Recognising and responding to abuse in the community: an audit of community nurses’ knowledge and confidence in Irelands mid-west region

Safeguarding adults at risk of abuse, harm or neglect is an essential aspect of healthcare delivery. Several cases of adult abuse have been reported in the Irish media over the years, including Leas Cross, Aras Attracta, the Grace Case, the Brandon Case (Phelan, 2023) and more recently the Emily Case (McIlroy, 2024). These cases highlight the need for stringent safeguarding practices in healthcare settings and in the community. Healthcare professionals, including community nurses, have a pivotal role in identifying, reporting and preventing abuse (Phelan, 2015, 2018; Liu et al., 2021; Duffy et al., 2022). However, there is a growing concern that many community nurses may not be fully aware of or compliant with safeguarding policies, despite the availability of resources and training programmes specifically developed for healthcare professionals (Naughton et al., 2010; Phelan, 2010a, 2010b; Brown-Nelson, 2018; Magruder et al., 2019; Yang et al., 2021; Butler, 2022; NSO, 2022).

This article presents the findings of an audit conducted in May 2024, aimed to assess the knowledge and understanding of safeguarding policies and practices among community nurses in the Mid-West region of Ireland. The NSO annual report (2022) highlighted a demise in safeguarding referrals from community nurses; consequently, the findings could potentially offer insights into the preparedness of community nurses to effectively safeguard adults and provide recommendations to improve safeguarding education and practice in the community setting.

Although there is no specific safeguarding adult legislation in Ireland, safeguarding practice is underpinned by national policy (Health Service Executive, 2014), national safeguarding guidelines [Health Information and Quality Authority (HIQA) and Mental Health Commission (MHC), 2019], and other legislation including the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 and the Assisted Decision-Making (Capacity) Act (ADMA) 2015. These frameworks set out standards, values and norms for healthcare workers, emphasising their duty of care to protect adults who are at risk of abuse. Safeguarding is also monitored and enforced by regulatory bodies such as HIQA, whereby the inspectors conduct inspections of Residential Care Settings for older adults, and for adults with disabilities to ensure compliance with policy and the relevant HIQA standards. While the Health Service Executive (HSE) and Section 38 organisations (voluntary or non-profit organisations providing health or social care under section 38 of the Irish Health Act 2004) must report concerns to local safeguarding teams, HIQA does not currently oversee adult safeguarding governance in community care settings in Ireland.

In Ireland, community nurses are at the forefront of the primary care team, managing patients in need of healthcare support while living at home (Burke et al., 2018). Community nurses often work in isolated environments, yet; they are part of an integrated multidisciplinary team who provide healthcare services to patients and their carers. Given their position, these nurses have a unique role in identifying early signs of abuse or neglect (Phelan, 2010b). However, concerns have been raised about the adequacy of the training and knowledge of community nurses when safeguarding adults from abuse, harm and neglect, the practical application of policies, and some community nurses may lack confidence in recognising or reporting abuse. Safeguarding referrals from the Community/Public Health Nursing (PHN) service reduced from a rate of 26% in 2016 to 5% in 2022 (NSO, 2022) and in 2023 (NSO, 2023) PHN/Community Registered General Nurse (RGN) referrals reduced further to 3.1% (n = 561). Considering both the demographic changes in the over 65-year-old population as outlined by the Central Statistics Office (CSO, 2024) and the international prevalence data on elder abuse in community settings (Yon et al., 2017), an increase in adult abuse reporting would be expected across all healthcare settings (NSO, 2022). The NSO (2022, 2023) statistics include reports reflecting adult abuse to those under the age of 65 years; notably, reports for those over 65 years old remained relatively consistent from 2022 to 2023 (13% increase), while reports for those over the age of 80 years old increased by 32%, reflecting the policy’s impact and advancements in safeguarding older adults in the community.

Previous research identified barriers to effective safeguarding practices can include a lack of training, uncertainty about what constitutes abuse, fear of repercussions for reporting, workload concerns, blurred definitions of abuse and inadequate support from management (Manthorpe et al., 2012; Myhre et al., 2020; Doyle et al., 2023). Yet, in a healthcare system where the older population is rapidly growing, it is vital to ensure community nurses are well-equipped with the knowledge and skills necessary to safeguard individuals who are ageing in place.

The aim of this audit was to establish community nurses’ knowledge and confidence in terms of identifying and reporting adult abuse in the community setting.

The objectives were to:

• determine the effectiveness of the online national adult safeguarding training programme for community nurses; and

• provide recommendations for safeguarding education and practice improvement to the Directors of PHN and to the NSO.

