ARTICLE
Advanced Practice Nursing in Child Maltreatment: Practice Characteristics Gail Hornor, DNP, CPNP, & Pamela Herendeen, DNP, CPNP
ABSTRACT Introduction: Child maltreatment is a problem of epidemic proportions in the United States. Pediatric nurse practitioners and other advanced practice nurses (APNs) have been caring for maltreated children for decades, yet to date no comprehensive assessment of their practice characteristics or their clinical and academic contributions to the field has been performed. The purpose of this study is to describe the practice characteristics of APNs who care for maltreated children. Method: A descriptive design was used for this study. Child advocacy centers and children’s hospitals were contacted to inquire about employment of child maltreatment APNs in their institution, and contact information for the lead APN was obtained. The Nurse Practitioner Survey was then sent to lead APNs by e-mail. Results: The majority of APNs who work primarily in child maltreatment are pediatric nurse practitioners who work in child advocacy centers. They are providing care to children with physical and/or sexual abuse concerns; however, APNs provide care for children with all types of child maltreatment concerns. Discussion: APNs play a vital role in the care of abused/ neglected children. Their important contributions include not only clinical care but also the provision of clinical and Gail Hornor, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children’s Hospital, Columbus, OH. Pamela Herendeen, Pediatric Nurse Practitioner and Associate Professor of Nursing, University of Rochester, Golisano’s Children’s Hospital, Rochester, NY.
didactic education to other professionals, parents, and the public. Research and publication are also essential to their role. J Pediatr Health Care. (2014) -, ---.
KEY WORDS Advanced practice nursing, child maltreatment
Child maltreatment is a problem of epidemic proportions in the United States. During 2011, approximately 681,000 children were victims of child maltreatment (U.S. Department of Health & Human Services, 2013). An estimated 1,570 children died nationally as a result of child abuse or neglect, a rate of 2.10 deaths per 100,000 children. Reports indicate that in 2011, 78% of victims experienced neglect, 18% were physically abused, 9% experienced sexual abuse, and 8% were psychologically maltreated. Finkelhor, Ormrod, & Turner (2007) and Turner, Finkelhor, & Ormrod (2010), in nationally representative samples of 2,030 children and 4,053 children, respectively, found that 69% and 66% of the children had experienced more than one form of child maltreatment. In an acknowledgment of the scope of the problem, the American Academy of Pediatrics has recognized child abuse pediatrics as a subspecialty, and the inaugural board certification was offered in 2009. The National Association of Pediatric Nurse Practitioners (NAPNAP) also recognizes the significance of the problem and sponsors a Special Interest Group dedicated to child maltreatment and neglect.
Conflicts of interest: None to report. Correspondence: Gail Hornor, DNP, CPNP, Center for Family Safety and Healing, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205; e-mail: Gail.hornor@ nationwidechildrens.org. 0891-5245/$36.00 Copyright Q 2014 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2014.02.003
www.jpedhc.org
DESCRIPTION OF PRACTICE CHARACTERISTICS LACKING Although authors have described the global pediatric nurse practitioner (PNP) role, as well as specific practice specialties such as inpatient, preoperative, cardiology, endocrinology, early intervention settings, and others (Borgmeyer et al., 2008; Freed et al., 2010; Katz et al., 2007; & Vaughese et al., 2006), no studies to date have described the practice characteristics of -/- 2014
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PNPs and/or other advanced practice nurses (APNs) in child maltreatment. PNPs and other APNs have been working in the area of child maltreatment for decades, yet to date no comprehensive assessment of their practice or their clinical and academic contributions to the field has been performed. For purposes of this study, a child maltreatment APN is defined as an APN who works as a member of a team dedicated exclusively to the assessment, diagnosis, and treatment of children and adolescents for whom there is a concern of suspected child maltreatment. PURPOSE OF THE STUDY The literature describes the practice characteristics of PNPs and other APNs in a variety of specialty roles, substantiating their contributions to the field. The practice characteristics of APNs working in the area of child maltreatment remain unexplored. The purpose of this study is to describe the practice characteristics of APNs in the area of child maltreatment in terms of the following: a. Type of APN educational preparation (e.g., PNP vs. family nurse practitioner [FNP]) b. Educational level c. Years practicing as an NP and practicing in child maltreatment d. Practice site e. Type of abuse concern addressed in practice f. Number of NPs in the facility g. Clinical education provided h. Academic appointment i. Academic activities j. Sexual assault nurse examiners REVIEW OF LITERATURE The PNP is an APN specializing in pediatric health care (NAPNAP, 1995). The PNP is a registered nurse who has completed a program of NP preparation at a school of nursing as part of a masters in nursing degree program. This education provides PNPs with advanced knowledge and clinical skills in child health care, which allows them to provide a wide range of health care services for children from birth through adolescence. The PNP collaborates with other health care professionals and practices as an interdependent member of the health care team to provide pediatric care. The PNP role emerged during the mid 1960s as registered nurses prepared at the certificate level through a formalized advanced educational program and evolved in the 1990s to nurses prepared at the masters-degree level (NAPNAP, 1995). The role continues to evolve with the development of the doctorate in nursing practice (DNP) as the proposed terminal credential and level of education for the PNP originally anticipated by 2015 (NAPNAP, 2008). PNPs are important members of the health care team that provides care to children (Freed, Dunham, 2
