Nurses' Attitudes Toward the Child Victims and the Perpetrators of Emotional, Physical, and Sexual Abuse

Ann H. Seidl, Marietta P. Stanton, Adele Pillitteri, Carol Smith, and Barbara Boehler^*

ABSTRACT: Nurses interact with children in a variety of hospital and community-based settings and are mandatory reporters of emotional, physical, and sexual child abuse.  Little is known about their comfort in dealing with victims or the abusers.  This descriptive study of 318 registered nurses attending a mandatory class for relicensure on child abuse examined differences among three types of abuse, ages of the victims, and the perpetrators.  Dependent t-tests revealed that nurses were significantly less comfortable with sexual abuse, abuse of infants, and dealing with fathers.  Recommendations for educational curricula and continuing education are made.
  

Although child abuse is a major and increasing concern in the United States affecting more than 2.4 million children annually (Clearinghouse on Child Abuse and Neglect Information, 1989), little is known about nurses' attitudes about child abuse.  Furthermore, even less is known about nurses' attitudes about child abuse perpetrators.  This situation is somewhat ironic, because nurses are mandated reporters and are likely to be at the forefront of child abuse identification due to the broad array of areas in which they practice.  Nurses may encounter child abuse in hospitals, emergency rooms, clinics, primary care facilities, public health agencies, schools, and camps.  Their attitudes about the victim and the perpetrator are basic to the interventions they select.

Nursing interventions are generally preventive and treatment-oriented, based on three goals.  At one level, nurses intervene with high risk families to prevent the child abuse from occurring.  This is called primary prevention.  At the next level of intervention, a nurse recognizes more subtle clues of abuse and intervenes to prevent further abuse.  At the tertiary level, nurses are involved in providing direct services to children who already have been emotionally, physically, or sexually abused. Some nurses are involved in direct interventions with perpetrators, either in counseling modalities or in group work or parenting classes.
  

Nursing and Child Abuse

The precise definition of child abuse that is associated with the state mandate for relicensure is different from that held by various professionals.  Social workers and nurses rate child abuse incidents as more serious than pediatricians and psychologists (Snyder & Newberger, 1986).  Paradoxically, nurses who had extensive knowledge regarding child abuse from practice in community health or in pediatric nursing assigned less seriousness to some situations.  Professionals' attitudes about child discipline are developed from their various cultural, educational, and religious backgrounds and influence nurses' perceptions of their own comfort with abuse.

Previous research on nurses' reactions to child abuse has documented reactions of anger, frustration, denial, and confusion (Chamberlain, 1974; Scharer, 1978; Stanley, 1987).  Heindl (1981) described nurses' interpersonal reactions with children who are abuse victims as failure to set appropriate limits for the child, exhibition of extraordinary attention to the child, and even rejection of the child who failed to respond as the nurse had expected.  These reactions, she explained, are based on nurses' fantasies that they can rescue the children under their care.  Frenken and Stolk (1990) concluded from interviews with nurses and several other types of professionals that the health care providers were overwhelmed with feelings of powerlessness, embarrassment, and disgust, and they had developed a strong identification with the abused victim.  Despite these feelings and attitudes, Sykes (1987) did not find differences between a nurse's awareness of child abuse and his or her attitude about the appropriateness of parent participation in the abused child's hospital care.  Nurses were not found to be more positive toward parent participation with abused or nonabused children.  So, it seems that nurses continue to support the involvement of parents with their children and are able to overcome their feelings.
  

Background

Child Abuse Victims

Child abuse has been described in the Bible and in mythology.  Currently, the incidence is thought to be increasing.  This increase may be a result of expansion of the definition of child abuse and decreasing acceptance of what had been considered acceptable child-rearing patterns in the past.  It was only a hundred years ago that the famous Mary Ellen case of 1874 was brought to the attention of the Court under the auspices of the Society for the Prevention of Cruelty to Animals.  That case became the basis for founding the Society for the Prevention of Cruelty to Children (Solomon, 1973).

