concept of vulnerability

CONCEPT ANALYSIS
Safeguarding Vulnerable Adults: Concept Analysis
Abstract
Aim. This study is to analyse the concept of safeguarding the vulnerable adults and the role of registered nurse.
Background. Registered nurse has major responsibilities in caring and safeguarding the vulnerable adult population. Reduction of health inequalities among vulnerable adults are top international healthcare priorities. Vulnerable adults are among most vulnerable of the populations, many people associate vulnerability with old age only, resulting in negative stereotypical views.
Understanding the concepts of vulnerability as relates to adults population, examines how and why adults could be vulnerable will help nurse to educates the vulnerable adults about the rights and choices available to them, enabling nurse to safeguarding the vulnerable adults and empower the vulnerable adults to participate fully in the society.
Data Sources. Data source include the Nursing Standard, The PubMed, Health & Social Care information Centre (hscic), Department of Health, Action on Elder Abuse, Offices of National Statistics (ONS), electronic databases were used to search for research papers, articles published between 2000-2013. The searching keywords used are ‘Vulnerable’, ‘Abuse’, ‘vulnerability’, ‘safeguarding’. Seventeen papers from variety of disciplines, including nursing, public health, social-care and medicine were reviewed.
Method. The concept analysis was done using Rodgers’ evolutionary method. Rodgers (2000) method of concept analysis was chosen because it is evolutionary in nature. Rodger method is not a fixed phenomenon but evolves over time.

Surrogate Terms/Related
Every disciplines ranging from economics and anthropology to psychology, science and engineering use the term vulnerability. The term vulnerability originates from the word vulnerable.
According to Chambers (1989) define vulnerability as a way of recognizing how difficult impact upon people and how people cope with them. Another researcher (Wisner et al, 2004) define vulnerability as a features of a person or group and their situation that determine their capacity to foresee, cope-with, reject and recover from the impact of a hazard whereas the Cambridge Advanced Learner’s Dictionary (2005) defines vulnerability as the ability to: ‘Be easily physically, emotionally, or mentally hurt, influenced or attacked.’
In a concept analysis of vulnerable by Purdy (2004), the term vulnerability refers to individuals of population viewed as unprotected exposed, undefended, sensitive or immature.
The term risk, which is often used and its many variation as a surrogate term in the discussion of vulnerability. The term risk was used to express chance of probabilities that a particular results will happen following a particular exposure, and implies the potential for poor outcome (Burt 2005).
The terms commonly used in the place of vulnerable were at risk, risk, risk behaviour, high risk, risk group, risk factor, risk categories and risk exposure.

Hilary and Mary (2008) studied that concepts, conceptualizing risk to older people only as a person can become vulnerable in the society at any age, could be at risk at any age but people associate vulnerability with old age. Vulnerability is the lived experience of risk. Appropriate Realm (Sample) Data Collection
This report contains information on referrals to adult social care safeguarding teams in England derived from the Abuse of Vulnerable Adults (AVA) data collection for the period 2010-11. It presents a variety of information on aspects of the safeguarding process.
It’s very important to note that this report is being made available to the public as Experimental Statistics, which is defined in the UK Statistics Authority Code of Practice for Official Statistics as new official statistics undergoing evaluation. They are published in order to involve users and stakeholders in their development and as a means to build in quality at an early stage. (HM Government Data.gov.uk)

Abuse of Vulnerable Adults in England 2010-11: Experimental Statistics - Final Report

Data Source: The Health and Social Care Information Centre http://www.hscic.gov.uk/searchcatalogue?q=Vulnerable+adults&area=&size=10&sort=Relevance
In 2000, the Department of health and the Home Office jointly published the ‘No Secrets’ documents. This document provide strategy for local authorities to work along with police, NHS, regulators and other partner agencies to tackle abuse and prevents its occurrence.
In order to respond to this, in 2004 the abuse of the older people was the subject of a Health Select Committee inquiry. This led to the Department of Health funding a project delivered by Action on Elder Abuse. The scope of this project included looking at the current recording systems used by local authorities and the development and piloting of new recording and reporting systems.
To consider categories, causes and effects of vulnerable conditions and the influence that these have on adult. Ageism, demography, type of abuse, location of alleged abuse, and numbers of referrals were examined.

Number of Referrals
Figure1: Referrals by client type and age group of Vulnerable adult, 2010-11 Age group Gender Client Type Percentage Distribution
Primary Client Type 18-64 65-74 75-84 85 and over Male Female Total
Physical Disability 18 13 30 39 34 66 46,720 49
Mental Health 36 13 26 24 35 65 22,030 23
Learning Disability 93 5 2 0 52 48 19,465 20
Substance misuse 87 9 3 1 50 50 915 1
Other Vulnerable People 35 14 25 26 38 62 5,930 6
Total 39 12 23 27 38 62 95,065
1. Figures may not add up to 100 per cent due to rounding
2. Based on information provided by 152 councils
Figure 1.1: Referrals by age group and gender of vulnerable adult, 2010-11
Age group Male Female
18-64 (37,240) 47 53
65-74 (11,080) 43 57
75-84 (21,545) 35 65
85 and over (25,190) 25 75
All Ages 38 62