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Lamarand, Loveland-Cherry, & Martyn, 2010). Currently nearly 13,000 PNPs practice in the United States (Pediatric Nursing Certification Board, 2010). Freed and colleagues (2010) surveyed a stratified random sample of 1200 PNPs to gain a better understanding of the role, primary care versus subspecialty focus of practice, professional setting, and responsibilities. A structured questionnaire was developed by Freed and colleagues (2010) and administered by mail. Of the 1200 surveys mailed, 905 were returned for a response rate of 82.4%. More than half of the participants (59%) worked in primary care, and the majority (64%) did not work in an inpatient setting. Most PNPs reported that they often perform general and specialty practice roles such as patient assessment and diagnosis, development of treatment plans, and immunizations. Freed and colleagues (2010) concluded that PNPs have an important role in pediatric primary and subspecialty care. Reider-Demer, Widecan, Jones, & Goodhue (2006) point out the continued evolution of the PNP role to meet the ever more complex health care needs of the pediatric population. The PNP role was initially developed to provide pediatric primary care. PNPs now practice in a variety of settings: private practices, hospital clinics, school clinics, and inpatient settings, including emergency departments (EDs) and intensive care units. PNPs are now providing not only primary care but secondary and tertiary care as well. PNPs practice in a variety of settings, and their effectiveness has been evaluated in these settings (Frisch, Johnson, Timmons, & Weatherford, 2010). As in the adult health care arena, more and more pediatric surgical procedures are being performed in outpatient settings. Children and parents report not feeling emotionally and educationally prepared for outpatient surgery (Frisch et al., 2010). Developmentally appropriate preoperative educational programs and parental involvement in the surgical experience have been found to help alleviate the anxiety of both parents and children. PNPs are being used in preoperative settings to perform physical examinations and provide preoperative education. A longitudinal study was conducted at Cincinnati Children’s Hospital by Vaughese, Byczkowski, Wittkugel, Kotagal, and Kurth (2006) to evaluate quality of care after the implementation of preoperative physical examinations and education performed by PNPs. Data were collected over 1 year at 3 months, 6 months, 9 months, and 12 months after commencement of the PNP program. Quality of care was evaluated on the basis of respiratory complication rate, preoperative preparation time, parental satisfaction, and staff satisfaction. Using a scale of 0 (worst care) to 10 (best care), an average overall rating of care was obtained at each data collection point. Overall mean scores were 9.49 (baseline), 9.50 (3 months), 9.48 (6 months), 9.29 (9 months), and 9.44 (12 months). Journal of Pediatric Health Care
Thus it was found that PNPs provided quality, costeffective care. Katz, Ceballos, Scott, & Wurm (2007) discussed the critical role of the PNP as a team member in early intervention partnerships with young children in foster care. Including PNPs on the team has proven to improve health care linkages for these vulnerable children. PNPs play a vital role in educating families on the importance of preventative health care and well visits and providing essential follow-through with identified health concerns. Katz and colleagues (2007) discuss the role of the PNP in providing care to children in foster care and the resulting increased compliance with care, increased percentage of immunized children, and decrease in the frequency of ED visits. PNPs also practice in a variety of inpatient settings. Borgmeyer, Gyr, Jamerson, and Henry (2008) evaluated the role of the PNP as care managers of children hospitalized with asthma. Other multidisciplinary team members including physicians, interns, nurses, and families were surveyed regarding their perceptions of the PNPs as care managers and educators. Care indicators of length of stay, readmission rate, and cost were also evaluated. Two hundred forty multidisciplinary team members participated in the survey, and all participants found PNPs to be effective in the inpatient asthma role. No significant differences were noted in length of stay, cost, readmissions, or severity of the condition of patients with asthma who were managed by PNPs versus physicians. PNPs in the inpatient asthma setting were found to be effective care managers and educators. METHODS Purpose The purpose of this study was to describe the practice characteristics of APNs in the area of child maltreatment. Design A descriptive design was used for this study. Institutional Review Board The Institutional Review Board at Nationwide Children’s Hospital approved this study prior to the recruitment of subjects. Participants were informed that completion of the survey implied consent. Procedures All children’s hospitals (183) and child advocacy centers (787) in the United States were contacted via email or phone to inquire about the employment of child maltreatment APNs within their organizations. Locations of children’s hospitals in the United States were obtained from the Children’s Hospital Association Web site, and locations of child advocacy centers were obtained from the National Children’s Alliance www.jpedhc.org
Web site. Three hundred twenty-three organizations stated that child maltreatment APNs were employed by their organizations, and a contact e-mail address was obtained for the lead APN. The Nurse Practitioner Survey (Appendix) was then sent to the lead APNs by e-mail. The Nurse Practitioner Survey is a 15-item questionnaire designed by the study investigators to describe specific aspects of APN practice in the area of child maltreatment. Demographic questions were specific to the lead APN, whereas practice/academic questions were aimed at describing all child maltreatment APNs practicing in the institution. The study investigators are expert child maltreatment APNs, each with more than 20 years of experience in the field, thus establishing content validity for the Nurse Practitioner Survey. The Nurse Practitioner Survey was also reviewed by an expert in survey design at the University of Rochester School of Nursing in Rochester, New York, to examine the survey design and structure of the questions. A reminder was sent by e-mail at 2and 4-week intervals to encourage nonresponders to return the survey. RESULTS One third (323) of children’s hospitals and child advocacy centers responded affirmatively regarding the use of child maltreatment APNs by their organizations and identified a lead APN best suited to complete the Nurse Practitioner Survey. The Nurse Practitioner Survey was then sent to the lead APNs, and 136 (42%) responded. The majority of lead APNs working in child maltreatment were PNPs (n = 82; 61%), followed by FNPs (n =46; 34%), clinical nurse specialists (n = 6; 4%), and physician assistants (n = 1; 1%). Nearly all were women (n = 129; 96%), with ages ranging from 25 to 34 years (n = 14; 10%), 35 to 44 years (n = 35; 26%), 45 to 54 years (n = 39; 29%), and 55 to 64 years (n = 40; 30%). The majority of participating APNs were white non-Hispanic (n = 123; 93%). Child maltreatment APNs were well educated; 106 (83%) of participants reported that their highest degree was a masterÕs degree of science/nursing, 18 (14%) had a doctorate in nursing practice, and four (3%) had a PhD. Well over half (n = 83; 61%) of participating lead APNs stated that they have practiced as an APN for more than 10 years, and 55 (41%) have practiced in child maltreatment for more than 10 years. Less than one third (n = 42; 32%) of participating APNs reported practicing in child maltreatment for fewer than 5 years. Composition of staffing varied per child advocacy center/childrenÕs hospital, with the number of PNPs ranging from 0 to 15 with an average of 1.66 PNPs per setting; FNPs ranged from 0 to 4 with an average of 1.02 FNPs per setting; and physicians ranged from 0 to 5 with an average of 1.97 physicians per setting. Only 51 (38%) of participants reported -/- 2014
