Keeping the child in focus while supporting the family

Abstract

Child maltreatment can lead to acute and long-term consequences, and it is important that at-risk children are identified early. Child healthcare (CHC) nurses in Sweden are in a position to identify child maltreatment, as they follow children and their parents from the child’s birth to school age. Therefore, the aim was to describe CHC nurses’ experiences when encountering families in which child maltreatment was identified or suspected. Individual open interviews with eight CHC nurses were performed and analysed using a qualitative content analysis. Findings revealed that keeping the child in focus, while supporting the family was essential for the nurses. This family-centred approach was assumed to benefit the child’s interests. Meeting families where child maltreatment was identified or suspected influenced the nurses, emotionally in different ways. Nevertheless, it was important to keep an open mind and communication build on honesty. Furthermore, the nurses requested professional supervision in order to help them learn from the situation ahead of the next time. This knowledge about CHC nurses’ experiences may form a basis for the development of interventions that aim to support the CHC nurses in their professional role, and thereby improve support to children and parents in the future.

Keywords

Child abuse family-centred care nurse–family relationships qualitative approaches

Background

There are no overall national statistics available in Sweden concerning the reporting of child maltreatment to social authorities. According to the Swedish National Board of Health and Welfare (2014), one reason for this is that different concepts are used when referring to child maltreatment, and as a result, under-reporting is still an issue in Sweden. However, one Swedish report showed that fewer than 50% of suspected cases of child maltreatment involving preschool children were reported (Swedish Government Official Reports, 2009). In 2010, Swedish police and school professionals reported approximately 140,000 cases, involving 60,000 children aged 0–18 years, to social authorities in Sweden. It was shown that there were few reports by healthcare professionals (Swedish National Board of Health and Welfare, 2012). This is consistent with reports from the United States, for example, where only 8.2% of the total number of reports to social authorities in 2010 came from healthcare professionals (Administration for Children and Families, 2010).

Swedish child healthcare (CHC) services encounter children and their parents from the child’s birth to school age. The Swedish child health service is free of charge and aims to promote children’s health and psychosocial development and strengthen parents in their parental role (Swedish Association of Local Authorities and Regions, 2014).

CHC nurses are in a position to identify child maltreatment and to advocate for the child’s protection, although to the best of our knowledge, few studies have examined CHC nurses’ experiences of encountering families in which child maltreatment is identified or suspected.

Previous research has reported that CHC nurses, in addition to general practitioners, under-report child maltreatment. This implies that children are not receiving the protection they require (Kara et al., 2014; Lazenbatt and Freeman, 2006). Different reasons for under-reporting have been discussed and include, for example, lack of knowledge and ignorance of the reporting process (Borres and Hagg, 2007; Gilbert et al., 2009a; Kara et al., 2014). Gilbert et al. (2009a) stated that one reason for not reporting may be related to concern about the impact of reporting on the family. A discrepancy between nurses’ experiences regarding the presence of child maltreatment has also been reported (Feng and Levine, 2005; Lagerberg and Sundelin, 2008). The greatest consensus within and among the different occupational groups occurs in the cases of serious child maltreatment (Pierce and Bozalek, 2004; Sundell et al., 2008).

Child maltreatment is to be seen as an overarching term encompassing child abuse and child neglect. Child abuse can be defined as physical, sexual and/or emotional abuse and child neglect as a child’s basic needs not being fulfilled (WHO, 2014). However, both child abuse and child neglect can cause both psychological and physical harm to a child (Norman et al., 2012). Previous studies have also shown long-term consequences, such as depression, criminal behaviour and effects on cognitive functioning in adulthood (Gilbert et al., 2009b; Gould et al., 2012). Child neglect may vary in severity, but neglected children are living in a danger zone for physical abuse (Hornor, 2014).

According to Swedish legislation, reporting is mandatory in cases where child maltreatment is suspected. The legislation covers all professionals in public or private-sector organizations who come in contact with children or adolescents. Furthermore, reporting cannot be done anonymously by these professionals (The Social Services Act, 2001).

Managing suspected child maltreatment cases is a challenge for CHC nurses. They need to approach the situation in an unbiased manner when confronting the parents with their suspicions. A Swedish study revealed that nurses in emergency clinical care at one university hospital expressed difficulties in maintaining a professional manner when encountering parents of maltreated children (Tingberg et al., 2008).

Knowledge about CHC nurses’ experiences is valuable and might form a basis for developing interventions that aim to support CHC nurses in their professional role. The interventions also aim to improve support for children and their parents, thereby reducing the risk of acute and long-term consequences.

