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International Journal of Nursing Practice 2015; 21 (Suppl. 1), 21–26

RESEARCH PAPER

Clinical competency in child maltreatment for community nurses in Taiwan Yi-Wen Chen MS RN Nurse, Department of Nursing, National Cheng Kung University Hospital, Tainan, Taiwan

Joh-Jong Huang MD Assistant Professor, Department of Family Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan

Tsung-Hsueh Lu MD MPD PhD Associate Professor, Institute of Public Health, College of Medicine, National Chen Kung University, Tainan, Taiwan

Jui-Ying Feng DNS RN PNP Associate Professor, Department of Nursing, National Cheng Kung University and Hospital, Tainan, Taiwan

Accepted for publication 1 January 2015 Chen Y-W, Huang J-J, Lu T-H, Feng J-Y. International Journal of Nursing Practice 2015; 21 (Suppl. 1): 21–26 Clinical competency in child maltreatment for community nurses in Taiwan The purpose of this cross-sectional study was to examine aspects of competency in child abuse among community nurses in Taiwan. A sample of 650 community nurses were recruited from public health centres (PHC) and outpatient clinics in Southern Taiwan. A structured questionnaire with five subscales, knowledge, skills, empowerment, team collaboration and self-reflection was developed and used for data collection. A total of 588 questionnaires were returned and used for analysis. Nearly 20% of community nurses reported having an acquaintance with a maltreatment history. Only 4.6% had experience of reporting a case of child abuse. Most nurses reported strong skills and abilities (empowerment, team collaboration and self-reflection). Outpatient clinic nurses scored higher in four subscales than the PHC nurses. Nurses who had a history as a victim or had reporting experience claimed better clinical competency. Unfortunately, community nurses had limited knowledge in child abuse. The findings support the development of continuing education programmes on child abuse for community nurses. Key words: child abuse, child maltreatment, clinical competency, community nurses, Taiwan.

INTRODUCTION The difference between community nurse reports and data from official records1 indicates that most cases of child abuse are hidden in communities and not reported or

Correspondence: Jui-Ying Feng, Department of Nursing, National Cheng Kung University, No.1 University Road, Tainan, 70101 Taiwan. Email: [email protected] doi:10.1111/ijn.12395

treated. Leung and his colleagues estimated that up to nearly three-quarters of adolescents have encountered abuse, but in Taiwan only 3.8% seek medical assistance.2 The potential negative consequences of untreated child abuse can be devastating and long-lasting.3–5 Early detection and intervention are crucial for maltreated children and their families in the community. Community nurses can play a significant role in identifying this health risk for vulnerable children. Nurses can © 2015 Wiley Publishing Asia Pty Ltd

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also play a key role in preventing abuse by educating parents and making referrals for supportive resources to ease family hardships.6,7 The Nurse Family Partnership programme is a home visitation program to provide support to disadvantaged families. Since it was implemented, it has successfully decreased the incidence (23– 24%)8 and mortality (5–19%) from child abuse.9 The roles and responsibilities of community nurses to care for high-risk children and families are broader and more complicated than that for nurses in hospitals. To aid disadvantaged children, community nurses must acquire a special skill set to assess and interact with children and families in crisis.10–12 Clinical nursing competency in managing child abuse has not been fully defined in the literature. Clinical competency refers to the ability to integrate one’s knowledge, skills, attitude, value and ethics to take actions in clinical situations. Clinical competency in child abuse includes clinicians’ abilities to recognize, assess, identify, report, treat and refer the abused child/family.13–15 It is also important to be able to collaborate with multidisciplinary professionals and to empower abused children and their parents. The empowerment and support from clinicians has shown a positive effect on improving parenting skills and the ability to handle family problems.16,17 Given the fact that child abuse is more often hidden in the community, it is important to understand and examine how case finding occurs. Community nurses in Taiwan are categorized as outpatient clinic nurses (OCNs) and public health nurses (PHNs). OCNs in Taiwan are employed by private clinics without additional certifications other than as a registered nurse. On the other hand, PHNs in Taiwan are public employees, certified by the national board examination, and occupy positions in local public health stations. Being public servants, PHNs commonly implement government projects to address cancer, mental illness, long-term care, smoking cessation, family planning and vaccination.18 However, the role and function of the PHNs do not usually include an emphasis on high-risk family identification or child protection. Only a few descriptive studies on clinical competency in child abuse have been published, but they have been limited to hospital-based nurses. The extent to which Taiwanese community nurses feel competent in dealing with child abuse is unknown. Educational programmes for community nurses targeting child abuse cannot be developed until a thorough needs assessment is complete. The purposes of this study were (i) to identify community © 2015 Wiley Publishing Asia Pty Ltd