The increase reflected in child abuse statistics may also be a result of increased reporting, because all states now have mandatory reporting laws as well as protection from criminal liability for those who report and penalties for failure to report.  A recent survey of all 50 states reported an increase in reports of approximately 10% from 1988 to 1989 (National Center on Child Abuse Research Prevention, 1990).
  

Child Abuse Perpetrators

Child abuse is considered to be linked to the escalation of both the number of adolescent parents and the drug crisis.  It is known that about 20% of the births in the United States are to teenagers.  Prior research has indicated that many teenagers are overwhelmed by the responsibilities of parenting and have unrealistic expectations of their children.  More current research fails to support this deficit model in all cases of adolescent parenting and is focusing on specifying the characteristics of those teenage parents at risk of child abuse.  Some states have observed that 90% of the cases of child abuse are associated with substance abuse by the perpetrator (National Center on Child Abuse Research Prevention, 1990).

It is well documented that child abusers include members of all races, religions, and ethnic backgrounds and that, frequently, parents who abuse children say that they were abused as children themselves.  Furthermore, it is known that abusive parents tend to be emotionally immature, have poor self-images and be socially isolated.  However, it is less well known that the abuser is more likely to be the mother in cases of physical abuse and the father or live-in boyfriend when abuse leads to the death of the child (Stanton, 1990).  In situations involving sexual abuse, the victim is more likely to be female and the molester more likely to be the father, stepfather, or other male family member.  When boys are sexually abused, however, the perpetrator is not likely to be a family member (Finkelhor & Baron, 1985).

Characteristics of different types of abuse and professionals' beliefs and attitudes about children at different ages may contribute to their relative degree of comfort in dealing with child victims.  For example, infants are generally perceived to be relatively helpless and vulnerable, needing adults' protection, whereas toddlers are often perceived as needing discipline.  In a similar vein, expectations about the roles of mothers and fathers as protectors of children, as compared with other adults, may affect the professional nurse's dealings with perpetrators of abuse.  To explore selected aspects related to nurses' dealing with abuse situations the following research questions were generated.

Research Questions

Assumptions

It was assumed from reviewing the literature involving the interrelationship of nursing and the abusive family that nurses' attitudes toward the family may affect the nursing care that the patient/victim receives (Gill, 1989; Heap, 1982; Steele, 1975).  It was also assumed that nurses who feel more comfortable dealing with victims of child abuse and parental abusers may provide better care and more objective interventions for those families than do nurses who feel uncomfortable dealing with abusive families.  The study also assumes that some nurses in the sample may have had previous experience with abusive families either clinically or personally.
  

Methodology

Design

This study was descriptive in nature and differentiated nurses' attitudes relating to three types of abuse — emotional, physical, and sexual.  It investigated whether attitudes differed in response to the age of the child.  It further examined nurses' attitudes toward mothers, fathers, and others as perpetrators of abuse and addressed whether these differences in attitudes related to the age of the child.
  

Procedure

Data concerning nurses attitudes were collected at a series of courses provided by the Continuing Education Department of the School of Nursing at the State University of New York at Buffalo based on a curriculum developed by the New York State Education Department.  The two hour course fulfills the requirements of Chapter 544 for all professional nurses who will apply for license recertification in New York State in 1992.  Data collection took place over a one-year period.  Questionnaires were handed out as nurses entered the classroom for a mandated course on the identification and reporting of child abuse and maltreatment.  Time was allotted before the beginning of the class for respondents to fill out and return the materials.
  

Sample

Three hundred eighty (380) nurses enrolled in the course.  Data were received from 318 nurses for an 84% return rate.  Partially completed questionnaires were included.
  

