Public Health Nurses in Child and Family Health Clinics role in preventing and detecting child maltreatment

A mixed-method study

Abstract

Background: Living without violence is essential for maintaining good physical and mental health and overall quality of life. The Norwegian Government has prioritized the prevention of domestic violence and the support of victims through policy documents, substantial funding allocation, and departmental initiatives. Child maltreatment, a critical aspect of domestic violence due to its profound and longlasting effects on children's physical and mental health, family dynamics, and broader societal welfare, has significant implications for individuals and communities alike. Child and Family Health Clinics play a pivotal role in Norway's healthcare system by providing universal services through a standardized program that includes a minimum of 14 check-ups before a child reaches school age, with most occurring in the first year of life. These clinics ensure timely identification of health and developmental issues, promote preventive care, and offer crucial guidance to families. Public health nurses, who serve as the primary caregivers at these clinics, are uniquely positioned to identify and prevent child maltreatment due to their regular and early interaction with families, allowing for early intervention and safeguarding children's well-being. Despite these prevention efforts, a 2017 government report, commonly referred to as a White paper, revealed that children were often overlooked in severe cases of maltreatment where earlier intervention was needed. The report highlighted challenges within health services, such as insufficient routine inquiries about maltreatment, lack of knowledge about its symptoms and signs, inadequate support for healthcare workers, and poor collaboration between services. Additionally, a 2019 report by the National Criminal Investigation Service found that over 70 percent of severe maltreatment cases involved children under one year old, with 50 percent involving children under five months. These children are too young to attend daycare, and public health nurses may be the only professionals outside the family who interact with them. However, only two cases were identified through routine examinations. In Norway, research on the role of public health nurses in detecting and preventing child maltreatment is limited. Moreover, there is a lack of detailed data on how the guidelines related to child maltreatment are interpreted and implemented. Aims: This PhD thesis aims to explore the role of public health nurses in Child and Family Health Clinics in detecting and preventing child maltreatment. Additionally, it seeks to identify educational and supportive needs by examining their knowledge, procedures and practices related to child maltreatment at a national level: 1. To explore how public health nurses in Child and Family Health Clinics detect and prevent child maltreatment. 2. To describe the detection and prevention practices of public health nurses in Child and Family Health Clinics and identify factors associated with increased identification of child maltreatment. 3. To investigate public health nurses’ self-perceived competence and decision-making in managing suspected child maltreatment cases. Methods: This doctoral thesis employs a mixed methods approach across three distinct but complementary papers to thoroughly explore the research topic. The methodology begins with qualitative interviews to capture individual experiences, followed by a quantitative cross-sectional study to examine broader trends, and integrates these approaches to gain a deeper understanding of public health nurses’ role in preventing and detecting child maltreatment. The first paper was a qualitative study including semi-structured interviews with fourteen public health nurses from 11 different child and family health clinics. Insights from these interviews and the findings informed the development of a comprehensive questionnaire used in the subsequent papers. The questionnaire covering topics such as demographics, guidelines, experiences with child maltreatment, vignetes, knowledge, and attiudes, with both closed and open-ended response options. The second paper focused on quantitative data, analyzing responses related to guidelines, collaboration, and influencing factors. Descriptive statistics were presented, and univariate and multivariate logistic regression analysis were conducted to identify factors associated with detection of different types of maltreatment. The third study employed a one-phase convergent mixed method approach, integrating qualitatve and quantitative data from the questionnaire. It assessed public health nurses' competence and clinical decision-making using a patent vignete. The mixed method approach provided a thorough and holistic understanding of the data by combining the strengths of both qualitatve and quantitative analysis.The final analysis in paper two and three included responses from 554 public health nurses working in child and family health clinics who partcipated in family consultations. Results: Study one explored how public health nurses detect and prevent child maltreatment, identifying three main themes where the public health nurses was: (i) integrating knowledge into daily work to prevent maltreatment, (ii) striving hard to detect child maltreatment, and (iii) experiencing the assignment to be complex and demanding. Study two confirmed many findings from the first study, showing that public health nurses follow clinical guidelines and use thorough assessment processes to monitor children's well-being and detect maltreatment. However, collaboration with other professionals, such as child protection services and general practioners, was infrequent. Suspicions of maltreatment were generally rare, but associated by public health nurses age and experience, with older public health nurses more likely to suspect physical abuse and those with more education more likely to suspect sexual abuse. Study three revealed that while public health nurses have a high level of recognition of child maltreatment, there is complexity and uncertainty in their assessments. Although they felt confident, few would report concerns to Child Protective Services or the police without further exploration. Conclusion: The three studies collectively provide a broad understanding of public health nurses' roles and practices in detecting and preventing child maltreatment in Norway. Study one highlights the integration of preventive knowledge into daily practice and the challenges public health nurses face, suggesting a need for clearer guidelines, tools, and beter collaboration with other healthcare providers. Study two emphasizes public health nurses' adherence to guidelines and the crucial role of collaboration across different professional groups, while also noting the influence of age and experience on maltreatment detection. Study three identifies a discrepancy between public health nurses' ability to recognize maltreatment and their confidence in managing it, indicating the need for further training and support. Overall, the studies underscore the need for improved collaboration, targeted guidelines, ongoing professional development, and structural changes within healthcare settings to better protect children. They also highlight the importance of providing practical strategies and support to enhance public health nurses' confidence and competence in handling maltreatment cases. Further research should evaluate the effectiveness of interventions such as training programs, initiatives for interprofessional collaboration, and updated guidelines in improving the reporting and management of child maltreatment, with a focus on organizational and educational factors.