1. Figures may not add up to 100 per cent due to rounding
2. Based on 95,065 referrals, where all key information was known, provided by 152 councils Figure 2: Referrals by client type and age group of vulnerable adult, 2010-11
Primary Client Type Age 18-64 65 and over
Physical Disability 22 66
Mental Health 22 24
Learning Disability 48 3
Substance misuse 2 0
Other Vulnerable People 6 7

1. Figures may not add up to 100 per cent due to rounding
2. Based on 37,240 referrals for the 18-64 age group and 57,,825 referrals for the 65 and over age group, provided by 152 councils Nature of Alleged Abuse
Table 3: Nature of alleged abuse of vulnerable adult, 2010-11
Nature of alleged abuse Percentage Total
Physical 30 34,490
Sexual 6 6,725
Emotional/psychological 16 18,525
Financial 20 23,295
Neglect 23 26,745
Discrimatory 1 925
Institutional 3 3,975
1. Figures may not add up to 100 per cent due to rounding
2. Based on 114,680 allegations of different types of abuse in 95,065 referrals
3. Based on information provided by 152 councils

Figure 3.1: Nature of referral, by gender of vulnerable adult,2010-11 Gender
Nature of alleged abuse Male Female
Physical (34,490) 30 30
Sexual (6,725) 4 7
Emotional/ Psychological (18,525) 15 17
Financial (23,295) 22 19
Neglect (26,745) 24 23
Discriminatory (925) 1 1
Institutional (3,975) 4 3

1. Figures may not add up to 100 per cent due to rounding
2. Based on 95,065 referrals, which may contain allegations of different types of abuse
3. Based on information provided by 152 councils

Relationship to Alleged Perpetrator Figure 4: Relationship between alleged perpetrator and vulnerable adult, 2010-11 Relationship of alleged perpetrator Percentage
Partner (6,925) 7
Other family member (16,905) 18
Health Care Worker (3,240) 3
Volunteer/ Befriender (320) 0
Social Care Staff (24,425) 25
Other Professional (2,840) 3
Other Vulnerable Adult (12,335) 13
Neighbour/ Friend (6,145) 6
Stranger (1,780) 2
Not Known (13,590) 14

Table shows evident that a quarter of abuse to the vulnerable adults recorded in the years was done social care staffs that are saddles with the responsibilities to take care of the vulnerable adults. The figure is closely followed by other family members who are not the partner of the victims. Identifying Attributes of the Concepts
Attributes, antecedents and consequences are the characteristic that describe various aspects of the concept as it is used in a discipline. In line with the evolutionary method of analysis which is the identification of concepts’ characteristic that appears over and over again (2000). Two major findings from the present concept analysis of vulnerability were: (i) changes in the concepts based on context and (ii) the close relationship between the concept and family and social care staff.
Defining attributes of vulnerability related to safeguarding the vulnerable adults gathered from literature were: core types of abuse which are physical, sexual, psychological, neglect and/or acts of omission, discriminatory, and financial and/or material (DH and Home office 2000).
Vulnerable adults are who are ‘18 years and over who are or may be in need of community care services by reason of mental or other disability, age or illness; and who are or may be unable to take care of him or herself, or protect him or herself against significant harm or exploitation’ (Department of Health and Home Office 2000). Examples of vulnerable adults: older people and those with mental health problems, learning disabilities, physical disabilities or illnesses that result in some degree of dependence on others.
Physical abuse may happen in different ways, from physical attacks, such as punching or slapping, to medication misuse or depriving people of appropriate nutrition or general care. Signs of physical abuse include bruising or injury to the body, sometimes in areas that are usually covered by clothing.
Nurses must be vigilant during the initial and ongoing assessment process, to identify any signs or symptoms that may indicate physical abuse
Sexual abuse in vulnerable adults may include rape and pressuring in to engage in any kind of sexual contact without consent. Vulnerable adults may be forced to watch pornographic material or participate in sexual activities/act against their wishes, including masturbation and oral and penetrative sex. Signs and symptoms of sexual abuses may include genital bruising, bleeding or infection (Pritchard 2003).
Psychological abuse includes verbal abuse (such as shouting and swearing), intimidation, threats and enforced social isolation.
Other abuses such as Discriminatory abuse, Neglect and acts of omission Financial and material abuse are some characteristic that appears over and over again
Institutional abuse this type of abuse manifests itself after repeated episodes of substandard care and is a direct result of poor clinical practice (DH and Home Office 2000).
Financial and material abuse type of abuse includes theft, fraud, material exploitation and misappropriation of property, possessions or finances. Symptoms and signs of financial and material abuse are that vulnerable adults are unable to pay their bills or buy good and enough food. They will appear neglected, malnourished, despite the fact that they have adequate financial means to support themselves (Pritchard 2003). O’Keeffe et al (2007) identified that financial abuse happened in 0.7% (approximately 56,600) of the general older population in the UK. Likewise, Action on Elder abuse (2004) claimed financial abuse as a frequently and commonly reported category of abuse. Crosby et al (2008) argued that lack of data to identify the actual prevalence of financial abuse in older people and suggested that existing figures underestimate the scale of the problem, with cases going either unreported or undetected. Crosby et al (2008) stated that up to 80% of financial abuse occurs in the home environment and 20% in the care environment, with 70% of all reported cases being perpetrated by a family member.