Instrument

The questionnaire was developed by four nursing school faculty members, all of whom had doctoral degrees and substantial knowledge and clinical experience in pediatrics and with child abuse.  The questionnaire consisted of four sections and included demographic questions.  Each component of the questionnaire measured different aspects of child abuse.  The component reported here focused on the demographic characteristics of the nurse sample and a 21-item scale measuring nurses' attitudes toward child abuse and the abuser.  Questions 1 through 7 specifically related to nurses' perceptions of how comfortable they would feel when dealing with child victims of emotional abuse and their abuser; questions 8 through 14 concerned nurses' attitudes toward physical abuse and abusers; and questions 13 through 21 involved nurses' attitudes toward sexual abuse and abusers.  Nurses were asked to determine their degree of comfort in dealing with a particular item by using a five-point Likert-type scale with 1 describing definite comfort and 5 indicating no comfort at all.  For example, one question was as follows: "I believe I could comfortably deal with an emotionally abused child aged 1 year to 12 years" (Answer l-2-3-4-5).  The higher the mean, the greater the discomfort in dealing with various aspects of abuse.  Individual instructions were provided for each section.  (See Appendix A for the questionnaire.)
  

Data Analysis

Data were coded and checked using standard procedures.  Face validity of the instrument was determined by a panel of nursing experts.  Internal consistency was determined by Cronbach's alpha (a = .95).  Descriptive data analysis techniques were used to evaluate all questionnaire items.  In addition, the relationships between demographic variables and nurses' attitudes were examined by use of parametric methods of data analysis.  The experimental type I error rate was set at < .05.  Using the multiple Bonferoni approach, the researcher set the first comparison at .05/1 = .05, the second comparison at .05/2 = .025, and the third comparison at .05/3 = .016 (Bird, 1975; Ramsey, 1982; Wu & Slakter, 1991).
  

Results

The mean age of the participants was 45 with a standard deviation ±10 years.  The youngest respondent was 24 years old and the oldest was 76 years of age.  The sample was 91% female and 9% male.  Approximately 94% of the sample were registered nurses and 6% were from allied health disciplines.  Of the nurses, approximately 27% were diploma graduates; 16% had associate degree preparation in nursing; 28% had a baccalaureate degree in nursing; 9% had master's preparation in nursing; and 20% had received a degree outside of nursing.  Eleven nurse practitioners were involved in the study.  The mean number of years as a nurse was 17 years with a standard deviation of ±10 years.

Of the nurses who participated, 39% listed their current or most recent primary work area as medical-surgical; 27% as pediatrics; 15% as geriatrics; and 15% as psychiatry.  Approximately 28% of the survey respondents were either unemployed, retired, failed to answer or were from another discipline.  Table 1 shows the diversity of work areas of the respondents.

In regard to marital status, the majority of respondents (72%) were married; 13% were single; and the remainder of the sample was widowed, separated, or divorced.  Respondents had an average of two children, with 23% of the sample never having had children.  The average age of the oldest child of the respondents was 20 years with a standard deviation of ±10 years; age of the second child was 19 ±10 years.  The gender distribution for the children in each group was: first child, 56% male; second child, 55% female.

In terms of how participants believed the mandated training would impact on their future practice, 46% thought it would have an effect.  However, 11% were undecided; and, 43% anticipated no effect.

A review of nurses' self-reported comfort levels in dealing with selected types of child abuse (emotional, physical, or sexual) in relation to the abused child's age indicated that nurses appear to feel least comfortable dealing with situations involving sexually abused children, especially infants under one year of age (see Table 2).  Significant differences were noted between nurses' comfort with sexual abuse and either physical or emotional abuse.  They also indicated more comfort with physical abuse than with emotional abuse (t = 2.93, p < .05) (See Table 3).  For comparison, nurses were also asked to respond to dealing with these same types of abuse of adults.  Similarly, nurses were significantly less comfortable dealing with sexual abuse than either physical or emotional abuse of adults (See Table 4) (t = 3.13, p < .05; t -4.62, p <.05). Close perusal of Tables 3 and 4 suggests that participants were somewhat more comfortable dealing with adult victims than child victims in all three abuse categories. The differences were small: 0.23 for emotional abuse, 0.20 for physical abuse, and 0.24 for sexual abuse.

Review of the nurses' self-reports in dealing with various types of abusers revealed that nurses seem least comfortable with an abusive father in all types of abusive situations (see Tables 5, 6, & 7). Nurses were most comfortable with mothers in emotional and physical abuse situations and strangers as perpetrators of sexual abuse.  The most difficulty was with the father in a sexually abusive situation (See Table 5).

