The Journal of School Nursing2021, Vol. 37(3) 176-184© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519863843journals.sagepub.com/home/jsn
Child abuse recognition and the protection of children is a global concern. In Sweden, the role of the school nurse (SN) is to promote schoolchildren’s health and development and to identify and prevent harm. The aim of this study was to describe Swedish SN experiences of suspecting, identifying, and reporting child abuse and to compare them with respect to (a) years of experience as SN, (b) age of SN, and (c) pupil population size. A descriptive design was used. Two-hundred and thirty-three SNs completed a survey detailing their experiences. Most SNs (96%) reported having suspected a child suffering from physical or psychological abuse. Approximately half of them reported occurrences of honor-related violence (54%) and of child sexual abuse (57%). SNs with less nursing experience reported significantly less recognition and reporting of child abuse. The findings indicate that experiences of child abuse are common. Thus, it is vital that SNs have the necessary competency and support to identify and report suspected child abuse.
abuse, school nurse, child maltreatment, honor-based violence, sexual abuse, neglect, health promotion, prevention
In this article, we report on a study of school nurses’ (SNs) experiences of suspecting, identifying, and reporting child abuse. Child abuse is defined as physical, sexual, and emotional abuse and/or neglect of persons under 18 years of age, resulting in actual or potential harm to the child’s health, survival, development, or dignity (World Health Organization, 2017). Abuse against children is globally common (World Health Organization, 2016), and it is well documented that children can be victims of child abuse both within and outside of their family. Moody, Cannings-John, Hood, Kemp, and Robling (2018) report that prevalence rates differ substantially by continent, child abuse category, and gender, although girls are at greater risk of sexual abuse on all continents (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). Furthermore, honor-related violence related to systems of patriarchal values and behavior poses a risk for girls (Mayeda & Vijaykumar, 2016), although boys may also be victims, for instance, as a consequence of an inappropriate relationships, being gay or having a disability (The National Health Service, 2019). The recognition of child abuse in all its forms and the protection of children being abused are of utmost importance to all involved in caring for them.
Safeguarding children is a global concern (United Nations Children’s Fund, 2017). Child abuse will have consequences for the well-being of the child. Physical abuse in childhood is linked to psychosomatic symptoms, risk of depression, higher rates of mental health problems and psychiatric disorders (Bonvanie, van Gils, Janssens, & Rosmalen, 2015; Burke, Hellman, Scott, Weems, & Carrion, 2011; Chen et al., 2010). Furthermore, negative influences on health and academic achievement are well-documented in the literature (De Bellis, Woolley, & Hooper, 2013). Children have the right to a meaningful life, safety, and dignity, and the Convention on the Rights of the Child (UNICEF, 2009) aims to safeguard these rights.
Sweden was the first country in the world to ban the physical abuse of children in 1979. However, almost 40 year later, one in three children report that they have been abused sometime during their upbringing (Landberg, Jernbro, & Jansson, 2017). Similar to many other countries, selected groups of Swedish professionals, for example, SNs, teachers, and doctors have a legislative requirement to report suspected cases of child abuse to government authorities. This includes a legal obligation to report the suspicion of a child in need of protection to authorities, without requiring proof that abuse has actually occurred (The Ministry of Health and Social Affairs, 2001). Although other countries, such as the UK, have no such legal requirement, nurses are still ethically obliged to intervene and report suspected abuse (Lines, Hutton, & Grant, 2017). Child abuse is stated to be underreported by nurses (Lines et al., 2017) and a study on Dutch nurses reported that while nurses are aware of their role in safeguarding children, they do not always take necessary actions when required (Louwers et al., 2012).
