An Evidence-Based Educational Intervention to Improve the Recognition and Photo Documentation of Child Abuse Injuries in a Rural Health Facility

Background: Child abuse is an unfortunate reality for millions of children across the United States every year. The consequences of abuse result in long term emotional problems, including aggressive behavior, depression, anxiety, and thoughts of suicide; physical consequences include risk of asthma, hypertension, cardiovascular disease, and obesity. Lack of education has been cited as one of the reasons that many clinicians fail to report suspected child abuse. This quality improvement intervention evaluated the impact of child maltreatment education on the knowledge of clinical facility staff, as well as their comfort in reporting suspected child abuse. This intervention was set in a rural, 99-bed acute-care healthcare facility in Sweetwater County Wyoming, and included participants from many departments, including administration, nursing, dietary, education, and quality improvement. Methods: The Ace Star Model of Knowledge Transformation was used in the development of this educational intervention. Discovery research was conducted, and an evidence summary occurred prior to the translation to guidelines; translation to guidelines included the development of a pre education assessment, which was conducted approximately two weeks prior to the education sessions. Practice integration occurred with the presentation of five, one-hour education sessions, which were conducted at the facility over a two-day period. Process, outcome, and evaluation occurred with the administration of a post education assessment, which took place approximately four to eight weeks following the education sessions and analysis of data. Intervention: A simple pre education assessment was conducted to evaluate participant comfort with recognizing child physical abuse, familiarity with state reporting hotlines, and mandates requiring the reporting of suspected abuse. Participant barriers to reporting suspected abuse were ascertained to evaluate possible reasons that abuse is under-reported in healthcare facilities. Finally, 11 questions were developed to assess participant knowledge of the general topic of child physical abuse. Education about abuse was presented to facility staff, and the assessment was re-administered four weeks after to determine the effectiveness of the child maltreatment education. Results: Following the intervention, there was a statistically significant improvement in participants' comfort in their ability to recognize child physical abuse (p = 0.02). Many participants were aware of the mandate to report suspected abuse, and most were unfamiliar with the reporting hotline; the education intervention resulted in a statistically significant increase in the familiarity with the reporting hotline (p = 0.18). The barriers mentioned in the pre-education assessment were significantly reduced following participation in the educational session, with many of the participants stating that they now had no barriers to reporting. Overall participant knowledge related to child maltreatment injuries (p = 0.0034) also showed a statistically significant increase. Conclusions: Based on feedback from participants, the information presented in this educational intervention was relevant to all who attended and was useful in improving their ability to recognize possible abusive injuries. The results showed improvements in most areas assessed, and the project lead believes that there is the potential for greater success with implementation of this educational intervention at additional sites, including those where the rates of child maltreatment may be higher.

Running head: CHILD ABUSE RECOGNITION/DOCUMENTATION An Evidence-Based Educational Intervention to Improve the Recognition and Photo Documentation of Child Abuse Injuries in a Rural Health Facility Tami L. Fikstad Byrd Project Chair: Amanda Al-Khudairi DNP Content Experts: Julie Balk DNP, Antoinette Laskey MD, Corey Rood MD University of Utah College of Nursing In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice CHILD ABUSE RECOGNITION/DOCUMENTATION An Evidence-Based Educational Intervention to Improve the Recognition and Photo 2 Documentation of Child Abuse Injuries in a Rural Health Facility Abstract Background: Child abuse is an unfortunate reality for millions of children across the United States every year. The consequences of abuse result in long term emotional problems, including aggressive behavior, depression, anxiety, and thoughts of suicide; physical consequences include risk of asthma, hypertension, cardiovascular disease, and obesity. Lack of education has been cited as one of the reasons that many clinicians fail to report suspected child abuse. This quality improvement intervention evaluated the impact of child maltreatment education on the knowledge of clinical facility staff, as well as their comfort in reporting suspected child abuse. This intervention was set in a rural, 99-bed acute-care healthcare facility in Sweetwater County Wyoming, and included participants from many departments, including administration, nursing, dietary, education, and quality improvement. Methods: The Ace Star Model of Knowledge Transformation was used in the development of this educational intervention. Discovery research was conducted, and an evidence summary occurred prior to the translation to guidelines; translation to guidelines included the development of a pre education assessment, which was conducted approximately two weeks prior to the education sessions. Practice integration occurred with the presentation of five, one-hour education sessions, which were conducted at the facility over a two-day period. Process, outcome, and evaluation occurred with