Editor’s Note
The following important, relevant and timely article was submitted by a novice author. The article takes the reader through the process of identifying a research question, identifying the research design and providing a step-by-step template for how to conduct and report a research study. Each aspect of the framework selected is illustrated as part of the process, thus enabling others to replicate and either confirm the findings or use as a guide for conducting a similar study.
As with all research, the first study uncovers the gaps and reveals the need for additional studies. However, there are also suggestions from the data for ways to address some of the gaps and perhaps reduce some of the inhibitory barriers to complete the paperwork required as a mandatory reporter of suspected child abuse.
The author worked with Dr. Mary Frances Pate during the research and then with Dr. Sandra Mott and Dr. Pate during the writing for publication process. This is a mentoring service offered to all SPN members who want to share their academic and clinical projects for advancing the science with their peers. The goal of mentoring is to guide the author through the process, use the submission as a guide for future novice authors, and prepare the novice author for submitting the next article for peer review.
Background and significance
Children are a vulnerable population and rely on care provided by others to ensure their health, safety, and well-being. Child maltreatment is a serious issue with harmful effects potentially influencing the trajectory of the affected child’s life with long-standing physiological, mental, emotional, and economic implications. Child maltreatment may occur in direct forms, such as physical, sexual, emotional and/or mental violence or neglect and in the indirect forms of exposure to domestic violence incidents, observing or learning about abuse experienced by another individual, or perceiving social and emotional isolation (
James, 2018
). The immediate risk is continued intentional injury and even death plus the probability of multiple long-term effects on child abuse survivors. Children under age four are at greatest risk for death from intentional maltreatment; and at such a young age, are developmentally at a disadvantage for self-advocacy (Sheldon-Sherman et al., 2013
).A cornerstone of preventing recurrence and escalation of childhood maltreatment is the reporting of suspected abuse to a governmental child protective agency. Once a report is filed, child protective agencies complete further investigation and intervene as necessary on behalf of the child/children identified. Mandated reporting laws exist to compel professionals employed in positions of frequent contact with children to file a report of known or suspected child abuse, usually via a toll-free number or standardized forms available from individual child protective agencies (Child Welfare Information
Gateway, 2016
).Nurses are often in front-line positions providing care for children who might be experiencing abuse and are considered mandated reporters of maltreatment. The nurse questioning abuse is required to report their suspicions or knowledge of child maltreatment to their local child protective agency as soon as possible. However, a variety of circumstances and factors may affect the process and place the nurse in a compromised or stressful situation (
James, 2018
). It is important to examine these factors to identify potential barriers in nurse mandated reporting of child abuse.Purpose statement
The purpose of this integrative literature review was to examine current data and research available on the topic of contributing factors that may influence nurses’ adherence to mandated reporting of suspected child maltreatment cases.
Research question
The following research question formed the basis for the literature review:
What barriers to the child abuse reporting experience emerge from the literature that may adversely influence nursing decisions to report suspected child abuse?
Methods
Design
An integrative review of the literature was conducted to learn the factors influencing nurses’ decisions about reporting child abuse; to gain insight into the existing researched concepts of mandatory nurse reporting; and to examine contributing factors to completion of reporting. Using Wittemore & Knafl’s (2005) methodology for integrative literature reviews, the stages of problem identification, literature search, data analysis and data comparison were applied to the review process (Wittemore & Knafl, 2005).
Literature search strategy
The online databases searched included the Cumulative Index of Nursing and Allied Health, or CINAHL Complete, PubMed, and ProQuest Nursing & Allied Health Source. The key terms of child, abuse, maltreatment, nurse, mandatory, mandated, report, and reporting were used. Some of these key terms were combined and a second search using child abuse AND nurse AND mandatory AND report was completed. A re-examination if the literature using the combined terms yielded sufficient literature for an integrative review.
Literature Search Limitations and Inclusion/Exclusion Criteria
Inclusion criteria
All peer reviewed literature from 2008-2018 related to perceptions and experiences of nurses when deciding whether or not to comply with mandated reporting of suspected child abuse. Literature had to be available in English in full text format through DePaul University’s library.
Exclusion criteria
Articles not pertaining to nursing perception of reporting barriers, not including information addressing the role of nurses in child abuse, or not reporting nurses’ perceptions on factors associated with reporting of child abuse were excluded.