Sweden schools have a school health service organization including professionals such as school physicians and nurses, psychologists, social workers, guidance counselors, and special education teachers. The main objective of the school health service is to provide medical, psychological, psychosocial, and special education services to support environments that promote schoolchildren’s learning, development, and health (Gustafsson et al., 2010; The National Board of Health and Welfare & Swedish National Agency for Education, 2016). The SN plays a key role in the Swedish school health service organization and a pivotal role in promoting schoolchildren’s health, academic achievement and development, as well as identifying and preventing harm to schoolchildren (The Swedish National Agency for Education, 2010). All professionals can, and are required by law, to make mandatory reports on schoolchildren suspected of being abused, but it is mainly the SN or school principal who generally make mandatory reports. Swedish SNs identify pupil’s health risks using a series of scheduled health dialogues with schoolchildren throughout the school years, based on a two-way interactive communication model (The National Board of Health and Welfare & Swedish National Agency for Education, 2016; The Swedish National Agency for Education, 2010). The identification of children at risk of abuse is an integral part of this dialogue. SNs also network with other professions within and outside the school to prevent and identify abuse against children.
Abuse against children is complex and may be difficult to detect. Alerting features for physical abuse includes unusual injuries, often with an absent or improbable explanation. Features for sexual abuse can be inappropriate sexualized behavior for the child’s age. Neglect can be suspected with child who present as dirty or with unsuitable clothing (Saperia, Lakhanpaul, Kemp, & Glaser, 2009). There are barriers and facilitators related to the reporting of child abuse. Barriers have been described in relation to lack of time, knowledge, and policy by those who would usually report suspected abuse. Problems related to communication with parents in the case of suspected abuse have also been mentioned as a barrier (Lines et al., 2017; Louwers et al., 2012). Additional barriers may be related to nurses’ experiences and beliefs that reporting could lead to poorer outcomes for children (Borimnejad & Khoshnavay Fomani, 2015). Furthermore, there may be challenges in the protecting of children and reporting of child abuse related to lack of legal support to undertake this role (Maul et al., 2019). Pediatric nurses with continued education including education on child abuse were found to express greater confidence in child abuse management and more likely to report suspected child abuse (Herendeen, Blevins, Anson, & Smith, 2014). Moreover, previous research points to trusting relationships between adults and children as important in identifying and supporting children suspected of being abused (Kraft & Eriksson, 2015).
The protection of children being abused is a major health concern. Suspicion, recognition, and reporting of child abuse is noted to be common among nurses internationally and in different contexts, such as nurses at emergency departments, pediatric awards, in public health services, or among SNs (Lines et al., 2017; Louwers et al., 2012; Pabis, Wronska, Slusarska, & Cuber, 2011; Rolim, Moreira, Gondim, Da Silva Paz, & De Souza Vieira, 2014). SNs meet a great number of children and have a key position in recognizing abused children and protecting them. There is a dearth of empirical knowledge regarding suspicion, identification, and reporting of child abuse among SNs. Therefore, the aim of this study was to describe Swedish SNs’ experiences of suspecting, identifying, and reporting child abuse and to compare them with respect to (a) years of experience as SN, (b) age of SN, and (c) pupil population size.
A cross-sectional survey design was used. The study followed the ethical regulations and guidelines outlined in Swedish law (The Ministry of Education and Research, 2003) and the Code of Ethics of the Declaration of Helsinki (World Medical Association, 2008).
A convenience sample of SNs was asked to complete the survey on their experiences of child abuse. Swedish SNs are registered nurses with at least a 3-year bachelor degree in nursing. The majority of the 3,000 or so SNs in Sweden also have a postgraduate degree specializing in child and/or school nursing.
Data were collected from SNs attending the annual National Swedish School Nursing Conference in 2018. Two of the researchers had a booth at the conference, and SNs who were passing their booth were asked to complete the survey. The survey was completed by 233 of 1,900 attendees who represented geographical areas across Sweden.