the administration of a post education assessment, which took place approximately four to eight weeks following the education sessions and analysis of data. CHILD ABUSE RECOGNITION/DOCUMENTATION 3 Intervention: A simple pre education assessment was conducted to evaluate participant comfort with recognizing child physical abuse, familiarity with state reporting hotlines, and mandates requiring the reporting of suspected abuse. Participant barriers to reporting suspected abuse were ascertained to evaluate possible reasons that abuse is under-reported in healthcare facilities. Finally, 11 questions were developed to assess participant knowledge of the general topic of child physical abuse. Education about abuse was presented to facility staff, and the assessment was re-administered four weeks after to determine the effectiveness of the child maltreatment education. Results: Following the intervention, there was a statistically significant improvement in participants' comfort in their ability to recognize child physical abuse (p = 0.02). Many participants were aware of the mandate to report suspected abuse, and most were unfamiliar with the reporting hotline; the education intervention resulted in a statistically significant increase in the familiarity with the reporting hotline (p = 0.18). The barriers mentioned in the pre-education assessment were significantly reduced following participation in the educational session, with many of the participants stating that they now had no barriers to reporting. Overall participant knowledge related to child maltreatment injuries (p = 0.0034) also showed a statistically significant increase. Conclusions: Based on feedback from participants, the information presented in this educational intervention was relevant to all who attended and was useful in improving their ability to recognize possible abusive injuries. The results showed improvements in most areas assessed, and the project lead believes that there is the potential for greater success with implementation of this educational intervention at additional sites, including those where the rates of child maltreatment may be higher. CHILD ABUSE RECOGNITION/DOCUMENTATION Keywords: child abuse, education, intervention, barriers, comfort 4 Introduction Problem Description Child maltreatment is a devastating reality facing millions of children in our country every year. During the fiscal year 2015, Child protective services (CPS agencies from across the United States received approximately four million referrals, involving approximately 7.2 million children (US Department of Health and Human Services (HHS), 2015). The claims related to these numbers involve possible child abuse and maltreatment, with 58.2% of these cases confirmed by investigation (HHS, 2015). Unfortunately, officials estimate that within the same period of time, 1,670 children died from injuries related to abuse, with approximately 74.8% of these children being under the age of three years; approximately 77.7% of fatalities involved at least one parent (HHS, 2015). Recognition of minor but suspicious sentinel injuries by healthcare providers allows for early intervention and treatment, and protection from future escalation of abusive injuries (Christian, 2015). Definitions of child abuse and maltreatment may vary slightly across the United States, with each state adopting a definition that is based on the minimum standards set forth in the Child Abuse Prevention and Treatment Act (CAPTA), 2010, which states: Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act, which presents an imminent risk of serious harm. (HHS, 2015) Some of the most significant risk factors associated with the maltreatment of children include drug, alcohol, and controlled substance abuse; poverty; mental health issues; living within a rural community (which may relate to lower educational attainment and fewer resources CHILD ABUSE RECOGNITION/DOCUMENTATION to support families); and combat experience among military members (Maguire-Jack & Font, 5 2016; Miyamoto, et. al, 2014; Rabenhorst, McCarthy, Thomsen, Milner, Travis & Colasanti, 2015; Raitasalo & Holmila 2017). Specifically tying these risk factors to the selected intervention community, almost 27% of the population of Sweetwater County, Wyoming, where this educational intervention was conducted, is under the age of 18 years, which leaves a large percentage of the population with a high potential of being affected by child maltreatment (Quorum, 2016). Approximately 14% of the population lives below the federal poverty level, almost 44% of the population has only a high school diploma or less education, the entire population is considered rural, and approximately 10% of the population has a history of military service (Quorum, 2016; US Census Bureau, 2015). Besides the long-term physical consequences related to the abuse, survivors, their families, and the nation as a whole face many other negative consequences a result of child maltreatment. Abuse in childhood may lead to many negative emotional consequences, including diagnosis of post-traumatic stress disorder (PTSD), aggression, explosive responses, depression, and suicidal ideation (American Academy of Pediatrics (AAP), 2008). Researchers are also finding an increasing number of long-term physical consequences stemming from exposure to adverse childhood experiences, including asthma, hypertension, hypercholesterolemia, myocardial infarction, obesity, and certain cancers, which add to the financial costs related to child maltreatment (Iniguez & Stankowski, 2016). Available Knowledge In 2008, the estimated lifetime economic burden relating to new cases of fatal and nonfatal child abuse was approximately $124 billion, which includes childhood healthcare costs, adult medical costs, productivity loss, child