Aim

The aim of this study was to describe CHC nurses’ experiences when encountering families in which child maltreatment was identified or suspected.

Method

Setting and participants

The study was conducted in southern Sweden at six different CHC centres after written consent was obtained from the manager responsible. The CHC nurses were recruited by the manager responsible for each CHC centre. Nurses’ names and contact addresses were forwarded to the first author, Madeleine Dahlbo (MD), who contacted the nurses, informed them again about the study and obtained verbal consent for participation. Written consent was obtained during the interviews.

The inclusion criteria stated that nurses should have more than six months’ experience of working within CHC and have been in contact with families in which child maltreatment was identified or suspected. A total of 15 female CHC nurses met the inclusion criteria. Eight nurses consented to participate, seven declined, with those who gave a reason citing their heavy workload.

The ages of the CHC nurses varied between 35 years and 62 years. Six of the nurses had specialist education in primary healthcare, one in paediatric nursing and one nurse had education in both specializations. Their nursing experience varied from 10 years to 41 years, with their CHC experience varying from 5 years to 29 years.

Data collection

The first author (MD) conducted individual open interviews with the nurses over the course of a three-month period. The interviews had an ‘open’ approach and contained probing questions, and questions for clarification such as ‘can you describe it in more detail?’ or ‘can you give me an example?’ were posed to give the nurses an opportunity to expand on their experiences. The interviews were recorded and later transcribed verbatim by the first author.

Analysis

The transcribed interviews were analysed using a qualitative content analysis inspired by Graneheim and Lundman (2004). First, the authors independently read the interviews to gain an overall sense of the data; a naive understanding. The authors then discussed the overall meaning of the interviews in relation to the aims of the study until agreement was reached. After that, the first author divided the interview text into meaning units (MUs), words or sentences related to the same meaning. These MUs were condensed, but still retained the meaning of what had been said. The condensed MUs were gathered into codes, and the codes with similar content were merged together. During these steps, the authors discussed the process repeatedly, and the codes were constantly compared with the original text. The codes were sorted into categories based on similarities and differences. During this process, some categories were dismissed, some were merged and new categories were formatted until the authors agreed on the result. The authors then re-read the interview texts to confirm that nothing of importance related to the aim had been left out. Finally, the authors discussed and reflected upon the categories in order to find an overarching category. Quotes from the interviews are used to elucidate the categories.

Ethics

The study was conducted in accordance with the Helsinki Declaration (2013). As this study involved CHC nurses who were being asked to describe personal and professional experiences and no individual data on children and their families can be identified, this research was not subject to Swedish research ethics legislation (Swedish law regarding research involving humans, 2008: 192). Consequently, it was not necessary to submit an application to the regional research ethics committee for staff approval. However, a local ethical approval was reviewed and approved in accordance with Kristianstad University’s procedures.

Findings

Keeping the child in focus while supporting the family was the overarching category reflecting CHC nurses’ experiences of encounters with families where child maltreatment was identified or suspected. This was arrived at because the nurses described how they had a family-centred approach that included individually directed support for the family, at the same time as they kept the child’s best interests in focus. The nurses weighed up what was best for the child against the discomfort that could occur when informing the parents of their suspicions. The nurses were affected in different ways, and this was described in the first category as being emotionally influenced. Since the goal was to support the family, the nurses expressed the importance of meeting the family with openness, thus formulating the second category. Finally, caring for those families was also associated with needing confirmation, which is the third category.

Being emotionally influenced

Facing families in which child maltreatment was identified or suspected was an unpleasant experience for the CHC nurses. This unpleasant experience was associated with both the child’s situation as the parents’ reaction when they were informed about the suspicion. The nurses found it difficult to ignore the fact that the parents would feel humiliated or discredited when faced with the suspicion. Nurses were aware that the parents could react with anger and of the risk that this anger could escalate to violence – even though the nurses had never experienced such a situation. As one nurse stated, ‘Maybe things could go wrong at some point, someone gets angry at you and such, you just don’t know’ (7).

The nurses were well aware that reporting is mandatory in the cases of suspected child maltreatment. Nevertheless, they described their concern as to whether or not they should report the suspected maltreatment. Sometimes, they were unsure if they had enough facts upon which to build a report and/or if a report might cause more harm than good for the child and the family. Concerns about submitting unsubstantial reports often resulted in reports being postponed. There was less uncertainty in cases where the signs of child maltreatment were obvious – such as visible injuries or bruises – and where the obvious signs of maltreatment were inconsistent with explanations provided by parents. However, the nurses explained that the parents knew how to hide the signs of maltreatment and subsequently did not attend the child health clinic. As a result, the nurses had to act, and they described a need to trust their instincts:

…sometimes you get the feeling that something’s not right in the family – but it’s difficult to put your finger on just what that is (5).

