Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
PARENT GENDER, VICTIM GENDER, AND FAMILY SOCIOECONOMIC LEVEL INFLUENCES ON THE POTENTIAL REPORTING BY NURSES OF PHYSICAL CHILLI ABUSE ADELE PILUTTERI, Ph.D., R.N. ANN SEZDL, Ph.D., R.N. CAROL SMITH, Ph.D., R.N. MARIETTA STANTON, Ph.D., R.N. State University of New York at Buffalo In 1974, the Federal Child Abuse Prevention and Treatment Act required reporting of child abuse in all states. Although nurses have since this time been designated as mandated reporters of abuse, only recently have nurses begun to hold positions where they are directly responsible for abuse reporting. This study investigated whether the gender of the victim, the gender of the abusing parent, or the family’s socioeconomic level influences the potential reporting of child abuse by nurses. Participants were shown three vignettes of children being admitted to an emergency room with symptoms of possible abuse. When asked if they would or would not report the incident as child abuse, participants indicated they were significantly less apt to report abuse when the victim was female rather than male, and when the family was perceived as being from a middle rather than a low or high socioeconomic background. The implication of this finding is that female children from middle-class backgrounds may be left less protected than others as nurses become more actively involved in child abuse reporting.
A recent national survey has projected that nearly 1.5 million children and adolescents are subjected to abusive physical violence each year (Straus & Gelles, 1990). When instances of sexual and emotional abuse and neglect are added to this number, abuse of children may occur to as many as 23 of every 1,OOO children. It rates as one of the most frequently seen child health problems in the United States today. Identifying child abuse became recognized as a medical problem in 1946 when Caffey (1946), a radiologist, reported the association of multiple bone fractures and subdural hematomas in children as possibly being caused by trauma. Sixteen years later, Kempe et al. (1962) coined the term “battered child.” In 1974, the federal government passed a law to protect children from abuse known as the Federal Child Abuse Address correspondence to Adele Pillitteri, 1004 Kimball Tower, S U M at Buffalo, Main Street Campus, Buffalo, NY 14214. Issues in Comprehensive Pediatric Nursing, 15r239-247, 1992 Copyright 0 I992 Taylor & Francis 0146-0862192$10.00 + .00
239
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
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Prevention and Treatment Act of 1974. This act requires health care personnel to identify and report abuse in children (Lazoritz, 1992). Nurses are named in the act as people who must report abuse either through being directly named or referred to under a broad category of “practitioners of the healing arts.” At the time this 1974 reporting law was passed, the average nurse in the United States worked in a hospital setting and was subordinate to a physician in responsibility. The responsibility for the identification and reporting of child abuse, therefore, routinely passed up the rank to a physician, so although the issue concerned nurses, few were actually involved directly in filing a report on suspected abuse. Today, a number of nurses maintain independent practices; thus they are directly responsible for reporting. A community or home care nurse who suspects that abuse has occurred in a home setting, for example, has this full responsibility; and a nurse practitioner or clinician who sees children independently has this full responsibility. An emergency room nurse who triages may have this responsibility. Even adult care nurses may become aware of abuse by a statement such as “I have to get home. I can’t trust my boyfriend to watch my children.” In some states, women who threaten the health of a fetus by drug abuse have been viewed by the court as child abusers (Rhodes, 1990). Maternal-newborn nurses, therefore, may be the ones to first discover that abuse is occurring. They may become aware that the problem seems likely during the postpartal period when they observe a mother who shows no interest in her newborn or treats her newborn in an emotionally abusive manner. Likewise, school nurses can become aware of a child who is dressed improperly for the weather (neglect) or has physical marks of abuse. In many instances in which a woman in the family is being battered, a child is being abused as well (McKibben, De Vos, & Newberger, 1989). An adult practitioner caring for abused women, therefore, might become aware of the problem and, if child abuse is suspected, must file a report. This increased responsibility obligates nurses to be able to recognize child abuse through interviewing and upon physical examination.