Data reduction
The literature search was organized according to the
Shimpuku and Norr, 2012
(Box 1). An initial search of PubMed with the original search terms in a combination of child abuse OR child maltreatment AND mandatory AND nurse AND reporting produced 132 articles. Following application of the refined order of key terms (child abuse AND nurse AND mandatory AND report), the resulting search produced 108 articles of which fifteen articles met inclusion criteria. There was one duplicate article and eight more were eliminated related to exclusion criteria leaving six articles that totally met all criteria.Box 1
Article reduction results.
Tabled
1
| Initial number of articles from resources: | 23,577 |
| Number following refined search by combining key words | 206 |
| Number following application of inclusion criteria | 57 |
| Number following elimination of duplicates | 51 |
| Number following application of exclusion criteria | 9 |
CINAHL Complete initially produced 20,778 articles when using the original key words across all searched databases. After refining the order of key terms to child abuse AND nurse AND mandatory AND report, the subsequent search resulted in 73 articles for review. Inclusion criteria eliminated all but 23 articles. Another article was eliminated as a duplicate. Exclusion criteria further eliminated 21 leaving only one article that met all criteria.
The initial search of ProQuest Nursing & Allied Health Source using the original order of key terms yielded 2,667 articles. The refined order of key terms resulted in twenty-five articles. Inclusion criteria netted 19 articles. Four articles were eliminated as duplicates and 13 because of exclusion criteria. Two articles remained that met all criteria.
A total of nine articles met inclusion and exclusion criteria. Each of the nine was carefully read and appraised with findings highlighted.
Data synthesis & analysis
The articles meeting all criteria were identified, analyzed, compared and categorized according to nursing perceptions extracted from the literature search. To display the data related to the inhibitory barriers of reporting child abuse as perceived and experienced by nurses, the Whittemore & Knafl (2005) model was used. A template was created to display the findings from the selected articles. Analysis of this methodical search provided insight into the nurses’ perspective when determining how to proceed with individual cases of suspected child abuse and implications for the mandatory reporting system.
To address the concept of barriers influencing nurse mandated reporting, articles were divided conceptually by contributing factors, allowing for more concise analysis, organization, and comparison of these emergent factors across the selected literature. The following template display consists of the headings: author and year, study type, study objective, sample size, and contributing factors to completion of mandated reporting (Table 1). The final step in this phase of the integrative literature review was to examine commonality of contributing factors, situations or circumstances perceived as barriers to completion of nursing mandated reporting.
Table 1Template for organizing findings from reviewed articles
| Author/Year | Study Type | Study Objective | Sample Size | Contributing Factors |
|---|---|---|---|---|
| Rolim, Moreira, Gondim, Paz, Vieira, (2014) | Cross sectional Logistic regression | To analyze the factors associated with nurse underreporting of child abuse in the primary health setting | N = 616 | Amount of education received by subject – 72.4 % did not report abuse when there was history of limited learning opportunities Level of trust in protection agency - 45.1% did not report based on level of mistrust |
| Natan, Faour, Naamhah, Grinberg, Klein-Kremer, (2012) | Descriptive Correlational Linear regression | To examine whether planned behavior theory is predictive of nursing and medical staff reporting of child abuse reporting | N = 185 | Perceived inadequate education - 60% reported receiving information, 56.5% reported feeling only moderately prepared to report abuse Level of trust in child protection authorities - 12.4% reported mistrust in child abuse authorities |
| Fraser, Mathews, Walsh, Chen, Dunne, (2010) | Logistic regression | To examine the relationship between nurse training, knowledge, characteristics, and attitudes on reporting child abuse and neglect | N = 930 | Poor knowledge of policy - 89.1% incorrectly identified child abuse reporting policy Uncertainty of extent of harm to the child - 21.1% did not report abuse even when suspecting abuse may have occurred |
Eisbach and Driessnack, 2010
Am I sure I want to go down this road? hesitations in the reporting of child maltreatment by nurses. Journal for Specialists in Pediatric Nursing. 2010; 15: 317-323https://doi.org/10.1111/j.1744-6155.2010.00259.x | Qualitative Cross sectional | To explore the process of pediatric nurses’ reporting of child abuse | N = 23 | Mean nursing experience - 27.6 years Knowledge and professional comfort level moderated reporting Uncertainty and concern regarding ramifications to reporting moderated reporting |