Audit has a vital role in promoting patient safety and ensuring adherence to evidence-based guidelines. At its core, the primary purpose of an audit is to enhance the quality of care provided to patients (Christina et al., 2016). Twycross and Shorten (2014) explain that audits typically follow a quality improvement cycle, measuring care against established benchmarks, implementing targeted actions to enhance care and tracking ongoing improvements to ensure they align with agreed-upon standards or benchmarks. Overall, our intention was to assess the current knowledge, practices and confidence levels of community nurses regarding adult safeguarding policies and practices to identify gaps and areas for improvement. By evaluating these key areas, the audit aimed to strengthen adult safeguarding practices in the community, enhance patient safety, promote adherence to national safeguarding standards and promote a culture of safeguarding in the community.

A cross-sectional audit, conducted at a single point in time to assess practices, compliance or outcomes against established standards or benchmarks (Setia, 2016), was undertaken to assess the knowledge and confidence of community nurses when identifying and reporting adult abuse in the community. A structured nine item questionnaire was initially developed by the ADMA lead for Ireland East hospital group and adapted for the purposes of this audit (see Supplementary Material 1). The tool was informed by the HSE national safeguarding policy (Health Service Executive, 2014) and best research practice guidelines. The questionnaire targeted nine key areas of adult safeguarding, including community nurses’ confidence in recognising abuse, their attitudes towards reporting concerns, the barriers they face in doing so and the identification of additional safeguarding supports needed within the community. An open-ended question also allowed respondents to state what supports they would like to enable them to report safeguarding concerns in their practice.

The audit targeted community nurses employed in the Mid-West region of Ireland (CHO Area 3), covering counties Clare, Limerick, North Tipperary and East Limerick. A total of 227 nurses including PHNs, community based RGN’s and community Clinical Nurse Specialists were invited to participate in the audit. Participation was voluntary, and all responses were anonymised to maintain confidentiality. The questionnaire was disseminated digitally in May 2024, with the Directors of PHN in the region acting as gatekeepers.

In general, formal ethical approval is not specifically required for an audit (Twycross and Shorten, 2014). In addition, the HSE National Office of Clinical Audit (NOCA) has provided guidance regarding ethical approval requirements for auditing, stating that a “clinical audit does not require ethical approval but, as always and in line with best practice, ethical issues should still be considered while also adhering to data protection principles” (HSE & NOCA, 2023, p. 39). Our audit was authorised by the general manager of the HSE NSO. We also gained permission from Head of Service Primary Care and the Director of PHN in the region to collect and analyse the data and disseminate the findings. This process ensured that the audit aligned with the ethical standards expected of audits (HSE & NOCA 2023). All participants were fully informed about the nature, purpose and scope of the audit, as well as the voluntary nature of their involvement. Confidentiality was maintained throughout, with no identifying information being collected. Participants were assured that their responses would be anonymised and used solely for the purpose of improving safeguarding practices among community nurses. Given the nature of the audit and its focus on professional knowledge and practice rather than patient interaction, the risk to participants was considered minimal.

Data from the survey were analysed using descriptive statistics to provide an overview of the participants’ knowledge and confidence when safeguarding adults and reporting concerns of abuse in the community setting. Microsoft Excel was used for organising, visualising and interpreting the survey results.

The audit findings are presented across four key areas captured from the survey responses: knowledge of abuse, confidence to report safeguarding concerns, barriers to reporting and safeguarding education and training. These themes provide insights into community nurses’ understanding of safeguarding practices, their readiness to act on concerns, the challenges they face in reporting abuse and the adequacy of safeguarding training programmes and support. Each of these areas highlights critical factors influencing effective adult safeguarding within community care settings.

The questionnaire asked participants to assess their familiarity with seven categories of abuse: physical, psychological, financial, sexual, neglect, institutional and discriminatory abuse to ascertain their understanding of the various forms of abuse, and if they recognised the signs and indicators of each category. Of the 28 community nurses who completed the survey, none reported familiarity with all seven categories. The three most common categories of abuse respondents were familiar with included neglect (96.4%), financial abuse (96.4%) and psychological abuse (92.9%) with respondents being least familiar with institutional abuse (57.1%) as presented in Figure 1.

Of those surveyed, 3.6% of respondents did not know how to report suspected abuse or harm within their working area. Twenty nine percent of respondent reported safeguarding concerns within the preceding 24 months, while 71.4% did not refer any safeguarding concerns. Of those who reported abuse within the past 24 months, Figure 2 shows that 14.3% of community nurses reported their concerns directly to their line managers, and 46.5% reported directly to a social worker. The remaining 39.5% referred to others including more senior staff, student PHN to PHN, General Practitioner and other healthcare professionals involved with the patient, as opposed to reporting directly to the safeguarding and protection teams.