LITERATURE REVIEW The reporting of child abuse is not a simple issue and involves concerns of both over- and under-reporting. The American Humane Society noted in 1984 that more than 58% of all reports of child abuse are over-reported or can not be substantiated (Schetky, 1986). In one study of anonymous reports, as many as 87.6% were revealed to be unfounded (Adams,
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Nurses’ Attitudes on Child Abuse
241
Barone, & Tooman, 1982). Reports by nonprofessionals are more likely to be incorrect than those by professionals. Substantiated reports are more common in two-parent families, minority children, and in younger married women than single-parent families, majority children, and older married women (Hawkins & Duncan, 1985). Under-reporting also occurs. In a national survey, Zellman (1991) discovered that as many as 40% of mandated reporters stated they had been in noncompliance or had not reported observed abuse at some time. In a study in this same area, Dukes & Kean (1989) found that only 47% of university undergraduate students who rated a vignette describing child abuse as severe also stated that they would take action to report the abuse. In this study, females rated abuse as more serious than males. A number of studies have attempted to identify whether witness or victim characteristics influence the reporting of child abuse. These results are often contradictory. In a study of physicians, Turbett & O’Toole (1980) found that physicians’ recognition of and response to potential child abuse were affected by the ethnic status and socioeconomic status of the parent (they stated they would report abuse more often in minority and poorer families). Osborne et al. (1988) confirmed this tendency with a study of university undergraduate students. Although it is known that physical abuse occurs across all socioeconomic levels, families with incomes under $15,000 a year account for four times the reported incidence of physical and sexual abuse and eight times the incidence of neglect than other families (National Center on Child Abuse and Neglect (NCCAN), 1988). When studying the characteristics of parents, Osborne et al. (1988) determined that subjects were more apt to report abuse when the abusing parent was female rather than male. In contrast, Koski and Mangold (1988) in a similar study of university students showed that female reporters were more apt to report child abuse when the victim was female and when the father was the abuser. However, NCCAN (1988) has reported that subjects are more prone to take action when the abuse victim is male rather than female. In a study of health professionals, Kean & Dukes (1991) found no differences in the incidence of reporting when the victim’s or parent’s gender was a variable. As nurses have not been independently responsible for reporting abuse in the past, they have been little studied as a group as to how the characteristics of victims and families influence their reporting decisions. It is difficult to predict their reactions from many of the preceding studies as they were conducted with undergraduate students who are not mandated reporters.
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HYPOTHESIS
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
The following three hypotheses were formulated for the present study. 1. When a child is perceived as being from a lower socioeconomic level, nurses will indicate they would report abuse significantly more frequently than when the child is perceived as being from a middle or higher socioeconomic level. 2. Nurses will report abuse at equal levels for both male and female parent caregivers. 3. Nurses will report abuse at equal levels for male and female child victims.
METHODOLOGY The methodology for this study was that of a quasi-experimental survey approach. Data were analyzed using an SPSS program. Dependent paired r-tests were used to determine significant relationships between variables. Study Sample
New York State mandated in 1990 that all registered nurses, along with other health care providers, complete a two-hour course on child abuse before being able to renew their professional licenses. Nurses from the community who enrolled at classes taught at the State University of New York at Buffalo were asked to complete a questionnaire during each twohour class. A total of 253 nurses attended these sessions and volunteered to complete the questionnaire. The mean age of the study participants was 45 years, with a range of 24 to 52 years. Ninety percent of the sample were female; nine percent were male; one percent did not report gender. The nursing educational level of the study participants is shown in Table 1. Table 1. Demographics of Study Sample: Education Level Education
No.
%
Diploma AD BSN MS
87 49 90 21
34.4 19.4 35.6 10.6
Nurses’ Attitudes on Child Abuse
243
The mean years that participants had worked as an RN was 17.9. Twenty-four percent of participants had no children; 9.7%, one child; 30.5%, two children; 21.5%, three children; and 13.2% had four children or more. Only 7% of the sample indicated they had made a report of child maltreatment or neglect in the last two years; only 3.7% had made a sexual abuse report in the last two years.