| Herendeen, Blevins, Anson, Smith, (2014) | Logistic regression | To examine experiences of pediatric nurse practitioners in identifying and managing child abuse, determine frequency of reporting, and describe attitudes, effects, and confidence when reporting child abuse | N = 643 | Perception of inadequate preparation - 47% believed they did not receive adequate education Supervisor did not agree with NP regarding abuse reporting - 13% |
| Francis, Chapman, Sellick, James, Miles, Jones, Grant, (2012) | Exploratory descriptive study | To examine how mandated professionals, identify suspected child abuse and their subsequent decision-making process in reporting | N = 7 | Deferred responsibility to a supervisor - 28% of participants |
| Jordan, MacKay, Woods, (2016) | Qualitative Descriptive t-test analyses | To explore nurse comfort level in initiating child protection measures | N = 174 | Lack of child abuse education - 48% reported no formal preparation despite working in school setting Lack of consensus among staff who should report suspected abuse |
| Davidov, Nadorff, Jack, Coben, (2012) | Cross Sectional | To examine home visiting nurses’ perspectives of an intention to report children’s exposure to domestic violence in the home setting | N = 532 | Concern about negative impact on nurse-client relationship = 56% Fear that reporting of abuse will cause disruption to the family - 54% |
| Kuruppu, Forsdike, Hegarty, (2018) | Qualitative Thematic analysis | To explore experiences and perceptions of general practitioner and practicing nurses’ mandatory reporting of child abuse | N = 17 | 58% of respondents did not report abuse citing following: Fear of incorrect diagnosis Distress from previous reporting experience Fear of negative impact on family-health provider relationship |
Data comparison
Highlighted findings were read and reread and the context scrutinized within as well as across articles for similarities and differences. The content topics were reviewed for relevance in answering research question.
Similar findings were grouped together into categories and labeled according to content topic -
Inadequacy of education
Provider’s level of trust in child protective agencies
Deferment of responsibility regarding reporting of abuse to another individual
Concern about a negative impact on the nurse-patient relationship
Data results
The four categories answered the research question and were labeled as the Inhibitory Barriers that interfered with nurses being mandatory reporters.
Inhibitory barriers
Inadequacy of education
While nurses knew that their professional scope of practice encompasses being a mandated reporter, there was a perceived level of inadequate knowledge when they encountered cases of known or suspected child abuse.
Rolim et al., 2014
found that the foremost factor preventing nurses from reporting cases of child abuse was their perceived lack of education. Similarly, - Rolim A.
- Moreira G.
- Gondim S.
- Paz S.
- Vieira L.
Factors associated with reporting of abuse against children and adolescents by nurses within Primary Health Care.
Revista Latino-Americana de Enfermagem. 2014; 22https://doi.org/10.1590/0104-1169.0050.2515
Natan et al., 2012
reported that healthcare workers claimed they had not received an adequate amount of information in the identification and management of child abuse and considered themselves only moderately prepared to complete reporting, although they knew they were obligated to do so. Even after nurses participated in various forms of education about child abuse and knew their role regarding reporting, many acknowledged uncertainty in appropriately identifying different forms of reportable child abuse as an obstacle. Nurses recounted that they were unprepared to adequately report cases of child emotional abuse, thus these types of abuse cases went underreported (Fraser et al., 2010
). Threaded throughout these studies was the nurses’ hesitancy to initiate reporting suspected child abuse because of their own level of confidence in their knowledge and understanding of the phenomenon. Limited exposure and experience in the process of identifying and reporting child abuse served as a significant barrier to function as a mandated reporter.- Fraser J.
- Mathews B.
- Walsh K.
- Chen L.
- Dunne M.
Factors influencing child abuse and neglect recognition and reporting by nurses: A multivariate analysis.
International Journal of Nursing Studies. 2010; 47: 146-153https://doi.org/10.1016/j.ijnurstu.2009.05.015
Level of trust
The process of reporting child abuse involves contacting authorities to complete an investigation into the claim to determine whether abuse had occurred, to what degree, and to implement corrective measures and consequences for credible cases of child abuse. The nurse does not bear the responsibility for any of these factors, but in reporting, transfers care within these parameters to outside authority. Distrust in the handling of child abuse investigations can adversely affect nurse reporting.