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that sexual assault nurse examiners also were employed by their programs. Child maltreatment APNs practice in a variety of settings, and many also practice in more than one setting (see Figure 1). More than half (n = 72; 58%) of participating child maltreatment APNs reported practicing at child advocacy centers, with 44 (35%) working in a hospital-based clinic. More than one fourth of participants reported that child maltreatment APNs within their institution provide care in an inpatient or ED setting. Lead APNs reported that child maltreatment APNs provide care to children with all types of maltreatment concerns (see Figure 2). The majority of responding APNs reported that child maltreatment APNs in their institution provide care to children with sexual abuse concerns (n = 117; 84%) and/or physical abuse concerns (n = 111; 84%) in an outpatient setting. APNs also provided care to children with concerns of neglect (n = 98; 74%), physical abuse in the ED or inpatient setting (n = 72; 55%), sexual abuse in the ED or inpatient setting (n = 74; 56%), emotional abuse (n = 66; 50%), foster care abuse (n = 54; 41%), and medical child abuse (n = 44; 33%). Child abuse APNs not only provide clinical care but are also involved in education, research, and publishing (see Figure 3). More than one fourth (n =36; 27%) of child abuse lead APNs held an academic appointment at a university. In addition, 36 (30%) of lead APNs reported that they and their fellow child maltreatment APNs were involved in child maltreatment research, and 23 (19%) published works related to child maltreatment. Education of professionals and the public is an important part of the child maltreatment APN role, and participants reported that they and their APN colleagues provided clinical education to APN
FIGURE 1. Child maltreatment practice sites. This figure appears in color online at www. jpedhc.org.
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FIGURE 2. Types of child maltreatment concerns for which advanced practice nurses (APNs) provide care. ED = emergency € nchausen syndrome department; MSBP = Mu by proxy; PA = physician’s assistant. This figure appears in color online at www.jpedhc.org.
students (n = 83, 74%); nurses (n = 78, 70%); nursing students (n = 70, 63%); resident physicians (n = 70, 62%); medical students (n = 70, 63%); and attending physicians (n = 54, 48%). Child maltreatment APNs also provided child maltreatment education by lecturing locally (n = 109; 90%), statewide (n = 65; 54%); and nationally (n = 31; 26%). Court testimony is an important part of providing care to abused/ neglected children, and lead APNs reported that they FIGURE 3. Advanced practice nurse (APN) child maltreatment activities. PA = physician’s assistant. This figure appears in color online at www.jpedhc.org.
Journal of Pediatric Health Care
and other child maltreatment APNs in the institution testify in court as expert witnesses for cases involving child sexual abuse (n = 106, 84%); physical abuse (n = 86, 67%); neglect (n = 64, 50%); emotional abuse (n = 38, 30%); and medical child abuse (n = 22, 17%). More than one tenth (n = 18, 14%) of child maltreatment lead APNs stated that APNs in their institutions do not provide expert testimony in court. DISCUSSION PNPs and FNPs play a vital role in the care of abused children. This care is provided in child advocacy centers, as well as in children’s hospitals in outpatient, inpatient, and ED settings. Often they see patients in multiple settings and have multiple roles. They work as part of multidisciplinary teams, typically providing care alongside child abuse pediatricians. The two more common types of maltreatment that entail assessment, diagnosis, and treatment by APNs are child sexual abuse and physical abuse. However, APNs also provide care for children with all types of child maltreatment concerns. The role of APNs within child abuse includes providing clinical education to nurses, nurse practitioners, nursing students, and to a lesser degree medical students, residents, and physicians. Child maltreatment APNs lecture widely to a variety of audiences at the local, state, and national level, providing important information regarding many different aspects of child maltreatment. Many child maltreatment APNs also provide a more direct role in educating the next generation of professionals by holding university appointments. Important contributions are added to the field of child maltreatment by the research and publications of child maltreatment APNs. Limitations A limitation of this study is that not all child advocacy centers and children’s hospitals responded to the survey, and thus some APNs working in child maltreatment may not have been invited to participate in the study or may have chosen not to participate. As a result, some practice characteristics of APNs in child maltreatment may exist that are not described by this study. Further research is needed to more completely describe the role of APNs in child maltreatment and also to evaluate their effectiveness in their clinical and academic roles. CONCLUSION Child maltreatment is indeed a problem of epidemic proportions in the United States, with the potential for serious ramifications for victims and their families. Child maltreatment can result in immediate and longterm consequences for its victims (Putnam, 2003). The consequences of child maltreatment can also affect
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the next generation of American children by altering the ability of victims to effectively parent their own children (Hornor, 2010). Recognizing the significance of the problem of child maltreatment and providing thorough, competent, and compassionate care to child victims is of the utmost importance. Understanding the practice characteristics of child maltreatment In this exciting time APNs helps to affirm of health care the contributions of reform with the APNs in the field and allows for a greater potential for role appreciation of their expansion and contribution to the changes for APNs, field of child maltreatment, both clinically it is crucial for APNs and academically. In in practice this exciting time of specialties to health care reform with the potential for define their role expansion and contributions to changes for APNs, it is their specialties. crucial for APNs in practice specialties to define their contributions to their specialties. This study demonstrates that PNPs and other APNs play crucial roles in the care of maltreated children.