welfare expenses, criminal justice costs, and special CHILD ABUSE RECOGNITION/DOCUMENTATION education expenses (Fang, Brown, Florence & Mercy, 2011). As of 2015, universal reporting of 6 abuse has been required in 18 states, including Wyoming and Utah, as well as Puerto Rico; healthcare workers are required reporters in all 50 states (Ho, Gross & Bettencourt, 2017). The danger for healthcare providers lies with the possibility of missing a diagnosis of abuse of a pediatric patient due to inadequate clinician education. Some of the initial indicators of abuse include anger, aggression, depression, and difficulty sustaining attention, all of which may be common presenting symptoms of other childhood disorders, resulting in misdiagnosis and continuation of abuse (AAP, 2008). Even in the case of physical abuse, bruising and broken bones are often easily explained as common childhood injuries that occur as a result of accidents (Christian, 2015). Recognizing abuse and making a report of suspicions can be one of the most difficult challenges that providers will face in their careers (Christian, 2015). Lack of knowledge about injuries that may be concerning, fear of making the situation worse, inaccurate perception of the severity of the situation, previous poor experiences with child protective services, and a fear of making an incorrect diagnosis are listed as the most common reasons that healthcare workers do not report suspected child maltreatment (Walsh & Jones, 2015). Rationale A recent study by Walsh and Jones (2016) indicates that receiving adequate education, including inservice training, written reminders about protocols, and role-playing discussions with family, plays a significant role in the comfort levels of providers responding to abuse. Through the implementation of the Ace Star Model of Knowledge Transformation, the project lead was able to perform a discovery of current research to conduct and evaluate current child abuse policies at a rural healthcare facility, followed by a literature review that investigated current local, state, and national standards as well as at-risk populations (UT Health Science Center, CHILD ABUSE RECOGNITION/DOCUMENTATION 2015). An evidence summary directly impacted the translation to guidelines with the 7 development of an educational plan based on evaluation of current clinician and clinical staff knowledge of child abuse recognition and photo documentation of child abuse injuries. Practice integration occurred with the implementation of the education to be delivered to the clinicians and clinical staff, followed by the outcome evaluation of the educational intervention. Ensuring that clinical staff members who come in contact with children both within and outside of the clinical setting receive continuing education about the recognition of child abuse is essential. With appropriate training, healthcare providers have the potential to stop the cycle of abuse, ensure that the child is placed within a safe environment, improve health outcomes, and possibly save lives. Specific Aims The aims of this project include the identification of clinician and clinical staff knowledge regarding recognition of patients who present with injuries that may indicate abuse, staff comfort with photo documentation of suspected injuries, and the development and implementation of evidence-based education and evaluation tools for clinicians and clinical staff. Project goals included a significant increase in participant knowledge about child abuse injuries, participants becoming increasingly comfortable with the process of reporting suspected abuse, and a significant decrease in participant barriers to reporting suspected abuse. Methods Context This quality improvement intervention was implemented at a small, rural, 99-bed acutecare healthcare facility in Sweetwater County, Wyoming. This facility is a vital resource for the community that it serves with the next closest hospital being over 100 miles away. This facility CHILD ABUSE RECOGNITION/DOCUMENTATION 8 serves a population of approximately 45,331 people, not including those who commute from unserved and underserved counties within Wyoming (Quorum, 2016). Study participants included clinical staff from the healthcare facility: registered nurses, medical assistants, nursing assistants, dietary staff, and unit clerks from many nursing departments as well as administrative and education staff. No other known quality improvement projects designed to increase clinical staff knowledge and comfort with child physical abuse were occurring at the same time as this research intervention at this facility. Interventions Clinical staff received a pre education needs assessment questionnaire to determine areas in need of additional education, participant familiarity with the recognition of child abuse injuries, and the reporting of suspected injuries. Additionally, this assessment sought to ascertain staff knowledge of procedures related to photo documentation of potentially abuse-related injuries. The educational intervention was developed using the results of the needs assessment survey, best evidence from a literature review, project lead clinical and educational experience, and consultation with noted content experts in the field of child maltreatment. Education was provided in five educational sessions to accommodate the differing schedules of clinical staff. Education sessions lasted approximately one hour and included information about the recognition of the most common abusive injuries in children, characteristics that may assist in distinguishing between abusive and non-abusive injuries, when to perform a skeletal survey, discussion of medical mimics, information to better photo document injuries, and reporting concerns related to child abuse both within the