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Child abuse and neglect education in schools of nursing in the province of British Columbia and the state… Watt, Judith Louise 1993

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CHILD ABUSE AND NEGLECT EDUCATIONIN SCHOOLS OF NURSINGIN THE PROVINCE OF BRITISH COLUMBIAAND THE STATE OF WASHINGTONbyJUDITH LOUISE WATTDiploma in Nursing, Vancouver General HospitalB.A., The University of British ColumbiaA THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTERS OF ARTSinTHE FACULTY OF GRADUATE STUDIESDepartment of Math and Science EducationWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIASeptember 1993© Judith Louise Watt, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)•^(Department of  147,7 nt4^A The University of British ColumbiaVancouver, Canada< t^'&1'1 L.Date e4 t /1793DE-6 (2/88)iiABSTRACTChild abuse and neglect has been an historical problemwhich has only entered our consciousness as legislation toprotect children has been passed. Public and media awarenesshas mushroomed along with the number of disclosures andincreasingly dramatic stories of abuse and neglect. Nurses,because of their many different places of practise, come incontact with many victims and offenders. How does theireducation prepare them for this task?The study surveyed of schools of nursing in BritishColumbia and the state of Washington through the directors ofnursing, associate deans, deans and coordinators, to instructorsand faculty members who teach child abuse and neglect education.Instructors and faculty members completed a questionnaire of 23questions about child abuse and neglect education in theirschools of nursing and about their own educational preparationand experience. The questionnaire was expanded from a similarstudy done in 1985-86.Not all schools of nursing have child abuse and neglecteducation. Of those indicating they teach child abuse andneglect, most devote 2-4 hours to teaching. Child abuse andneglect education is taught in a wide variety of nursing subjectareas. There are fewer resources (both personnel and print andmedia) being used in teaching child abuse and neglect in 1993than in 1985-86. The majority of facultymembers and instructors were not educated in the province orstate in which they now teach and also the majority did notreceive child abuse and neglect education during theirbaccalaureate education. Instructors and faculty members fromWashington had more suggestions for improving child abuse andneglect education than did those from British Columbia.Education about reporting child abuse and nursing and sexuallytransmitted diseases is inconsistent. There is very littlechild abuse and neglect interprofessional education.While the diversification of nurses' job placements makesthem ideal professionals to identify, prevent, and treat childabuse and neglect, their educational preparation does not appearadequate for this task.ivTABLE OF CONTENTSAbstractTable of Contents^ ivList of Tables viiiAcknowledgements^ xiDedication^ xiiINTRODUCTION 1Chapter One^Statement of the Problem^ 1Introduction^ 1The Research Problem 4Rationale and Justification forStudying Child Abuse and Neglect inSchools of Nursing^ 4Why Ask the Question? 4The Research Question 6Definition of Terms Used 13Summary^ 15Chapter Two^Review of Literature^ 17Introduction 17Legislative Mandates 18Education of Professionals Dealing withChild Abuse and Neglect^ 23Education of Nursing Students^26Similarities Between the Province ofBritish Columbia and the State of Washington 28Summary^ 30Chapter Three Methodology 31Introduction 31Population^ 311993 Survey 34Questionnaire 36Confidentiality^ 38Administration of Child Abuse andNeglect Questionnaire^ 38Data Analysis 39Limitations^ 39Chapter Four Results of the Study^ 42Introduction 42Results of the Survey 43Teaching of Child Abuse and NeglectEducation^ 43Number of Hours Child Abuse and NeglectEducation is Taught^ 43Number of Students Receiving ChildAbuse and Neglect Education^46Types of Nursing Students ReceivingChild Abuse and Neglect Education^47Location of Instructors' and FacultyMembers' Baccalaureate Degrees 49Child Abuse and Neglect EducationInstructors and Faculty Members haveReceived^ 50Number of Years Instructors or FacultyMembers have Taught Child Abuse andNeglect Education^ 52Why Instructors and Faculty MembersTeach Child Abuse and NeglectEducation^ 53Satisfaction with Child Abuse andNeglect Education Offerings^54Importance of Child Abuse and NeglectEducation^ 55Importance of Different Types of ChildAbuse and Neglect in Educating NursingStudents 56Suggestions for Improving Child Abuseand Neglect Education^ 64Preferred Number of Hours of ChildAbuse and Neglect Education^65Subject Areas Where Child Abuse andNeglect Education Taught 67Methods of Teaching Child Abuse andNeglect Education^ 71Others Teaching Child Abuse and NeglectEducation^ 72Personnel Resourses used in TeachingChild Abuse and Neglect Education^73Non-personnel Resources used inTeaching Child Abuse and NeglectEducation^ 76Types of Assignments Given to NursingStudents Regarding Child Abuse andNeglect Education^ 80Necessity to Report Child Abuse andNeglect^ 81Necessity to Report SexuallyTransmitted Diseases^ 82Interprofessional Child Abuse andNeglect Education 84viChapter Five Conclusions and Recommendations^87Introduction^ 87Low Number of Response Rates 87Changes in the Number andLocation of Schools of Nursing inBritish Columbia^ 88Nursing Care of Child Abuse andNeglect Patients in the Provinceof British Columbia 89Number of Hours of Child Abuse andNeglect Education^ 90Baccalaureate Training of Instructorsand Faculty Members 91Child Abuse and Neglect Education ofthe Instructors and Faculty Members^92Assignment or Choice? Why Instructorsand Faculty Members Teach Child Abuseand Neglect Education^ 93Instructor and Faculty Satisfaction^94Importance of Child Abuse and NeglectEducation^ 94Importance of Different Types of ChildAbuse and Neglect for Inclusion in anEducational Program^ 94Child Abuse and Neglect Education inSchools of Nursing; Suggestions forImprovement^ 94Subject Area Where Child Abuse andNeglect Education Taught^95Method of Teaching Child Abuse andNeglect Education^ 96Do Others in Your School of NursingTeach Child Abuse and Neglect Education 96Personnel Resources used in Child Abuseand Neglect Education in Schools ofNursing^ 97Print, Tape and Film Resources used inChild Abuse and Neglect Education inSchools of Nursing^ 97Changes in Print, Tape and FilmResources used in Child Abuse and NeglectEducation in Schools of Nursing from1985 - 86 to 1993^ 98Types of Assignments 98Education Regarding the Reporting ofChild Abuse and Neglect and SexuallyTransmitted Diseases^ 98Interprofessional Education^99Recommendations Concluded from theStudy^ 100Conclusion 102viiBibliography^ 104Appendix A^Schools of Nursing and Their Location inthe Province of British Columbia^108Appendix B^Schools of Nursing and Their Location inthe State of Washington^ 110Appendix C^Populations of British Columbia Communitieswith Schools of Nursing in 1985^113Appendix D^Populations of the State of WashingtonCommunities with Schools of Nursing in 1985 115Appendix E^Correspondence^ 117Appendix F^Letters to Instructors and Faculty Members 121Appendix G^Questionnaire^ 124viiiLIST OF TABLESTable 1Table 2Table 3Table 4Table 5Table 6Table 7Table 8Table 9Table 10Table 11Number of hours of child abuse and^44neglect educationNumber of hours of child abuse and neglect^45education in 1985 - 86 and 1993 in the province ofBritish ColumbiaNumber of hours of child abuse and neglect^46education in 1985 - 86 and 1993 in the state ofWashingtonApproximate number of students receiving child^47abuse and neglect educationTypes of nursing students receiving child abuse 48and neglect educationLocation and type of instructors' and faculty^50members' baccalaureate degreeChild abuse and neglect education of instructors 51and faculty members while receiving their nursingeducationNumber of years the Instructor or Faculty member 53has taught child abuse and neglect educationWhy instructors or faculty members are teaching 54child abuse and neglect educationLevel of satisfaction with child abuse and neglect55educationHow important is child abuse and neglect education56Table 12 Importance of types of child abuse and neglect^60to include in a nursing program in B. C. byrank ordering each type of abuse or neglectTable 13 Importance ofto include inordering eachTable 14 Importance ofto include inrank orderingtypes of child abuse and neglect^61a nursing program in B. C. by ranktype of abuse or neglect individuallytypes of child abuse and neglect^62a nursing program in WA byeach type of abuse or neglectTABLE 15Table 16Table 17Table 18Table 19ixImportance of types of child abuse and neglect^63to include in a nursing program in WA byrank ordering each type of abuse or neglectindividuallySuggestions for improving child abuse and neglect 65education in own school of nursingPreferred number of hours of child abuse^66and neglect educationSubject areas where child abuse and^68neglect education is taughtSubject areas where child abuse and neglect^69education was taught in 1985 - 86 and 1993in the province of British ColumbiaTable 20 Subject areas where child abuse and neglect^70education was taught in 1985 - 86 and 1993in the state of WashingtonTable 21 Number of subject areas where child abuse^71and neglect education is taughtTable 22 Methods of teaching child abuse and neglect^72educationTable 23 Others teaching child abuse and neglect education 73in the same school of nursingTable 24 Personnel resources used in teaching child abuse 74and neglect educationTable 25 Personnel resources used in child abuse and^75neglect education in 1985 - 86 and 1993in the province of British ColumbiaTable 26 Personnel resources used in child abuse and^76neglect education in 1985 - 86 and 1993 inthe state of WashingtonTable 27 Non-personnel resources used in teaching^78child abuse and neglect educationTable 28 References used in child abuse and neglect^79education in 1985 - 86 and 1993 in theprovince of British ColumbiaTable 29 References used in child abuse and neglect^80education in 1985 - 86 and 1993 in the state ofWashingtonTable 30Table 31Table 32Table 33Types of assignments^ 81Responsibility of reporting suspected child^82abuse and neglect taught in schools of nursingResponsibility of reporting sexually transmitted 83diseases taught in schools of nursingWhich must be reported first if a child has both 84a sexually transmitted disease and suffers fromchild abuse and neglect?Table 34 Are other professionals who also deal with child 85abuse and neglect cases educated with nursingstudents?Table 35 Interprofessional child abuse and neglect^86education.xiACKNOWLEDGEMENTSFirst, I wish to thank the Department of Math and ScienceEducation for accepting me as a graduate student to do an indepth degree on the subject of child abuse and neglect when noschool of nursing would allow more than 20 per cent in thisarea, and especially Drs. C.J. Anastasiou and R. W. Carlisle forexpanding their courses to include a health science educationstudent. I also wish to thank my advisors Drs. P. James Gaskelland Linda Peterat for their direction and assistance during the1993 survey, Penny Batchelor for helping with the printing andgetting both myself and the computer back and forth fromVancouver, and the support and encouragement of Susan Schmittenand Dr. Diana Carter.This thesis would not have been possible without the kindcooperation of the directors of nursing, deans, associate deans,coordinators, faculty members and instructors who participatedin the study and for their support I am grateful. I alsowish to thank the National Clearinghouse on Family Violence andthe Registered Nurses Association of British Columbia.For encouragement since 1974 to examine the area of childabuse and neglect in more depth, I am indebted to Dr. SydneySegal.DEDICATIONThis is dedicated in memory of Thomas McCrea Watt who encouragedme to attend university.xii1CHAPTER 1STATEMENT OF THE PROBLEMIntroductionThe reporting of child abuse and neglect is mandatory inthe province of British Columbia and in the state of Washington.Finkelhor (1979) suggested that one in four girls and one ineight boys would be sexually abused before the age of 18. TheBadgley report (1984) estimated that one in two girls and one infour boys has an unwanted sexual experience before the age of18. Sexual abuse is but one of seven types of child abuse andyet in this type of abuse alone, a large number of children areaffected.^The other types of child abuse and neglect arephysical neglect, physical abuse, emotional neglect, emotionalabuse, verbal abuse and passive abuse. When one considers therecent media attention in Canada focused on abuses in orphanagesand residential schools, it appears that few students escapedsome sort of abuse or neglect. What child can escape harsh andderogatory words from adults in positions of trust and powerwhile growing up? In our western society today it is difficultto imagine any child not experiencing some sort of abuse--whether severe or mild, during their maturation process.Childhood appears to be very hazardous.In the nursing profession, one often sees the long rangeeffects of untreated child abuse and neglect; self-neglect andself-destruction, mental illness, cyclical abuse of wives and2children, difficulties in parenting, unemployment and poor self-esteem to name but a few. Child abuse and neglect are costly interms of economics in our health care and social welfare systemsand costly in terms of human value as survivors often strugglewith low self-esteem and its effects.Child abuse and neglect are not a new twentieth centuryphenomena. The Code of Hammurabi, written in 1750 B.C. containsthe first known record of punishment for any type of child abuse(Ford in Smith, 1978). The first medical recognition of a caseof child abuse was in New York in 1888 (Solomon, 1973). Thecase was tried by the American Society for the Prevention ofCruelty to Animals as there were no child protection laws at thetime. The advocacy efforts of a nurse named Wheeler wereinfluential in the creation of the New York Society for thePrevention of Cruelty to Children at that time (Hayes, 1981).In 1883 a similar child protection society was started inLiverpool, England. The Toronto Children's Aid Society wasstarted in 1891. The need for child protection was beingrecognized. Child abuse and neglect were first described indetail in the medical literature in a landmark article by Kempe,Silverman, Steele, Droegemueller and Silver in 1962 in anarticle entitled "The Battered-Child Syndrome". Eventually theterm was changed to child abuse and neglect to be moreencompassing of other types of abuse. In 1984 as the area ofchild abuse and neglect erupted, Heins (1984) commented on theoriginal article. This too became a landmark article in the3child abuse and neglect literature. Both of these articles arecited frequently in the nursing child abuse and neglectliterature.With the development of child protection agencies over onehundred years ago and current child protection legislation, onewould hope that children would be protected and that violationswould be reported. Nurses are morally and legally mandated toreport child abuse and neglect and can be criminally charged fornot reporting it. For years abused children have been admittedto hospital for a variety of causes, patched up and sent homewithout the issue of child abuse and neglect ever being dealtwith or even addressed. Many of these children were laterreturning to the emergency room as adults in psychiatric crisis-- grown up abused children. During my experiences in emergencypsychiatry and paediatrics, I began to see a lot of grown-upabused children and a lot of abused children. After finding outabout their abuse the question was always why had other nursesnot documented and reported it? Since the introduction ofchild abuse prevention programs, reporting has shifted frommedical personnel to school teachers. Why were the publichealth nurses in the schools not reporting? Why were hospitalemergency and ward nurses not reporting?4The Research ProblemRationale and Justification for Studying Child Abuse and Neglect Education in Schools of NursingHow are future nurses prepared educationally to detectchild abuse and neglect? Are nursing students today beingeducated about the signs and symptoms of the different types ofchild abuse and neglect, including behaviourial and physicalindicators and are they aware of the long term effects andindicators of untreated child abuse in children, adolescents andadults?Why ask the Question? In 1985, (Watt, 1987) all the schools of nursing in theprovince of British Columbia were contacted regarding theircurriculum content on child abuse and neglect. The number ofhours was startlingly scant with a range from zero to about fourhours. Because the state of Washington was at the worldforefront at the time in terms of child abuse convictions,victim support and offender treatment, the study was repeated inthe state of Washington in 1986. The results were similarexcept that two schools of nursing had very high curriculumcontent on child abuse and neglect. Since the time of thisinitial study there has been a lot of publicity and mediaexposure about child abuse. The number of cases being reportedis increasing. Have the schools of nursing reflected thesesocietal changes in their curriculum content?5Until the 1985 - 86 study of child abuse and neglecteducation in schools of nursing was undertaken, there was nodocumentation on child abuse and neglect education in schools ofnursing in British Columbia and Washington. The results of thatstudy were disappointing in that they showed that schools ofnursing were not educating nursing students in enough depth todeal with the magnitude of child abuse and neglect nor were theyable to discern suspected cases of child abuse and neglect andreport them.This study repeats the original study of 1985 - 86 andexpands it to include new questions and areas of concern.Between 1985 and 1993 cases of child abuse and neglect weremushrooming and disclosures were in the media almost daily. Noteven the church could escape and many church authorities facedaccusations. The current study of 1993 hopes to answer thequestion of whether the child abuse and neglect education inschools of nursing has increased to reflect the current trend.It should be borne in mind while reading this research thattransplant surgery also mushroomed and that Acquired ImmuneDeficiency Syndrome (AIDS) began to appear on the medicalhorizon during the same time period. Schools of nursing did notlengthen their programs and yet these new subject areas also hadto be included in the curriculum.With nursing now taking a more holistic approach to thecare of patients or clients, nurses can no longer nurse "Mrs. B.in bed four with a fractured left hip, four days post-operative,6and is she cranky!" Now they must consider, among other things,her age, her living situation, how she occupies her time, herfamily and friends, whether she has a support system nearby, andher behaviour patterns. Perhaps the anger she shows at beingdisturbed stems from fear. And perhaps that fear is rooted inearly unresolved childhood abuse. With such a high statisticalincidence of child abuse and neglect, nurses must be able torecognize both present and long term behaviourial effects ofchild abuse and neglect.The Research Question This study focuses on child abuse education in schools ofnursing in the province of British Columbia and the state ofWashington. It has focused on three central question areas:^1.