Y-W Chen et al.

nurses’ current level of competency in child abuse; and (ii) to examine the relationships between professional characteristics and clinical competency in child abuse among community nurses.

METHODS A cross-sectional, descriptive, correlational study was conducted to explore the clinical competency in child abuse among community nurses in Taiwan.

Sample and procedure Community nurses were recruited from the public health centres and outpatient clinics in Southern Taiwan. A power analysis for a median effect size of 0.6 and power of 0.8 required a sample size of 295. After obtaining approval from the university’s Institutional Review Board, the researcher contacted the administrators in Department of Health in every division in southern Taiwan. There are seven divisions (four cities and three counties) in southern Taiwan. Two sites declined to participate, and the balance agreed to participate in this study. Head nurses of public health centres and outpatient clinics were approached for their willingness to participate in this study. A total of 650 questionnaires were delivered by mail or in person to nurses in 27 outpatient clinics and 72 public health centres in the five divisions in Southern Taiwan. A total of 588 questionnaires with complete data were returned by mailed or picked up by the researcher in 1 week.

Measurement A self-reported questionnaire entitled the Child Abuse Competency Questionnaire or CACQ (護理人員處理 兒童虐待之臨床能力) was developed in Mandarin Chinese to measure clinical competence in child abuse. The items of the CACQ were derived from related instruments and literature, and were written to reflect child maltreatment.19–22 The CACQ consists of 66 items with 5 subscales of knowledge (17 items), skills (31 items), empowerment (6 items), team collaboration (5 items), and self-reflection (7 items). Knowledge items are true– false questions that address signs, symptoms and behavioral indicators of physical, psychological and sexual abuse as well as neglect. For scoring, correct responses were assigned a value of 1 point. The remaining subscales are scored using a 6-point Likert scale (strongly disagree = 1, strongly agree = 6). Higher scores indicate that nurses perceive greater clinical competency in child

Clinical competency in child maltreatment

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Table 1 Sample demographics (n = 588)

Gender Marital status Education

Female Single High School or Diploma Bachelor or above Public Health Center Outpatient Clinics

Workplace Pre-service child abuse education In-service child abuse education Pre-service education In-service education Acquaintance was child abuse victim

Partially Adequate Partially Adequate

n

%

583 188 266 314 466 122 182

99.1 32.2 45.9 54.1 79.3 20.7 31.4

195

33.2

506 542 117

86.1 92.2 20.1

Note. Missing values are not included in frequency table.

abuse. Four experts (two nursing professors and two pediatric physicians) were invited to validate the items of the CACQ. Content validity indexes of the CACQ were 0.90–0.96 for representativeness and 0.84–0.98 for clarity. Construct validity was established by exploratory factor analysis. Thirty-three PHNs from one centre were recruited for the pilot study to examine the preliminary reliability and the readability for the instrument. Cronbach’s alphas for the subscales in the pilot study ranged from 0.91 to 0.98.23 Cronbach’s alphas for the subscales for the main study ranged from 0.85 to 0.98.