facility and to law enforcement/child protective services. Additionally, an executive summary containing pertinent information related to the CHILD ABUSE RECOGNITION/DOCUMENTATION abusive injuries was provided to the intervention site for use in the future when child abuse 9 injuries are suspected. Four weeks following the educational intervention, the assessment questions were re-administered to those who were able to participate in the education intervention, with the purpose of evaluating the efficacy of the education that was provided. Study of the Interventions This project included a single-site, quality improvement intervention. The project lead selected the use of a pre education needs assessment, an educational intervention, and a posteducation assessment. The post assessment data were compared to the pre education assessment data to determine the success of the educational intervention in increasing clinical staff knowledge and comfort regarding the recognition of child abuse injuries and photo documentation of abusive injuries, improving participant comfort with reporting suspected abuse, and decreasing barriers to reporting. A goal of this quality improvement intervention, by using pre assessment, education, and post assessment data, was to achieve a statistically significant improvement in clinical staff familiarity with the recognition of potential abusive injuries, comfort with the photo documentation of potential abusive injuries, familiarity with local/facility reporting procedures, and a reduction in participant barriers to reporting. Measures No previously validated questionnaires that assessed the information being studied by this project were available; therefore, a new assessment tool was created using the expected outcomes from the intervention as guidance. The tool was then administered to a test group of registered nurses to assess readability and to determine whether questions met project outcomes. CHILD ABUSE RECOGNITION/DOCUMENTATION After making changes based on test group feedback, the assessment tool was sent to clinical 10 faculty and two content experts in the field of child maltreatment for validation and modification. Pre education and post education assessments were conducted using Red Cap, which is a tool used to build online questionnaires, surveys, and databases. An online link was sent to all anticipated participants two weeks prior to the educational intervention. The pre education assessment was also made available for study participants to complete in person prior to the educational intervention presentation if they had not done so previously. The questionnaire consisted of the following types of questions: five identifying questions used to aid in conducting statistical analysis at the conclusion of the project; four questions to ascertain the comfort and familiarity of participants with recognition, reporting, and documenting of child physical abuse; one question to determine perceived barriers of participants; and an additional 11 knowledgebased questions. All participants completed the same pre and post education assessments, and all assessment questions were required for submission of the questionnaire; therefore, all questionnaires were complete. The only data entry on the part of the researchers was the addition of a pre and post education designation based on assessment date to improve the ability to conduct pre and post education statistical analysis of the data. Educational sessions were conducted at the clinical facility in a small education classroom, which accommodated approximately 10 students per session. Each of the sessions took approximately one hour, and participants were paid by the intervention facility for staff education inservice. The pre education needs assessment and post education assessment had a completion time of approximately five minutes each, and were unpaid by the intervention facility. CHILD ABUSE RECOGNITION/DOCUMENTATION Analysis 11 Descriptive statistics were used to conduct an analysis of demographic data. A quantitative assessment was conducted pre and post intervention, followed by analysis of the data. Due to the small sample size, Fisher's exact test was used to determine the effectiveness and statistical significance of the educational intervention in increasing comfort and familiarity in the recognition of child physical abuse and knowledge regarding the appearance of abusive injuries. Differences between participants were analyzed using identifiers that allowed for matching pre and post education assessment responses at the conclusion of the project period. Ethical Considerations This project was considered a quality improvement intervention, and therefore was considered Institutional Review Board exempt. There are no known conflicts of interest and no unexpected benefits, problems, costs, or failures noted by the project lead, related specifically to this quality improvement intervention. Results Participants Forty participants responded to the pre education assessment during the two-week period, with 16 of them attending the education sessions, as attendance was voluntary and was not widely advertised. Eleven of the 16 participants who attended the education sessions responded to the post education assessments. No discernible common characteristics were identified in the sample results of those who did not complete all sections of this project. The participants who did not complete all three components of the intervention--the pre education assessment, education session attendance, and post education assessment completion--were excluded from the overall analysis as the results were analyzed using parametric testing. CHILD ABUSE RECOGNITION/DOCUMENTATION Intervention Timeline 12 The intervention site was contacted in June 2017; agreements