When asked about factors that prevented participants from acting in response to a perceived risk or sign of abuse, the highest proportion of survey respondents (21.5%) cited specific barriers when they said they had previously reported a concern that had not been addressed. Fourteen percent of respondents stated that they were unable to report their concerns because the patient did not want to discuss the concern with them, and 14.3% mentioned a range of other barriers to reporting, including not knowing what to do over the weekend, being afraid of the patient’s hostility, and not reporting due to the patient’s request not to report. Eighty six percent of respondents said they would like to feel more confident when managing safeguarding issues during the course of their workday. Participants also stated the need for a statutory framework for adult safeguarding similar to child protection.

Ninety six percent of respondents completed the HSEland core training programme Safeguarding Adults at Risk of Abuse within the previous three years. The final question asked about the support’s community nurses need to manage safeguarding concerns. The respondents provided comments regarding the local safeguarding and protection team, saying they “feel well supported”, “the safeguarding team are very helpful by telephone” and “give good practical advice”. However, it was suggested that additional in-person training sessions, case scenario discussions and increased face-to-face interaction between the nursing staff and the safeguarding team following a referral would be helpful. Having someone to talk to and offer guidance in the event that certain safeguarding criteria are not satisfied was also suggested.

The audit findings provide a preliminary insight into the safeguarding practices of community nurses, highlighting significant areas for improvement while acknowledging limitations due to the low response rate (13%). While the low rate suggests caution in interpreting the results, the insights gained can still help identify gaps in meeting safeguarding standards. Wu Zhao and Fils-Aime (2022) advise that online surveys produce an 11%–12% lower response rate than other types of surveys, suggesting while the response rate may limit the generalisability of our findings, it is within the expected range for an online survey. In addition, the responses obtained still provide valuable insights into current community adult safeguarding practices, highlighting areas for improvement and emphasising the need for targeted interventions in community settings.

Firstly, the findings reveal knowledge gaps in recognising various types of abuse, with none of the respondents stating they were familiar with all seven categories of abuse as outlined on page 9 of the Safeguarding Vulnerable Persons at Risk of Abuse National Policy & Procedures (HSE, 2014). This finding suggests a need for enhanced training that includes comprehensive coverage of all abuse types, ensuring community nurses can meet the standard of promptly identifying any form of abuse (Duffy, 2023). To address this knowledge gap, the addition of regular, scenario-based training on all categories of abuse could potentially improve community nurses’ awareness and capability, aligning their practice more closely with safeguarding policies and better preparing them to spot subtle or less common forms of abuse. Community nurses have a pivotal role in identifying and responding to various forms of abuse that may occur within community settings (Kurmi et al., 2024). With the growing number of HSE home support services and care packages for older adults and adults with disabilities, many of which are delivered by external providers, there is a pressing need for constant vigilance to detect abuse, harm or neglect within community care settings. Beyond the more commonly recognised types of abuse, community nurses must also be aware of the growing spectrum of abuse, presenting in even more complex forms of exploitation, such as cuckooing, mate crime, domestic abuse, human trafficking and modern slavery (Longhurst, 2018).

Cuckooing involves a perpetrator moving into the home of a vulnerable individual, typically under the guise of friendship, and gradually taking control of their property, finances or other possessions (Spicer et al., 2020). This type of abuse can severely compromise a person’s autonomy and may go unnoticed without a keen understanding of its signs, particularly as this type of abuse often involves coercion and intimidation masked as companionship. Similarly, mate crime is a form of exploitation where individuals with disabilities or vulnerabilities are targeted by those who pretend to be their friends, exploiting them for personal gain (Doherty, 2020). Domestic abuse can include physical, emotional, financial and psychological harm, and often goes undetected in community settings, especially if the individual is isolated or reluctant to disclose their situation (Boyle and Murphy‐Tighe, 2022). Community nurses need to recognise the indicators of domestic abuse, as many victims rely on trusted healthcare providers to notice and respond appropriately to their suffering. Awareness of human trafficking and modern slavery is crucial, as victims are not always hidden from society. Many interact with community services, seeking healthcare, dental care, attending schools or workplaces (Combs and Arnold, 2022). Recognising subtle indicators and understanding the complexities of human trafficking are essential for timely intervention. By understanding these various forms of abuse, community nurses can better protect adults who may have an increased risk of experiencing abuse, to ensure the protection of the persons human rights and well-being, contributing to a broader safeguarding culture that addresses all forms of exploitation and abuse (Duffy et al., 2024).