RESULTS Demographics Most respondents were female (99.1%), and worked in the public health centres (79.3%). About two-thirds were married and more than half had bachelor degrees or above. The majority of respondents were PHNs with bachelor degree (52.8%), while most OCNs held junior college degree (41.5%). The average age of respondents was 38.9 years old (SD = 9.21, range: 20–59 years old). Subjects had worked as a nurse from 4 months to 38.1 years with a mean of 15.9 years (SD = 8.91) (Table 1). A small minority of nurses (4.6%) indicated they had ever reported child abuse, and few (5.9%) admitted

having encountered at least one suspected incidence but had not reported the abuse. ‘Insufficient evidence’ was the most common reason for failure to report. One-fifth reported having witnessed or knew someone who had been a victim of child abuse. However, very few nurses self-identified as child abuse victims (2.6%) or as domestic violence victims (4.8%). Nearly one-third indicated having child abuse education in their nursing school or in-service education. Nearly 20% (n = 113) of the sample had received child abuse education in the past year, and most felt the education was only ‘partially adequate’ for their job (Table 1). Table 2 describes the differences on subscales between PHNs and OCNs. The maximum knowledge score was 17, but the mean for the total sample was 12.5 (SD = 4.09). However, only 93 nurses (15.8%) correctly answered all of the knowledge items. Most nurses perceived that they were skillful (M = 117.1, SD = 27.35), possessed the abilities of empowerment (M = 23.5, SD = 5.65), team collaboration (M = 19.5, SD = 4.97) and self-reflection (M = 28.3, SD = 6.1). Except for knowledge, OCNs scored higher than PHNs on the rest of the subscales. Comparisons between personal characteristics, professional characteristics and clinical competency in child abuse were also computed. Clinical competency in child abuse was negatively associated with age and nursing experience. Community nurses who received education in the past year perceived they were competent (t = 2.72 and 2.92, P < 0.05, respectively). Nurses who reported being victims of child abuse rated themselves higher in four areas (skills, empowerment, team collaboration and self-reflection; t = 2.01–2.38, P < 0.05). Nurses who had reported suspected cases previously scored higher in knowledge (t = 3.26, P < 0.01) and in self-reflection (t = 2.19, P < 0.05). All subscales, except knowledge, were highly intercorrelated (r = 0.71–0.82) (Table 3).

DISCUSSION This study was the first to examine clinical competency regarding child abuse among community nurses in Taiwan. Our sample included 466 public health nurses, which accounted for 57.7% of all public health nurses in the five regions surveyed. Most community nurses perceived they were capable and possessed the characteristics of empowerment, team collaboration and self-reflection. However, very few (4.6%) nurses had ever of reported © 2015 Wiley Publishing Asia Pty Ltd

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Y-W Chen et al.

Table 2 Self-reported clinical competences Competencies

Overall n=588 Mean (SD)

PHC† n = 466 Mean (SD)

OC‡ n = 122 Mean (SD)

t Value

Possible range

Knowledge Skill Empowerment Team collaboration Self-reflection

12.5 (4.09) 117.7 (27.35) 23.5 (5.65) 19.5 (4.97) 28.3 (6.13)

12.8 (4.18) 116.2 (26.48) 23.1 (5.46) 19.2 (4.79) 27.9 (6.00)

11.7 (3.55) 125.2 (28.92) 25.7 (5.46) 20.9 (5.02) 30.3 (5.52)

-2.52* 3.20** 4.52** 3.38** 3.87**

0–17 31–186 5–30 7–42 6–36

* P < 0.05, ** P < 0.01. † PHC, public health centres; ‡ OC, outpatient clinics, Table 3 Relationship among Pearson’s r. (n = 588)

1. Knowledge 2. Skill 3. Empowerment 4. Team collaboration 5. Self-reflection

clinical

competencies

using

1

2

3

4

1 0.06 0.07 0.08* 0.14**

1 0.79** 0.71** 0.75**

1 0.79** 0.77**

1 0.82**

* P < 0.05, ** P < 0.01.

