Crimes against children, particularly sexual abuse, can lead to devastating lifelong consequences for the child, their caregivers, and society at large. Children who experience sexual abuse are vulnerable in the worst of situations. The U.S. Department of Health and Human Services (2017) reports that child maltreatment, including sexual abuse, is one of the greatest threats facing the health, welfare, and social well-being of children. In 2016, state and local child protective services received approximately four million referrals involving the alleged maltreatment of 7.4 million children. Within this population, approximately 8.5% of these children had allegations of sexual abuse (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2017). It is estimated that one in five girls and one in 20 boys in the United States are sexually abused in some manner before they reach the age of 18 years (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2017).
These statistics are likely underreported and do not represent the true magnitude of this problem. Most children delay or never disclose child sexual abuse to their nonoffending caregivers, family members, friends, or others in authoritative positions (London, Bruck, Ceci, & Shuman, 2005; London, Bruck, Wright, & Ceci, 2008). One of the reasons for this lack of disclosure is that the perpetrator is frequently a parent, a family member, or a friend of the family, and the child may fear the consequences if they disclose. There are several reasons that have been postulated for this including the child's fear of loss, punishment, disbelief, guilt, embarrassment, and/or shame. The lack of or prolonged delay in disclosure has the potential to result in serious medicolegal implications for the patient, family, and other individuals including a paucity of evidence to support criminal charges (Chadwick, Castillo, Kuelbs, Cox, & Lindsay, 2010).
The emergency department (ED) is frequently the point of entry into the healthcare system for children, particularly in an acute crisis situation such as pediatric sexual abuse. ED use for pediatric health care is escalating, and it is estimated that nearly 25% of all patients evaluated in EDs in the United States are under the age of 18 years (Wier, Yu, Owens, & Washington, 2013). To achieve optimal patient outcomes with this vulnerable, pediatric, sexual abuse patient population, the emergency care team must possess a specific body of knowledge and skills. Collaboration must also occur with expert medical, nursing, and psychosocial specialists as well as with legal and administrative community partners. Specifically, emergency nurses must possess the knowledge and skill set to initiate and engage in a focused trauma-informed developmental history and physical examination, specialized examination techniques and evidence collection procedures, and interprofessional collaboration with social work, law enforcement, child protective services, and child advocacy personnel. Ideally, this would be performed by a certified pediatric sexual assault nurse examiner (SANE-P). However, many facilities do not have professional nurses who have achieved this certification. In the absence of a SANE-P, the evidentiary examination may be performed by providers who may not have had specialized education in this area of emergency medical practice.
Facilitators and barriers have been identified regarding the appropriate recognition of abuse, provision of care, and reporting of pediatric sexual abuse. Barriers may include the practitioner's inexperience with this patient population, reluctance about discussing the situation with patients and their nonoffending caregivers, fear of being wrong about the abuse, and hesitancy about becoming involved with the legal system and court proceedings. Many healthcare providers report their current level of education and training regarding the identification and intervention of child maltreatment as deficient (Jordan, MacKay, & Woods, 2016; Jordan & Moore-Nadler, 2014; Louwers, Affourtit, Moll, de Koning, & Korfage, 2010; Menoch, Zimmerman, Garcia-Filion, & Bulloch, 2011). Unfortunately, pediatric sexual abuse is not a topic that is consistently covered in academic curricula, and mandatory continuing education for registered nurse licensure is only required in four states in the United States. Nurses frequently request more education to facilitate and advance all aspects of their knowledge and skill set in this specialized area (Elarousy, Helal, & deVilliars, 2012; Jordan et al., 2016; Jordan & Moore-Nadler, 2014).
Interprofessional Education: A Key Initiative to Improving Patient Outcomes
The National Academy of Medicine (formally the Institute of Medicine [IOM] of the National Academies) has challenged all members of the healthcare team to move away from functioning in specialty silos and commit to engaging in interprofessional teams to improve patient quality and safety (IOM, 2013). The approach to optimizing the care of a child who has experienced sexual abuse requires the expertise and collaboration among many specialists who share similar values and ethics toward the ultimate goal of the safety and protection of children. One strategy to strengthen collaboration among the professionals involved in the care of the sexually abused child is through interprofessional education (IPE).
In its simplest form, IPE is defined as a situation in which “learners from two or more health and/or social care professions engage in learning with, from, and about each other to improve collaboration and the delivery of care” (World Health Organization, 2010, p. 7). As applied to the care of the sexually abused child, the IPE approach can provide the interprofessional team insight into the scope of each other's practices, including their knowledge, skill set, and roles and responsibilities. IPE also provides the opportunity to enhance communication and strengthen collaborative professional relationships.