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Instrument
Two vignettes depicting children with common symptoms of child abuse and one vignette depicting a child with symptoms more reflective of leukemia than abuse were devised for the study. In the first vignette, the child was a 2Vi-year-old male; in the second, a female infant; in the third, a female preschooler. The use of vignettes to investigate reporting of child abuse is a commonly employed strategy (Dukes & Kean, 1989; Osbome et al., 1988). This methodology allows the abuse situation to be held constant while variables such as the gender of the abuser and the socioeconomic level of the family are varied systematically. In this study, the vignettes were varied systematically as to socioeconomic level and sex of the caregiving parent at each class session so at different times the families represented upper, middle, and lower class backgrounds; the gender of the potentially abusing parent was varied to be male or female. A sample vignette was as follows: Kelly is a 1-year-old you see in an emergency room. She has an ecchymotic area 2 inches in diameter on her forehead. She responds only to painful stimuli; respiratory rate is 14/minute. Her mother states the bruise on her forehead is because she crawled under the coffee table for a toy yesterday and then raised her head and struck the bottom of the table. Her mother is unable to account for her present sleepiness. Kelly’s father is unemployed. Her mother works as a cocktail waitress part time. Their clothing suggests finances are a problem. The father states he first noticed Kelly’s sleepiness when he walked into the house an hour ago. The mother, who was watching Kelly, states she was waiting for Kelly’s father to return before she took any action. Both parents report that Kelly is a “picky” eater and “into everything.”
Participants were asked to read each vignette and then indicate on a five-point Lickert type scale whether based on the information given they were: certain to report abuse (Score 1); very likely to report abuse (Score 2), undecided as to whether to report or not (Score 3); not likely to report abuse (Score 4); or sure they would not report abuse (Score 5).
244
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The questionnaire was first pretested by 48 undergraduate students. The reliability correlation between this pretest and the actual participant score was .735.Internal reliability was determined by a measure of internal consistency, Cronbach’s alpha (a) = .95. FINDINGS Findings are discussed in relation to the three hypotheses. Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Hypothesis One When a child is perceived as being from a low socioeconomic level, nurses will report abuse significantly more frequently than when the child is perceived as being from a middle or higher socioeconomic level. This hypothesis was partially supported. As can be seen in Table 2, 84.8% of participants indicated that they would report abuse when the family was depicted as being from a high socioeconomic background; 80.4% stated that they would report abuse when the family was depicted as being from a low socioeconomic background. In contrast, when the family was depicted as being from a middle income background, only 54.6% of participants indicated that they would report abuse. The mean scores of both the high socioeconomic and the low socioeconomic background groups are significantly different from the middle socioeconomic background group (mean scores of 2.0263 and 1.1715 compared to 2.2129, p =
PARENT GENDER, VICTIM GENDER, AND FAMILY SOCIOECONOMIC LEVEL INFLUENCES ON THE POTENTIAL REPORTING BY NURSES OF PHYSICAL CHILLI ABUSE ADELE PILUTTERI, Ph.D., R.N. ANN SEZDL, Ph.D., R.N. CAROL SMITH, Ph.D., R.N. MARIETTA STANTON, Ph.D., R.N. State University of New York at Buffalo In 1974, the Federal Child Abuse Prevention and Treatment Act required reporting of child abuse in all states. Although nurses have since this time been designated as mandated reporters of abuse, only recently have nurses begun to hold positions where they are directly responsible for abuse reporting. This study investigated whether the gender of the victim, the gender of the abusing parent, or the family’s socioeconomic level influences the potential reporting of child abuse by nurses. Participants were shown three vignettes of children being admitted to an emergency room with symptoms of possible abuse. When asked if they would or would not report the incident as child abuse, participants indicated they were significantly less apt to report abuse when the victim was female rather than male, and when the family was perceived as being from a middle rather than a low or high socioeconomic background. The implication of this finding is that female children from middle-class backgrounds may be left less protected than others as nurses become more actively involved in child abuse reporting.
A recent national survey has projected that nearly 1.5 million children and adolescents are subjected to abusive physical violence each year (Straus & Gelles, 1990). When instances of sexual and emotional abuse and neglect are added to this number, abuse of children may occur to as many as 23 of every 1,OOO children. It rates as one of the most frequently seen child health problems in the United States today. Identifying child abuse became recognized as a medical problem in 1946 when Caffey (1946), a radiologist, reported the association of multiple bone fractures and subdural hematomas in children as possibly being caused by trauma. Sixteen years later, Kempe et al. (1962) coined the term “battered child.” In 1974, the federal government passed a law to protect children from abuse known as the Federal Child Abuse Address correspondence to Adele Pillitteri, 1004 Kimball Tower, S U M at Buffalo, Main Street Campus, Buffalo, NY 14214. Issues in Comprehensive Pediatric Nursing, 15r239-247, 1992 Copyright 0 I992 Taylor & Francis 0146-0862192$10.00 + .00