Every so often, the uncertainty resulted in the nurses finding it difficult to ‘switch off’ and they continued to think of the family outside of work.

Meeting the family with openness

The nurses felt it was important to keep an open mind when caring for families in which child maltreatment was identified or suspected. This implies communication built on honesty. This honesty was essential to establishing trust between the nurses and the parents. Trust facilitated the continuing work with the parents, and this in turn benefitted the child. The honesty also implied that the nurses always informed the parents before they reported their suspicious of child maltreatment to social authorities:

Don’t keep things hush-hush, but be open about what I think and mention it to the parents, don’t just report it to the authorities or contact social services on the sly…just…put the cards on the table (4).

Few parents reacted with aggression, with the nurses putting this down to direct and honest communication. They described how some parents reacted with gratitude because someone had paid attention to their situation and wanted to help them. However, some parents distanced themselves and ended their visits to the CHC centre. Usually, they went to another CHC centre. The nurses were well aware of these reactions and felt that they were prepared to talk about it with the parents. The nurses’ focus was on the child’s well-being and on not being judgemental about how families live their lives:

But we have to give people the right to live their own lives and bring up their children in their own way. Just as long as the children are doing ok with it (4).

The nurses’ experiences of CHC were described as an important factor when meeting parents. This experience gave the nurses confidence that helped them to keep an open mind. They felt it improved their chances of recognizing the families’ own resources, as well as those surrounding the families and, as a result, of finding suitable solutions that could support the family as a whole.

Needing confirmation from colleagues

Being able to discuss cases where child maltreatment was identified or suspected with colleagues was essential for the nurses. They could then receive confirmation of their actions, thus helping them to manage the situation. Ideally, they would receive confirmation from colleagues before submitting a report. One nurse described her collaboration with a physician as follows:

Of course you don’t really know that there’s anything wrong with the child – it doesn’t necessarily have to be mistreatment, you know – it could be that something is physically wrong, actually (8).

The nurses expressed a wish to receive feedback from the authorities about their report. The feedback would not just provide them with information about the situation in question, and it would also provide them with knowledge that could be used in the future. However, due to Swedish confidentiality legislation, this was uncommon.

Like, what’s happened? Has it amounted to anything? I never know if anything has been done. I don’t even know if they’ve taken the matter further or not. Sure, you can ask the parents – but they don’t always want to tell you (3).

The nurses demanded professional supervision as this would give them an opportunity to discuss their thoughts with a professional supervisor. Being able to discuss the situation was believed to be a good support measure for handling the situation, and as a way to make the nurses better prepared for the next time, they encounter a family in which child maltreatment was identified or suspected. One nurse described this as ‘more meetings with the child psychologist, where we can sit and be debriefed by her about on-going cases’ (6).

Discussion

The results revealed that CHC nurses had a family-centred approach (Institute for Patient- and Family-Centred Care, 2014), aiming to support the family as a whole, and thereby benefit the child. This included acting in a non-judgemental way towards the parents and always informing them about their suspicions and about their legal role in reporting. This way of interacting with families is emphasized by Hornor (2014), for example, who stated that it is important for nurses to explain their legal role in reporting and also inform the parents that someone else will investigate the situation. This way of acting might help the parents to understand that reporting is a way of supporting them in their parental role. This is also consistent with the aim of Swedish CHC, namely to reduce mortality, disease and disability in children and to support parents in their parental role in order to create positive conditions for the child’s development (Swedish Association of Local Authorities and Regions, 2014).

In the present study, the nurses found it important to maintain professional communication built on respect for the individual family. In one essential aspect, this result differs from another Swedish study investigating emergency care (EC) nurses’ professionalism with maltreated children and their parents. The EC nurses wanted to act professionally in their encounters with parents even though they found this difficult. However, just as with the present study, the child’s safety was in focus for the EC nurses (Tingberg et al., 2008). One reason for the different result in terms of the professional approach might be that Swedish CHC nurses have an established relationship with the parents and the child, because they follow the child from birth until the age of six (Swedish Association of Local Authorities and Regions, 2014). They most often have opportunities to react and take action before the child is severely hurt, whereas a nurse in an emergency department meets the child and the parents in a situation where the child is already injured and in need of EC.

