Professional Curiosity and Safeguarding Adults

Professional Curiosity and Safeguarding

Lack of professional curiosity is increasingly being highlighted in Safeguarding Adults Reviews (SARs) nationally as a contributing factor to serious harm or deaths. 

What is professional curiosity?  

Professional curiosity is the exploration and development of a deeper understanding of what is happening with an individual or those around them. This is achieved through a robust understanding of an individual’s history, good communication skills, proactive questioning, application of legislation, identification of patterns of concern, ability to hold difficult conversations and respectful challenge. The primary feature of professional curiosity is the avoidance of making assumptions and taking information or a situation at face value. There are many barriers an individual may experience which will reduce the likelihood of them disclosing abuse or neglect directly. Therefor professional curiosity will enable the practitioner to more readily identify signs and indicators. 

Professional curiosity is not something that can or should be turned on and off or used at particular times. Rather, it should be seen as a way of life, a way of professional practice and a way of being – so that a curious approach permeates all aspects of the practitioners’ interactions (Research in Practice Professional curiosity in safeguarding adults December 2020). 

However, it is accepted that there are many barriers to effective professional curiosity. It is important that organisations and professionals are aware of these and take steps to reduce them to enable the development of a culture that supports the maintenance of professional curiosity 

Barriers to effective professional curiosity Disguised compliance 

The appearance of a caregiver, family member, or organisation cooperating with services in order to avoid raising suspicions, to alleviate the practitioner’s concerns, and, ultimately, to eliminate the professional’s involvement entirely. 

The ‘rule of optimism’ 

Practitioners rationalise new or escalating risk despite there being clear evidence that there should be concern. 

Not identifying accumulating risk 

Viewing each incident in isolation without context or consideration of an individual’s history and not considering the risk in relation to the cumulative effect of recurring incidents. 


The perception that actions become ‘normal’ or ‘natural’ and are an accepted part of an individual’s daily life. This leads to a lack of professional challenge or questioning. 

Professional deference 

Practitioner’s perception that another professional is of ‘higher status,’ hence, they are unwilling or afraid to challenge that professional’s view. 

Confirmation bias 

The search for evidence that supports or confirms the practitioner’s existing view and rejection of any evidence that may challenge their existing view as incorrect. 

Knowing but not ‘wanting’ to know 

Having a sense that something is wrong but not being able to form the feeling into a reasoned evidence-based view. 

Diagnostic overshadowing 

Attributing all the evidence in an individual’s life to their diagnosis rather than taking a broader view, considering relationships, environment, trauma, coercion, poor levels or inappropriate support etc. 

Remote working

An additional barrier to professional curiosity is remote working and it is important to recognise and act in relation to this when connecting remotely with both people who are at risk of abuse, neglect, and other agencies. It is important to consider that remote conversation can: 

  • Alter relationships 
  • Create a barrier to successful communication 
  • Create a reduced ability to read the non-verbal content of a conversation 
  • Create a wish to terminate the conversation as soon as possible due to anxiety, unwillingness or ability to use the required technology 
  • Enable difficult conversations to be terminated more easily 
  • Reduce ability for the professional to see the ‘whole’ picture and assess accumulating risk 
  • Reduces awareness of who else may be present during a conversation but out of sight 

In addition, remote working limits opportunities to model good professional curiosity by more experienced practitioners. When you are in ‘earshot’ of a conversation you can learn how to ask good questions. 

There are additional barriers that practitioners need to be aware of: 

  • Poor supervision and management support 
  • Complexity and pressure of work 
  • Preconceived ideas and values 
  • Lack of openness to new knowledge 
  • Fear of respectful challenge 
  • Fear of holding difficult conversations 
  • Lack of confidence in managing tension 
  • Discounting information that cannot be proven 

Organisational values that foster effective professional curiosity

The values of an organisation will have a significant impact on the likelihood that professional curiosity will thrive. Ensuring the workforce: 

  • Have time and capacity 
  • Approach practice from a strength-based perspective 
  • Ensure those with lived experience are actively involved in safeguarding 
  • Display competence in relation to recording which is supported through effective processes and procedures 
  • Are provided with good supervision and management support.  
  • Are legally literate and have a robust knowledge of safeguarding 
  • Are provided with effective training which provides positive impact at a service and organisational level and links to increased competence 

To find out more about how to cultivate professional curiosity at a strategic level join our Level 5 Safeguarding Adults accredited programme. 