239
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
240
A. Pillitteri et al.
Prevention and Treatment Act of 1974. This act requires health care personnel to identify and report abuse in children (Lazoritz, 1992). Nurses are named in the act as people who must report abuse either through being directly named or referred to under a broad category of “practitioners of the healing arts.” At the time this 1974 reporting law was passed, the average nurse in the United States worked in a hospital setting and was subordinate to a physician in responsibility. The responsibility for the identification and reporting of child abuse, therefore, routinely passed up the rank to a physician, so although the issue concerned nurses, few were actually involved directly in filing a report on suspected abuse. Today, a number of nurses maintain independent practices; thus they are directly responsible for reporting. A community or home care nurse who suspects that abuse has occurred in a home setting, for example, has this full responsibility; and a nurse practitioner or clinician who sees children independently has this full responsibility. An emergency room nurse who triages may have this responsibility. Even adult care nurses may become aware of abuse by a statement such as “I have to get home. I can’t trust my boyfriend to watch my children.” In some states, women who threaten the health of a fetus by drug abuse have been viewed by the court as child abusers (Rhodes, 1990). Maternal-newborn nurses, therefore, may be the ones to first discover that abuse is occurring. They may become aware that the problem seems likely during the postpartal period when they observe a mother who shows no interest in her newborn or treats her newborn in an emotionally abusive manner. Likewise, school nurses can become aware of a child who is dressed improperly for the weather (neglect) or has physical marks of abuse. In many instances in which a woman in the family is being battered, a child is being abused as well (McKibben, De Vos, & Newberger, 1989). An adult practitioner caring for abused women, therefore, might become aware of the problem and, if child abuse is suspected, must file a report. This increased responsibility obligates nurses to be able to recognize child abuse through interviewing and upon physical examination.
LITERATURE REVIEW The reporting of child abuse is not a simple issue and involves concerns of both over- and under-reporting. The American Humane Society noted in 1984 that more than 58% of all reports of child abuse are over-reported or can not be substantiated (Schetky, 1986). In one study of anonymous reports, as many as 87.6% were revealed to be unfounded (Adams,
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Nurses’ Attitudes on Child Abuse
241
Barone, & Tooman, 1982). Reports by nonprofessionals are more likely to be incorrect than those by professionals. Substantiated reports are more common in two-parent families, minority children, and in younger married women than single-parent families, majority children, and older married women (Hawkins & Duncan, 1985). Under-reporting also occurs. In a national survey, Zellman (1991) discovered that as many as 40% of mandated reporters stated they had been in noncompliance or had not reported observed abuse at some time. In a study in this same area, Dukes & Kean (1989) found that only 47% of university undergraduate students who rated a vignette describing child abuse as severe also stated that they would take action to report the abuse. In this study, females rated abuse as more serious than males. A number of studies have attempted to identify whether witness or victim characteristics influence the reporting of child abuse. These results are often contradictory. In a study of physicians, Turbett & O’Toole (1980) found that physicians’ recognition of and response to potential child abuse were affected by the ethnic status and socioeconomic status of the parent (they stated they would report abuse more often in minority and poorer families). Osborne et al. (1988) confirmed this tendency with a study of university undergraduate students. Although it is known that physical abuse occurs across all socioeconomic levels, families with incomes under $15,000 a year account for four times the reported incidence of physical and sexual abuse and eight times the incidence of neglect than other families (National Center on Child Abuse and Neglect (NCCAN), 1988). When studying the characteristics of parents, Osborne et al. (1988) determined that subjects were more apt to report abuse when the abusing parent was female rather than male. In contrast, Koski and Mangold (1988) in a similar study of university students showed that female reporters were more apt to report child abuse when the victim was female and when the father was the abuser. However, NCCAN (1988) has reported that subjects are more prone to take action when the abuse victim is male rather than female. In a study of health professionals, Kean & Dukes (1991) found no differences in the incidence of reporting when the victim’s or parent’s gender was a variable. As nurses have not been independently responsible for reporting abuse in the past, they have been little studied as a group as to how the characteristics of victims and families influence their reporting decisions. It is difficult to predict their reactions from many of the preceding studies as they were conducted with undergraduate students who are not mandated reporters.
242
A. Pillitteri et al.
HYPOTHESIS
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
The following three hypotheses were formulated for the present study. 1. When a child is perceived as being from a lower socioeconomic level, nurses will indicate they would report abuse significantly more frequently than when the child is perceived as being from a middle or higher socioeconomic level. 2. Nurses will report abuse at equal levels for both male and female parent caregivers. 3. Nurses will report abuse at equal levels for male and female child victims.