REFERENCES Borgmeyer, A., Gyr, P. M., Jamerson, P. A., & Henry, L. D. (2008). Evaluation of the role of the pediatric nurse practitioner in an inpatient asthma program. Journal of Pediatric Health Care, 22, 273-281. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7-26. Freed, G. L., Dunham, K. M., Lamarand, K. E., Loveland-Cherry, C., & Martyn, K. (2010). Pediatric nurse practitioners: Roles and scope of practice. Pediatrics, 126, 846-850. Frisch, A. M., Johnson, A., Timmons, S., & Weatherford, C. (2010). Nurse practitioner role in preparing families for pediatric outpatient surgery. Pediatric Nursing, 36, 41-47. Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24, 358-364. Katz, L., Ceballos, S. G., Scott, K., & Wurm, G. (2007). The critical role of a pediatric nurse practitioner in an early intervention program for children with prenatal drug exposure. Journal for Specialist in Pediatric Nursing, 12, 123-127. National Association of Pediatric Nurse Practitioners. (1995). NAPNAP white paper on educational preparation and role parameters of pediatric nurse practitioners. Journal of Pediatric Health Care, 9, 96-97. National Association of Pediatric Nurse Practitioners. (2008). NAPNAP position statement on the doctorate of nursing practice. Journal of Pediatric Health Care, 22, 25A-26A. Pediatric Nursing Certification Board. (2010). Retrieved from www. pncb.org Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 269-278.
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Reider-Demer, M., Widecan, M., Jones, D. C., & Goodhue, C. (2006). The evolving responsibilities of the pediatric nurse practitioner. Journal of Pediatric Health Care, 20, 280-283. Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38, 323-330.
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U.S. Department of Health & Human Services. (2013). Child Maltreatment 2012. Retrieved from http://www.childwelfare. gov/pubs/guide2012/guide.pdf Vaughese, A., Byczkowski, T., Wittkugel, E., Kotagal, U., & Kurth, D. (2006). Impact of a nurse practitioner-assisted preoperative assessment program on quality. Pediatric Anesthesia, 16, 723-733.
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Appendix Nurse Practitioner Survey 1. What type of nurse practitioner are you? PNP/ FNP/CNS/PA/Other 2. What is your highest educational level in nursing? MS or MSN/DNP/PhD/Other 3. How many years have you practiced as an NP? _____ 4. How many years have you practiced as an NP in child maltreatment? _____ 5. What is your age? ____ 6. What is your gender? Male/Female 7. What is your race/ethnicity? White nonHispanic/Hispanic/African-American/Asian/ Multi-race/ethnic/Other (specify) ___________ 8. How many of the following positions does your facility employ to manage child abuse? PNP ____ FNP ____ CNS ____ PA _____ Physician ____ Other ______ Sexual assault nurse examiners _____ 9. What is your child maltreatment practice site? (select all that apply) Hospital-based clinic Community-based clinic In-patient hospital care Emergency department Child advocacy center Other (specify) ________________ 10. You and your NPs provide care to children with what types of abuse concerns? (select all that apply) Physical abuse (outpatient) Physical abuse (inpatient and/or ED) Sexual abuse (outpatient) Sexual abuse (inpatient and/or ED) Neglect Emotional abuse MSBP
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Foster care 11. You and your NPs provide child maltreatment clinical education to which of the following? (select all that apply) Nursing students APN students Nurses Medical students Residents Physicians Other (specify) ________________________ 12. Do you have an academic appointment at a university? Yes/No 13. You and your NPs participate in which of the following activities related to child maltreatment? (select all that apply) Lectures locally Lectures statewide Lectures nationally Research Publication Other (specify) _______________ 14. Does your child abuse program include a pediatric SANE program? Yes/No 15. Advanced practice nurses or physicians in your program testify in court as expert witnesses for which of the following types of child maltreatment? Sexual abuse Physical abuse Emotional abuse Neglect MSBP Do not testify as expert witnesses APN = advanced nurse practitioner; CNS = clinical nurse specialist; DNP = doctorate in nursing practice; ED = emergency department; FNP = family nurse practitioner; MS = master of science; MSBP = M€ unchausen syndrome by proxy; MSN = master of science in nursing; NP = nurse practitioner; PA = physician’s assistant; PNP = pediatric nurse practitioner; SANE = sexual assault nurse examiner.