A survey combining closed-ended and open-ended questions was used. A set of nine closed-ended questions pertaining to experiences of three areas such as (a) children physically or psychologically abused within the family, (b) honor-related violence, and (c) child sexual abuse were used. To determine the frequency of the SNs’ experiences, they were asked to answer questions on a 4-point Likert-type scale: never experienced (1), have experienced, but not over the past year (2), have experienced 1–3 times over the past year (3), and have experienced 4 times or more over the past year (4). Demographic characteristics such as age, work experience as a SN, specialist nursing degree, and size of their pupil population were also gathered. Three open-ended questions were used for qualitative descriptions—Two of these questions concerned experiences of mandatory reporting made by other professionals and other forms of child abuse not requested in the survey. The third open-ended question allowed the participants to freely share anything else they wished to emphasize about child abuse or suspected child abuse. The open-ended, free-form survey questions allowed SNs to report their answers as open text.
Reported answers related to the frequency of different experiences and demographic characteristics. These were analyzed descriptively using IBM SPSS Statistics software, Version 24 and presented as frequency, percentage, mean, and range. SNs as a group were divided according to experience, age, and number of pupils each was responsible for, for comparison purposes. To compare SNs’ work experiences, those with more than or less than 3 years’ work experience were divided in two groups. Mean age was used to split the SNs in two equal groups to make comparison with regard to their age. To analyze differences with respect to the number of pupils, each SN was responsible for, those with more or less than 500 children were compared. We analyzed differences between groups using X2 tests. The level of statistical significance was set at .05.
Answers to the open-ended questions were analyzed with a method for qualitative content analysis (Elo & Kyngäs, 2008). Text reported by the nurses was carefully read several times by two of the authors and reviewed for content. The content was condensed and sorted into a summarizing text. These descriptions were reviewed and discussed among all authors until consensus on content was reached.
It was made clear that participation was voluntary, and written informed consent was obtained from all participants. The survey was answered anonymously and no personal identifiers were requested or retained.
A total of 233 SNs completed the survey. They were all women, aged 26–69 (M = 50, SD = 9.2). They had work experiences as a SN ranging from 1 to 48 years (M = 10, SD = 9.7). Almost everyone (98%, n = 288) had a specialized nursing degree, most of them in district nursing (n = 132) or pediatric nursing (n = 66). Just over half the population (58%, n = 136) reported the size of their pupil population to be 500 pupils or less, and the rest of them had more than 500.
Child abuse within the family. Most SNs reported having experiences of child abuse within the child’s family (see Table 1). Almost all of them (96%, n = 223) had experiences of suspecting children being victims of physical or psychological abuse within the family. The number of SNs with experiences of children who admitted to being abused was lower (86%, n = 200). Most SNs (84%, n = 193) had made a mandatory report of the abuse. Half of the SNs (50%, n = 116) had made a mandatory report within the past year.
Honor-related violence. The second area concerned experiences of honor-related violence. Approximately half of SNs (54%, n = 125) reported experiences regarding honorrelated violence against children (see Table 2). There were only a few (11%, n = 26) with experiences from honorrelated violence within the past year. In total, approximately a third of all SNs (36%, n = 85) had experiences of making a mandatory report of the abuse, and 1 of 10 (10%, n = 23) had made a mandatory report within the past year.
Child sexual abuse. Experiences of child sexual abuse were less common (see Table 3). Among the SNs, 57% (n = 133) had suspected child sexual abuse. Fewer (42%, n = 97) had experiences from children admitting sexual abuse, and only 37% (n = 86) had made a mandatory report on suspected sexual abuse. Only 8% (n = 19) had made a mandatory report on sexual abuse within the past year, despite the fact that the frequency of SNs with experiences of children admitting to this form of abuse was 14% (n = 32), during the same period.
Statistical analyses of differences between SNs with varying amounts of work experience showed that SNs with less work experience reported significantly less experiences of child abuse in all areas (see Table 4). There were also some significant differences between younger and older SNs, when comparing frequency of reported experiences of honorrelated violence, with regard to age (see Table 5). No significant differences were found among the SNs frequency of experiences with regard to size of pupil population in their organization.