Chi-square analyses were performed to determine if there were any differences between and among groups of nurses in their comfort levels in dealing with various forms of abuse/abusers based on differences in the demographic data.  Categories were collapsed and categorized as being "definitely" or "very likely to be able to deal with," "undecided" or "unlikely would be able" or "not at all able to deal with" the types of abuse or the abusers.  There were no significant relationships between nurses' age, length of time being a nurse, marital status, or number of children and comfort dealing with abuse and child abuse perpetrators.  However, a significant relationship was found between the gender of the nurse and some aspects of abuse.  Male nurses perceived themselves to be more likely to deal comfortably with emotionally abused teenagers (Chi-square=5.985, df=2, p<.05), although no gender differences were noted in the ability to deal with the perpetrator.
  

Emotional Abuse

Further perusal of Table 2 indicates the majority (69%) felt they were comfortable dealing with an emotionally abused adult.  Over 50% indicated comfort with an emotionally abused infant (54%), children aged 1 to 12 (60%), and teenagers aged 13 to 18 years (56%).  Although the data are preliminary and the number is small, a significant relationship (Chi-square=5.985, df=2, p<.05) between gender of the nurse and the ability to deal with emotionally abused teenagers was determined.  Further, when it comes to emotional abuse, nurses are significantly more comfortable dealing with the mother as the perpetrator than the father (t = 5.78, p <.05) or strangers (t = 2A9, p <.05) (See Table 6).
  

Physical Abuse

Again, the majority of nurses (71%) perceived themselves to be able to deal with a physically abused adult (see Table 2).  Over 57% felt they could deal with the physical abuse of an infant under one year.  Almost 70% were comfortable with the physically abused child from 1 to 12 years (66%), and teenagers 13 to 18 years (64%).  However, 67% were undecided or unlikely to be able to deal with a perpetrator of physical abuse.  The gender of the nurse did not significantly relate to the nurses' ability to deal with the perpetrators of physical abuse for various aged children.  Nurses had significantly more difficulty with the father as perpetrator than with the mother (t =5.40, p <.05) or a stranger (t = 3.21, p <.05) (See Table 7).
  

Sexual Abuse

Sixty-five percent of nurses thought they were likely to be able to deal with a sexually abused adult (see Table 2).  This did not differ by the gender of the nurse.  Over half (53%) were undecided or unable to deal with sexual abuse of an infant, although 52% were comfortable dealing with sexual abuse of a child from 1 to 12 years, and teenagers.  However, 80% were undecided or unlikely to be able to deal with the sexual abuser, particularly if the sexual abuser were the father (see Table 5).  Male nurses, when compared to females, were significantly more comfortable dealing with the sexually abusive mother (Chi-square = 7.67, df =2, p=.02), and the abusive fathers (Chi-square = 6.32, df = 2, p = .04).  In general, when dealing with a sexual abuse perpetrator, nurses are significantly less comfortable with the father than with the mother (t =4.60, p <.05) or strangers (t =5.06, p <.05) (See Table 8).
  

Summary and Conclusions

Analysis of the data demonstrated that, overall, more than half of the nurses surveyed felt comfortable dealing with all three types of abuse and victims of all age groups, but were undecided or unable to deal with the perpetrators of child abuse.  However, nurses were most comfortable dealing with emotional and physical abuse and least comfortable with sexual abuse.  Significantly, nurses are uncomfortable with the emotional abuse of infants under one year and teenagers.  Nurses are also uncomfortable dealing with children under a year and who have been physically or sexually abused.  Nurses were more comfortable dealing with abusive mothers as opposed to fathers.  They were least able to deal with fathers as perpetrators of sexual abuse.

The results of this study suggest that nurses do not feel comfortable dealing with child abusers.  We recommend that nursing educators incorporate information about abusers into the curriculum.  Nurses may benefit from continuing education that relates to abused children under one year old.  Although the gender of the nurse may influence perceptions of the abused and the abuser, this requires further exploration.  The nurses' demographic characteristics do not seem to be related to perception.
  

Recommendations of Further Research

The following are research and practice recommendations based on the findings of this study:

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Appendix A - Questionnaire