^Which schools of nursing in British Columbia andWashington have child abuse and neglect education?a. How many hours of child abuse and neglecteducation do nursing students receive?b. How many and what type of nursing students areenroled in schools of nursing?2.^Who teaches child abuse and neglect education inschools of nursing?a. Where did instructors and faculty members receivetheir education and do they have a baccalaureatedegree in nursing?b. Did they receive child abuse and neglect7education in their nursing education?c. What is their child abuse and neglect teachingexperience?d. Why do instructors and faculty members teachchild abuse and neglect education?e. What is their degree of satisfaction with thechild abuse and neglect education offered intheir school of nursing?f. How important do instructors and faculty membersview child abuse and neglect education?g. What changes and suggestions would instructorsand faculty members have regarding the childabuse and neglect education offered in theirschool of nursing?h. How many hours would they prefer were devoted toteaching child abuse and neglect education?3. What content makes up child abuse and neglecteducation in schools of nursing in British Columbiaand Washington?a. In what subject areas are child abuse and neglecteducation taught?b. What teaching methods are used?C.^Was it interprofessional in nature or not? If itIs interprofessional education, with whom arenursing students taught?d.^What personnel actually teach the nursing8students child abuse and neglect education? Doothers in the faculty also teach child abuse andneglect education?e. What resources are used to teach child abuse andneglect education?f. What types of assignments are given in childabuse and neglect?g.^Are nursing students in their school of nursingtaught about reporting child abuse and neglectand sexually transmitted diseases?Questions regarding the preparation, education and teachingexperience of the instructors and faculty members were addressedto see what the level of experience and preparation was in thearea of child abuse and neglect education. Were the instructorsand faculty members themselves taught what they now are teachingnursing students? Were the instructors and faculty membersexperienced in teaching child abuse and neglect education orwere they just beginning to teach in this subject area?Because the instructors and faculty members teaching childabuse and neglect will probably be aware of the subject in moredepth than their colleagues, the question of instructor orfaculty satisfaction with the child abuse and neglect content isan important one to consider. Do they agree with the timedevoted to teaching child abuse and neglect education in theirschool of nursing? Do they agree with the resources being usedin child abuse and neglect education in their school of nursing?9Do they agree with where the child abuse and neglect educationis being presented in their curriculum and the content theirnursing students are receiving? How do instructors and facultymembers see theory versus clinical experience with child abuseand neglect education? Do they have suggestions for changingand improving the child abuse and neglect education at theirschool of nursing? Do instructors and faculty members viewchild abuse and neglect education as important for nursingstudents?The question about the number of hours devoted to childabuse and neglect education is an important one to consider whenone is aware of the complexity of the issues surrounding childabuse and neglect. Are the students getting enough of abackground in child abuse and neglect to be aware of theproblem, to be able to identify suspected cases of child abuseand neglect and to be able to look for long term effects of bothtreated and untreated cases of child abuse and neglect? Are thenumber of hours of child abuse and neglect education areflection of the pervasiveness of the problem?Knowing the number and types of nursing students receivingchild abuse and neglect education is important for severaldifferent reasons. There are several different types of nurses:registered nurses, licensed practical nurses, licensed nurses,practical nurses, psychiatric nurses, nurses aides and nursingassistants. In the province of British Columbia the requirementis that anyone suspecting child abuse or neglect, including10registered nurses, report suspected cases of child abuse andneglect to the superintendent. In the state of Washington bothregistered nurses and licensed nurses are required to reportchild abuse and neglect. In the state of Washington oftenseveral different types of nurses begin their training togetherand then are separated into their different groups as they beginto specialize. In the province of British Columbia, nursingstudents eligible for registration upon graduation andpsychiatric nursing students may do their first year of trainingtogether. Because not all nurses are mandated by law to reportchild abuse and neglect, a mixed nursing class may have adifferent emphasis. The number of students receiving childabuse and neglect education could make a difference to thereporting of child abuse and neglect in the future especially ifthey are aware they must, by law, report suspected cases ofchild abuse and neglect.Where child abuse and neglect education is presented in anursing program has some influence on where and how it will beperceived by the nursing students. For example, if a nursingstudent receives child abuse and neglect education inpaediatrics, s/he may tend to look for behaviourial indicatorsof abuse and neglect in children. If s/he receives child abuseand neglect education in obstetrics, s/he may look for signs ofpast physical trauma in the genitalia or if child abuse andneglect education is presented in psychiatry s/he will look atthe long term effects and possibly the costs of untreated11childhood abuse and neglect. Child abuse and neglect educationpresented in human violence will focus more on the horrificlife-threatening types of physical abuse and neglect and sexualabuse and will probably not include sexually transmitteddiseases. Therefore, it is important to consider the questionof where child abuse education is being presented in a nursingprogram.The question of how child abuse and neglect education istaught and by whom is also an important one to consider. If theinstructor or faculty member is assigned the topic and thinksthe time could be much better spent on AIDS protection for thenurses, the nursing students will probably not learn as muchabout child abuse and neglect as they would from an instructoror faculty member who is a survivor of child abuse or neglectand thinks the topic is of paramount importance. If a formervictim of sexual abuse speaks to nursing students they will beexposed to a much different perspective than if a sexual abuseoffender who has violated over sixty children speaks to them.Nurses will meet both victims and offenders during their nursingcareer; they need to know how to identify both.Resources used to teach about child abuse and neglect canhave a dramatic impact on the students. Because a lot of finematerials have been developed to educate about child abuse andneglect in the past 10 years the question about the types ofresources being used needs to be considered. Few resources havebeen developed for use specifically in the field of nursing but12there are many resources available to professionals working inthe area of child abuse and neglect and to the general publicwhich could be adapted for use in schools of nursing.Because of the mandatory reporting laws for child abuse andneglect and sexually transmitted diseases in the province ofBritish Columbia and the state of Washington, the questionsabout educating nursing students about the issues surroundingreporting are important ones to consider. Are nursing studentsmade aware of their responsibility to report? In the provinceof British Columbia, are they aware of the order in which toreport if both a sexually transmitted disease and child abuse orneglect are present? In the province of British Columbia, areinstructors and faculty members aware of the order in which toreport sexually transmitted diseases and child abuse and neglectif both are present?13Definitions of terms usedDefinitions of terms used in this study are as describedbelow:1) Physical neglect: "involves the deprivation ofnecessities, such as food, clothing, shelter,supervision, medical care and education." (Whaley &Wong, 1993, p. 406)2) Physical abuse: The definition for physical abuse istaken from the 1985 definition by the Ministry ofHuman Services; "Physical abuse: Is defined as anyphysical force or action which results in or maypotentially result in non-accidental injury to a childwhich exceeds that which could be consideredreasonable discipline." (Ministry of Human Resources,1985, p.6)3) Emotional Neglect: "generally refers to the failureto meet the child's needs for affection, attention,and emotional nurturance. It may also include lack ofintervention for or fostering of maladaptivebehaviour, such as delinquency or substance abuse."(Whaley & Wong, 1993, p. 406) Emotional neglect mayalso include overprotection "as it deprives childrenof the opportunity to develop to their fullpotential." (Whaley & Wong, 1993, p. 681)4) Emotional Abuse: "refers to the deliberate attempt todestroy or significantly impair a child's self-esteem14or competence. Emotional abuse may take the followingforms: rejecting, isolating, terrorizing, ignoring orcorrupting the child." (Whaley & Wong, 1993, p. 406)5) Sexual Abuse: The definition of sexual abuse is takenfrom the 1985 definition by the British ColumbiaMinistry of Human Services; Sexual Abuse: "Is definedas any sexual touching, sexual intercourse or sexualexploitation of a child and may include any sexualbehaviour directed to/at a child." (Ministry of HumanResources, 1985, p.6)6) Verbal abuse: Verbal abuse is a type of emotionalabuse but because it is so common is often listed asa separate type of abuse.7) Passive abuse: Is that psychological abuse that oftengoes unnoticed and often accompanies other types ofabuse. Psychological abuse should always beconsidered a factor in sexual abuse and in childrenwitnessing the abuse of others.8) Registered Nurse: "A graduate trained nurse who hasbeen licensed by a state authority after passingqualifying examinations for registration. (Webster's Ninth Collegiate Dictionary, 1983, p.992)9) Eligible for registration: A nursing student who hassuccessfully completed a prescribed nursing course asrequired by the licensing body will be consideredeligible for registration upon graduation. (The15licensing body may require additional requirements tobe met such as successfully completing examinations,prior to granting a license to practise.)10) Child abuse and neglect education: Education about thesigns and symptoms, prevention, support, reporting,treatment and long term effects of abuse and neglectduring childhood.SummaryIn the society of today both the public and professionalsare more aware of child abuse and neglect and the consequencesof treated and untreated child abuse and neglect. Estimates ofthe prevalence of child abuse and neglect and particularlychildhood sexual abuse are much greater than we ever imagined.Disclosures of whole communities of children having been abused,whether Indian bands, schools, child care facilities, orphanagesor churches are becoming more commonplace in our newspapers andon television. Both the children who were the victims and theirfamilies are deeply affected. Many victims are reporting anddisclosing abuse long after it happened. Was there no contactwith those mandated to report such abuse during the time theabuse was occurring? Are those mandated to report child abuseand neglect educated about their responsibility to report childabuse and neglect and have they received sufficient education toidentify suspected cases of child abuse and neglect?This study investigates the child abuse and neglect16education of nursing students who are registered or eligible forregistration. Nurses are one of the categories of peoplemandated to report suspected cases of child abuse and neglectthat have a lot of contact with children. Are they adequatelyprepared for this task?17CHAPTER 2REVIEW OF THE LITERATUREIntroductionChild abuse and neglect education is still a relatively newtopic area. Ten years ago there was very little research andliterature on the topic and what was there was often anecdotaland of poor quality. Since then the field has mushroomed andthe research and literature have mushroomed along with theinterest in the topic.There is now a considerable body of literature on childabuse and neglect looking at both the victims and offenders butthe literature on training of professionals dealing with childabuse and neglect is quite scarce. This literature focus hasnot blossomed in the past few years as other areas of childabuse and neglect literature have and so there are still not asmany resources and references to cite when undertaking such astudy. This study looks only at the nursing profession and itschild abuse and neglect education of nursing students. It doesnot examine the training of other professionals. This studyshould therefore be considered only as an initial investigationand from the responses in this study perhaps further studiescould be developed to gain more detailed information.18Legislative MandatesPrior to examining nursing education, the documentationregarding reporting legislation should be considered.In the province of British Columbia, Section 7 of Chapter11 of the Family and Child Services Act (1980) of B. C. states:Duty to report7.^(1) A person who has reasonable grounds to believethat a child is in need of protection shallforthwith report the circumstances to thesuperintendent or a person designated by thesuperintendent to receive such reports.(2) The duty under subsection (1) overrides a claimof confidentiality or privilege by a personfollowing any occupation or profession, except aclaim founded on a solicitor and clientrelationship.(3) No action lies against a person making a reportunder this section unless he makes it maliciouslyor without reasonable grounds for his belief.(4) A person who contravenes subsection (1) commitsan offense. (The Ministry of Human Resources,1985, p. 69)This section clearly states that it is the duty of any "personwho has reasonable grounds" to report child abuse and neglect.The legislation of the state of Washington is more specificin who must report child abuse and neglect and the time frame in19which they must report suspected cases of child abuse andneglect. In the state of Washington, Section 26.44 Abuse ofChildren and Adult Dependent Persons - Protect - Procedurestates:26.44.030.^Reports - Duty and Authority to make - Dutyof receiving agency - Duty tonotify.