Natan et al., 2012
found that nurses cited distrust in government officials handling abuse investigations and fear of retaliatory legal charges as barriers to completion of child abuse reporting. Rolim et al., 2014
in a study within a larger study learned that nurses were less likely to report cases of suspected child abuse when there was a level of distrust in the protection agency. These same nurses reported fear of legal involvement when reporting to a child protection agency. The findings suggest that trust in child abuse authorities and the legal system is a significant factor in nurses’ comfort level when deciding on reporting action, even though it is mandated for suspected child abuse. Perceptions of mistrust in the agency, a lack of trust in the management of a case once reported and concern about the nurses’ responsibility for continued care, or the uncertainty regarding legal ramifications to the reporting nurse may inhibit well-intentioned nursing staff across the spectrum of experience from completing an important component of their role.- Rolim A.
- Moreira G.
- Gondim S.
- Paz S.
- Vieira L.
Factors associated with reporting of abuse against children and adolescents by nurses within Primary Health Care.
Revista Latino-Americana de Enfermagem. 2014; 22https://doi.org/10.1590/0104-1169.0050.2515
Deferred responsibility
When considering the mandated nature of reporting suspected child abuse, the implication is that direct care nursing staff who suspect child abuse will unhesitatingly report the information with supporting evidence to their supervisor. However, this interpretation does not account for the individual nature and confidence in professional judgement of the supervisor now tasked with making the decision to report. Within the literature, direct care nurses reported the deferment of responsibility for reporting cases of suspected child abuse to another, usually more experienced or senior in rank.
Herendeen et al., 2014
found that nearly 12 percent of surveyed advanced practicing nurses did not report a case of suspected child abuse when the physician with whom they were collaborating disagreed with their assessment of child abuse, deferring the final determination to their physician colleague. Forty-nine percent of the nurses surveyed within the study reported that in cases not reported to a child protection agency, the case had been referred to “another professional.” Francis et al., 2012
found comparable results when nursing staff had to decide whether to report their suspicions of child abuse; the nurses reported referring suspicious child abuse cases to practice physicians for final assessment and determination. Jordan et al., 2017
surveyed school nurses and found a divergence in opinion on whom would be responsible for reporting cases of child abuse. School nurses advocated that non-nursing school staff with the greatest amount of firsthand knowledge of abuse should be responsible for reporting to child protective agencies, however school staff stated the reporting should be the responsibility of the nurse. These research findings indicate that nurses may defer cases of suspected child abuse when there is uncertainty and the option to seek opinion from an immediate supervisor, or when there is not a collaborative understanding regarding responsibility of abuse reporting.Impact on nurse-patient relationship
One of the core components of nursing is a therapeutic nurse-patient relationship founded on the principles of care, trust, and wisdom. (
Halldorsdottir, 2008
). Nurses care for patients throughout the range of healthy to vulnerable states. Maintaining the integrity of the nurse-patient relationship facilitates an ongoing therapeutic relationship based on teamwork and trust. A perceived breach in the therapeutic relationship could impede gainful communication between the patient and nurse. The perceived threat of rupture in the therapeutic relationship could cause a nurse pause when debating the decision to report perceived child abuse. In a study conducted by - Halldorsdottir S.
The dynamics of the nurse–patient relationship: introduction of a synthesized theory from the patient’s perspective.
Scandinavian Journal of Caring Sciences. 2008; 22: 643-652https://doi.org/10.1111/j.1471-6712.2007.00568.x
Kuruppu et al., 2018
, nurses revealed that there were times they experienced distress about complying with mandated reporting of child abuse related to the potential for adverse effects on the nurse-patient relationship. The study participants reported that while they knew they were ultimately acting in the best interest of the child when mandated to report suspected abuse, they were concerned about the parents’ perception of being judged or falsely accused of a such serious and stigmatizing complaint. Davidov et al., 2012
, similarly found that less than half of the nurses in their study sample thought they should be mandated to report cases of suspected abuse with more than sixty six percent sharing the concern that reporting suspected abuse could damage the nurse-patient relationship and cause harm to the family. These findings indicate that nurses value their commitment to maintaining therapeutic relationships with their patients and the process of reporting suspected child abuse can cause a fracture in the nurse-patient relationship and distress for the nurse. Nurses have to objectively weigh the benefits of reporting and initiating intervention against the fallout or backlash to an established or budding therapeutic relationship when reporting their suspicions of child abuse.Discussion
Within this literature review, nurses identified multiple contributing factors that were analyzed and combined to reveal four inhibitory barriers to reporting perceived child abuse: Inadequacy of education, Level of trust, Deferred responsibility, and Impact on nurse-patient relationship. Nurses reported distress related to their inadequate preparation for managing suspicions of child abuse. They stated that they were not confident in their ability to identify the various forms of child abuse or follow the proper protocol for reporting incidences of suspected child abuse. A sense of mistrust in the child protective agencies was listed as a contributing component to reservations when deciding whether to report suspicions of child abuse. It was not unusual for nurses to defer the responsibility for making the final decision whether or not to file a report to an immediate supervisor or professional experienced in evaluation of abuse and subsequent action. Nurses expressed caution and wished to avoid jeopardizing the significant nurse-patient relationship by reporting suspected child abuse.