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Advanced Practice Nursing in Child Maltreatment: Practice Characteristics Gail Hornor, DNP, CPNP, & Pamela Herendeen, DNP, CPNP
ABSTRACT Introduction: Child maltreatment is a problem of epidemic proportions in the United States. Pediatric nurse practitioners and other advanced practice nurses (APNs) have been caring for maltreated children for decades, yet to date no comprehensive assessment of their practice characteristics or their clinical and academic contributions to the field has been performed. The purpose of this study is to describe the practice characteristics of APNs who care for maltreated children. Method: A descriptive design was used for this study. Child advocacy centers and children’s hospitals were contacted to inquire about employment of child maltreatment APNs in their institution, and contact information for the lead APN was obtained. The Nurse Practitioner Survey was then sent to lead APNs by e-mail. Results: The majority of APNs who work primarily in child maltreatment are pediatric nurse practitioners who work in child advocacy centers. They are providing care to children with physical and/or sexual abuse concerns; however, APNs provide care for children with all types of child maltreatment concerns. Discussion: APNs play a vital role in the care of abused/ neglected children. Their important contributions include not only clinical care but also the provision of clinical and Gail Hornor, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children’s Hospital, Columbus, OH. Pamela Herendeen, Pediatric Nurse Practitioner and Associate Professor of Nursing, University of Rochester, Golisano’s Children’s Hospital, Rochester, NY.
didactic education to other professionals, parents, and the public. Research and publication are also essential to their role. J Pediatr Health Care. (2014) -, ---.
KEY WORDS Advanced practice nursing, child maltreatment
Child maltreatment is a problem of epidemic proportions in the United States. During 2011, approximately 681,000 children were victims of child maltreatment (U.S. Department of Health & Human Services, 2013). An estimated 1,570 children died nationally as a result of child abuse or neglect, a rate of 2.10 deaths per 100,000 children. Reports indicate that in 2011, 78% of victims experienced neglect, 18% were physically abused, 9% experienced sexual abuse, and 8% were psychologically maltreated. Finkelhor, Ormrod, & Turner (2007) and Turner, Finkelhor, & Ormrod (2010), in nationally representative samples of 2,030 children and 4,053 children, respectively, found that 69% and 66% of the children had experienced more than one form of child maltreatment. In an acknowledgment of the scope of the problem, the American Academy of Pediatrics has recognized child abuse pediatrics as a subspecialty, and the inaugural board certification was offered in 2009. The National Association of Pediatric Nurse Practitioners (NAPNAP) also recognizes the significance of the problem and sponsors a Special Interest Group dedicated to child maltreatment and neglect.
Conflicts of interest: None to report. Correspondence: Gail Hornor, DNP, CPNP, Center for Family Safety and Healing, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205; e-mail: Gail.hornor@ nationwidechildrens.org. 0891-5245/$36.00 Copyright Q 2014 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2014.02.003
www.jpedhc.org
DESCRIPTION OF PRACTICE CHARACTERISTICS LACKING Although authors have described the global pediatric nurse practitioner (PNP) role, as well as specific practice specialties such as inpatient, preoperative, cardiology, endocrinology, early intervention settings, and others (Borgmeyer et al., 2008; Freed et al., 2010; Katz et al., 2007; & Vaughese et al., 2006), no studies to date have described the practice characteristics of -/- 2014
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PNPs and/or other advanced practice nurses (APNs) in child maltreatment. PNPs and other APNs have been working in the area of child maltreatment for decades, yet to date no comprehensive assessment of their practice or their clinical and academic contributions to the field has been performed. For purposes of this study, a child maltreatment APN is defined as an APN who works as a member of a team dedicated exclusively to the assessment, diagnosis, and treatment of children and adolescents for whom there is a concern of suspected child maltreatment. PURPOSE OF THE STUDY The literature describes the practice characteristics of PNPs and other APNs in a variety of specialty roles, substantiating their contributions to the field. The practice characteristics of APNs working in the area of child maltreatment remain unexplored. The purpose of this study is to describe the practice characteristics of APNs in the area of child maltreatment in terms of the following: a. Type of APN educational preparation (e.g., PNP vs. family nurse practitioner [FNP]) b. Educational level c. Years practicing as an NP and practicing in child maltreatment d. Practice site e. Type of abuse concern addressed in practice f. Number of NPs in the facility g. Clinical education provided h. Academic appointment i. Academic activities j. Sexual assault nurse examiners REVIEW OF LITERATURE The PNP is an APN specializing in pediatric health care (NAPNAP, 1995). The PNP is a registered nurse who has completed a program of NP preparation at a school of nursing as part of a masters in nursing degree program. This education provides PNPs with advanced knowledge and clinical skills in child health care, which allows them to provide a wide range of health care services for children from birth through adolescence. The PNP collaborates with other health care professionals and practices as an interdependent member of the health care team to provide pediatric care. The PNP role emerged during the mid 1960s as registered nurses prepared at the certificate level through a formalized advanced educational program and evolved in the 1990s to nurses prepared at the masters-degree level (NAPNAP, 1995). The role continues to evolve with the development of the doctorate in nursing practice (DNP) as the proposed terminal credential and level of education for the PNP originally anticipated by 2015 (NAPNAP, 2008). PNPs are important members of the health care team that provides care to children (Freed, Dunham, 2
