The 33 interviews (conducted between June 2007 and January 2008) lasted on average 38 (range 22–76) minutes each.
First, the health professionals were asked if they ever suspected child abuse in the ED and what they found difficult about these situations. Four of the seven pediatricians found it difficult to discuss suspected child abuse with the parents; this was mainly due to practical problems (e.g. limited time, lack of a suitable/quiet location) and personal barriers (e.g. fear of an unjustified suspicion). The two surgeons had a similar experience and also mentioned the problem of separating the child’s medical treatment from the investigation of possible abuse. They considered medical treatment to be their prime responsibility and prefer to leave investigation of abuse to other professionals, e.g. the pediatrician or the Child Abuse Center (Table
, proposition 2). Five ED nurses considered communication to be a limiting factor, e.g. when parents questioned the need for a head-to-toe examination when their child had a local injury only.
Propositions presented to the interviewees at the end of the interview
Child abuse framework
During the interviews, the following elements of the Inspectorates’ Child Abuse Framework (Table
) were mentioned.
A. Policy (propositions 1–3): Health professionals saw active support from the hospital Board as a positive factor, whereas the lack thereof was seen as a bottleneck. When the Board was supportive they arranged for example the appointment of a special child abuse attendant. The Board unanimously indicated that they were open to a more active policy on the detection of child abuse. However, one Board member remarked: ‘It’s difficult to find budgeting in these times of cutbacks’ and another said: ‘We can tackle all sorts of problems of our society but if there are no financial compensations, then we should really limit to our core business; treating real pathology.’
B. Child abuse team, child abuse attendant, collaboration Child Abuse Center (propositions 4, 5): Three of the 7 hospitals had a child abuse team which focused on policy and/or cases. Organizing a team meeting was a bottleneck ‘…because it’s difficult to meet during working hours and people aren’t so willing to meet after work’. Five Board members found the appointment of a child abuse attendant useful, but ‘…no money was available’, or ‘it belongs to the normal package of social work’. One Board member was ‘…not in favor of creating functions with special areas, as the primary person (ED nurse) would no longer feel responsible’.
The health professionals were satisfied with the collaboration with the Child Abuse Center.
C. Protocol for suspected child abuse (propositions 6–8): All physicians stated that their hospital had a protocol for suspected child abuse. However, among the other interviewees, not all were aware of it or did not know where to find the protocol.
At the time of the interviews, screening for child abuse by completing a SPUTOVAMO form (or a checklist derived from SPUTOVAMO) was conducted in 5 of 7 participating hospitals; 2 hospitals did not screen for child abuse because of disagreement about its usefulness or about the profession that should complete the screening instrument. Irrespective of whether or not screening took place, the majority thought that child abuse is not always detected in the ED. ED managers agreed that screening belongs to the work of the ED. However, during busy hours ED nurses often disregard the checklist, even though it can be filled in relatively quickly.
D. Professional development (propositions 9, 10): In all hospitals the pediatricians provided some training on recognizing and dealing with child abuse, albeit sporadically and without a structured program. In one hospital, all staff had recently received intensive training in detecting child abuse. A fast turnover of ED staff (especially junior doctors) was an obstacle to organizing teaching and maintaining the level of knowledge. Two physicians found that lack of motivation among the ED staff was also an obstacle. Almost all nurses and physicians stated that more emphasis should be placed on detecting child abuse during their basic training.
Also interviewed were five child abuse experts and in addition, we asked an implementation expert for advice on how to implement a screening protocol for child abuse at EDs.
A. Policy: To ensure funding for the policy to tackle child abuse, two experts advised to adjust the DBC code (Diagnostic/Treatment code in the Dutch medico-financial system) for child abuse ‘…then hospitals will receive the money they need for this type of care’.
B. Child abuse team, child abuse attendant, collaboration with the Child Abuse Center: The experts think that child abuse teams are necessary for good collaboration between the various disciplines. Two experts advised to evaluate the policy twice a year with the complete team; for specific cases they advised to review these only with the specific professionals involved. Four experts found it worthwhile to invest in and appoint an attendant specifically for child abuse, especially because psychosocial research and referral to child care entails considerable time and effort. A child abuse attendant can guarantee quality control, rapidity of treatment or referrals, and proper follow-up of patients.
C. Protocol for suspected child abuse: Introduction of a national protocol, with local modifications, was supported by the experts. This will ensure uniformity of the process and prevent each hospital having to develop its own protocol.
All experts found screening for child abuse at EDs worthwhile, and considered a head-to-toe examination an essential part of screening, because important signs of child abuse often can be found on the skin. This is not standard practice for all ED nurses, because they often have a problem with undressing a child completely when the child has only a local complaint or injury. Overall screening for child abuse can become more acceptable for ED nurses and parents if the hospital informs all parents about the routine screening process, e.g. via brochures, flyers, announcements, etc.
D. Professional development: The experts emphasised that for successful screening and early detection of child abuse, ED staff needs adequate training. This can be realized by including detection of child abuse in the medical training of physicians and nurses; in this way physicians will also learn to include child abuse in their differential diagnosis. Important topics during training are interviewing techniques/communication skills, and relating injuries with the history and developmental phase of the child.
When implementing improvements in a workplace, it is important to proceed along appropriate steps. The following steps are based on the model of Grol et al. [10
The first step is to define ‘good care’ based on the literature and/or expert opinions. Then, indicators are defined to measure the quality of good care, e.g. ‘…during the triage ED nurses will screen for child abuse in more than 90% of the children’. Subsequently, the current situation is investigated in the participating hospitals, i.e. do they meet the indicators of good care? If not, the barriers to this are explored by means of interviews or questionnaires. A decision is made as to which part of the implementation package is needed in each hospital, and implementation can then start. Finally, the effect can be measured by the indicators of good care.
The facilitators and barriers for screening of child abuse at emergency departments are summarized in Table
Facilitators and barriers for screening of child abuse in emergency departments