Although the concepts and processes of IPE have been addressed in the literature for nearly half of a century, it has not been emphasized as a high priority in traditional education and training for healthcare providers. Since the development of the Institute for Healthcare Improvement Triple Aim framework as an approach to optimizing the performance of health systems, the need to move forward with IPE has intensified (Berwick, Nolan, & Whittington, 2008; IOM, 2015). The Triple Aim Framework has three dimensions: (a) improving patient experience through quality and satisfaction, (b) improving the health of populations, and (c) reducing the per capita cost of healthcare. All three dimensions of Triple Aim can be addressed through IPE (Institute for Healthcare Improvement, 2017).
In the current healthcare landscape, there is a strong initiative for interprofessional collaboration and team-based care to achieve the goals of patient safety, quality of care, patient and provider satisfaction, population health, and cost (Walsh, Reeves, & Maloney, 2014). To achieve these goals, there is a high demand placed on the emergency care provider team workforce. This requires a paradigm shift from the traditional specialty-specific education and training toward an interprofessional collaborative approach.
In the emergency care environment, all providers are expected to function as a team, but traditional education methods have been fragmented and conducted in specialty silos. In a recent Cochrane Collaborative Review, it was stated that IPE interventions produced positive outcomes in ED culture, patient satisfaction, collaborative team behavior, and reduction of clinical error rates in ED teams (Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). Emergency care providers hold a powerful position in the interprofessional team approach for the identification and intervention of children with alleged sexual abuse. Commitment to IPE is paramount to the achievement of optimum patient outcomes for the sexually abused child.
The objectives of this study were twofold: (a) to examine the effectiveness of a comprehensive interprofessional educational intervention program in increasing the knowledge, confidence, and self-efficacy of emergency care providers in the recognition and management of children who have experienced alleged sexual abuse and (b) to explore concerns that the interprofessional team face surrounding comfort with and engaging/interacting with this patient population, their nonoffending caregivers, and other partners of the protective team including law enforcement and child protective services. The theoretical framework of the Integrated Change Model was used to guide this project. This model describes factors including knowledge, skills, attitudes, and self-efficacy and hypothesizes that the more of these attributes a person possesses, the more likely intentions will be turned to actions to achieve a goal (Schols, de Ruiter, & Öry, 2013).
This study was conducted in two phases using a mixed-method research design. The first phase was a 3.5-hour face-to-face, evidence-based, interprofessional didactic education intervention for members of the emergency care team (i.e., nursing, medicine, social work, behavior health, and law enforcement) in a large full-service tertiary emergency care system in the southeastern United States. This medical care system includes the following specialized pediatric services: a designated children's ED, a comprehensive pediatric inpatient unit, and a pediatric intensive care unit.
The content of the educational program was designed through a collaborative approach involving a certified emergency nurse practitioner who is also nationally certified as a SANE-P, a board-certified pediatric emergency physician, an ED social worker/forensic interviewer, and a forensic emergency nurse. The content of the educational offering included an evidence-based approach to the following topics: (a) definition, incidence, and prevalence of pediatric sexual abuse; (b) role of the provider as a mandatory reporter; (c) obtaining a developmentally appropriate clinical history; (d) conducting an age-appropriate/developmentally appropriate physical examination; (e) ED triage and treatment; (e) collection of forensic evidence; (f) medicolegal issues and documentation; (g) interviewing techniques; and (h) the interprofessional team approach. The content incorporated nationally accepted clinical guidelines for the care of the sexually abused child (Office on Violence Against Women, U.S. Department of Justice, 2016). The speaker for each of the sections of the education program was selected based on their scope of practice, experience, and content expertise.
A hard-copy written pretest and posttest study design was used to measure the effect of this education program on the participants' knowledge, confidence, and self-efficacy in the identification and intervention of children who have experienced alleged sexual abuse. Demographic data were also obtained from the participants. The evaluation tools were designed by the primary investigator and were reviewed for face validity by expert physicians, nurses, and a nurse research consultant. Data were collected anonymously to protect the privacy of the participants, using numerical coding to match the pretests and posttests. Descriptive statistics and t test analysis were used to compare participants' knowledge, confidence, and self-efficacy related to emergency care of a child who has experienced alleged sexual abuse preintervention and postintervention.
The demographic section of the data collection tool included information regarding (a) profession of the participant and, if a nurse, the number of years employed as a registered nurse and the number of years working in emergency care; (b) highest academic degree obtained; (c) previous education regarding pediatric sexual abuse; (d) number of children cared for in the previous 6 months with alleged sexual abuse; (e) belief that education regarding pediatric sexual abuse would be of benefit to the participant; and (f) belief that supplemental education regarding child maltreatment should be a requirement for care providers who work with children in the emergency care setting.