(1) When any practitioner, professional school personnel,registered or licensed nurse, social worker, psychologist,pharmacist, or employee of the department has reasonablecause to believe that a child or adult dependent person hassuffered abuse or neglect, he shall report such incident,or cause a report to be made, to the proper law enforcementagency or to the department as provided in RCW (RevisedCode of Washington) 26.44.040. The report shall be made atthe first opportunity, but in no case longer than forty-eight hours after there is reasonable cause to believe thatthe child or adult has suffered abuse or neglect. (West,Revised Code of Washington Annotated, 1986, 26, p.565)In the province of British Columbia, the Venereal DiseaseAct limits sharing of all information regarding theinvestigation and treatment of a sexually transmitted disease.Therefore, once a sexually transmitted disease has been reporteda health worker must obtain authorization from the Minister ofHealth to release information (Ministry of Human Resources,1985, p.19).^This would suggest the reporting of suspected20cases of child sexual abuse prior to confirmation of a sexuallytransmitted disease.In the state of Washington, the Revised Code of Washingtonlimits the sharing of information about a sexually transmitteddisease. Paragraph 3 of Section 70.24.022 Interviews,examination, counseling or treatment of infected persons orpersons believed to be infected of the Revised Code ofWashington states;(3) All information gathered in the course of contactinvestigation pursuant to this section shall beconsidered confidential. (West, Revised Code of Washington Annotated, 1986, 70, p.79)This would suggest that the state of Washington could end up inthe same sort of conflict of interests as the province ofBritish Columbia except that in the state of Washington Section70.02.900 Conflicting laws has the following provision;(1) This chapter does not restrict a health care providerfrom complying with obligations imposed by federal orstate health care payment programs or federal or statelaw.^(West, Revised Code of Washington Annotated,1986, 70, p.20)Therefore, it would appear that in the state of Washington onecan report both suspected child abuse and neglect and sexuallytransmitted diseases and not be concerned about the order ofreporting. Both are mandated to be reported under state law byhealth care providers and section 70.02.900 allows a health care21provider the latitude to comply with both reporting laws.The legislature of both the province of British Columbiaand the state of Washington suggest mandated reporting byregistered nurses. Burgess (1990) who has been at the forefrontin undertaking research and publishing in the area of familyviolence, cautions that the "recent upsurge of interest andconcern for the rights of children led to the passage of lawsmandating reporting of suspected or documented cases of childabuse or neglect. Nurses, therefore, are required by law toreport cases to the appropriate state agency" (p. 96). Rhodes(1987) states that nurses who work in areas frequented bychildren should be familiar with their state's reportingrequirements. Kreitzer (1981) points out that nurses "are in akey position to identify when abuse and neglect may beoccurring" (p. 150). Broome and Daniels (1987) suggest this ispossible because "nurses are able to observe and interact withfamilies in ways accessible to few other disciplines" (p.17).Nurses have for a long time been seen as "a primary patientadvocate" (Gill, 1989, p.40). There are a multitude of uniquerelationships that nurses have which put them in many positionswhere they can observe abused and neglected children: Nursesare in the labour and delivery rooms where they can observe theinteraction of the parents to the newborn; in paediatric clinicswhere they can observe the parent-child interaction in thewaiting room and during the examination; in emergency roomswhere they can observe the parent-child interaction as well as22behaviourial and clinical indicators of abuse; in physiciansoffices where they can see the same child come in repeatedly forproblems and can also assess the parental stress level; in thehome where the public health nurse can observe the familyinteractions, the living situation, and indicators of abuse andneglect in the children; and in schools where the school nursecan observe repeated bruising in various stages of healing andbehaviourial and emotional problems (Broome & Daniels, 1987;McKeel, 1978; Shives, 1990).McKittrick (1981) discusses indicators of abuse and reasonsfor not reporting. Reasons for not reporting have been donemore clearly by Olds in her textbook Maternal-Newborn Nursing ,where the author gives six reasons for nurses not reportingabuse and neglect:1. Professional denial because the child orparent looks well or the nurse has known thefamily for a long time and refuses tobelieve abuse and neglect could happen2. Professional doubt about the nurse's role3. Fear of retribution, perhaps because of ahistory of violence in the family4. Lack of "belief in the system," especiallyif the family was previously reported withno subsequent improvement5.^Professional neglect or failure tounderstand that the risk to the child is23increased when abuse or neglect is notreported6. Conflict between professionals over theimportance of reporting (Olds, 1988, p.86)When one views the reasons Olds suggests for nurses notreporting child abuse and neglect, one can see a lot of itemswhich should be covered in child abuse and neglect education forregistered nurses.Education of Professionals Dealing withChild Abuse and NeglectThe need for educating nurses and other professionals aboutchild abuse and neglect was suggested prior to 1974 by Rashidwho was at the time Special Assistant to the Acting AssociateChief, Children's Bureau, Office of Child Development,Department of Health, Education, and Welfare in the UnitedStates of America. Rashid's suggestion was summarized byNazzaro in 1974;We at least need to talk about the problem with graduatesocial worker candidates, nursing students, and graduatemedical men and women who are going into their internshipsand residencies, or better yet we need to develop a wholecurriculum for use at the graduate or undergraduate level.How would it be to sit down with a total law schoolpopulation and generally present them the case of childabuse in this country. (Nazzaro, 1974, p. 352)24What was proposed in the Nazzaro discussion was an educationalprogram for all the different types of professionals that mightbe in contact with child abuse and neglect cases.In 1992, Gallmer and Bonner stated that in the area ofchild abuse and neglect education, "academic training ofprofessionals such as physicians, psychologists, nurses,attorneys and social workers has not kept pace with the demandfor expertise." (p.513) They then describe a program wherefunding was given to ten universities to develop and operategraduate level interprofessional child abuse and neglecteducation. Seven per cent of the students enroled were nurses.They conclude the article by saying, "to date, universityeducation has typically failed to prepare professionals to meetthe demands for expertise that child abuse and neglect casespresent" (p. 520).Sevel (1989) observed that "some professionals are stillnot reporting suspected child abuse and neglect" which was"attributed partly to the inability of professionals torecognize the signs of child abuse and neglect or their25reluctance to confront the family with their suspicions" (p.80).Like Gallmer and Bonner, Sevel inferred that "institutions ofhigher education have been lax in providing future professionalsthe training necessary to meet their legal responsibilities toreport suspected child abuse and neglect" (p.80). Because ofthese observations and conclusions, Ohio State Universitydeveloped a "competency-based interdisciplinary graduate programconsisting of three interdisciplinary courses: child abuse andneglect, interprofessional care and clinical practise" (p. 81).The course enroled 30 students from "allied medicine, education,law, medicine, nursing, psychology, social work and theology"(p.81). The teaching methods were "team teaching, casemethodology and group discussion" (p.81). Sevel concluded that"further research is needed on impact of interprofessionaleducation on public policy issues" (p.82).Hibbard, Serwint and Connolly (1987) reported on aninterprofessional program for professionals for evaluation ofpossible sexual abuse. The program was attended by 51physicians, nurses and C. P. A. workers who indicated a desireto attend the free symposium. The study suggested that therewas a strong need for continued professional education (p.517).Positive outcomes from the study were the coordination ofservices and the fact that participants extended the program totheir own communities (p.518).26Education of Nursing StudentsEducation of nursing students was usually not directlystated in the child abuse and neglect literature but rather wasimplied. By this it is meant that the nurse should be able todo certain things or should know certain things. For example,Rhodes (1987) statement that nurses who work in areas frequentedby children should be familiar with their state's reportingrequirements.In the professional nursing journals there are manyarticles describing child abuse and neglect in detail. Shives(1990) gives detailed indicators of different types of abuse andneglect and possible offenders. Mittleman, Mittleman and Welti(1987) give detailed physical and behaviourial descriptions andphotographs of physical abuse. Jurgrau (1990) describesphysical abuse, sexual abuse and emotional abuse in detail.Leaman (1979) also describes the nurses' recognition of childabuse and neglect. D'Avanzo (1990) provides detaileddescriptions and photographs of sexual abuse.Several articles described where, how or what certain typesof nurses should do when confronted with child abuse andneglect. Lewin (1990) describes the nurse's "position to fosterrelationships that effect overall recovery" and suggests thatthe nurse "should be aware of the wide range of behaviours thatmay occur as the child reflects the feelings about the abuse"(p. 264). Gill (1989) talks about the importance of the triagenurse in the emergency room. Broome and Daniels (1987) talk27about the "nurses' ... unique position to identify families atrisk" (p. 17). They say that "home and family is the area wherenursing professionals as a whole can make the most impact inassisting children and parents who are at risk for, or currentlyassessed as experiencing, child abuse" (p. 21).To help nurses with child abuse and neglect identification,several articles described assessment tools. Burgess, Hartmanand Kelly (1990) wrote a detailed article on the TRIADSchecklist for assessing child abuse and neglect. Finkelhor(1984) gives details in the area of child sexual abuse and isconsidered to be one of the experts in this field. Broome andDaniels (1987) gave several examples of assessment toolsincluding; HOME (Home Observation for measurement of theEnvironment), NPI (Neonatal Perception Inventory), and theFeetham Family Functioning Survey.Scherb (1988) gave a set of very detailed standardized careplans for the emergency room nurse for child abuse and neglect.As nursing care plans are one of the ways nurses plan theirpatient care, the development of these care plans is veryhelpful when dealing with such a difficult subject area.Three articles discuss the psychological impact of dealingwith child abuse and neglect. Josten (1978) says that a "nursemust work to accept emotionally the fact that the entire familyunit needs and is worthy of help" (p.111). Both Gill (1989) andHayes (1981) describe "burn out" experienced by nurses dealingwith child abuse and neglect.28The nurse must also be prepared to work on aninterdisciplinary team on child abuse and neglect (Christensen,Schommer, & Velasquez, 1989).The only direct statement found about the child abuse andneglect education of nurses was by Kelley (1986, p. 201) whichsaid "pediatric nurses need to be knowledgeable about childsexual abuse." Kelley did not say how the nurses were toacquire this knowledge but did include a detailed description ofwhat paediatric nurses can do.Similarities between the Province of British Columbiaand the State of WashingtonBoth the province of British Columbia and the state ofWashington are dominated by their communities lying in thePacific Northwest. While they are located in differentcountries and governed by different types of legislature andhave differently funded health care systems, they share a numberof things in common.The populations and types of communities having schools ofnursing were very similar in the 1985 - 86 study (Appendixes C& D). In the 1993 study the province of British Columbia hasdramatically increased the number of schools of nursing with newschools of nursing opening in smaller and sometimes moreisolated communities. This demonstrates a shift from the typesof communities which had schools of nursing in the past. Itshould be pointed out that in the years between the 1985 - 8629study and the 1993 survey, the province of British Columbiafaced a critical nursing shortage and nurses had to be recruitedfrom the United Kingdom and the Philippines to fill the manyvacancies.Both the province of British Columbia and the state ofWashington have a short history of immigrant settling,rainforest coastlines, gulf islands, mountains and a temperateclimate. The people in the Pacific Northwest are noted fortheir outdoor recreational activity, especially on weekends, andfor the lowest church attendance averages in their nations.Despite the international boundary which separates them, theprovince of British Columbia and the state of Washington aremore similar to each other than they are different.The state of Washington and especially Seattle, have beenat the world forefront as far as child abuse and neglectlegislation, treatment and education were concerned when the1985 - 86 study was undertaken. In 1993, child abuse andneglect legislators from the province of British Columbia are atthe Canadian forefront in terms of training prosecutor andjudges (B. Saunders, April 20, 1993).30SummaryThere is no published literature and research available onthe specific education of nursing students in the area of childabuse and neglect. The current study appears to be the onlystudy in this area and therefore should be considered aspreliminary knowledge suggestive of further study andinvestigation.31CHAPTER 3METHODOLOGYIntroductionThe method used in this study was survey research. Letterswere sent to the directors of nursing, deans, associate deansand coordinators requesting that they distribute questionnairesto their instructors and faculty members teaching child abuseand neglect education. Names and addresses for the schools ofnursing in the province of British Columbia were obtained fromthe Registered Nurses Association of British Columbia. Namesand addresses for the schools of nursing in the state ofWashington were obtained from State-Approved Schools of Nursingand Directory of RN to BSN programs in the library.PopulationThe population for the study was all schools of nursing inthe province of British Columbia (19) and in the state ofWashington (28). Only those schools of nursing which educateregistered nurses and/or nurses eligible for registration upongraduation were included in the study. Schools of nursing whichtaught practical nursing, nursing assistants and nurses aideswere not considered unless these students were in combinedclasses with nurses who were later eligible for registration.Since the original study was conducted, the province ofBritish Columbia has introduced a program of affiliated schools32of nursing. These schools of nursing teach only the first yearor first two years of a nursing program. Affiliated schools ofnursing have been set up by the University of Victoria andBritish Columbia Institute of Technology. The University ofVictoria is affiliated with the following six colleges; CamosunCollege in Victoria, Malaspina College in Nanaimo, North IslandCollege in Campbell River, Okanagan University College inKelowna, University College of the Cariboo and VancouverCommunity College in Vancouver. The British Columbia Instituteof Technology is responsible for East Kootenay Community Collegeand at the time of this research was also responsible forNorthern Island College. (In the fall of 1993, Northern LightsCollege will be joining New Caledonia.) The Associate Dean atBritish Columbia Institute of Technology is also responsible forOpen University.The consent of the director of nursing, dean, associatedean or coordinator was considered to be obtained if s/hedistributed the questionnaire to the instructors and/or facultymembers teaching child abuse and neglect education in theirschool of nursing. The consent of the instructors or facultymembers was considered to be obtained when they completed thequestionnaire and returned it to the researcher at the addressgiven at the University of British Columbia.The schools of nursing which participated in the 1985 - 86study from the province of British Columbia were BritishColumbia Institute of Technology, Camosun College, Cariboo33College, Douglas College, College of New Caledonia, OkanaganCollege, Selkirk College, University of British Columbia,University of Victoria, Vancouver Community College andVancouver General Hospital. These were all the schools ofnursing in the province of British Columbia at that time and allof them participated. The schools of nursing which participatedin the 1993 study from the province of British