Identifying Consequences of the Concepts
Consequences are the events or states that occur as a result of the concept (Rodger 2000)
The effects and consequence of psychological abuse can be difficult to recognise, especially when nurses have not known the vulnerable adult for long. However, nurses working in longer-term care areas may identify changes in a patient’s personality or general behaviour. For example, the vulnerable adult may revert from an outgoing individual to one who is withdrawn and has unusually low self-esteem. They may also develop depression (Pritchard 2003). Alternatively, the vulnerable adult may disclose a fear of upsetting their abuser.
Sexually abused individual may appear withdrawn or depressed and demonstrate low self-esteem. They may also be unaware that the sexual activities in which they have been forced to participate constitute abuse. Consequently, they may unknowingly disclose the abuse to healthcare professionals.
Media coverage has identified numerous incidents of what could be considered institutional abuse within a range of NHS organisations. The Mid Staffordshire NHS Foundation Trust Inquiry (2010), for example, identified a strong organisational culture of poor care, resulting in the mortality and morbidity of patients. More recently, the Parliamentary and Health Service Ombudsman (2011) reported several incidences of poor nursing practice that demonstrated a lack of care and compassion or patients across a variety of NHS organisations. The DH (2010) recognised that there is a lack of robust, adult, safeguarding systems in place within the NHS. Consequently, concerns about institutional abuse are not being reported and there is a shortage of formal data to identify the prevalence of this type of abuse in vulnerable adults (DH 2009).

Identifying a model case of the Concept
Model case development enables concept clarity by exploring the life scenario, including antecedent and attributes. Safeguarding vulnerable adults as relate to Emily’s case, she is age 79 and has dementia. Emily’s family cared for her at home since her diagnosis some years ago. She was on admission, during the initial assessment, you identify that she is extremely malnourished and emaciated, and her skin integrity has been compromised resulting in a grade 2 sacral pressure ulcer. This ulcer is not dressed and her family members have not mentioned the existence of a pressure ulcer .
The model case contains mental health illness and family factors that could strongly suggest there some form of abuse. It’s could be sort of physical abuse which is evident of her extreme malnourishment, it’s could be neglect and acts of omission as results of her un-reported and un-dressed pressure ulcer. The nurse has duty of care to raise necessary concerns with the view of safeguarding the Emily who is highly vulnerable.

Another model case scenario two (2) is a case of Helen who attends antenatal in your practices. Helen is 36yrs; she just came from Polish and she does not understand English. She normal come to the hospital and communicates through the help of her husband who look gentle and nice. During one of her antenatal routine check- up you notice some bruising to her arms and legs. She tries to hide these bruises and she wouldn’t say anything especially when the husband is in the room.
When you asked the husband how she sustained the bruising, he tells you that she fell. However, he appears nervous and avoids eye contact. The account he gives you does not appear to explain the extent of the injuries.
At this point the nurse should safeguard the pregnant vulnerable adults, this could be a case of physical abuse, domestic violent, sexual assault to which Helen has not consented. Helen should be taken to a separate room, interview her with the help of an interpreter and ensure necessary help is given.

Results. As result of the analysis, a person can become vulnerable at any age including the adulthood age. All adults have the potential to become vulnerable at some stage in their live because of the ageing process or illness like stroke, mental illnesses which may cause them to become more dependent on others for their care needs. Therefore, it’s very important for nurses to be aware of the factors that may contribute to an individual’s vulnerability and how best to safeguard the vulnerable adults.
Accessing the vulnerability in adults without talking in to account aspects of social construction and the categories, causes and effects could lead to inappropriate service provision. More funding and efforts in raising nurses’ awareness, training and development on topic like safeguarding the vulnerable adults in the society. Training will enable nurses to able to recognise and distinguish between socially made and genuine forms of vulnerability.

Conclusion. The protection or safeguarding of vulnerable must be an integral part of everyday nursing practice. Nurses have a key role in the protection of vulnerable adults. Abuse can occur in a range of environment, including NHS and voluntary organisations, private care homes and patients’ personal home. Nurses need to be aware of adults in their care who could be vulnerable to and at risk of abuse. Nurses have duty of care to recognise the signs and symptoms of abuse and to act upon any concerns. They are required to make patient care their primary concern and ensure that protecting vulnerable adults is an integral part of everyday nursing practice (NMC 2008, 2011b).
To safeguard the vulnerable adult, nurse must be train to acquired adult safeguarding skill to ensure robust safeguarding practices. Very importantly, nurses need to understand the different types of adult, nurse need to understand the different types of adult abuse and the associated signs and symptoms, ensuring that any abuse is reported appropriately. Nurses need to continue to be vigilant in recognising abuse of vulnerable patients and ensure that they act accordingly.
Keywords: concept analysis, frailty, vulnerability, dignity, nursing care, risk, abuse, clinical governance, older people

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