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Polypharmacy and Dementia

As health and social care trainers we straddle the medical and social model, and believe whole heartedly, holistic, and integrated practice is required to enable positive outcomes, and well-being within our communities. Within each realm of medical and social perspective, many factors which may be viewed in isolation maybe interdependently linked: manipulating one factor, may impact upon others. We need to take a balanced approach, informed by consent, and at times, pharmacological strategies are warranted, and at others times we should consider non-pharmacological approaches.
It is our responsibility, within training sessions, to encourage staff to reflect upon their clients and the complex nature of the conditions, to equip them with skills to observe, report and signpost. One subject raised within sessions is polypharmacy. Many of the services we train are commonly working with comorbidity, and complexities around fluctuating sates, often resulting in competing care and treatment strategies. To support discussions relating to polypharmacy, we developed some resources with the aim to get people to think and reflect more broadly about the topic.

Inappropriate polypharmacy is a very real and present threat, as many prescribing practitioners face tensions between treating common conditions and the risks associated with polypharmacy.

Many people with dementia, together with older population are affected by polypharmacy. Older people generally will have multiple health conditions which require medication. However, given the potential communication difficulties presented with dementia, particularly around problematic pain management, it is possible that there is a higher prevalence of polypharmacy in this group.
There is no clear definition for Polypharmacy: Sometimes numerical: for example greater than 6. Accepting a numerical definition of polypharmacy has the disadvantage: does not recognise that in some cases the combination use of certain medications is beneficial to the older person. Inappropriate polypharmacy is when the person takes more drugs than are clinically indicated.
Polypharmacy is a concern in this group because there are age-related physiological changes that alter the ways in which drugs are handled by the body. This may include:

• Reduced renal function
• Reduced liver function
• Reduced ratio of body fat to water
• Delayed stomach emptying

There are substantial risks of polypharmacy: for example, there may be severe side effects, some of which further compound cognitive challenges. There may also be drug-drug interactions and drug-disease interactions. The impact can be far reaching; Side effects may cause drowsiness leading to an increased risk of falls. There may be impacts on appetite and poor nutrition leading to multiple problems, not least a compromised immune system. Further than a physiological level, for example certain medications may impact on changes to sexual drive, impacting on identity and ultimately self-esteem. Changes in mood caused by the medication, coupled with cognitive difficulties may lead to emotional distress and challenging communication. In some instances the inappropriate use of medication can create the very problem that it is trying to solve.

There are many possible causes of inappropriate polypharmacy:
• Multiple physicians
• Self-medicating
• Over the counter medicines including herbal preparations
• Medicine dependent culture
• Medication administration errors
• Treating medication side effects with other medications: e.g. a medication may cause constipation, may then be prescribed a laxative. Alternatively maybe appropriate to consider non drug approach: diet.

When the side effects of medication are misdiagnosed as symptoms of another condition. Further medication is prescribed (Cascade prescribing), further side effects and unanticipated drug interactions may present. Older people with dementia who take a cholinesterase inhibitor and who experience urinary incontinence are more likely to receive an anticholinergic medicine to manage their symptoms
Drugs including some antidepressants, muscle relaxants, antispasmodics, and antihistamines may have anticholinergic effects and, therefore, may cause confusion, blurred vision, dry mouth, light-headedness, constipation, and difficulty with urination and/or loss of bladder control causing additional difficulties for a PWD.

Some examples from research:

In a prospective cohort study of 294 older people 22% percent of patients taking 5 or less medications were found to have impaired cognition as opposed to 33% of patients taking 6-9 medications and 54% in patients taking 10 or more medications.
Also in this paper: Polypharmacy affected patient’s nutritional status. A prospective cohort study found that 50% of those taking 10 or more medications were found to be malnourished or at risk of malnourishment
Jyrkka J, Enlund H, Lavikainen P, et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 2010;20:514–522. [PubMed]
A study in elderly patients with dementia reported that those patients who reported a fall had an increased prevalence of polypharmacy
Lee CY, Chen LK, Lo YK, et al. Urinary incontinence: an under-recognized risk factor for falls among elderly dementia patients. Neurourol Urodyn. 2011;30:1286–90. [PubMed]
American study
Two-thirds of hospitalisations for adverse events involved four medicines or classes — warfarin, insulins, oral antiplatelet agents or oral hypoglycaemic agents — taken alone or in combination
Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002–12. [PubMed]