Experience of mandatory reports made by other professionals. SNs’ experience of mandatory reporting by other professionals within or outside the school was high (91%, n = 211). Reports were commonly made by the school principal (n = 130) and school social workers (n = 124). A few nurses reported concerns raised by teachers, parents, and neighbors.
Experiences of other forms of child abuse than those requested in the survey. There were a small number of reports on other kinds of child abuse, such as violence between children at school (n = 12) and between children during their leisure time (n = 8). Additionally, there were some lone reports on violence from siblings, from partners, or from immigrants for those in temporary immigrant accommodation.
Other aspects highlighted by the SNs from open text answers regarding child abuse or suspected child abuse. Some of the SNs (n = 42) commented on other aspects they wanted to address. Short comments, about 1–3 lines, were made on different aspects of importance when suspecting or recognizing abused children. They underscored the importance of paying attention to the individual child, of listening to their story, the importance of asking questions and to believe in the story narrated by the child. Collaboration between professionals in and outside school was stressed as crucial. They also described the need for ongoing education and professional tutoring on the topic.
Child abuse was a common experience among the SNs in this study and presumably a continuing challenge for SNs as a profession. Experiences of physical or psychological abuse were the most common, followed by experiences of child sexual abuse and experiences of honor-related violence. Despite the fact that a legal ban on abuse of children has been in place in Sweden since 1979 and all professionals within the school system are required by law to report suspicion of child abuse to government authorities (The Ministry of Health and Social Affairs, 2001), the findings seem to indicate that SNs do not report all pupils they suspect of being abused. One remarkable and concerning result of this study is that SNs do not always report even when children admit to having been abused. Deeper reflection on the circumstances affecting SNs’ mandatory reporting is obviously necessary. The literature reports aspects that contribute to failure in mandatory reporting such as lack of knowledge in identifying child abuse (Lines et al., 2017; Taylor & Bradbury-Jones, 2015) and uncertainty about what the possible consequences of reporting would mean for the child (Borimnejad & Khoshnavay Fomani, 2015). Furthermore, research shows that honor-related violence is complex and difficult to manage for professionals such as SNs (Alizadeh, Törnkvist, & Hylander, 2011). SNs may avoid addressing sexual abuse, which in turn can affect possibilities to detect such abuse. This avoidance could be linked to the arousal of strong feelings, a complicated disclosure process, and ambivalence to address the issue (Engh Kraft, Rahm, & Eriksson, 2017). Alizadeh, Törnkvist, and Hylander (2011) point out that school staff want to involve parents in the process of reporting abuse but they are afraid that these actions could make the situation worse for the child.
The result also shows that SNs with less work experience reported significantly less recognition and reporting of child abuse. Similar to the study by Rolim, Moreira, Gondim, Da Silva Paz, and De Souza Vieira (2014), nurses with more years of work experience more readily report child abuse. Studies with a child perspective show that multiple psychosomatic symptoms were associated with child physical abuse (Jernbro, Svensson, Tingberg, & Janson, 2012) as well as sexual abuse (Bonvanie et al., 2015). This highlights the fact that SNs need to consider and exclude abuse as a possible cause for children suffering from psychosomatic symptoms. The question “Can this be caused by abuse?” needs to be uppermost on the SN’s mind.
Findings from the present study’s open answers highlight the importance of listening to the individual child and believing in their story. Research shows that early intervention and a child-centered approach in the organization of school health care and social care is of the utmost important in protecting children from abuse (Peckover & Trotter, 2015). Group interventions for children exposed to domestic violence, and/or their families, are described as cost effective and well received, but there is limited evidence for their effectiveness (Bunston, Pavlidis, & Cartwritght, 2016; Howarth et al., 2016). However, according to Fellin et al. (2019), group interventions that offer a safe place to identify, discuss, and value one’s own and others emotional response and coping strategies were shown to be effective. Group activities could be a way for SNs to provide vulnerable children with opportunities to create a confident and safe relationship with a SN. The results of the present article raise concerns about how to increase the frequency of SNs’ mandatory reporting of child abuse. There is also real need for better understanding on why reports are not happening in specific instances, and what other elements can help to address this.