According to Swedish legislation (The Social Services Act, 2001), reporting is mandatory, even if child maltreatment is only suspected; something the nurses in the present study were well aware of. Nevertheless, under-reporting remains an issue in Sweden (Swedish Government Official Reports, 2009), as is the case in other countries (Kara et al., 2014; Lazenbatt and Freeman, 2006). In our study, the nurses described how they were sometimes concerned about submitting an unsubstantial report and how this would, in turn, affect the family. It is not possible to interpret whether such a concern is based on lack of knowledge and/or experience, or is connected to a desire to not upset the family in case the suspicions of maltreatment prove to be unfounded. The failure to report in order to avoid upsetting the family has also been found in earlier research (Gilbert et al., 2009a; Louwers et al., 2012). Lack of knowledge and/or experience of recognizing child maltreatment has been identified as a reason for not reporting, with both nurses and physicians in paediatric care expressing a need for more knowledge and training in factors related to child maltreatment and, most importantly, how to deal with their own feelings when they encounter these families (Ben Yehuda et al., 2010; Louwers et al., 2012; Tingberg et al., 2008).

In the present study, detecting and reporting child maltreatment or suspected child maltreatment was found to be stressful. Nurses requested professional supervision in the form of a ‘debriefing’ in order to help them learn from the situation ahead of the next time. The need for professional supervision has also been identified in earlier research (Tingberg et al., 2008). An action programme to be instigated in the event of suspected child maltreatment that was developed by Region Skåne (2006; 2011) states that each unit that encounters children and their family’s needs to have internal guidelines concerning reporting and support for the person making a report. The unit should have a named contact person whose training in the field of child maltreatment is up to date and who is also responsible for internal training in the unit. The action programme appears to be one way of increasing knowledge and skills in terms of detecting and reporting child maltreatment. According to the programme, nurses should be offered supervision. However, further studies are needed to investigate to what extent the organization offers supervision, whether CHC nurses use it and nurses’ experiences of this supervision. It should be noted that none of the nurses mention the action programme during the interviews. Studies conducted in the United Kingdom have demonstrated that an educational programme can improve the identification rate for child maltreatment (Benger and Pearce, 2002). However, a recently published review showed that instruments for identifying abused children were not good enough, suggesting that there is a need to develop screening instruments before screening/education programmes can be developed (Bailhache et al., 2013).

Another way to meet the nurses’ need for support might be to develop models for partnerships between the various professionals involved when child maltreatment is reported. Detecting, reporting and managing cases of child maltreatment is to be seen as complex care, which potentially benefits from more holistic care in which various professionals work in partnership (Whiting, Scammell, Bifulco, 2008). One barrier to the development and implementation of partnership models is the various organizational structures involved. The nurses in this study also described confidentiality rules as being a hindrance.

In a Swedish interview study, Lagerberg and Sundelin (2008) described how the way nurses dealt with child maltreatment was associated with their expertise and experience. Nurses who had received training about factors associated with child maltreatment found it easier to report their suspicions. The CHC nurses in the present study described their general experience in CHC as an important factor as it gave them confidence to deal with the situation and, most importantly, improved their chances of supporting the family in a difficult situation.

One limitation of this study is that the CHC nurses were recruited by the manager responsible for each CHC centre, which may have influenced the selection of nurses. The nurses included may have been more motivated to describe their experiences and/or have a greater interest in the topic compared to the average CHC nurse. In addition, only female nurses participated. However, the nurses who participated differed in educational background and work experience, which strengthened the result. Furthermore, the methodological description and the analysis process are clearly described, and quotes from the interviews are used to confirm the result (Lincoln and Guba, 1985). Another limitation might be that only eight nurses participated in the study. However, the interviews contained in-depth information, which is considered to compensate for the small sample size.

Conclusion

Early detection of child maltreatment is important in order to protect the child and support the family (Gilbert et al., 2009b). The results indicated that Swedish CHC nurses were aware of their duty to report and that they prioritized keeping the child’s best interests in focus without judging the family. One question raised is to what extent the regional action programme concerning suspected child maltreatment (2006; 2011) is actually used in the region where the study took place, as none of the CHC nurses mention it. The programme provides nurses and other professionals with knowledge and internal training in child protection. The programme also offers supervision, which the nurses in this study requested.

Footnotes

Acknowledgements

The authors express their gratitude to the child healthcare nurses who participated in the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

References

Administration for Children and Families (2010) Child Maltreatment 2010. Washington: The Children’s Bureau. http://www.acf.hhs.gov/programs/cb (accessed 4 April 2016).

Bailhache

Leroy

Pillet

. (2013) Is early detection of abused children possible? A systematic review of the diagnostic accuracy of the identification of abused children. BMC Pediatrics 13: 202.

Ben Yehuda

Attar-Schwartz

Ziv

. (2010) Child abuse and neglect: reporting by health professionals and their need for training. Israel Medical Association Journal 12: 598–602.