Columbia wereBritish Columbia Institute of Technology, Camosun College,Cariboo College, Douglas College, East Kootenay CommunityCollege, Malaspina College, Northern Island College, NorthernLights College, Okanagan University College, University Collegeof the Cariboo, University College of the Fraser Valley,University of Victoria and Vancouver General Hospital/Universityof British Columbia program at Vancouver General Hospital.Trinity Western University, a privately funded Christianuniversity, is developing a nursing program for the fall of 1993but was unable to submit a questionnaire as the school was notyet open at the time if this research. City University, aprivate university, was officially listed as a school of nursingby the Registered Nurses Association of B. C. at the time ofthis research but it had closed and not informed theassociation. Therefore, the number of schools of nursing wasrevised from 20 to 18. It should be noted that 13 of 18 schoolsof nursing chose to participate in the 1993 study. All of theschools of nursing which participated in the 1985 - 86 study andthe 1993 study are publicly funded. A complete list of the34schools of nursing is found in Appendix A.The schools of nursing which participated in the 1985 - 86study from the state of Washington were Bellevue CommunityCollege, Clark College, Columbia Basin College, IntercollegiateCenter for Nursing Education (Eastern Washington University,Washington State University and Whitworth College), PacificLutheran University, Peninsula College, Seattle CentralCommunity College, Seattle Pacific University, SeattleUniversity, University Of Washington, Wenatchee Valley Collegeand Yakima Valley College. The schools of nursing from thestate of Washington which participated in the 1993 study wereBellevue Community College, Clark College, Columbia BasinCollege, Grays Harbor College, Seattle Central CommunityCollege, Seattle Pacific University of Health Sciences,Shoreline Community College, Skagit Valley College, TacomaCommunity College, Walla Walla College and Walla Walla CommunityCollege. Two of the universities which participated in the 1985- 86 study were privately funded Christian universities. In the1993 study, no privately funded universities or collegesparticipated in the study. A complete list of the schools ofnursing in the state of Washington is given in Appendix B.1993 SurveyLetters were sent to 20 directors of nursing, deans,associate deans, presidents and coordinators in the province ofBritish Columbia and 26 directors of nursing, deans, associate35deans and coordinators in the state of Washington explaining thestudy and soliciting the participation of their school ofnursing (Appendix F). In the state of Washington, three schoolscontinued to share a common administration (IntercollegiateCenter for Nursing Education; Eastern Washington University,Washington State University and Whitworth College). It waslearned after the questionnaires had been sent that one schoolof nursing, City University had closed its school of nursing.They had not officially notified the Registered NursesAssociation of B. C. and so were still officially listed andtherefore included in the study. Trinity Western University wasinvited to participate in the research if their program wasdeveloped enough in May 1993.It was assumed that consent was given by the director ofnursing, dean, associate dean or coordinator by theirdistribution of the questionnaires to their instructors and/orfaculty members. Consent of the instructors and/or facultymembers was assumed by their returning the completedquestionnaire.Questionnaires were mailed 30 April 1993 in BritishColumbia to the directors of nursing, deans, associate deans orcoordinators of schools of nursing in the province of BritishColumbia. Questionnaires were mailed 30 April in the state ofWashington to the directors of nursing, deans, associate deansor coordinators of schools of nursing in the state ofWashington. As mentioned before, the director of nursing, dean,36associate dean or coordinator was asked to distribute thequestionnaire to their instructors and/or faculty members. Ina covering letter included with the questionnaire, instructorsand/or faculty members were asked to complete and mail thequestionnaire back to the University of British Columbia withintwo weeks. (Appendix G) A reminder was sent to those directorsof nursing, deans, associate deans or coordinators for whichresponses were not received by 7 June 1993 (Appendix F).All replies were included in the study. Thirteen of 18(72%) schools of nursing in the province of British Columbiareturned completed questionnaires or letters of explanation.Eleven of 28 (39.3%) schools of nursing in the state ofWashington returned completed questionnaires. One school ofnursing in the province of British Columbia sent two completedquestionnaires. Two schools of nursing in the state ofWashington sent two completed questionnaires.QuestionnaireThe child abuse and neglect education questionnaire(Appendix H) was developed to find out about child abuse andneglect education in schools of nursing in the province ofBritish Columbia and the state of Washington. The questionnairecontained 23 questions asking for information about theeducation of the instructor or faculty member, the number ofstudents receiving child abuse and neglect education, how manyyears the instructor or faculty member has taught child abuse37and neglect education, the type(s) of nursing students beingtaught, in what area child abuse and neglect education is taughtand whether or not it is being taught in more than one area, thenumber of hours devoted to child abuse and neglect education intheir school of nursing and also the number of hours theinstructor would prefer, whether the child abuse education istaught alone or team taught and whether or not other instructorsor faculty members also teach child abuse education, whether theinstructor or faculty member chose to teach the subject or itwas assigned to them, how important the instructor or facultymember feels child abuse and neglect education is, how importantthe seven different types were in the eyes of the instructor orfaculty member, how satisfied the instructor or faculty memberwas with the child abuse and neglect education at their schoolof nursing, suggestions for improving child abuse and neglecteducation at their school of nursing, the types of written andmedia resources and speakers they used in the child abuse andneglect education, the types of assignments the nursing studentswere expected to complete regarding child abuse and neglect,whether or not nursing students were made aware of reportingchild abuse and if the abused or neglected child had a sexuallytransmitted disease which they would report first (the childabuse or neglect or the sexually transmitted disease), and ifthere was any interdisciplinary teaching of the child abuse andneglect education in their college or university.38The questionnaire was developed from replies received from the1985 - 86 study (Watt, 1987) and readings in more currentliterature.ConfidentialityIn this study, the instructors or faculty membersresponding was asked only to identify the completedquestionnaire by the name of the school of nursing. Someinstructors and faculty members chose to identify themselves byname as well. One of the instructors or faculty members alsoidentified herself as a survivor of childhood abuse.Administration of the Child Abuse and Neglect Questionnaire Two copies of the child abuse and neglect education and anexplanatory letter to the instructors or faculty members weremailed to each director of nursing, dean, associate dean or co-ordinator with a letter of explanation to the director ofnursing, dean, associate dean or co-ordinator explaining theresearch and requesting their school of nursing participate inthe study. In both the letter to the director of nursing, dean,associate dean or coordinator and the letter to the facultymember or instructor it was explained that the instructor orfaculty member would return the completed questionnaire directlyto the researcher. Completion of the questionnaire would nottake more than 30 minutes.39Data Analysis The responses of each instructor and faculty member wererecorded using only the school of nursing for identification.Results for the province of British Columbia and the state ofWashington were recorded separately. Where more than one replywas received from a school of nursing, they were identified byschool of nursing followed by "a" or "b".For those schools of nursing that replied to both the 1985- 86 letter and the 1993 questionnaire, their responses to thequestions of subject area where taught, references and resourcesused (both print and speakers) and the number of hours of childabuse and neglect education were compared. Responses of the1985 - 86 study and the 1993 study were compared to see if therewas a general indication of change in either the method ofpresentation, content or the number of hours that child abuseand neglect education was being taught.LimitationsThere are limitations of the study which should be noted.1) Participation in the study by the directors ofnursing, deans, associate deans or coordinators and theinstructors or faculty members was completely voluntary.Many of the schools of nursing chose not to participate inthe study. The director of nursing, dean, associate deanor co-ordinator may have consented to the participation oftheir school of nursing but the instructors or faculty40members may have refused to participate. The differencesbetween those schools of nursing which chose to participateand those who chose not to participate is not known. Inthe 1985 - 86 study two private universities participated.One of these universities had the possibility of anextremely high number of hours of child abuse and neglecteducation. In the 1993 study no private universitiesparticipated. Therefore, the results cannot necessarily begeneralized to all the schools of nursing in the provinceof British Columbia and the state of Washington.2) The information obtained about child abuse and neglecteducation was only what the director of nursing, dean,associate dean or co-ordinator wished to describe in the1985 - 86 study and only what the instructors or facultymembers wished to describe in the 1993 study.3) In the 1985 - 86 study, a letter was sent to thedirector of nursing, dean, associate dean or co-ordinatorof each school of nursing in the province of BritishColumbia or the state of Washington. They replied byletter describing the child abuse and neglect education attheir school of nursing. Most of the letters were verydetailed especially in the area of listing resources.There was a 100 per cent (11 of 11) response rate in theprovince of British Columbia and 50 per cent (14 of 28) ofthe schools of nursing sent responses in the state ofWashington. In the 1993 study, a formalized questionnaire41was sent with a covering letter was sent to the director ofnursing, dean, associate dean or co-ordinator requestingthat they pass the questionnaire to the instructors orfaculty members teaching child abuse and neglect education.The response rates were lower than when the director ofnursing, dean, associate dean or co-ordinator was asked toreply by letter. The 1993 survey listed fewer resourcesbeing used and contained less detailed responses than the1985 - 86 letters even though there was ample spaceprovided with these questions in the 1993 questionnaire.It appears that nursing educators prefer to write letterscontaining their own input and thought organization eventhough this took more time than completing a questionnaire.42CHAPTER 4RESULTS OF THE STUDYIntroductionThis study was conducted to investigate the number of hoursbeing devoted to child abuse and neglect education and thecontent and presentation of that education and to whom.It repeated an earlier study (Watt, 1987) and soughtinformation on changes since 1985-86 and additional information.Data from British Columbia and Washington schools of nursingwere sought to see if there was a difference in child abuse andneglect education because of the different legal structuresregarding child protection and management and sexuallytransmitted disease reporting. The province of British Columbiahad greatly expanded its schools of nursing from 11 to 18between the initial study of 1985 - 85 and this study. Thenineteenth school of nursing is scheduled to accept students inSeptember of 1993. This school of nursing was also contactedand asked to participate if they had designed their child abuseand neglect education. This is the first private school ofnursing in the province of British Columbia and unfortunately noreply was received. No longer were the schools of nursingconcentrated in the Pacific Northwest as British Columbia hadnow set up schools of nursing in many smaller outlying centres.Data were obtained from 13 of 18 schools of nursing inBritish Columbia and 11 of 28 schools of nursing in Washington.Results of the SurveyTeaching of Child Abuse and Neglect Education From those that responded, child abuse and neglecteducation is not taught in all schools of nursing in theprovince of British Columbia and from the schools of nursingthat responded, is taught in all the schools of nursing in thestate of Washington. In 1985 - 86, one school of nursing inboth British Columbia and Washington did not teach child abuseand neglect education. In 1993, four schools of nursing inBritish Columbia stated that they do not teach child abuse andneglect education. Three of these schools of nursing teach thefirst year a nursing program only while the fourth school ofnursing teaches registered nurses only.Number of Hours Child Abuse and Neglect Education is Taught In Table 1, the number of hours of education is examined.Question seven asked "On average, how many instructional hoursdo nursing students have on child abuse education?" Asmentioned earlier, because of the satellite program in theprovince of British Columbia, some schools of nursing have nochild abuse and neglect education. All schools of nursing inthe state of Washington that completed questionnaires have childabuse and neglect education. In the schools of nursing that do4344have child abuse and neglect education, the majority have two tofour hours of child abuse and neglect education.TABLE 1Number of hours of child abuse andneglect educationB. C.^WA0 hours 6< 1 hour 11 - 2 hours 2 32 - 4 hours 4 74 - 6 hours 1* 16 - 8 hours 1No response 1Total 14 13*The school stated that this could be increased ifthe student chose to study child abuse and neglectfor their in-depth study.Table 2 shows the number of hours of child abuse andneglect education in British Columbia in 1985-86 and 1993.From the results obtained, it is difficult to draw any45conclusions except to say that the number of hours hasprobably not increased from 1985-86 to 1993.TABLE 2Number of hours of child abuse and neglecteducation in 1985 - 86 and 1993 in theprovince of British Columbia1985 - 86^1993B.C.I.T.^ 2 I - 3^ 2 - 4Camosun College^2+ Developing newprogramCariboo College^2 + 2^2 - 4 + less than1 hour inpaediatricsOkanagan University^ 2 - 4CollegeUniversity of^No direct^ 2 - 4Victoria teachingVancouver General 1 - 2HospitalTable 3 shows the number of hours of child abuse andneglect education in the state of Washington in 1985-86 and1993. It does not look like there has been an increase inchild abuse and neglect education in schools of nursing whichparticipated in the 1985-86 and 1993 studies.46TABLE 3Number of hours of child abuse and neglecteducation in 1985 - 86 and 1993 in thestate of Washington1985 - 86^ 1993Bellevue Community^2^ 2 - 4Clark College 1 2 - 4Columbia Basin^ 2 - 3^ 2 - 4CollegeSeattle Central^ 2 - 4CommunityCollegeSeattle Pacific^2 hrs. in Paeds^1 - 2University ofHealth SciencesNumber of Students Receiving Child Abuseand Neglect Education Table 4 shows the approximate number of studentsreceiving child abuse and neglect education in schools ofnursing. The question asked the "number of nursing studentsyou teach child abuse education to each year." From thereplies received, the maximum class size is 120 nursingstudents which is much smaller than many undergraduatecourses.47TABLE 4Approximate number of students receiving childabuse and neglect educationB. C.^WA< 10 students 110 - 2526 - 50 3 651 - 75 3 376 - 8990 - 99 1 2100 - 120 1 1No answer 5 1Total 14 13Types of Nursing Students Receiving ChildAbuse and Neglect EducationTable 5 shows the number of different types of nursingstudents in each of the schools of nursing. Anyone who suspectschild abuse and neglect is required to report it in BritishColumbia while both registered nurses and licensed nurses(called licensed practical nurses in B. C.) are required toreport suspected child abuse and neglect in the state ofWashington. The question attempted to see if this difference inmandatory reporting also showed a difference in the way48registered and other nursing students were educated. In BritishColumbia nursing students eligible for registration and thosealready registered are not educated with other nursing studentswhereas in of Washington, one school of nursing indicateddifferent types of nursing students were educated together.Because of the low number of responses, no trend can beestablished.TABLE 5Types of nursing students receiving childabuse and neglect educationB.