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Lamarand, Loveland-Cherry, & Martyn, 2010). Currently nearly 13,000 PNPs practice in the United States (Pediatric Nursing Certification Board, 2010). Freed and colleagues (2010) surveyed a stratified random sample of 1200 PNPs to gain a better understanding of the role, primary care versus subspecialty focus of practice, professional setting, and responsibilities. A structured questionnaire was developed by Freed and colleagues (2010) and administered by mail. Of the 1200 surveys mailed, 905 were returned for a response rate of 82.4%. More than half of the participants (59%) worked in primary care, and the majority (64%) did not work in an inpatient setting. Most PNPs reported that they often perform general and specialty practice roles such as patient assessment and diagnosis, development of treatment plans, and immunizations. Freed and colleagues (2010) concluded that PNPs have an important role in pediatric primary and subspecialty care. Reider-Demer, Widecan, Jones, & Goodhue (2006) point out the continued evolution of the PNP role to meet the ever more complex health care needs of the pediatric population. The PNP role was initially developed to provide pediatric primary care. PNPs now practice in a variety of settings: private practices, hospital clinics, school clinics, and inpatient settings, including emergency departments (EDs) and intensive care units. PNPs are now providing not only primary care but secondary and tertiary care as well. PNPs practice in a variety of settings, and their effectiveness has been evaluated in these settings (Frisch, Johnson, Timmons, & Weatherford, 2010). As in the adult health care arena, more and more pediatric surgical procedures are being performed in outpatient settings. Children and parents report not feeling emotionally and educationally prepared for outpatient surgery (Frisch et al., 2010). Developmentally appropriate preoperative educational programs and parental involvement in the surgical experience have been found to help alleviate the anxiety of both parents and children. PNPs are being used in preoperative settings to perform physical examinations and provide preoperative education. A longitudinal study was conducted at Cincinnati Children’s Hospital by Vaughese, Byczkowski, Wittkugel, Kotagal, and Kurth (2006) to evaluate quality of care after the implementation of preoperative physical examinations and education performed by PNPs. Data were collected over 1 year at 3 months, 6 months, 9 months, and 12 months after commencement of the PNP program. Quality of care was evaluated on the basis of respiratory complication rate, preoperative preparation time, parental satisfaction, and staff satisfaction. Using a scale of 0 (worst care) to 10 (best care), an average overall rating of care was obtained at each data collection point. Overall mean scores were 9.49 (baseline), 9.50 (3 months), 9.48 (6 months), 9.29 (9 months), and 9.44 (12 months). Journal of Pediatric Health Care
Thus it was found that PNPs provided quality, costeffective care. Katz, Ceballos, Scott, & Wurm (2007) discussed the critical role of the PNP as a team member in early intervention partnerships with young children in foster care. Including PNPs on the team has proven to improve health care linkages for these vulnerable children. PNPs play a vital role in educating families on the importance of preventative health care and well visits and providing essential follow-through with identified health concerns. Katz and colleagues (2007) discuss the role of the PNP in providing care to children in foster care and the resulting increased compliance with care, increased percentage of immunized children, and decrease in the frequency of ED visits. PNPs also practice in a variety of inpatient settings. Borgmeyer, Gyr, Jamerson, and Henry (2008) evaluated the role of the PNP as care managers of children hospitalized with asthma. Other multidisciplinary team members including physicians, interns, nurses, and families were surveyed regarding their perceptions of the PNPs as care managers and educators. Care indicators of length of stay, readmission rate, and cost were also evaluated. Two hundred forty multidisciplinary team members participated in the survey, and all participants found PNPs to be effective in the inpatient asthma role. No significant differences were noted in length of stay, cost, readmissions, or severity of the condition of patients with asthma who were managed by PNPs versus physicians. PNPs in the inpatient asthma setting were found to be effective care managers and educators. METHODS Purpose The purpose of this study was to describe the practice characteristics of APNs in the area of child maltreatment. Design A descriptive design was used for this study. Institutional Review Board The Institutional Review Board at Nationwide Children’s Hospital approved this study prior to the recruitment of subjects. Participants were informed that completion of the survey implied consent. Procedures All children’s hospitals (183) and child advocacy centers (787) in the United States were contacted via email or phone to inquire about the employment of child maltreatment APNs within their organizations. Locations of children’s hospitals in the United States were obtained from the Children’s Hospital Association Web site, and locations of child advocacy centers were obtained from the National Children’s Alliance www.jpedhc.org
Web site. Three hundred twenty-three organizations stated that child maltreatment APNs were employed by their organizations, and a contact e-mail address was obtained for the lead APN. The Nurse Practitioner Survey (Appendix) was then sent to the lead APNs by e-mail. The Nurse Practitioner Survey is a 15-item questionnaire designed by the study investigators to describe specific aspects of APN practice in the area of child maltreatment. Demographic questions were specific to the lead APN, whereas practice/academic questions were aimed at describing all child maltreatment APNs practicing in the institution. The study investigators are expert child maltreatment APNs, each with more than 20 years of experience in the field, thus establishing content validity for the Nurse Practitioner Survey. The Nurse Practitioner Survey was also reviewed by an expert in survey design at the University of Rochester School of Nursing in Rochester, New York, to examine the survey design and structure of the questions. A reminder was sent by e-mail at 2and 4-week intervals to encourage nonresponders to return the survey. RESULTS One third (323) of children’s hospitals and child advocacy centers responded affirmatively regarding the use of child maltreatment APNs by their organizations and identified a lead APN best suited to complete the Nurse Practitioner Survey. The Nurse Practitioner Survey was then sent to the lead APNs, and 136 (42%) responded. The majority of lead APNs working in child maltreatment were PNPs (n = 82; 61%), followed by FNPs (n =46; 34%), clinical nurse specialists (n = 6; 4%), and physician assistants (n = 1; 1%). Nearly all were women (n = 129; 96%), with ages ranging from 25 to 34 years (n = 14; 10%), 35 to 44 years (n = 35; 26%), 45 to 54 years (n = 39; 29%), and 55 to 64 years (n = 40; 30%). The majority of participating APNs were white non-Hispanic (n = 123; 93%). Child maltreatment APNs were well educated; 106 (83%) of participants reported that their highest degree was a masterÕs degree of science/nursing, 18 (14%) had a doctorate in nursing practice, and four (3%) had a PhD. Well over half (n = 83; 61%) of participating lead APNs stated that they have practiced as an APN for more than 10 years, and 55 (41%) have practiced in child maltreatment for more than 10 years. Less than one third (n = 42; 32%) of participating APNs reported practicing in child maltreatment for fewer than 5 years. Composition of staffing varied per child advocacy center/childrenÕs hospital, with the number of PNPs ranging from 0 to 15 with an average of 1.66 PNPs per setting; FNPs ranged from 0 to 4 with an average of 1.02 FNPs per setting; and physicians ranged from 0 to 5 with an average of 1.97 physicians per setting. Only 51 (38%) of participants reported -/- 2014