METHODOLOGY The methodology for this study was that of a quasi-experimental survey approach. Data were analyzed using an SPSS program. Dependent paired r-tests were used to determine significant relationships between variables. Study Sample
New York State mandated in 1990 that all registered nurses, along with other health care providers, complete a two-hour course on child abuse before being able to renew their professional licenses. Nurses from the community who enrolled at classes taught at the State University of New York at Buffalo were asked to complete a questionnaire during each twohour class. A total of 253 nurses attended these sessions and volunteered to complete the questionnaire. The mean age of the study participants was 45 years, with a range of 24 to 52 years. Ninety percent of the sample were female; nine percent were male; one percent did not report gender. The nursing educational level of the study participants is shown in Table 1. Table 1. Demographics of Study Sample: Education Level Education
No.
%
Diploma AD BSN MS
87 49 90 21
34.4 19.4 35.6 10.6
Nurses’ Attitudes on Child Abuse
243
The mean years that participants had worked as an RN was 17.9. Twenty-four percent of participants had no children; 9.7%, one child; 30.5%, two children; 21.5%, three children; and 13.2% had four children or more. Only 7% of the sample indicated they had made a report of child maltreatment or neglect in the last two years; only 3.7% had made a sexual abuse report in the last two years.
Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Instrument
Two vignettes depicting children with common symptoms of child abuse and one vignette depicting a child with symptoms more reflective of leukemia than abuse were devised for the study. In the first vignette, the child was a 2Vi-year-old male; in the second, a female infant; in the third, a female preschooler. The use of vignettes to investigate reporting of child abuse is a commonly employed strategy (Dukes & Kean, 1989; Osbome et al., 1988). This methodology allows the abuse situation to be held constant while variables such as the gender of the abuser and the socioeconomic level of the family are varied systematically. In this study, the vignettes were varied systematically as to socioeconomic level and sex of the caregiving parent at each class session so at different times the families represented upper, middle, and lower class backgrounds; the gender of the potentially abusing parent was varied to be male or female. A sample vignette was as follows: Kelly is a 1-year-old you see in an emergency room. She has an ecchymotic area 2 inches in diameter on her forehead. She responds only to painful stimuli; respiratory rate is 14/minute. Her mother states the bruise on her forehead is because she crawled under the coffee table for a toy yesterday and then raised her head and struck the bottom of the table. Her mother is unable to account for her present sleepiness. Kelly’s father is unemployed. Her mother works as a cocktail waitress part time. Their clothing suggests finances are a problem. The father states he first noticed Kelly’s sleepiness when he walked into the house an hour ago. The mother, who was watching Kelly, states she was waiting for Kelly’s father to return before she took any action. Both parents report that Kelly is a “picky” eater and “into everything.”
Participants were asked to read each vignette and then indicate on a five-point Lickert type scale whether based on the information given they were: certain to report abuse (Score 1); very likely to report abuse (Score 2), undecided as to whether to report or not (Score 3); not likely to report abuse (Score 4); or sure they would not report abuse (Score 5).
244
A. Pillitteri et al.
The questionnaire was first pretested by 48 undergraduate students. The reliability correlation between this pretest and the actual participant score was .735.Internal reliability was determined by a measure of internal consistency, Cronbach’s alpha (a) = .95. FINDINGS Findings are discussed in relation to the three hypotheses. Issues Compr Pediatr Nurs Downloaded from informahealthcare.com by University of Auckland on 11/25/14 For personal use only.
Hypothesis One When a child is perceived as being from a low socioeconomic level, nurses will report abuse significantly more frequently than when the child is perceived as being from a middle or higher socioeconomic level. This hypothesis was partially supported. As can be seen in Table 2, 84.8% of participants indicated that they would report abuse when the family was depicted as being from a high socioeconomic background; 80.4% stated that they would report abuse when the family was depicted as being from a low socioeconomic background. In contrast, when the family was depicted as being from a middle income background, only 54.6% of participants indicated that they would report abuse. The mean scores of both the high socioeconomic and the low socioeconomic background groups are significantly different from the middle socioeconomic background group (mean scores of 2.0263 and 1.1715 compared to 2.2129, p =