The effects of child abuse are chronic and harmful to the well-being of the child throughout the lifespan. More immediately, a child that has experienced an incident of abuse is at an increased risk for subsequent abuse as well as permanent injury or death (
Sheldon-Sherman et al., 2013
). Nurses are in position to not only identify abuse but to report the indicators and symptoms of abuse to the proper authorities. Previous literature established that the nurse may experience an emotional burden when confronted with the professional role expectation of mandatory reporting of suspected child abuse. The literature identified various factors involved in the process of reporting that may be distressful and adversely affect completing the report (James, 2018
).As learned from this integrative review of the literature one of the major factors inhibiting suspected child abuse reporting were perceived inadequate preparation to initiate and complete the reporting process. Nurses knew that they were obligated to report their observations but stated that their toolbox of reporting skills was incomplete. To increase the completion of mandatory reporting while addressing the issue of distress experienced by nurses, standardized education programs, practice opportunities and reporting protocols are needed to help build confidence and address the concerns of nurses.
Limitations
A total of nine articles were analyzed as part of the literature review process. Although the pertinent research articles provided an understanding of barriers nurses experience when making child abuse reporting decisions, there were some limitations. There was a limited amount of current research covering the topic, and some of the articles had relatively small sample sizes, therefore the findings may not necessarily have been representative of the whole. Further, the studies did not take into account nurses’ belief systems and cultural background or personal histories regarding what constitutes abuse. Additionally, the studies did not consistently clarify any amount of education nurses may have received prior to conducting the study.
Nursing Implication
Addressing inhibitory barriers to adequate reporting will assist in increasing the nurses’ awareness of barriers to mandatory reporting when encountering cases of suspected child abuse. Nurses providing care to children need to increase competency in identifying and overcoming perceived barriers to the child-abuse reporting process. Supportive measures need to be available to overcome barriers in providing sensitive, therapeutic care in suspected child abuse cases.
Direction for Future Research
Further research is needed to examine these four barriers to child abuse reporting so that adequate educational programs can be developed for addressing the needs of nurses. Using the data shared concerning the four inhibitory barriers as well as evidence-based research into the effects of child abuse, education programs that include simulation and guided practice need to be developed to help mitigate reporting distress and increase nursing competency in suspected child abuse reporting. Implementation of the aforementioned programs could help decrease the emotional burdens experienced by nurse reporters and facilitate an increase in child protective measures.
Conclusion
Four inhibitory barriers to nurse reporting of suspected child abuse were identified in this literature review: inadequacy of education, level of trust, deferred responsibility, and impact on nurse-patient relationship. Given the serious nature of immediate and long-term effects experienced by child abuse victims, proper identification, advocacy, and timely reporting by competent nurses can assist child protective services in assuring the well-being and safety of affected children. The challenge for nursing leaders, both academic and clinical, is to devise creative and informative programs that provide the education, skills and resources to mitigate the inhibitory barriers to reporting suspected child abuse situations. Relief of the personal distress experienced by nurses within these reporting situations may positively affect the effectiveness of reporting and subsequent intervention measures. Education and practice unique to the needs of pediatric nurses will assist in overcoming these barriers and provide for greater awareness, advocacy, and empowerment in managing the distress of reporting child abuse cases.
References
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Article info
Publication history
Published online: July 03, 2020
Footnotes
☆The mission of the Society of Pediatric Nurses is to support its members in theirpractice. One means of accomplishing this mission is to keep membership informed of innovative initiatives involving the board, committees, and members that promote research, clinical practice, education, and advocacy within the larger pediatric healthcare community. This department serves that purpose.
☆☆Department editor: Sandra Mott PhD, RN-BC, CPN
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© 2020 Published by Elsevier Inc.