^C. WANurses already registered 2Eligible for registrationupon graduation8 10Both RNs and eligible forregistration upon graduation1Eligible for registrationupon graduation with othernursing students1No response 4 1Total 14 1349Location of Instructors' and Faculty Members' Baccalaureate Degree Table 6 shows where the instructors and faculty membersreceived their baccalaureate degrees. In both British Columbiaand Washington, the majority of instructors and faculty membersreceived their nursing education in a province or state otherthan the one in which they now teach child abuse and neglecteducation to nursing students. This is significant because bothBritish Columbia and Washington have mandatory reporting laws.If nurses are being educated in provinces or states where childabuse and neglect reporting is done differently, they may beunaware of the importance of teaching this information. Also,in British Columbia, child abuse and neglect must be reportedbefore reporting a sexually transmitted disease if the child hasboth because of the confidentiality laws surrounding thereporting of sexually transmitted diseases.50TABLE 6Location and type of instructors' and facultymembers' baccalaureate degreeB. C.^WANursing baccalaureate 13 12Non-nursing baccalaureate 1U.S.A., other than WA 9Washington 2Canada, other than B.C. 8British Columbia 2No answer 4 1Total 14 13Child Abuse and Neglect Education Instructors and Faculty Members have ReceivedTable 7 shows the child abuse and neglect education thatinstructors or faculty members had received when they werereceiving their nursing education. Question number two askedthe "number of nursing students you teach child abuse educationto each year." No instructors or faculty members from BritishColumbia indicated that they had received child abuse andneglect education while they did their basic nursing educationand eight of 14 responded that they definitely did not receivechild abuse and neglect education. The state of Washington51educators had five of 13 instructors or faculty members who hadreceived child abuse and neglect instruction while they receivedtheir basic education. In British Columbia, two instructors orfaculty members could not remember whether or not they hadreceived child abuse and neglect education, while fourinstructors or faculty members in the state of Washingtoncouldn't remember whether or not they had received child abuseand neglect education.TABLE 7Child abuse and neglect education of instructorsand faculty members while receiving their nursingeducationChild abuse & neglect ed.^B. C. responses WA responsesNo answer 4 1Cannot remember 2 4No child abuse & neglect ed. 8 3Child abuse & neglect ed. rec'd 0 5Total 14 1352Number of Years Instructors or Faculty Members have Taught Child Abuse and Neglect EducationThe number of years which the instructor or faculty memberhas taught child abuse and neglect education differed widely.Question number one asked the "number of years you have beenteaching child abuse education to nursing students?" Six of the13 schools of nursing in British Columbia which did respond tothe survey had no answer for this question. Some of theseschools of nursing sent accompanying letters explaining thatthey were affiliated schools of nursing and that they onlytaught the first year of the nursing program. In these firstyear only affiliated schools of nursing, child abuse and neglecteducation was not introduced until the second year by either theBritish Columbia Institute of Technology or the University ofVictoria.53TABLE 8Number of years the Instructor or Faculty memberhas taught child abuse and neglect educationB. C.^ WANo answer to question^6^ 1< a year^ 21 - 2 years 2^ 12 - 5 years^ 55 - 10 years 1^ 410 or more years^ 3 2Total^ 14^ 13Why Instructors and Faculty Members Teach ChildAbuse and Neglect Education Schools of nursing are different than many college anduniversity faculties in that because nursing students areeducated in all areas of nursing prior to registration they canoften move from teaching in one area to another. Therefore,once they have been accepted as an instructor or faculty memberat a school of nursing, they can often move to another positionwhen a vacancy occurs. It should be noted that in the provinceof British Columbia, one school of nursing has the child abuseand neglect education taught exclusively by an outside agency.Table 9 shows why instructors and faculty members are teaching54child abuse and neglect information.TABLE 9Why instructors or faculty members are teachingchild abuse and neglect educationB.^C. WAAssigned to teach it 1 1Chose to teach it 3 5Both assigned + chose toteach3 6Taught by outsidefacility1Do not teach it 3No response 3 1Total 14 13Satisfaction with Child Abuse and Neglect Education Offerings In Table 10 instructors and faculty members were asked toindicate their level of satisfaction with child abuse andneglect education in their school of nursing. Question 15asked the instructors or faculty members to circle theirchoice and comment if they wished to about the question, "Ingeneral, are you satisfied with the child abuse education inyour school of nursing?" The state of Washington had a55greater range of responses than the province of BritishColumbia.TABLE 10Level of satisfaction with child abuseand neglect educationB.^C. WAVery satisfied 7 26 2 35 3 44 3 232 1Not at all satisfied 1No response 6 1Total 14 13Importance of Child Abuse and Neglect EducationIn Table 11, instructors and faculty members were askedto rank order how important they felt it was for nursingstudents to receive child abuse and neglect education. Morethan two-thirds of the respondents indicated that child abuseand neglect education was very important for nursing students.56TABLE 11How important is child abuse and neglect educationB. C.^WAVery important 7 8 116 1 15 1432Not impt. at all 1No response 4 1Total 14 13Importance of Different Types of Child Abuse andNeglect in Educating Nursing Students. In question 14, instructors and faculty members wereasked to rank order in order of importance how important theyfelt seven different areas of child abuse and neglecteducation were. Question 14 was worded, "Rank order thefollowing types of child abuse in terms of their relativeimportance to educating nursing students at your school ofnursing." Some instructors and faculty members rank orderedthe seven types of child abuse and neglect while some rank57ordered each area of child abuse or neglect on a scale of oneto seven. The seven areas of child abuse and neglect beingconsidered were physical neglect, physical abuse, emotionalneglect, emotional abuse, sexual abuse, verbal abuse andpassive abuse.Responses to this question were more varied than for anyother question. Differences between British Columbia and thestate of Washington were also noted.In the province of British Columbia, two respondentsranked physical neglect as most important, one ranked sexualabuse and one respondent ranked verbal abuse as most importantto stress in a child abuse and neglect curriculum. In thestate of Washington, three respondents ranked physical abuseas most important and three ranked sexual abuse as mostimportant to stress in a child abuse and neglect curriculum.In the province of British Columbia, two respondentsranked passive abuse as second most important and tworespondents marked physical abuse as second most important tostress in a child abuse and neglect curriculum. In the stateof Washington, three marked sexual abuse as second mostimportant, one marked physical neglect, one marked physicalabuse and one marked emotional abuse as second most importantto include in child abuse and neglect education in theirschool of nursing.In British Columbia, for third rank, one respondentmarked physical abuse, one respondent marked emotional abuse58and one marked sexual abuse while three marked emotional abuseas third most important to include in child abuse and neglecteducation in their school of nursing. In Washington, onemarked physical abuse, one marked emotional neglect, onemarked verbal abuse and three marked emotional abuse as thirdmost important to stress in a child abuse and neglectcurriculum.For fourth rank, in British Columbia, two instructors orfaculty members marked physical neglect, one marked emotionalneglect and two marked verbal abuse as fourth most importantto emphasis in a child abuse and neglect curriculum. In thestate of Washington, two marked physical neglect, one markedphysical abuse and three marked verbal abuse as fourth mostimportant to include in child abuse and neglect education intheir school of nursing.In British Columbia for fifth rank, two respondents choseemotional neglect and three chose emotional abuse as fifthmost important to include in child abuse and neglect educationin their school of nursing. In Washington for fifth rank, tworespondents chose physical neglect, three chose emotionalneglect and one chose verbal abuse as fifth most important tostress in a child abuse and neglect curriculum.For sixth rank, in British Columbia, one instructor orfaculty member ranked physical neglect, two ranked sexualabuse, and two ranked verbal abuse as sixth most important tostress in a child abuse and neglect curriculum. In59Washington, one instructor or faculty member ranked physicalneglect, two ranked emotional neglect, one ranked emotionalabuse and one ranked verbal abuse as sixth most important toinclude in child abuse and neglect education in their schoolof nursing.In the province of British Columbia, two respondentsmarked physical abuse as least important and three markedpassive abuse as least important. In the state of Washington,all six respondents to this question marked passive abuse asleast important to include in child abuse and neglecteducation in their school of nursing.In British Columbia one school of nursing said all formsof child abuse and neglect were equally important to educatingtheir nursing students, one instructor or faculty member saidshe had not heard the lecture (child abuse and neglect istaught by an outside agency) and so could not comment, oneinstructor or faculty member did not understand the question,five instructors or faculty members did not reply to thequestion and one instructor or faculty member answered thequestion in two different ways. From the responses receivedthe following table was constructed to summarize the results.60TABLE 12Importance of types of child abuse and neglectto include in a nursing program in B. C. byrank ordering each type of abuse or neglectMost^1^2^3^4^5^6^7^LeastImportant ImportantPhysical^2^2^1neglectPhysical 2^1 2abuseEmotional^ 2^1^2neglectEmotional 2^1^3abuseSexual^2^1^2abuseVerbal^1^2^2abusePassive 2 3abuseTotal^561TABLE 13Importance of types of child abuse and neglectto include in a nursing program in B. C. byrank ordering each type of abuse or neglect individuallyMost^1^2^3^4^5^6^7^LeastImportant ImportantPhysical^1^1neglectPhysical^2abuseEmotional 2neglectEmotional^1abuseSexual^2abuseVerbal 1^1abusePassive^ 1^1abuse*Total^2*One instructor/faculty member put a ? for this typeof abuse.62TABLE 14Importance of types of child abuse and neglectto include in a nursing program in WA byrank ordering each type of abuse or neglectMost^1^2^3^4^5^6^7^LeastImportant ImportantPhysical^ 1^2^2^1neglectPhysical^3111abuseEmotional 1^3^2neglectEmotional^ 1^3^2abuseSexual^3^3abuseVerbal 1^3^1^1abusePassive^ 6abuseTotal^663TABLE 15Importance of types of child abuse and neglectto include in a nursing program in WA byrank ordering each type of abuse or neglect individuallyMost 1 2 3 4 5 6 7 LeastImportant ImportantPhysicalneglect 2 1Physicalabuse 2Emotionalneglect 1 1 1Emotionalabuse 2 1Sexualabuse 2 1Verbalabuse 11 1Passiveabuse* 1Total^3*One instructor/faculty member put a ? for this typeof abuse.64Suggestions for Improving Child Abuse and Neglect EducationTable 16 gives suggestions from instructors and facultymembers on how to improve the child abuse and neglecteducation in their school of nursing. Question number 6 wasan open ended question. More time to teach child abuse andneglect education was the most frequent request of the stateof Washington instructors and faculty members. While theprovince of British Columbia instructors and faculty memberswere less satisfied with the child abuse and neglect educationin their school of nursing, they also had fewer suggestionsfor improving the child abuse and neglect education at theirschool of nursing.65TABLE 16Suggestions for improving child abuse and neglecteducation in own school of nursingB.^C. WAInclude media 1Increase time allowed 1 6Include in clinical setting 1More visual aides 1More coordination withinstructors or faculty1Clarification 1Up to date literature 1Program presently beingchanged2Increase detail & personallearning1No response to question 11 6Total 14 13Preferred Number of Hours of Child Abuseand Neglect Education Table 17 reports how many hours the instructors orfaculty members would prefer were devoted to teaching childabuse and neglect education to nursing students. Questionseven was repeated asking how much the instructors or faculty66members would prefer to spend teaching child abuse and neglecteducation. In the province of British Columbia, threeinstructors or faculty members preferred an increase in thenumber of hours and one instructor or faculty member preferreda decrease in the number of hours. In the state of Washingtonmost instructors or faculty members wanted an increase in thenumber of teaching hours for child abuse and neglecteducation.TABLE 17Preferred number of hours of child abuseand neglect educationB.^C. WA1 - 2 1 12 - 4 5 54 - 6 2 36 - 8 18 - 10 1> 10 hours 1No response 6 1Total 14 1367Subject Areas Where Child Abuse and Neglect Education Taught Child abuse and neglect education may be taught under awide variety of subject areas (Table 18). Question six asked,"What subject area are you teaching child abuse education inyour school of nursing?" and then gave nineteen choicesincluding a space to include any others. Because theimplications of child abuse and neglect affect so many otherareas of health care and human interaction, child abuse andneglect education is often covered in more than one subjectarea (Table 19). The most common place to teach child abuseand neglect education is in paediatrics. The subject areacategories were developed from the areas where child abuse andneglect education was taught in the 1985 - 86 study asindicated by the directors of nursing, deans, associate deansand coordinators of the schools of nursing at that time.68TABLE 18Subject areas where child abuse andneglect education is taughtB. C.^WACommunity Health 1 2Field Placement 1Paediatrics 5 7Psychiatry 1 2Mental Health 1Trauma 1 2Nursing Theory 1 1Maternal/Child 1 2Parent/Child 1Family Nursing 1 1Human Violence 1Disruptive lifestyles 1 1Ethical issues 1No response 5Total 14* 13**Several schools of nursing reported child abuse andneglect education in more than one subject area.Table 19 shows the changes between 1985-86 and 1993 forsubject area. Subject areas are more diversified in 1993.69TABLE 19Subject areas where child abuse and neglecteducation was taught in 1985 - 86 and 1993in the province of British Columbia1985 - 86^1993Vancouver General 1st yr. SociologyHospital^Nursing 221 (Paeds)B.C.I.T.Camosun Collegecourse contentCariboo CollegeUniversity ofVictoriaPaediatricsObstetricsII (under trauma)III/DisruptiveLifestylesCommunity HealthNursing 410Sociology 305PaediatricsParent/ChildTraumaEthicsDeveloping newHuman ViolenceDisruptivebehaviourPaediatricsAbusive behaviourPaediatricsEthical issuesMaternal/childPsychiatryAll areas?Didn'tunderstandquestionOkanagan University PaediatricsEthical issuesTable 20 looks at the subject area where child abuse and neglecteducation was taught in the state of Washington. Like BritishColumbia, the areas for teaching child abuse and neglecteducation are more diversified in 1993.70TABLE 20Subject areas where child abuse and neglecteducation was taught in 1985 - 86 and 1993in the state of Washington1985 - 86^1993Bellevue Community Nursing of Children^PaediatricsPsychosocialClark CollegeColumbia BasinCollegeSeattle CentralCommunityCollegeSeattle PacificUniversity ofHealth SciencesNursing 130final 1/4 ofsecond yearPaediatricsMat/ChildPsychiatryTrends & IssuesNursing TheoryPaediatricsMat/ChildPsychosocialCommunity HealthAbuse (electivecourse)PaediatricsAbuse behaviourMental HealthTraumaNursing theoryPaediatricsMat/ChildParent/ChildPsychiatryPsychosocialMental HealthTraumaDisruptiveLifestylesAbuse behaviourPaediatricsParent/ChildEthicalCommunity HealthDisruptiveLifestyles71TABLE 21Number of subject areas where child abuseand neglect education is taughtB.^C. WAOne subject area 6* 8Two subject areas 3 4Three subject areas 1No response 5Total 14 13*One of these schools of nursing states that the topic ismentioned only and is not taught until the next year whenthey attend B.C.I.T.Methods of Teaching Child Abuse and Neglect Education Schools of nursing often use team teaching in theirsubject areas. Question nine asked "Do you teach child abuseeducation alone in your section/department or as part of ateam?" Team teaching means that more than one instructor orfaculty member is present with students at each instructionalperiod. This is not the same as different instructors orfaculty members teaching different sections or differentclasses of the same subject area. Table 22 looks at theincidence of team teaching and teaching alone. There is a72higher incidence of team teaching in the state of Washingtonthan in British Columbia.TABLE 22Methods of teaching child abuseand neglect educationB. C.