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that sexual assault nurse examiners also were employed by their programs. Child maltreatment APNs practice in a variety of settings, and many also practice in more than one setting (see Figure 1). More than half (n = 72; 58%) of participating child maltreatment APNs reported practicing at child advocacy centers, with 44 (35%) working in a hospital-based clinic. More than one fourth of participants reported that child maltreatment APNs within their institution provide care in an inpatient or ED setting. Lead APNs reported that child maltreatment APNs provide care to children with all types of maltreatment concerns (see Figure 2). The majority of responding APNs reported that child maltreatment APNs in their institution provide care to children with sexual abuse concerns (n = 117; 84%) and/or physical abuse concerns (n = 111; 84%) in an outpatient setting. APNs also provided care to children with concerns of neglect (n = 98; 74%), physical abuse in the ED or inpatient setting (n = 72; 55%), sexual abuse in the ED or inpatient setting (n = 74; 56%), emotional abuse (n = 66; 50%), foster care abuse (n = 54; 41%), and medical child abuse (n = 44; 33%). Child abuse APNs not only provide clinical care but are also involved in education, research, and publishing (see Figure 3). More than one fourth (n =36; 27%) of child abuse lead APNs held an academic appointment at a university. In addition, 36 (30%) of lead APNs reported that they and their fellow child maltreatment APNs were involved in child maltreatment research, and 23 (19%) published works related to child maltreatment. Education of professionals and the public is an important part of the child maltreatment APN role, and participants reported that they and their APN colleagues provided clinical education to APN
FIGURE 1. Child maltreatment practice sites. This figure appears in color online at www. jpedhc.org.
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FIGURE 2. Types of child maltreatment concerns for which advanced practice nurses (APNs) provide care. ED = emergency € nchausen syndrome department; MSBP = Mu by proxy; PA = physician’s assistant. This figure appears in color online at www.jpedhc.org.
students (n = 83, 74%); nurses (n = 78, 70%); nursing students (n = 70, 63%); resident physicians (n = 70, 62%); medical students (n = 70, 63%); and attending physicians (n = 54, 48%). Child maltreatment APNs also provided child maltreatment education by lecturing locally (n = 109; 90%), statewide (n = 65; 54%); and nationally (n = 31; 26%). Court testimony is an important part of providing care to abused/ neglected children, and lead APNs reported that they FIGURE 3. Advanced practice nurse (APN) child maltreatment activities. PA = physician’s assistant. This figure appears in color online at www.jpedhc.org.
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and other child maltreatment APNs in the institution testify in court as expert witnesses for cases involving child sexual abuse (n = 106, 84%); physical abuse (n = 86, 67%); neglect (n = 64, 50%); emotional abuse (n = 38, 30%); and medical child abuse (n = 22, 17%). More than one tenth (n = 18, 14%) of child maltreatment lead APNs stated that APNs in their institutions do not provide expert testimony in court. DISCUSSION PNPs and FNPs play a vital role in the care of abused children. This care is provided in child advocacy centers, as well as in children’s hospitals in outpatient, inpatient, and ED settings. Often they see patients in multiple settings and have multiple roles. They work as part of multidisciplinary teams, typically providing care alongside child abuse pediatricians. The two more common types of maltreatment that entail assessment, diagnosis, and treatment by APNs are child sexual abuse and physical abuse. However, APNs also provide care for children with all types of child maltreatment concerns. The role of APNs within child abuse includes providing clinical education to nurses, nurse practitioners, nursing students, and to a lesser degree medical students, residents, and physicians. Child maltreatment APNs lecture widely to a variety of audiences at the local, state, and national level, providing important information regarding many different aspects of child maltreatment. Many child maltreatment APNs also provide a more direct role in educating the next generation of professionals by holding university appointments. Important contributions are added to the field of child maltreatment by the research and publications of child maltreatment APNs. Limitations A limitation of this study is that not all child advocacy centers and children’s hospitals responded to the survey, and thus some APNs working in child maltreatment may not have been invited to participate in the study or may have chosen not to participate. As a result, some practice characteristics of APNs in child maltreatment may exist that are not described by this study. Further research is needed to more completely describe the role of APNs in child maltreatment and also to evaluate their effectiveness in their clinical and academic roles. CONCLUSION Child maltreatment is indeed a problem of epidemic proportions in the United States, with the potential for serious ramifications for victims and their families. Child maltreatment can result in immediate and longterm consequences for its victims (Putnam, 2003). The consequences of child maltreatment can also affect
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the next generation of American children by altering the ability of victims to effectively parent their own children (Hornor, 2010). Recognizing the significance of the problem of child maltreatment and providing thorough, competent, and compassionate care to child victims is of the utmost importance. Understanding the practice characteristics of child maltreatment In this exciting time APNs helps to affirm of health care the contributions of reform with the APNs in the field and allows for a greater potential for role appreciation of their expansion and contribution to the changes for APNs, field of child maltreatment, both clinically it is crucial for APNs and academically. In in practice this exciting time of specialties to health care reform with the potential for define their role expansion and contributions to changes for APNs, it is their specialties. crucial for APNs in practice specialties to define their contributions to their specialties. This study demonstrates that PNPs and other APNs play crucial roles in the care of maltreated children.