Benger

Pearce

(2002) Simple intervention to improve detection of child abuse in emergency departments. BMJ: British Medical Journal 324: 780.

Borres

Hagg

(2007) Child abuse study among Swedish physicians and medical students. Pediatrics International 49: 177–182.

Feng

Levine

(2005) Factors associated with nurses’ intention to report child abuse: a national survey of Taiwanese nurses. Child Abuse & Neglect 29: 783–795.

Gilbert

Kemp

Thoburn

. (2009a) Recognising and responding to child maltreatment. The Lancet 373: 167–180.

Gilbert

Widom

Browne

. (2009b) Burden and consequences of child maltreatment in high-income countries. The Lancet 373: 68–81.

Gould

Clarke

Heim

. (2012) The effects of child abuse and neglect on cognitive functioning in adulthood. Journal of Psychiatric Research 46: 500–506.

10.

Graneheim

Lundman

(2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education today 24(2): 105–112.

11.

Hornor

(2014) Child neglect: assessment and intervention. Journal of Pediatric Health Care 28: 186–192, quiz 193–184.

12.

Institute for Patient- and Family-Centred Care (2014) Available at: http://www.ipfcc.org (accessed 1 November 2015).

13.

Kara

Caliskan

Suskan

(2014) Comparison of the levels of knowledge and approaches in relation with child abuse and neglect in residents of pediatrics, pediatricians and practitioners working in the province of Ankara. Turk Pediatri Arsivi 49: 57–65.

14.

Lagerberg

Sundelin

(2008) Child Health Care in Change, Results of an Intervention Trial. Stockholm: Gothia. (In Swedish. Law about research involving humans [2008: 192]. Available at: http://www.lagboken.se/Views/Pages/GetFile.ashx?portalId=56&cat=27526&docId=181354&propId=5 (accessed 1 November 2015). (In Swedish).

15.

Lazenbatt

Freeman

(2006) Recognizing and reporting child physical abuse: a survey of primary healthcare professionals. Journal of Advanced Nursing 56: 227–236.

16.

Lincoln

Guba

(1985) Naturalistic Inquiry. Beverly Hills, California: Sage Publications.

17.

Louwers

Korfage

Affourtit

. (2012) Facilitators and barriers to screening for child abuse in the emergency department. BMC Pediatrics 12: 167.

18.

Norman

Byambaa

. (2012) The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLOS Medicine 9: e1001349.

19.

Pierce

Bozalek

(2004) Child abuse in South Africa: an examination of how child abuse and neglect are defined. Child Abuse & Neglect 28: 817–832.

20.

Region Skåne (2006; 2011) Program of Action for Suspicious of Child Maltreatment. Kristianstad, Sweden. (In Swedish).

21.

Sundell

Egelund

Löfholm

. (2008) Child Health Care Investigations – A Knowledge Overview. Stockholm: Gothia. (In Swedish).

22.

Swedish Association of Local Authorities and Regions (2014) National Guidelines for Child Health Care. Available at: http://www.rikshandboken-bhv.se/ (accessed 10 October 2015). (In Swedish).

23.

Swedish Government Official Reports (2009) Child protection study – act on support and protection for children and young people (LBU) (SOU 2009: 68). Available at: http://www.regeringen.se/content/1/c6/12/97/51/cbbe4527.pdf (accessed 9 September 2015). (In Swedish).

24.

Swedish National Board of Health and Welfare (2012) Reports to Social Services for Children and Young People – An Investigation of Its Scope and Regional Differences. Stockholm, Sweden: Swedish National Board of Health and Welfare. (In Swedish).

25.

Swedish National Board of Health and Welfare (2014) Children Who are Abused or at Risk for Abuse, a Guide for Health Care and Dental Care about Reporting and Responsibility. Stockholm, Sweden: Swedish National Board of Health and Welfare. (In Swedish).

26.

The Social Services Act [2001: 453] (2001) Available at: http://www.notisum.se/rnp/sls/lag/20010453.htm (accessed 10 October 2015). (In Swedish).

27.

Tingberg

Bredlov

Ygge

(2008) Nurses’ experience in clinical encounters with children experiencing abuse and their parents. Journal of Clinical Nursing 17: 2718–2724.

28.

Whiting

Scammell

Bifulco

(2008) The health specialist initiative. Professionals’ views of a partnership initiative between health and social care for child safeguarding. Qualitative Social Work 7(1): 99–117.

29.

WHO (2014) Child Maltreatment. Available at: http://www.who.int/topics/child_abuse/en/ (accessed 10 October 2015).