^WATeam teaching 1 6Subject area taught alone 7 6Team teaching + teaching alone 1No response 5 1Total replies 14 13Others Teaching Child Abuse and Neglect Education Table 23 examines the question of whether or not othersalso teach child abuse and neglect education. Question 11asked " Are other faculty/instructors outside of yourdepartment responsible for teaching a similar unit on childabuse education in your school of nursing?" It seems that alot of other instructors or faculty members also teach childabuse and neglect education but they did not completequestionnaires.^Instructors and faculty members in theprovince of British Columbia indicated that about one quarterof the respondents do not know whether or not child abuse and73neglect education is covered in other subject areas in theirschool of nursing.TABLE 23Others teaching child abuse and neglect educationin the same school of nursingB. C.^WANo^ 3^ 7Yes 2 IDon't know^ 4^ 3*No response 5 2Total^ 14^ 13*One questioned whether child abuse and neglect educationwas perhaps being covered in psychiatry.Personnel Resources Used in Teaching Child Abuse and Neglect EducationMany different people interact with abused children.Question 23 asked, "What resource people do you use in yourchild abuse presentation(s)?" The choices presented wereother faculty/instructors, social worker, police, lawyer,C.P.A. worker, sheriff, victim, offender, or other(s). Table24 examines which of these resource people are being utilizedby the schools of nursing in their child abuse and neglect74education. One British Columbia university was not includedin this question because the faculty member had checked everyresource including those only available in the state ofWashington.TABLE 24Personnel resources used in teaching child abuseand neglect educationB. C.^WASocial worker 1 3Other faculty 3 5C.P.A. worker 3School nurse 1Continuing Education 1RNs working with familieswith abuse1Coworker 1Former victim 1 1Clinical instructor 1Red Cross 2Special guest speaker 1No resources used 1No response 7Total 14* 13**More than one personnel resource was used in severalschools of nursing.75Table 25 examines the personnel resources used in childabuse and neglect education in the province of BritishColumbia in 1985 - 86 and 1993.TABLE 25Personnel resources used in child abuse andneglect education in 1985 - 86 and 1993in the province of British Columbia1985 - 86^1993B.C.I.T.Camosun CollegeCariboo CollegeNoformer abuser4FacultyRed Cross teamDeveloping newprogramSpecial guestspeaker inpaediatricsOkanagan University^1^Other facultyUniversity of^ Yes All markedVictoriaVancouver General^Yes^Red Cross doesall teachingTable 26 examines the personnel resources used in childabuse and neglect education in the state of Washington.76TABLE 26Personnel resources used in child abuse and neglecteducation in 1985 - 86 and 1993in the state of Washington1985 - 86^1993Bellevue Community^?^Other facultyContinuingEducationClark College^ ?^ NoneColumbia Basin ? Other facultyCollege C.P.A. workerSeattle Central^?^Other facultyCommunityCollegeSeattle Pacific^Yes^Question notUniversity of answeredHealth SciencesNon-Personnel Resources Used in TeachingBecause of an explosion of media attention on child abuseand neglect, the number of resources and our knowledge aboutchild abuse and neglect has multiplied exponentially in thepast ten years. Question 18 asked, "What resource materials doyou require your nursing students to use?" The choicespresented were read assigned pages in a textbook, readassigned articles, do own personal research in library,interview someone, or other. The resources used in british77Columbia in 1993 were Brown (1992), Canadian NursesAssociation (1992), Little (1985), National Clearinghouse onFamily Violence (1990), Shives (1990) and Whaley and Wong(1989, 1992). In Washington the resources used in 1993 wereD'Avaneo (1990), Jurgrau (1990), Whaley and Wong (1992) andWilson (1992). Whaley and Wong had been used in both BritishColumbia and Washington in 1985 - 86. In Table 27 resourcesused to teach child abuse and neglect education in schools ofnursing are tabulated.78TABLE 27Non-personnel resources used in teachingchild abuse and neglect educationB. C.^WAAssigned textbook 4 12Assigned articles 6 7Personal research 1 1Interview someone 1Seminar 1Personal journal writing 1Community option 1Library research 1 1C.P.A. information 1Clinical conference 1Video 1Practicum with family 1Child abuse Research & 1Education ProductionsNo response 7Total 14 13Table 28 looks at the references used in child abuse andneglect education in the province of British Columbia.79TABLE 28References used in child abuse and neglecteducation in 1985 - 86 and 1993 in theprovince of British Columbia1985 - 86^1993B.C.I.T.^Video purchase^Assigned textbookplannedCamosun College^Yes^ Developing newprogramCariboo College^Yes Assigned articlesin all butpaediatricsOkanagan University^Yes^ Assigned textbookCollege^ Assigned articlesLibrary researchChild AbuseResearch andEducationProductionsUniversity of^-^ Personal researchVictoria Practicum withfamilyVancouver General^?^ Assigned articlesHospital80Table 29 looks at the references used in child abuse andneglect education in the state of Washington.TABLE 29References used in child abuse and neglecteducation in 1985 - 86 and 1993in the state of Washington1985 - 86^ 1993Bellevue CommunityClark CollegeColumbia BasinCollegeSeattle CentralCommunityCollegeYesAssigned textbookFilmYesAssigned textbookSeminarsJournalsAssigned textbookAssigned articlesAssigned textbookAssigned articlesAssigned textbookAssigned textbookVideotape^Seattle Pacific^Yes, in first 2University of coursesHealth SciencesTypes of Assignments Given to Nursing Students Regarding Child Abuse and Neglect Types of assignments are often an indication of the depthin which a topic is covered. Therefore, instructors andfaculty members were asked in question 19, "What types of81assignments do you ask your nursing students to do on thesubject of child abuse?"TABLE 30Types of assignmentsB.C. WAWrite a paper 1Nursing conference 1Nursing care plan 3Class discussion 1 2Collaborative planning 1Group work 1Seminar 1Observe in field 1Case presentation 1Self-directed learning module 1Student choice 1Examination questions 3In-depth study option 1Total 14 13Necessity to Report Child Abuse and NeglectBecause registered nurses are mandated in both of British82Columbia and the state of Washington to report suspected childabuse and neglect, it is important to see whether or notnursing students are being educated about their legal duty toreport suspected cases of child abuse and neglect. Question20 asks "Are nursing students at your school of nursing madeaware of their responsibility to report child abuse?"TABLE 31Responsibility of reporting suspected child abuseand neglect taught in schools of nursingB.^C. WAYes 9 11No 1Don't knowNo reply 5 1Total 14 13Because three schools of nursing in the province ofBritish Columbia stated that they do not teach child abuse andneglect education, it can be assumed that their response tothis question would also be a "No" responses.Necessity to report Sexually Transmitted Diseases Sexually transmitted diseases must also be reported.Question 21 asked "When a child has a sexually transmitted83disease, are nursing students at your school of nursing madeaware that a Registered Nurse must report both a sexuallytransmitted disease and child abuse?" Because there can be aconflict in reporting sexually transmitted diseases and childabuse or neglect in British Columbia, instructors or facultymembers were first asked about the reporting of sexuallytransmitted diseases (Table 32) and then asked in which ordersexually transmitted diseases and child abuse and neglectshould be reported (Table 33). Faculty members or instructorswere also given the option of replying that reporting was nota law in their province or state.TABLE 32Responsibility of reporting sexually transmitteddiseases taught in schools of nursingB. C.^WAYes^ 5^ 9No 2Don't know^ 2 + 1*^1No reply 5 + 1- 1Total^ 14^ 13*One school of nursing replied: "Collective agreement ofall working with the child."_One school of nursing answered the rest of the questionbut omitted this section of the question.84TABLE 33Which must be reported first if a child has both asexually transmitted disease and suffers from childabuse and neglect?B.^C. WASexually transmitteddisease 1Child abuse or neglect 4 3No reply 5 1Did not complete thispart of the question 2 7Don't know 2* 1Equal 1Total 14 13*One instructor or faculty member replied: "Collectiveagreement of all working with the child."Interprofessional Child Abuse and Neglect Education In 1974, Nazzaro summarized the suggestion of Rashidwhich was that a whole educational program integrating thedifferent types of professionals that might be in contact withabuse and neglect cases be initiated. Question 22 asked, "Arenursing students at your school of nursing taught about childabuse in a group of only nursing students or together withother professionals who will also have to deal with aspects of85child abuse?" Table 34 examines this question of professionalintegration.TABLE 34Are other professionals who also deal withchild abuse and neglect cases educatedwith nursing students?B. C.^WANursing students taught^7^ 11aloneNursing students taughtwith other professionalsdealing with child abuseand neglectNursing students taughtalone and with otherprofessionals dealingwith child abuse andneglectNo replyTotal116^ 114 13The last question asked with whom nursing students weretaught. Question 23 was worded, "If you answered "with otherprofessionals in the above question, which professionals areyou aware of that are taught with your nursing students?" Inboth the province of British Columbia and the state ofWashington, nursing students were taught with social work86students only. They were not taught with law students,education students, dental students or medical students.Again it should be noted that one university from the provinceof British Columbia checked all the categories even thoughmany do not exist in that university. The university inquestion did not have a dental school, pharmacy school ormedical school.TABLE 35Interprofessional child abuse and neglect educationB.^C. WANursing students alone 7 11Nursing students withsocial work students1 1No reply 6 1Total replies 14 1387CHAPTER 5CONCLUSIONS AND RECOMMENDATIONSIntroductionConclusions and recommendations of this study are fairlygeneral because of lack of supporting research literature. Oneof the recommendations of this study is that there be moreresearch into the child abuse and neglect education of nursingstudents and other professionals that work in the areas of childabuse and neglect prevention, treatment and education.Low Number of Response Rates A possible reason for the low response rates in theprovince of British Columbia and the state of Washington mayhave been the time of year the questionnaires were sent. Aprilis when most academic institutions are having examinations. Inthe province of British Columbia in particular, responses werenot as detailed as in the 1985-86 survey. Possible reasons forthis are that last time the survey was completed directly by thedirector of nursing, dean, associate dean or coordinator andalso the survey was more informal. Many of the directors ofnursing, deans, associate deans and coordinators sent verydetailed letters often with large packages containing copies ofthe articles and pamphlets they use. In 1985-86, they appear tohave preferred to compose their own replies as noted by the 100per cent response rate. In the state of Washington the88international postal rate may be a barrier to returning thequestionnaires.Recommendations for improving the response rate are to sendquestionnaires at a different time of year, to use a U.S.A.postal box for replies from the state of Washington, to contacteach school of nursing directly in person or by telephone andask who teaches the child abuse and neglect content and mail thequestionnaire directly to them and to follow-up with personalinterviews or telephone calls.Changes in the Number and Location of Schools of Nursing in British Columbia In 1985 - 86 there were 11 schools of nursing in theprovince of British Columbia. In 1993 there were 34 differentnursing programs listed within 20 schools of nursing. They wereunder the guidance of 20 directors of nursing, deans, associatedeans and coordinators. The change represented the developmentof many satellite schools of nursing in small isolatedcommunities. This means that prospective nursing students areable to study nursing while living in their own home or neartheir own home during the first year of their studies. Lettersfrom several directors of nursing, deans, associate deans andcoordinators suggested that these first year only schools do notteach any child abuse and neglect education to their students.The British Columbia Institute of Technology and the Universityof Victoria are responsible for teaching child abuse and neglect89education to these students. The problem with this approach isthat both the British Columbia Institute of Technology and theUniversity of Victoria are located in large urban centres andthese affiliated first year schools of nursing may be in smalleroften rural communities. At the British Columbia Institute ofTechnology and the University of Victoria the resourcesintroduced will probably be resources available in large urbancentres, most of which will not be available in the smallercommunities. Northern and isolated communities are more likelyto have to deal with a large segment of the community disclosingabuse (for example, in former residential schools) than arelarge urban centres. Therefore, it would seem prudent thatnursing students be educated in their own area about child abuseand neglect so that those who will remain to practise nursingthere will be familiar with the local resources.Nursing Care of Child Abuse and Neglect Patients in the Province of British Columbia At present in the province of British Columbia, nurses arenot teaching about child abuse and neglect in preventativemedical programs (unless they are involved with the Red Cross orthe C.A.R.E. kit) but are caring for many patients for whomabuse and neglect are their primary or secondary problem but notnecessarily the problem they present with when they enter themedical system. For example, it is known that the incidence ofchild abuse and neglect, and particularly sexual abuse, is a90factor in suicide of children and young adults, eatingdisorders, drug and alcohol abuse, prostitution, runaways,promiscuity, teenage pregnancy, depression, various psychiatricdiagnoses and stress related disorders. The manifestations ofchildhood abuse and neglect may be present until the abuse andneglect are recognized and treated in adulthood. Perhaps ifnurses were required to teach about child abuse and neglect inpreventative medicine and community nursing, schools of nursingwould be giving them a more comprehensive background in the areaof child abuse and neglect. Until nurses are working on thepreventative side of medicine, should they not be able toidentify and help counsel or refer to treatment victims ofchildhood abuse and neglect? Perhaps we need to rethink theamount of educational time devoted to childhood abuse andneglect when we hear echoed the Badgley report (1984) statisticsof one in two females and one in four males will have anunwanted sexual experience before the age of 18. The incidenceof childhood sexual abuse appears to be much greater than theincidence of childhood fractures and yet a large part of thepaediatric examination for registration focuses on orthopaedics.Nursing education appears to be in a large part a preparationfor the writing of registration examinations.Number of Hours of Child Abuse and Neglect EducationWhen the 1985 - 86 study was undertaken it was surprisingat how little time was being spent on child abuse and neglecteducation in schools of nursing considering the social and91cultural prevalence of abuse. From 1985 to 1993 the profile ofchild abuse and neglect continued to climb but the number ofhours of child abuse and neglect education remained virtuallythe same. In the state of Washington, instructors and facultymembers generally wanted an increase in the number of hours ofchild abuse and neglect education while one instructor orfaculty member wanted a decrease in the number of child abuseand neglect education and most of the respondents were satisfiedwith the current number of hours of child abuse and neglecteducation.As stated earlier, some of the schools of nursing in theprovince of British Columbia have no child abuse and neglecteducation while all schools of nursing in the state ofWashington that replied, have child abuse and neglect educationin 1993.Baccalaureate Training of Instructors and Faculty Members Most instructors and faculty members receive theirbaccalaureate training outside British Columbia and the state ofWashington where they now teach. Perhaps the provinces andstates where they are receiving nursing training do not requiremandatory reporting of child abuse and neglect and/or so