REFERENCES Borgmeyer, A., Gyr, P. M., Jamerson, P. A., & Henry, L. D. (2008). Evaluation of the role of the pediatric nurse practitioner in an inpatient asthma program. Journal of Pediatric Health Care, 22, 273-281. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7-26. Freed, G. L., Dunham, K. M., Lamarand, K. E., Loveland-Cherry, C., & Martyn, K. (2010). Pediatric nurse practitioners: Roles and scope of practice. Pediatrics, 126, 846-850. Frisch, A. M., Johnson, A., Timmons, S., & Weatherford, C. (2010). Nurse practitioner role in preparing families for pediatric outpatient surgery. Pediatric Nursing, 36, 41-47. Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24, 358-364. Katz, L., Ceballos, S. G., Scott, K., & Wurm, G. (2007). The critical role of a pediatric nurse practitioner in an early intervention program for children with prenatal drug exposure. Journal for Specialist in Pediatric Nursing, 12, 123-127. National Association of Pediatric Nurse Practitioners. (1995). NAPNAP white paper on educational preparation and role parameters of pediatric nurse practitioners. Journal of Pediatric Health Care, 9, 96-97. National Association of Pediatric Nurse Practitioners. (2008). NAPNAP position statement on the doctorate of nursing practice. Journal of Pediatric Health Care, 22, 25A-26A. Pediatric Nursing Certification Board. (2010). Retrieved from www. pncb.org Putnam, F. W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 269-278.
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Reider-Demer, M., Widecan, M., Jones, D. C., & Goodhue, C. (2006). The evolving responsibilities of the pediatric nurse practitioner. Journal of Pediatric Health Care, 20, 280-283. Turner, H. A., Finkelhor, D., & Ormrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38, 323-330.
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U.S. Department of Health & Human Services. (2013). Child Maltreatment 2012. Retrieved from http://www.childwelfare. gov/pubs/guide2012/guide.pdf Vaughese, A., Byczkowski, T., Wittkugel, E., Kotagal, U., & Kurth, D. (2006). Impact of a nurse practitioner-assisted preoperative assessment program on quality. Pediatric Anesthesia, 16, 723-733.
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Appendix Nurse Practitioner Survey 1. What type of nurse practitioner are you? PNP/ FNP/CNS/PA/Other 2. What is your highest educational level in nursing? MS or MSN/DNP/PhD/Other 3. How many years have you practiced as an NP? _____ 4. How many years have you practiced as an NP in child maltreatment? _____ 5. What is your age? ____ 6. What is your gender? Male/Female 7. What is your race/ethnicity? White nonHispanic/Hispanic/African-American/Asian/ Multi-race/ethnic/Other (specify) ___________ 8. How many of the following positions does your facility employ to manage child abuse? PNP ____ FNP ____ CNS ____ PA _____ Physician ____ Other ______ Sexual assault nurse examiners _____ 9. What is your child maltreatment practice site? (select all that apply) Hospital-based clinic Community-based clinic In-patient hospital care Emergency department Child advocacy center Other (specify) ________________ 10. You and your NPs provide care to children with what types of abuse concerns? (select all that apply) Physical abuse (outpatient) Physical abuse (inpatient and/or ED) Sexual abuse (outpatient) Sexual abuse (inpatient and/or ED) Neglect Emotional abuse MSBP
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Foster care 11. You and your NPs provide child maltreatment clinical education to which of the following? (select all that apply) Nursing students APN students Nurses Medical students Residents Physicians Other (specify) ________________________ 12. Do you have an academic appointment at a university? Yes/No 13. You and your NPs participate in which of the following activities related to child maltreatment? (select all that apply) Lectures locally Lectures statewide Lectures nationally Research Publication Other (specify) _______________ 14. Does your child abuse program include a pediatric SANE program? Yes/No 15. Advanced practice nurses or physicians in your program testify in court as expert witnesses for which of the following types of child maltreatment? Sexual abuse Physical abuse Emotional abuse Neglect MSBP Do not testify as expert witnesses APN = advanced nurse practitioner; CNS = clinical nurse specialist; DNP = doctorate in nursing practice; ED = emergency department; FNP = family nurse practitioner; MS = master of science; MSBP = M€ unchausen syndrome by proxy; MSN = master of science in nursing; NP = nurse practitioner; PA = physician’s assistant; PNP = pediatric nurse practitioner; SANE = sexual assault nurse examiner.
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