The second part of the data collection tool was composed of 10 objective multiple-choice questions that covered specific topics included in the education program. Specifically, the questions focused on physical findings associated with pediatric sexual abuse, clinical guidelines for the care of a child with alleged sexual abuse, the legal age of consent, documentation, and case scenarios for the approach to the child and the nonoffending caregiver. Examples of two of the multiple-choice questions are presented in Table 1. The third part of the data collection tool was directed toward obtaining data regarding knowledge, confidence, and self-efficacy preeducation and posteducation. Using a five-item Likert-type scale, participants were asked to rate their level of confidence, knowledge, and skills regarding identification and interventions related to child maltreatment preeducation and posteducation.
The second phase of this study was conducted using focus groups to expand on the application of knowledge. Each focus group was led by the primary investigator, limited to 1.5 hours in length, with a maximum of 10 participants in each session. A case study approach was used to guide the discussion regarding the interprofessional care of the sexually abused child in the ED. A case study was presented to the participants, and a semistructured discussion followed. This discussion included essential components of interaction with the child, medical care, ethical issues, and effective communication with members of the interprofessional team. Time was also allotted to encourage participants to bring up additional concerns and suggestions for ways to improve care. An example of a case study that was used is presented in Table 2. The focus group sessions were audiotaped and transcribed verbatim. Content analysis was used to identify emergency themes. Written informed consent was obtained from participants in the focus groups.
Approval from the institutional review board was obtained before the implementation of this program. Informed written consent was obtained from each participant. Continuing education contact hour credits (3.5) were awarded to participants upon completion of Phase 1 of this didactic education program, and an additional 1.5 contact hours were awarded upon completion of Phase 2.
There were 36 participants in this study. The vast majority of the participants were ED registered nurses (63%), followed by ED social workers trained in forensic interviewing (20%), ED advanced practice providers including nurse practitioners and physician assistants (14%), and behavioral health workers and law enforcement (3%). Most of the participating registered nurses (73%) had at least 7 years of nursing experience, and 53% of the nurses had at least 6 years of experience in the emergency care setting.
Of significance, only 30% (n = 11) of participants recalled ever participating in education on the subject of pediatric sexual abuse. However, 60% (n = 22) of study participants stated that they had cared for a child with suspected or confirmed sexual abuse in the 6 months before this study. When participants were asked whether additional education in pediatric sexual abuse would be of benefit to their clinical practice, 100% responded “yes.” All participants agreed that education regarding child maltreatment should be required for all emergency care providers who care for children and that an interprofessional and collaborative education approach would be most beneficial.
Evaluation of Knowledge
The content-specific 10-question pretest and posttest were administered to participants immediately before and after the didactic education session. Both descriptive and inferential statistics were used for data analysis. The mean score on the pretest was 62.2%, with a range in scores from 20% to 90%. The mean score on the posttest was 88.8%, with a range in scores from 70% to 100%. This was statistically significant with a p value of <0.01. Figure 1 provides documentation of the comparative distribution of scores on the pretest and posttest illustrating the increase in scores after education intervention.
The question that was most frequently answered incorrectly was a case scenario that evaluated whether sexually transmitted infection (STI) prophylaxis should be administered to a 10-year-old girl after forcible penile–vaginal penetration with a 16-year-old male adolescent. On the basis of evidence presented in the national guidelines for medical evaluation of pediatric sexual abuse, the correct answer is that prophylactic STI treatment should not be administered (U.S. Department of Justice, 2016). On the pretest, 89% of participants (n = 32) stated that they would administer STI prophylaxis, and on the posttest, 14% (n = 5) stated they would administer prophylaxis.
The second question that was most frequently answered incorrectly was about whether patients would have an abnormal genital examination after sexual abuse. On the basis of national evidence, only 5% of sexually abused children have an abnormal genital examination (Office on Violence Against Women, U.S. Department of Justice, 2016). On the pretest, 67% (n = 24) answered this question incorrectly, and on the posttest, only one participant (0.03%) answered this question incorrectly. The importance of this knowledge deficit has the potential for serious medicolegal implications; if the examiner expects physical evidence indicative of sexual abuse and observes no abnormal findings, he or she may question the credibility of the disclosure.
Evaluation of Confidence and Self-Efficacy
The third area of data collection was the participant's self-disclosed level of knowledge, confidence, and self-efficacy. Participants were asked to rate themselves on eight statements that reflect their level of knowledge, skills, and confidence using a Likert-type scale. The participants did this self-evaluation immediately before and after the education intervention. The results are presented in Table 3. There was a statistically significant improvement in every item on this assessment, which supports the premise that education leads to an increase in knowledge, confidence, and self-efficacy.