Existing barriers to reporting such as the nondetection of signs and symptoms, failure in gathering information that confirms concerns, and lack of communication with social services must be addressed (Harding, Davison-Fischer, Bekaert, & Appleton, 2019). Dahlbo, Jakobsson, and Lundqvist (2017) found that suspecting child abuse is stressful for nurses and requires professional supervision in order to reflect and learn for next time. Other research argues that care for children should move from family-centered care to a child-centered care approach (Coyne, Hallström, & Söderbäck, 2016). Parents and professional dominance constructs an asymmetric adult relationship toward the child, which may deflect focus from the child. The child’s perspective is necessary in order to view and strengthen the child as an agent with his or her own experiences and wishes that need to be respected and negotiated. The child’s own perspective is particularly relevant in Sweden at present as the United Nations Convention on the Rights of the Child Declaration is proposed as law from next year, 2020. Hopefully, more countries will follow the same development in strengthening children’s rights. All SNs must take a child-rights perspective in order to protect the child and create a safe and sustainable life and school environment.
Child abuse is something SNs must be prepared for in their everyday work lives. Ongoing education and support can help ensure that SN’s can encourage children’s stories about bad experiences. Competence in managing and supporting children in need can be encouraged by reflections, supervision, and debriefing.
A child perspective seems imperative for SNs when meeting children at risk of abuse or neglect. The understanding and sensitivity of children’s expressions, both verbal and nonverbal, may be a key feature in abuse identification, and more focus is needed on the SNs’ interaction with these children. Improved communication skills, based on a child perceptive, would help SNs’ dialogues with children and are in line with the aims of Convention on the Rights of the Child (UNICEF, 2009).
This study was limited to the voluntary reporting of SNs attending the National School Nursing Conference in Sweden in 2018. However, a sufficiently large sample was obtained that allowed for comparisons. Findings may be restricted to a specific Swedish context, which may impair transferability to other countries.
To our knowledge, this study is the first of its kind. Moreover, there is a dearth of studies on SNs’ perspectives of how they act when suspecting and reporting sexual and honor abuse. Thus, more knowledge is needed to understand the underlying processes and barriers for the reporting of child abuse and for safeguarding children. The development of interventions for supporting SNs in detecting and caring for children suffering from abuse is an issue for future research.
This study addresses the frequency of SNs’ experiences of suspecting, identifying, and reporting child abuse. The findings indicate that experiences of child abuse are common among Swedish SNs. SNs must have the necessary conditions and competencies to identify and report child abuse and ultimately to protect and prevent children from harm and support their learning, development, and health. The findings of this study emphasize the vital role SNs play in protecting children from child abuse.
We thank all school nurses who participated in this study for their valuable efforts. We also thank Senior Lecturer Magnus Lundin, Department of Engineering at University of Borås, for discussions and help with statistical analyses.
All authors contributed to the conception of the article, acquisition as well as analysis of the data, drafting of the article along with the critical revisions. All agree to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Annelie J. Sundler, RN, PhD https://orcid.org/0000-0002-9194-3244
Margaretha Larsson, RN, PhD https://orcid.org/0000-0001-7368-953X
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Annelie J. Sundler, RN, PhD, is an associate professor at the University of Borås, Borås, Sweden.
Marie Whilson, RN, PhD, is a senior lecturer at the University of Skövde, Skövde, Sweden.
Laura Darcy, RN, PhD, is a senior lecturer at the University of Borås, Borås, Sweden.
Margaretha Larsson, RN, PhD, is a senior lecturer at the University of Skövde, Skövde, Sweden.
1 Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
2 Institution of Health and Learning, University of Skövde, Skövde, Sweden
Corresponding Author:Annelie J Sundler, RN, PhD, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås SE-501 90, Sweden.Email: annelie.sundler@hb.se