The results of the audit indicated confidence in reporting concerns varied among the respondents, which may compromise the consistency and timeliness of reporting concerns. This finding points to a potential gap in the support structures available to community nurses when managing complex cases of abuse, a standard required for effective safeguarding. Providing access to a designated safeguarding community liaison person for consultations may empower community nurses to act confidently. Clinical Nurse manager (CNM) grade 2 roles have been introduced within the community safeguarding teams, with two CNM 2’s currently in position. These nurse managers working within the community safeguarding teams are expected to enhance communication with community nurses, facilitating more effective reporting of safeguarding concerns and supporting a coordinated approach to the prevention of adult abuse. Strengthening safeguarding support mechanisms through collaboration with social work colleagues would also likely increase compliance with best practice reporting guidelines and encourage a culture of zero tolerance for abuse in community care (Liu et al., 2021).

Barriers to reporting concerns were another relevant finding in this audit with respondents citing factors such as fear of repercussion, uncertainty about reporting outcomes, and perceived lack of support where participants stated some referrals were not accepted by the local safeguarding and protection teams with reporting thresholds being too high. Twenty one percent of respondents stated their concerns were not accepted by the safeguarding team; therefore, these community nurses were slower to refer cases. This finding suggests a need to explore the interface between the referrer (community nurses) and the safeguarding teams’ criteria for acceptance of referrals. There is scope to develop clearer guidance in relation to adult safeguarding referral criteria as this is an area where there seems to be much confusion, time wasting and conflict between disciplines.

Participants also reported some patients did not consent to the nurses reporting their concerns to the safeguarding agencies, leaving them with ethical challenges in terms of their reporting responsibilities (Saghafi et al., 2019). Safeguarding adults specifically focuses on upholding an individual’s right to live safely and free from harm. Therefore safeguarding adults in need of protection requires professionals and organisations to collaborate to minimise risks and prevent instances of abuse or neglect (Duffy et al., 2025). Central to safeguarding efforts is respecting the person’s preferences, values, and beliefs when determining any necessary actions (Phelan, 2010b). With supportive decision-making legislation now in place in Ireland, healthcare professionals are indeed presented with challenges in terms of reporting concerns to the safeguarding agencies. Casey (2024) suggests more training and supports are needed to ensure continued integration of the Government of Ireland (2015) in clinical practice. The reporting barriers the community nurses in our audit experienced reflects other research findings (Offen, 2021) where healthcare professions hesitate to report abuse due to fear of personal or professional consequences, fear of losing trust with their patients and being unsure how and to whom to report their concerns. Nevertheless, reluctance to reporting abuse concerns is inconsistent with the HSE policy and standards which advocate for a zero-tolerance approach to abuse with clear, reporting pathways (HSE, 2014).

Finally, respondents’ feedback on education and training reflects the need for ongoing safeguarding education to strengthen community nurses’ competencies. National policy states that healthcare professionals or staff working in older persons services and services for adults with disabilities are mandated to complete the HSE eLearning National Adult Safeguarding programme at least three yearly. The findings of this audit highlight a need for more accessible, face-to-face training focused on abuse identification, reporting processes and regulatory updates, all of which could potentially close the identified knowledge gaps.

The first phase of this project has proven invaluable in identifying areas for improvement for the NSO, particularly in terms of education gaps for community nurses. The lessons learned from this audit will guide the next steps in refining both the questionnaire and strategies to address the gaps, ensuring a stronger foundation for a broader implementation of safeguarding adult policy and procedures to practice. While the low response rate limits the generalisability of the findings, these results suggest areas for improvement, particularly pointing to targeted interventions that could enhance safeguarding practices among community nurses and better align with Irish national safeguarding standards.

Our audit fundamentally highlighted the need to strengthen a culture of safeguarding adults within community healthcare settings where the commitment to protecting adults must be both comprehensive and actively supported. The gaps identified a brief insight into community nurses’ knowledge, confidence and support for reporting abuse in the mid-west region of Ireland, where targeted improvements can reinforce safeguarding practices, fostering an environment where abuse is readily recognised and acted upon without hesitation. There is scope for the NSO to undertake a national audit of community nurses safeguarding practices. Furthermore, there is scope to extend the audit to other disciplines to gain more extensive knowledge of staff awareness of good adult safeguarding practice.

Developing a safeguarding culture in the community healthcare setting requires more than policy; it calls for continuous education, accessible resources and a supportive framework that empowers community nurses to respond confidently to abuse concerns (HIQA and MHC, 2019; McIlroy, 2024). Regular audits of safeguarding practices, like this one, have a crucial role in assessing the effectiveness of current protocols, identifying areas for improvement and ensuring alignment with the national safeguarding standards. Audits also promote accountability and encourage a proactive approach to quality improvement, reminding healthcare teams of their shared responsibility to protect adults at risk of abuse in the community. Moving forward, consistent monitoring and ongoing audits will be essential to measure progress, address future challenges and reinforcing a culture of safeguarding within community care.

The supplementary materials for this article can be found online.