The second phase of this study included interprofessional focus groups based on case study discussions. The most significant underlying theme of all focus group discussions was the importance of interprofessional communication and collaboration among everyone involved in the care of a child with alleged sexual abuse. As stated by nurse participants:
As an ED nurse the most important thing I learned from this experience is to make the most of my strengths as a nurse and work closely with others in their specialty area. I learned so much from our social worker's presentation and now I understand their role and perspective. We have to work together because sometimes I think we can do more damage than good with everyone with different backgrounds asking all sorts of the same question in different ways.
It would be the best scenario if all of us could participate in the certification course and earn our SANE-P. Sometimes we don't have the right resources available to care for these children and are very nervous that we are not doing the right thing for the child. It would also give us more credibility with law enforcement, child protective services and in court.
Another one of the strongest themes that emerged was the importance of minimizing interviews by multiple people in the ED. All participants agreed that, to achieve best practice, each specialist must function within his or her designated scope of practice. Specifically, this was a discussion point regarding obtaining the history from the patient and/or nonoffending caregiver. As stated by participants:
As the primary ED nurse, we really need to minimize the number of interviews. You already have the triage nurse, the primary nurse, an attending or nurse practitioner who is going to ask questions, then a social worker, law enforcement etc. So maybe we could find a way to have everybody from the medical team in the room at one time to get the patient history.
That would be the perfect world, because then we are minimizing interviews, and they only have to say it once.
I think Social Work should lead. As a medical provider and a nurse, we should all be there, but the social worker is the most experienced and approaches it in the best way. They are the ones trained in forensic interviews.
It would be great for Child Life to interact with the child while we are getting the history so that they are not worried about what their caregiver is telling us and can focus on fun activities. They can minimize some of the trauma to the child.
There was agreement among all participants that all care providers need to be knowledgeable and uphold the national triage guidelines and ED interventions must be aligned with them. Another common theme that was identified in all focus groups was the importance of sustained ongoing IPE and also to include law enforcement and social services in educational activities. It was suggested to have case review presentations led by the members of the team that were involved in the care of the particular child. As stated by one nurse:
It was so helpful for me to sit at the table with law enforcement and behavioral health. When we have a child in the ED that has been sexually abused everyone is pretty tense. It is always so busy that we never have time to really discuss the situation with them. It was such a great experience to learn and discuss cases side by side with professionals from other disciplines. I now understand their roles in a different light and know and respect what they do. I hope that they understand the role of the nurse better.
Several participants verbalized the need for education on human trafficking as our geographical area is one of the highest locations in the nation for this criminal activity.
Emergency care providers are uniquely qualified to assume leadership, advocacy, and collaboration with all members of the interprofessional team to ensure the safety and protection of children. Optimal patient outcomes for the sexually abused child through an evidence-based approach can only be attained when all team members contribute their unique specialized knowledge and skill set in a collaborative effort. There is a need for the generation, application, and dissemination of interprofessional strategies to achieve evidence-based best practice in the specialized area of pediatric sexual abuse. Although it is recognized that registered nurses who have not completed didactic and clinical education/training to become a SANE-P should not be examining the genitalia of children, in many parts of the country, nationally certified SANE-Ps are few in numbers. In our case, a medical provider (or an advanced practice provider) always conducts the genital and evidentiary examination, with a registered nurse at the bedside to assist the provider. The nursing staff in the pediatric ED are, in general, extremely motivated in advancing their education in the care of the sexually abused child; the difficulty arises in attaining the supervised examinations to complete the clinical portion of the SANE-P certification requirements. We recognize that, although this additional education contributes to their knowledge and skill, it is by no means a substitute for the content of the national certification course.
The results of this study support the strategy of the development and sustainment of IPE to improve quality and safety in the care of the child with alleged sexual abuse. On the basis of the themes identified through the didactic and focus group discussions, several practice changes were designed and implemented that are presented in Table 4.
One limitation to this study was that it was conducted only in one healthcare system in one geographical location involving only 36 participants. There also was a limited number of individuals from law enforcement and behavioral health. Another limitation was that data were collected regarding knowledge, confidence, and self-efficacy immediately after an educational intervention. Follow-up studies should include a longitudinal approach to evaluate retention of knowledge and confidence level over time.
Implications for Forensic Nursing
Multimodal methods of education should be developed, implemented, and tested for effectiveness and sustainability. Forensic nurses hold a critical role as a member of the interprofessional team and must contribute their unique knowledge and skill set to maximize the safety and protection of the patient, the integrity of evidence collection, and the promotion of the patient's health and recovery.
All members of the interprofessional team must work collaboratively to achieve best practice for this vulnerable high-risk pediatric population. There must be a commitment to sustained education for everyone involved in this care of the alleged sexually abused child. Nurses who care for this vulnerable patient population should strive to successfully complete the SANE-P certification.