theyare not receiving child abuse and neglect education. If this isthe case, particularly in the province of British Columbiabecause of the unusual legislative emphasis, a course in child92abuse and neglect should be made mandatory prior to receiving aregistration number in the province of British Columbia or thestate of Washington.Child Abuse and Neglect Education of the Instructors and Faculty Members In question four, the instructors and faculty members wereasked whether or not they had received child abuse and neglecteducation in their baccalaureate training. No instructors orfaculty members from the province of British Columbia indicatedthat they had received child abuse and neglect education. Ofthe nine British Columbia instructors and faculty members whoanswered this question, seven indicated that they had notreceived child abuse and neglect education. Of the 13 state ofWashington responses, five indicated that they had receivedchild abuse and neglect education and three indicated that theyhad not received child abuse and neglect education. It wouldtherefore seem prudent to demand showing the successfulcompletion of a course on child abuse and neglect prior toallowing an instructor or faculty member to teach child abuseand neglect education, especially in the province of BritishColumbia. This could be accomplished by creating professionaldevelopment courses for registered nurses. Completion of sucha course could be made a condition for registration in thefuture so that all schools of nursing will have adequate childabuse and neglect education and all practising nurses who did93not complete such a course prior to registration will havecompleted a professional development course.Assignment or Choice? Why Instructors and Faculty members Teach Child Abuse and Neglect EducationIn the state of Washington, 11 of 13 respondents indicatedthey were able to choose teaching child abuse and neglecteducation. Being able to choose your teaching subject wouldprobably suggest a greater interest and possibly greaterfamiliarity in the subject area. Even though respondents wereasked only to use their school of nursing name foridentification many from the state of Washington signed theirname and included personal notes. One state of Washingtonrespondent indicated that she was a survivor of childhood sexualabuse and told of telling her nursing students. She stated thatmany of the students then disclosed for the first time that theytoo were victims of childhood abuse. The instructor of thisschool of nursing stated that students who do disclose feelaffirmed and accepted.In the province of British Columbia, four respondentsindicated they were able to choose to teach child abuse andneglect education. One school of nursing does not teach childabuse and neglect education to its students but has the RedCross instruct them. The instructor or faculty member wasunaware of the course content provided by the Red Cross.94Instructor and Faculty SatisfactionThe state of Washington instructors and faculty members areslightly more satisfied than their colleagues in the province ofBritish Columbia.Importance of Child Abuse and Neglect Education Child abuse and neglect education is deemed very importantby the majority of instructors and faculty members in theprovince of British Columbia and the state of Washington.Importance of Different Types of Child Abuse andNeglect for Inclusion in an Educational ProgramOf all the questions in the 1993 study, this one showed thegreatest difference between the instructors and faculty membersof the province of British Columbia and the state of Washington.There is a great difference in what the province of BritishColumbia and the state of Washington instructors and facultymembers view as important for their nursing students to learnabout child abuse and neglect. No explanations are possible atthis time because of the small sample size. It is suggestedthat a further study focus on this area of study with a largersample.95Child Abuse and Neglect Education in Schools of Nursing; Suggestions for Improvement While the province of British Columbia instructors andfaculty members are less satisfied than their state ofWashington colleagues about the child abuse and neglecteducation in their schools of nursing, they also had lesssuggestions for how to improve the child abuse and neglecteducation. Eleven of the province of British Columbiarespondents had no reply while six of the state of Washingtonrespondents had no response. Six of the state of Washingtonrespondents requested more time. In the province of BritishColumbia one respondent suggested an increase in the time.It would seem that more time would improve the child abuseand neglect education. Other suggestions were to update theliterature, include media, include child abuse and neglecteducation in a clinical setting, use more visual aides, havemore coordination with other instructors and faculty members andclarification.Subject Area Where Child Abuse and Neglect Education Taught The subject area in which child abuse and neglect educationis introduced has an influence on how it is perceived.Therefore, it would be best if child abuse and neglect educationwere included in all areas of the curriculum where it mightoccur or else be taught as a separate subject area on its own.96Method of Teaching Child Abuse andNeglect Education in 1993 Almost half of the schools of nursing in the state ofWashington that responded indicated that they have team teachingfor child abuse and neglect education. Only two of the 11schools of nursing in the province of British Columbia respondedindicating that they have team teaching.Having a co-worker to share with would offer support forthose instructors and faculty members dealing with thisdifficult topic. Also if a nursing student was to disclose pastchildhood abuse or neglect it would allow one of the instructorsor faculty members to be free to be with that student. Teamteaching was the method of choice in all interdisciplinary childabuse and neglect education described in the literature whichincluded nurses. (Hibbard & Serwint, 1987; Sevel, 1989)Do Others in Your School of Nursing TeachChild Abuse and Neglect Education? In the province of British Columbia two instructors orfaculty members indicated that they knew of others teachingchild abuse and neglect education while four instructors orfaculty members indicated that they did not know if others werealso teaching child abuse and neglect education. In the stateof Washington one instructor or faculty member nursing indicatedthat other areas teaches child abuse and neglect education, andthree did not know whether or not another area teaches child97abuse and neglect education. Therefore, it would seem thatbetter coordination and knowledge of what other instructors andfaculty members teach in their courses is needed by schools ofnursing.Personnel Resources used in Child Abuse and Neglect Education in Schools of Nursing In the state of Washington, instructors and faculty membersmake more use of personnel resources than do their colleagues inthe province of British Columbia. One university in theprovince of British Columbia marked all the resources includingthose only found in the state of Washington (eg. C.P.A. workerand sheriff).Print, Tape and Film Resources Used in Child Abuse and Neglect Education in Schools of Nursing In the state of Washington, schools of nursing use assignedtextbook readings as their primary resource supplemented byarticles (seven) and personal research, seminar, journals,option of a community placement, library research, interview,C.P.A. information, clinical conference and video (one each).In the province of British Columbia most schools of nursinguse assigned articles (five), a few used assigned textbookreadings (three), personal research and practicum with a family(one each). Six respondents from the province of BritishColumbia did not answer this question.98Changes in Print, Tape and Film Resources Used in Child Abuse and Neglect Education in Schools of Nursing from 1985 - 86 to 1993 There appears to be a decrease in the types of resourcesused from 1985 - 86 to 1993, particularly in the area of filmsand videos.Types of assignments In the province of British Columbia, Nine of 14 respondentsdid not answer this question. Two of the schools of nursinggive an examination, one school of nursing has a choice ofassignment and one has a self-directed learning module.In the state of Washington, one school of nursing usesnursing care plans, one school of nursing uses collectiveplanning and one school of nursing uses group work and oneschool of nursing uses a seminar.Education Regarding the Reporting of Child Abuse and Neglect and Sexually Transmitted Diseases When asked about which to report first, child sexual abuseor a sexually transmitted disease if a child had symptoms ofboth, two British Columbian instructors or faculty membersincorrectly said to report the sexually transmitted diseasefirst or by collaboration of all concerned. This question wasomitted by many instructors and faculty members from the stateof Washington, perhaps because they do not have a conflict in99the order in which to report. Because of the mandatoryreporting laws in both British Columbia and Washington,reporting laws should be included in all undergraduate nursingeducation and possibly be mandated inservice like cardio-pulmonary resuscitation training is until all registered nursesare aware of the reporting laws.Interprofessional Education At present in the province of British Columbia and thestate of Washington only one school of nursing in each theprovince and state has interprofessional education. Both theseschools of nursing educate nursing students with social workstudents for child abuse and neglect education.The recommendations of Nazzaro are still sadly lacking 19years later. It would be improper to make suggestions about aforeign country's method of education and so the suggestionwould be that the province of British Columbia and particularlythe University of British Columbia, as it is the onlyeducational institution which educates doctors, psychologists,pharmacists, social workers, nurses, teachers and lawyers,establish an integrated child abuse and neglect educationalsystem.100Recommendations Concluded from the Study1.^Resourcesa. That a list of print, film and video resources becreated for use with nursing students. This listwould be updated annually and circulated toschools of nursing. A list such as this could becompiled by an agency such as the RegisteredNurses Association of British Columbia.b. That schools of nursing in British Columbia makegreater use of National Clearinghouse on FamilyViolence. That The Mountain and Beyond bepreviewed by nursing instructors and facultymembers teaching child abuse and neglecteducation.c. That libraries supporting schools of nursingconsider purchasing a copy of Campbell andHumphries (1984) or a similar book dealing withfamily violence from a nursing perspective.101^2.^Educationa. That child abuse and neglect reporting laws bemandatory in all nursing education.b. That indepth inservice education be establishedfor practising nurses, particularly those inhospitals and public health.c. That child abuse and neglect education bemandatory in all schools of nursing teachingdiploma, baccalaureate, refresher and graduatenursing students. That the number of hours beincreased to allow adequate preparation to teachhow to identify, prevent and care for child abuseand neglect victims and how to deal with theemotional challenges and legal implications anurse may face with both victims and offenders.d. That an interdisciplinary course of child abuseand neglect education be established atuniversities in British Columbia and Washington.^3.^Researcha.^That more studies be done looking at child abuseand neglect in schools of nursing particularlylooking at how the instructional time is spent.b.^That studies looking at actual reporting of childabuse and neglect by registered nurses be done.102C.  That if this study is repeated that it be done ata different time of year and that instructors andfaculty members are interviewed by telephone orin person so that more detail may be obtained andclarification can be done.ConclusionThe article by McKittrick opens with "child abuse is aloaded term. Most people have already formed opinions on thesubject" (1981, p. 103). The nurse has to deal with bothvictims and offenders (often at the same time) and this can bestressful and confusing. What they may have thought about childabuse and neglect can change as they establish relationshipswith their clients and patients. This could be particularlydifficult for a young nursing student or practising nurse whomay also be caring for someone who is dying of cancer, an angryalcoholic and an ill pregnant woman on the same day. Nurses areexpected to competently handle a variety of different anddifficult emotionally charged situations at the same time.Child abuse and neglect is part of the family violence web.Statistics are demonstrating that it is more common than unusualto have experienced some sort of child abuse or neglect.Newberger in Goldson (1991) wrote "We are coming to see that theessential element in child abuse (and neglect) is not theintention to destroy a child but rather the inability of aparent to nurture his offspring" (p. 1493). Nurses are in a103unique position of respect and trust and can help to educate andsupport the family and possibly intervene before child abuse orneglect occur. Nurses are highly visible in a multitude ofsettings perhaps more than any other profession associated withchild abuse and neglect. Why not capitalize on the nurses'diversification and make nurses the primary workers in theprevention and treatment of child abuse and neglect? Why noteducate nurses of the future to be prepared for this uniquerole? The answers to these questions lie in future research andimprovement of child abuse and neglect education in schools ofnursing.104BIBLIOGRAPHYBadgley, R.F. (1984). Sexual Offences Against Children inCanada: Summary. Ottawa: Canadian Government PublishingCentre.Broome, M. E. & Daniels, D.^(1987). Child abuse: Amultidimensional phenomenon. Holistic Nursing Practise,1,2, p. 13.Brown, L. (1992). Hidden secrets: Child abuse. Nursing B. C..Mar/Apr, 10 - 12.Burgess, A. (1990). Psychiatric nursing in the hospital andcommunity. (5th ed.) Norwalk, Conn.: Appleton and Lange.Burgess, A., Hartman, C. & Kelly, S. (1990). Assessing childabuse: the triads checklist. Journal of Psvchosocial Nursing, 28, 4, 6-14.Campbell, J. & Humphreys, J. (Eds.). (1984). Nursing care of victims of family violence. Reston, VA: Renton PublishingCo.Canadian Nurses Association. (1992). Family violence clinical guidelines for nurses. Ottawa: Author.Christensen, M.L. and Schommer, B.L. and Velasquez, J.(1984). An interdisciplinary approach to preventing childabuse. American Journal of Maternal Child Nursing, 9, 2,107-112.D'Avanzo, C.E. (1990). Incest: Break the silence, break thecycle. RN, 53, 10, 34-36.Finkelhor, D. (1979). Sexually victimized children. New York:Free Press.Finkelhor, D. (1984). Child sexual abuse: New theory andresearch. New York: Free Press.Gallmeier,^T.^&^Bonner,^B.^(1992).