All Party Parliamentary Group on Dementia (2008) Always a last resort: inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes. Alzheimer’s Society. London.
Kleijer BC, van Marum RJ, Egberts AC, Jansen PA, Knol W, Heerdink ER. (2009). Risk of cerebrovascular events in elderly users of antipsychotics. J Psychopharmacol. Nov;23(8):909-14. Epub 2008 Jul 17.
NHS Information Centre (2012) National Dementia and Antipsychotic Prescribing Audit.
Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Archives of internal medicine 2005;165:808–13. [PubMed]

Helen Behrens and Caroline Bartle Follow Us

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Has self-neglect made safeguarding murky?

I suspect most practitioners were surprised to see The Care Act was very thin when it came to safeguarding. It wasn’t until the Statutory Guidance draft in June did we see the familiar list come to being again – with the added abuse ‘exploitation’. Of course, this was rather pointless as exploitation is involved in all abuse – there is always an exchange of power.
Then the final Care and Support Statutory Guidance in October makes further changes. Some of which are rather good – It removes exploitation sensibly.   Adding Domestic Violence was welcome – although I think it should read Domestic Abuse. The change to Organisational from Institutional – some have noted is also an improvement, as this is more likely to include a wider scope of provision and not just residential care. I for one, would have preferred it to read Organisation/Institutional as now the Community Care Act 1990 is no longer law – I am rather concerned that the Care Act is not specifically endorsing the right for people to be supported in ordinary not institutional environs. I guess, the older persons sector has always ignored that ideology with care homes of over 100 beds. Nothing ordinary about that.
The adage of Modern Slavery is vital – and reminds us all of the increasing and shocking examples of mainly migrants fleeing poverty to come to the UK to find a life, only to be forced into labour and sex work, having their passports removed and any means of escape barred. I imagine most of us are both pleased that it has come into safeguarding, as well as rather saddened by the need for it.
It’s the final list entry – self-neglect – that seems to be the most controversial. At the same time as the Local Authority loses its powers to intervene with the repeal of The National Assistance Act, there is now a duty to treat self neglect as an abuse. For so many reasons I find it preposterous to have this as an abuse. In the first instance, the definition of abuse the guidance chooses to define abuse as involving a perpetrator and a victim. Where is the perpetrator in self-neglect, if the person has capacity?   Surely, where a person does not have capacity then it is neglect and not self neglect that applies. I would also stress that it is almost impossible for practitioners to agree on what constitutes self neglect. Who decides? Against what standards? I smoke and to many non smokers, this may be seen as self neglect and arguably it is. Frankly, this adage makes a mockery of the rather wonderful 6 key principles of safeguarding:

These words were well considered and appear in a very precise order. I am rather enjoying this when training safeguarding. The idea that we start with the empowerment and rights and choice – supporting the person to retain or regain capacity is a vital place to start in safeguarding. Everything we do in care provision is safeguarding and prevention – from health and safety standards to supervision and training. And supporting the person to prevent abuse is key to empowerment. Proportionality is placed here and this makes sense of the whole list – If we are going to intervene, then we must understand and apply the Mental Capacity Act and ensure that we use the least restrictive approach when acting – making sure our actions are proportionate to not only the outcomes, but also the person’s right to be in control of their own decision making. Protection is necessary when a person does not have capacity and may be more interventionist, expecting partnership working where those involved are sure of their responsibility and held accountable. I adore this list. It helps all practitioners truly understand the ideology of safeguarding. Where exactly does ‘self-neglect’ fit in here? If the person has capacity, then empowerment and prevention is the proportionate response. If the person does not have capacity then we need to protect and not doing so would constitute neglect.
I am at odds as to how to justify self-neglect as an abuse at all. I have the right to choose my lifestyle which, if you looked in my dusty corners, some may say is self-neglect.
The change from investigation to enquiry – don’t get me started! – that will have to wait for another rant.
Blog by Trish O’Hara – Dec 2014Follow Us

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