation. This large sample size allows for a wide spread of variations in age, sex, socioeconomic background, length of service, previous employment, previous education and educational route into paramedicine; importantly directly comparing pre– and post–registration paramedic views, thus allowing the researcher to identify possible patterns and differences within subgroups of the profession.

It is through such research that the profession will be able to quantify and identify the educational and developmental needs required to assure safe and effective practice. The profession remains without a clear cut professional identity and while this research does not aim to produce a clearly defined identity, it does aim to produce a foundation of knowledge on which the profession is able to progress in the terms of child and young persons' protection and safeguarding and the psychosocial factors that underpin this task; the importance of which this author hypothesis is largely underestimated and miscomprehended.

Implications for practice

As alluded to already within the review of literature, there is limited availability of educational literature as applied to paramedic safeguarding and protection, and what is available tends to focus on physical signs and symptoms. Although the author recognises that universities across the country are now including such education within their curriculum (Brady and Haddow, 2011) which has not been included within this review, this education has only been available to newly qualified staff and in small proportions, and not to the majority of paramedics who qualified through previous training regimes. Yorkshire Ambulance Service (2012) has recently produced a distant learning package that covers most aspects of safeguarding and welfare of children and young people, from emotional and sexual abuse, signs of neglect and the communication strategies required to fully provide joined up care. Other ambulance services have similar packages soon to be released which address the issues raised regarding university education and previous training regimes, however research is required to investigate the uptake and application of this knowledge in practice.

Practitioners need to take up opportunities of additional education, either from local universities, college of paramedic conferences, or distance learning packages in areas the author has highlighted. By becoming aware of the deeper underpinning knowledge of safeguarding and the psychosocial factors that play as much a part as the physical factors, services and individual practitioners will be able to provide more efficient care that may prevent harm and protect children and young people. By encouraging, promoting and undertaking research such as that proposed by the author, into the perceptions and attitudes staff hold to these less understood paramedic roles, we can identify the learning needs if any that need addressing, in order to improve the care we provide.

Conclusions

This article has reviewed the literature surrounding the difficult to define area of a paramedics' role in the safeguarding and protection of children and young people. It has highlighted a potentially alarming lack of international literature that fully encompasses the full biopsychosocial aspects related to such an emphatically emotive and topical area of emergency and unscheduled health and social care. Articles such as Brady (2012) as well as this can be viewed as highly controversial because they challenge deeply engrained professional assumptions, but one argues that challenges are positive, as being able to re-examine what we think to be the truth is one of the hallmarks of good science and human achievement (Magnanti, 2012). This article is another example of only a few that continues to question and scrutinise the roles, responsibilities and identities of paramedics in relation to the care they deliver to service users that require psychosocial involvement. The author suggests that it is incumbent of the paramedic profession to reflect and investigate attitudes, thoughts and opinions relating to their role in the protection and safeguarding of children and young people, in order to assess and constantly evaluate the efficiency with which they are providing care to the youngest and perhaps most vulnerable in our communities and populations.