child abuse cases, which strongly suggests that competency and knowledge are important in case finding and developing effective care programmes. The average score on the knowledge subscale was 74%. Most community nurses were able to identify the types of physical injury that are signs of abuse. Nurses were less sensitive to soft signs of neglect (e.g. missing vaccinations or regular health checkups). However, these soft signs may be a prelude to injury or abuse later. Most nurses perceived that they were capable of providing care for injuries, but perhaps not for psychological harm. Nearly half of nurses (44.6%) were comfortable with their role as an advocator for the abused children. It was unexpected to find that OCNs with less education scored higher in several areas than PHNs who were more educated. Further, PHNs in Taiwan are public employees who are required to obtain 40 continuing education hours yearly while OCNs have no such requirement. One possible explanation could be that OCNs had more opportunities working with children in a © 2015 Wiley Publishing Asia Pty Ltd

variety of settings including pediatrics or family medicine. It is possible that other professionals take the lead in reporting child abuse in these settings. Thus, the OCNs became more aware and report more capability as a result. Unlike other studies,24,25 our findings indicate that nurses with long work histories felt less competent in addressing child abuse. One explanation might be practice fatigue or burn-out. Some studies found that older generations of providers may not believe that physical discipline constitutes child abuse.26,27 Child abuse is still a relatively new concept in Taiwanese society. This requires that nurses challenge traditional parental practices. Further, some nursing leaders28 assert that senior nurses in Taiwan are rigid and resistant to change. As a result, child abuse training must be developed for both nurses and families. A history of being abused as a child may yield two different outcomes: abuse may sensitize the professionals’ awareness to act or inhibit engagement in child abuse cases. Our study suggests that nurses with a history of abuse report stronger clinical competency (e.g. skills, empowerment, team collaboration, self-reflection). This result was consistent with other studies,29 where physicians with past abuse history were more confident to identify suspected cases and more willing to help victims. Likewise, community nurses with an abuse history in this study felt more competent in their skills, empowerment, team collaboration and self-reflection, but not in knowledge. Nearly one-fifth of nurses reported that some of their acquaintances were victims of child abuse. Compared to the official rate reported of only 3.7%,30 this implies that many child abuse victims are still hidden, unreported

Clinical competency in child maltreatment

and not receiving help. In this study only 4.6% of nurses had ever reported a case of child abuse, but 5.9% acknowledged their failure to report. Community nurses appeared to have a much lower rate of reporting compared with 14–30% of reporting rate by hospital nurses in Taiwan.31,32 Possible reason for this difference is that more serious cases of abuse require medical care, whereas minor injuries, psychological or sexual abuse is simply more difficult to detect or subsequently validate in the community. This study is limited by the cross-sectional design, thus, causality cannot be determined. Another limitation is that clinical competence in child abuse was evaluated by selfreport data. Willingness to disclose their own failure to report, a professional failing, reflects negative competence in clinical settings. Thus, our data may reflect an under-reporting; the actual rate may be much higher. The CACQ is the first instrument to examine clinical competency in child abuse in Taiwan. The psychometric properties should be further tested among different groups of health-care professionals and in different clinical locations. Only about one-third of nurses in this study had received pre-service or in-service child abuse education. To combat this fault, the educational and evaluation process could be improved by integrating vignettes or simulations to reinforce competencies in child abuse reporting and advocacy. Community nurses face more difficult challenges to assess and identify child abuse in the community due to more subtle signs and complicated family problems. This study demonstrates the need to highlight child protection and abuse detection and reporting as a priority in working agendas for community nurses.

Conclusion The findings from this study highlight the need for continuing education programmes for community nurses. Although nurses assert they are competent in child abuse, this fact is not reflected in this study. It is also problematic that so few nurses have ever reported these cases in this large geographic area. The results of this study provide a foundation for developing a culturally and clinically appropriate training programme to improve care regarding child abuse.

DISCLOSURES The authors declare no conflict of interest.

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Clinical competency in child maltreatment for community nurses in Taiwan.

The purpose of this cross-sectional study was to examine aspects of competency in child abuse among community nurses in Taiwan. A sample of 650 commun...
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