^University-basedinterdisciplinary training in child abuse and neglect.Child Abuse and Neglect, 16, 513-521.Gill, F. T. (1989). Caring for abused children in theemergency department. Holistic Nursing Practise, 4, 1, 37-43.105Goldson, E. (1991). The affective and cognitive sequelae ofchild maltreatment. Paediatric Clinics of North America,38, 6, 1481-1496.Hayes, P. (1981). The long-term treatment of victims of childabuse. Nursing clinics of North America, 16, 1, 139-147.Heins, M. (1984). The Battered Child Revisited. JAMA, 251, 24,3295-3300.Hibbard, R. A. & Serwint, J. (1987). Educational program onevaluation of alleged sexual abuse victims. Child Abuse andNeglect, 11, 513-519.Josten, L. (1978). Out-of-Hospital Care for a Pervasive FamilyProblem-- Child Abuse. Maternal Child Nursing, 3, 111- 116.Jurgrau, A. (1990). How to spot child abuse. RN, 53, 10, 26-33.Kelley, S. J. (1986). Learned helplessness in the sexuallyabused child. Issues in Comprehensive Pediatric Nursing, 9,3, p. 193 - 207.Kempe,C. H., Silverman, F. N., Steele, B. F., Droegemueller,W., & Silver, H. K. (1984). The Battered-Child Syndrome.JAMA, 251, 24, 3288-3294. (Reprinted from JAMA, 1962, 181:17-24).Kreitzer, M. (1981). Legal aspect of child abuse: Guidelinesfor the nurse. Nursing clinics of North America, 16, 1,149-161.Leaman, K. (1979). Recognizing and Helping the Abused Child.Nursing '79, 9, 64-67.Lewin, L. (1990). Establishing a therapeutic relationshipwith an abused child. Pediatric Nursing, 16, 3, 263-264.Little, M. (1985). Taking Action Against Child Sexual Abuse.The Canadian Nurse, 81, 37-39.McKeel, N. (1978). Child Abuse Can be prevented. AmericanJournal of Nursing, 78, 9, 1478 - 1482.McKittrick, C. A. (1981). Child abuse: Recognition andreporting by health professionals. Nursing clinics of NorthAmerica, 16, 1, p. 103.106Mittleton, R., Mittleton, H., Wetli, C. (1987). What childabuse looks like. American Journal of Nursing, 87, 9, 1185-1188.National Clearinghouse on Family Violence. (1990). TheMountain and Beyond [Multi-media). Ottawa: Author.Nazzaro, J. (1974). Child Abuse and Neglect. Exceptional Children, 40, 351-354.Olds, S. B. and London, L. and Ladewig, P. (1992). Maternal-Newborn Nursing; A Family-Centered Approach. Menlo Park.CA: Addison-Wesley Publishing Co.Rhodes, A. M. (1987). Identifying and reporting child abuse.MCN, 12, 6, 339.Scherb, B. J. (1988). Standardized care plans: suspectedabuse and neglect of children. Journal of EmergencyNursing, 14,1, 44-47.Sevel, F. (1989). Interprofessional approaches to publicpolicy issues: Graduate program in child abuse and neglect.Family and Community Health, 12, 3, 80-82.Shives, L. R. (1990). Basic concepts of psychiatric - mental health nursing (2nd ed.). New York: Lippincott.Smith, D. (1978). The maltreatment of children, Baltimore:University Park Press.Solomon, T. (1973). History and demography of child abuse.Pediatrics, 51, 773-776.The Ministry of Human Resources. (1985). Inter-ministry child abuse handbook. Victoria, B. C.: Queen's Printer.Watt, J. L. (1987). Child abuse reporting by registerednurses; is it a reflection of their training- - A look at the training of nursing students in British Columbia andWashington state. Unpublished manuscript.Webster's (1983). Ninth New Collegiate Dictionary. Markham,ON:Thomas Allen & Son Ltd.West. (1986). Revised Code of Washington Annotated, Title 26,Domestic Relations. St. Paul, MN: West Publishing Co.West. (1986). Revised Code of Washington Annotated, Title 70,Public Health and Safety. St. Paul, MN: West Publishing Co.107Whaley, L. & Wong, B. (1989). Essentials of pediatric nursing.St. Louis, Missouri: C. V. Mosby Co.Whaley, L. & Wong, B. (1983). Nursing care of infants and children. (2nd ed.) Scarbourough: C. V. Mosby Co.Whaley, L. and Wong, B. (1992). Nursing care of infants andchildren. (4th ed.) St. Louis, Missouri: C. V. Mosby Co.Wilson, H. & Kneisl, C. R. (1992). Psychiatric nursing.Redwood, CA: Addison-Wesley Nursing.APPENDIX A108109SCHOOLS OF NURSING AND THEIR LOCATIONIN THE PROVINCE OF BRITISH COLUMBIASchools of nursing^ LocationBritish Columbia Institute of Technology/^BurnabyOpen UniversityCamosun College^ VictoriaCollege of New Caledonia^ Prince GeorgeDouglas College^ New WestminsterEast Kootenay CranbrookKwantlen College^ SurreyMalaspina College NanaimoNorth Island College^ Campbell RiverNorthern Lights College Dawson CreekOkanagan University College^ KelownaOpen Learning Agency^ BurnabySelkirk College CastlegarTrinity Western University^ LangleyUniversity College of the Cariboo^KamloopsUniversity College of the Fraser Valley^ChilliwackUniversity of British Columbia^VancouverUniversity of Victoria^ VictoriaVancouver Community College VancouverVancouver General Hospital^ VancouverAPPENDIX B110SCHOOLS OF NURSING AND THEIR LOCATIONIN THE STATE OF WASHINGTONSchools of nursing^ LocationBellevue Community College^ BellevueClark College^ VancouverColumbia Basin College^ PascoEverett Community College EverettGonzaga University, Dept. of Nursing^SpokaneGrays Harbor College^ AberdeenHighline Community College^ Des MoinesIntercollegiate Center for Nursing Education Spokane(4 sites)Lower Columbia College^ LongviewOlympia College^ BremertonPacific Lutheran University^ TacomaPeninsula College^ Port AngelesSaint Martin's College LaceySeattle Central Community College^SeattleSeattle Pacific University School of^SeattleHealth SciencesSeattle University School of Nursing^SeattleShoreline Community College^ SeattleSkagit Valley College^ Mount VernonSouth Puget Sound Community College^OlympiaSpokane Community College^ SpokaneTacoma Community College Tacoma111112University of Washington^ SeattleWalla Walla Community College Walla WallaWalla Walla School of Nursing^ Portland, ORWenatchee Valley College WenatcheeYakima Valley College^ YakimaAPPENDIX C113POPULATIONS OF BRITISH COLUMBIA COMMUNITIESWITH SCHOOLS OF NURSING IN 1985114School of NursingBritish Columbia Instituteof TechnologyCamosun CollegeCariboo CollegeDouglas CollegeNew Caledonia CollegeOkanagan CollegeSelkirk CollegeUniversity of BritishColumbiaUniversity of VictoriaVancouver Community CollegeVancouver General HospitalCommunityBurnabyVictoriasurrounding areaKamloopsNew Westminstersurrounding areaPrince GeorgeKelownaCastlegarVancouversurrounding areaVictoriasurrounding areaVancouversurrounding areaVancouversurrounding areaPopulation136,49464,379233,48164,04838,5501,268,18367,55959,1967,251414,2811,268,18364,379233,481414,2811,268,183414,2811,268,183APPENDIX D115116POPULATIONS OF WASHINGTON STATE COMMUNITIESWITH SCHOOLS OF NURSING IN 1985School of Nursing^Community^PopulationBellevue Community College^Bellevue 73,903Clark College^ Vancouver^ 43,141Columbia Basin College^Pasco 17,944Intercollegiate Center for^Spokane^ 171,300Nursing EducationEastern Washington^Cheney 7,630UniversityWashington State Pullman^ 23,579UniversityWhitworth College^Spokane 171,300Pacific Lutheran University Tacoma^ 158,501Peninsula College^Port Angeles^17,311Seattle Central Community^Seattle 490,077CollegeSeattle Pacific University^Seattle^ 490,077School of Health SciencesSeattle University^Seattle 490,077University of Washington^Seattle^ 490,077Wenatchee Valley College^Wenatchee 17,444Yakima Valley Community^Yakima^ 49,826APPENDIX E117THE UNIVERSITY OF BRITISH COLUMBIA118Faculty of EducationDepartment of Mathematics andScience Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-5422^Fax: (604) 822-4714Current dateDean/Director/Chair/Head/CoordinatorSchool of NursingAddressCityPostal/Zip CodeDearThis letter is sent to you requesting that your school ofnursing participate in a research study involving all theschools of nursing in British Columbia and Washington State.The study is a survey of the curriculum content on child abuseas presented by schools of nursing which educate registerednurses and nursing students who are later eligible to writeexaminations for registration. The purpose of the project isto see if the number of hours and/or content has changedcompared to a study undertaken in 1985-86. The study will beavailable in the University of British Columbia library shouldany schools of nursing wish to borrow it and see the resourcesthat are in use at other schools of nursing. This shouldhopefully help to expand the list of resources available tonursing students in the Pacific Northwest which will in turnlead to a greater understanding of child abuse by nursingstudents. This study could be used by schools of nursing andR.N.A.B.C. in suggesting resources and curriculum content tohelp nurses to have a better understanding and recognition ofchild abuse and its effects and to help them to comply withB.C.'s mandatory reporting law.By distributing the questionnaire, you are giving your consentfor your school of nursing to participate in the study.Faculty/ Instructors have the right to refuse to answer anyquestion(s) or the questionnaire without jeopardizing theirstanding in your institution. Faculty/ Instructors are askedto return the questionnaire directly to me.No names of faculty or instructors will be used in thereporting of the study. Items will be identified by school ofnursing only.2If further clarification is needed, I will be happy to assistyou. My address is as follows;Judith L. WattScience EducationU.B.C. Faculty of Education2125 Main MallVancouver, B. C. CANADAV6T 1Z4or you may call me at home at (604) 948-0848. You may alsocontact one of my faculty advisors; Jim Gaskell (phone number604 822-5846) and Linda Peterat (phone number 604 822-4808).Thanking you for your anticipated kind cooperation in thisstudy.Sincerely,Judith L. Watt119120DearA month ago, I sent you a request toparticipate in a research study on childabuse education in schools of nursing. Yourreply is very important to this research andwould be greatly appreciated. Perhaps yourinstructors/faculty members were too busy tocomplete the research questionnaire withinthe dates given. Could you please ask themto complete it as soon as possible andforward it to me. If you need morequestionnaires please contact me.Thank you for your consideration.Judith L. Watt^ SignatureScience Education Phone no.U.B.C. Faculty of Education2125 Main MallVANCOUVER, B.C. V6T 1Z4APPENDIX F121THE UNIVERSITY OF BRITISH COLUMBIA122Faculty of EducationDepartment of Mathematics andScience Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-5422^Fax:(604) 822-4714Current dateDear Faculty member/Instructor;You have been asked by the dean/ director/ chair/ head orcoordinator of your school of nursing to complete thefollowing questionnaire. By distributing the questionnaire,your dean/ director/ chair/ head or coordinator has givenconsent for your school of nursing to participate in thestudy. You have the right to refuse to answer any question(s)or the questionnaire without jeopardizing your standing intheir institution. By completing and returning thequestionnaire, you are giving your consent to participate inthe study. You are asked to return the questionnaire directlyto me and not to give it back to the dean/director/chair headof your school of nursing.The study will be looking at information on child abuseeducation in schools of nursing in British Columbia andWashington where nursing students who are registered nurses orare later eligible to be registered nurses are being educated.The purpose of the project is to see if the number of hoursand/or content has changed compared to a study undertaken in1985-86.The study will be available in the University of BritishColumbia library should any schools of nursing wish to borrowit and see the resources that are in use at other schools ofnursing. This should hopefully help to expand the list ofresources available to nursing students in the PacificNorthwest which will in turn lead to a greater understandingof child abuse by nursing students. This study could be usedby schools of nursing and R.N.A.B.C. in suggesting resourcesand curriculum content to help nurses to have a betterunderstanding and recognition of child abuse and its effectsand to help them to comply with B.C.'s mandatory reportinglaw.1232The questionnaire should take you 30 minutes to complete. Youmay take longer to complete it if you wish to include longerexplanatory notes or include examples of your references orresources. On completion of the questionnaire you are askedto return it along with any copies of course outlines andobjectives and resources you might wish to send, to me at thefollowing address;Judith L. WattScience EducationU.B.C. Faculty of Education2125 Main MallVancouver, B. C. CANADAV6T 1Z4Mailing envelopes and postage have not been included becauseof the great variation in size and shape in responses to thesurvey of 1985-86.No names of faculty or instructors will be used in thereporting of the study. Items will be identified by school ofnursing only.If you have any questions about this research, please contactme, Judith Watt (home phone 604 948-0848) under the guidanceof faculty members Jim Gaskell (phone number 604 822-5846) andLinda Peterat (phone number 604 822-4808).Thanking you for your anticipated kind cooperation in thisstudy.Sincerely,Judith L. WattAPPENDIX G124125Faculty/Instructor Questionnaireon Child Abuse Educationin Schools of NursingName of School of Nursing:Answer the questions below using an "X" or check in thebrackets. If you wish to give more detail, use the spacesprovided or include extra sheets. Please match with thequestion number when providing more details. Thisquestionnaire should take 30 minutes to complete.Please return the completed questionnaire by 17 May, 1993.1. Number of years you have been teaching child abuseeducation to nursing students:O less than 1 yearO 1+ - 2 yearsO 2+ - 5 yearso 5+ - 10 yearso over 10 years2.^Number of nursing students you teach child abuseeducation to each yearO fewer than 10 studentsO 10 - 25 studentsO 26 - 50 studentsO 51 - 75 studentsO over 75 studentsIf over 75 students, please give approximate number ofstudents3. At the time of your child abuse instruction, are thenursing students you are teaching (mark all that apply):O registered nursesO eligible for registration on completion of program &examsO other types of nursing students (eg. practicals,aides)4. Did you receive child abuse education while you were anursing student?O NoO Can't remember• Yes1265.^Did you complete your baccalaureate degree in nursing in:O B. C.O WashingtonO CanadaO United States of AmericaO Other countryIf another country, where?O I do not have a baccalaureate in nursingO I have a non-nursing baccalaureate6. What subject area are you teaching child abuse educationin your school of nursing? (Please check all thatapply.)0 Paediatrics 0 Human Violence0 Obstetrics 0 Trauma0 Maternal/Child 0 Ethical issues0 Parent/Child 0 Trends and issues0 Psychiatry 0 Community health0 Mental Health o Advanced community0 Psychosocial 0 Nursing theory0 Sociology 0 Disruptive lifestyles0 Field placement 0 Abuse/Abusive behaviour0 Other (please list all that apply) ^7.^On the average, how many instructional hours do nursingstudents have on child abuse education?0 Do not teach 0 8+ - 10 hours0 Up to 1 hour 0 10+ - 12 hours0 1 - 2 hours 0 12+ - 14 hours0 2+ - 4 hours 0 14+ - 16 hours0 4+ - 6 hours 0 16+ - 18 hours0 6+ - 8 hours 0 18+ - 20 hours0 More than 20 hoursIf more than 20 hours, how many instructional hours?127On the average, how much instructional time (in hours)would you prefer to spend teaching child abuse education?0 Do not teach 0 8+ - 10 hours0 Up to 1 hour 0 10+ - 12 hours0 1 - 2 hours 0 12+ - 14 hours0 2+ - 4 hours 0 14+ - 16 hours0 4+ - 6 hours 0 16+ - 18 hours0 6+ - 8 hours 0 18+ - 20 hours0 More than 20 hoursIf more than 20 hours, how many instructional hours? ^9.^Do you teach child abuse education alone in yoursection/department or as part of a team?O Team teachingO Alone10. Do you teach child abuse education because it wasassigned to you or because you chose to teach this topic?O Assigned to meO I chose this topicO Both11. Are other faculty/instructors outside of your departmentresponsible for teaching a similar unit on child abuseeducation in your school of nursing?O NoO YesO Don't know12. What area(s) of child abuse education is/(are) taught inyour school of nursing? (Check all that you are awareof, please.)O Paediatrics^0 Human ViolenceO Obstetrics 0 TraumaO Maternal/Child 0 Ethical issuesO Parent/Child^0 Trends and issuesO Psychiatry 0 Community healthO Mental Health^0 Advanced communityO Psychosocial^0 Nursing theoryO Sociology^0 Disruptive lifestylesO Field placement 0 Abuse/Abusive behaviourO Other (please list all that apply) ^8.12813. How important do you think it is for a nursingstudent to receive child abuse education? (Pleasecircle your choice.)Very^7^6^5^4^3^2^1^Not reallyimportant necessary14. Rank order the following types of child abuse in terms oftheir relative importance to educating nursing studentsat your school of nursing.Rank order4^5^6^7^Least importantMost important^1 2^3Physical neglect ( )Physical abuse ( )Emotional neglect ( )Emotional abuse ( )Sexual abuse ( )Verbal abuse ( )Passive abuse ( )15. In general, are you satisfied with the child abuseeducation in your school of nursing? (Please circle yourchoice.)^Very 7^6^5^4^3^2^1^Totallysatisfied dissatisfiedComment:16. What would you like to see happen at your school ofnursing to improve child abuse education? (If you feelit could be improved. Please continue on the back ofthis page if necessary.)12917. What resource people do you use in your child abusepresentation(s)? (Please check all that apply.)O Other faculty/instructors^0^Social workerO Police^ 0^LawyerO C.P.A. worker^ 0^SheriffO Victim 0^OffenderO OtherIf other, please specify: ^18. What resource materials do you require your nursingstudents to use? (Please check all that apply.)O Read assigned pages in a textbookO Read assigned articlesO Do own personal research in libraryO Interview someone• OtherPlease list or attach a list of assigned readings and ifpossible give author, date, and publication details:13019. What types of assignments do you ask your nursingstudents to do on the subject of child abuse?O Write a paperO Present an inserviceO Nursing care planO OtherIf other, please describe:20. Are nursing students at your school of nursing made awareof their responsibility to report child abuse?O NoO YesO Don't know, not covered in my area but may becovered in another part of the program.21. When a child has a sexually transmitted disease, arenursing students at your school of nursing made awarethat a Registered Nurse must report both:A. a sexually transmitted disease andB. child abuseO NoO YesO Don't know, not covered in my area but may becovered in another part of the program.O Not a law in my province or stateWhich one must be reported first (A or B)?13122. Are nursing students at your school of nursing taughtabout child abuse in a group of only nursing students ortogether with other professionals who will also have todeal with aspects of child abuse?O As nursing students onlyO With other professionals23. If you answered "with other professionals" in the abovequestion, which professionals are you aware of that aretaught with your nursing students?O law studentsO medical studentsO dental studentsO social work studentsO education studentsThank you for completing this questionnaire. Please feel freeto include any extra information or comments which you feelmay be of interest.PLEASE RETURN THE QUESTIONNAIRE BY 17 MAY 1993 TO:Judith L. WattScience EducationU.B.C. Faculty of Education2125 Main MallVancouver, B. C. CANADAV6T 1Z4

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