and a project timeline were established. Content experts were contacted and clinical time was spent by the project lead in the field of child maltreatment over a period of four months from August through October 2107. No existing assessment tools were available that would collect the information that the project coordinators were seeking to research, and therefore an original assessment tool was developed, piloted, and approved by the content experts prior to implementation. During the four-month period that the project lead was working with the content experts, the educational presentation and assessments were developed through consultation and research into current national standards from the American Academy of Pediatrics. The project lead traveled to Sweetwater County, Wyoming in November 2017 to provide education sessions, with three sessions occurring on the first day and two sessions on the second day. The post education assessment data were originally designated to be collected over a twoweek period, four weeks after the educational sessions. However, a holiday occurred during this time period, and the window for responses to be accepted was increased to four weeks to allow adequate time for participant response; this was the only change that was made was to the intervention timeline. Pairing of pre and post education responses with statistical analysis and interpretation of the data was conducted over a six-week period in early 2018, which was followed by the results being sent to the intervention site. Analysis of Statistical Data The pre education needs assessment showed that many study participants were uncomfortable in their ability to recognize child physical abuse (Chart 1). Although most of the participants were familiar with the state mandate for universal reporting of suspected child CHILD ABUSE RECOGNITION/DOCUMENTATION maltreatment (Chart 2), many were unaware of the reporting hotline that is available to report 13 suspicions of child abuse (Chart 3). Most participants were also unsure about the process of photo documenting suspicious injuries within the healthcare facility, and through discussion at the education sessions, those who were most familiar with each of the above named areas were the specially trained sexual assault nurse examiners (SANE) who respond to suspected intentional injuries within the healthcare facility (Chart 4). When addressing the perceived barriers that impacted participant reporting of abuse, limited knowledge of abuse and neglect were the most commonly cited reasons (Chart 5). The educational intervention resulted in a statistically significant improvement in the participants' comfort in their ability to recognize child physical abuse (p = 0.02), a statistically significant increase in knowledge of the State of Wyoming abuse and neglect reporting hotline (p = 0.18) (Table 1). The intervention also resulted in an overall increase in the participants' familiarity with the state's child abuse reporting mandate (p = 0.23) and with the process of photo documenting injuries related to child maltreatment (p = 0.59), although these results were not considered statistically significant (Table 1). The pre education assessment showed many participants listed one or more barriers to reporting suspected abuse, including limited knowledge of abuse and neglect, being unfamiliar with the reporting process, and being unsure that reporting will result in help for the child. The post education assessment showed that these barriers to reporting suspected child maltreatment appeared to have been significantly reduced by attending the child maltreatment education sessions (Table 2). Of note, the SANE nurses at the education sessions requested addition of an option for none of the above on the survey, because they were confident in their ability to recognize abuse and felt no barriers to reporting suspected abuse; the post education results reflect this change, which was made to the assessment. CHILD ABUSE RECOGNITION/DOCUMENTATION 14 Pertaining to the knowledge questions in the assessment, most of the individual responses did not indicate statistically significant improvements (Chart 3), but an overall analysis of the 11 knowledge-based questions demonstrated a mean score of correct answers of 6.36 with a standard deviation of 2.01 on the pre assessment, and a mean of 8.81 with a standard deviation of 1.40 on the post assessment. Statistical significance was achieved by an overall increase in knowledge (p = 0.0034) (Chart 7) of ~2.5 questions. The one question with a statistically significant improvement shown by p value of <0.05 concerned whether the age of a bruise can be accurately estimated by its appearance (p = 0.004). No change in knowledge was shown in two questions from pre education to post education: the medical mimics of abuse injuries (p = 1.0) and the mechanism of injury for a spiral fracture (p = 1.0). Discussion Summary The results of this analysis show that the specific aims of this educational intervention were statistically significant based on the overall analysis, and clinically significant based on participant feedback. Clinical staff knowledge regarding maltreatment and reporting of maltreatment was adequately assessed, and the educational intervention was developed highlighting areas of clinical staff knowledge deficit. The intervention resulted in an increase in staff familiarity with recognizing injuries resulting from maltreatment, increased comfort in the process of reporting suspected maltreatment within their state, and a statistically significant increase in clinical staff's overall knowledge of maltreatment injuries and their mechanisms. Even though there was a loss of participants from the time of the needs assessment to the educational intervention, and another slight loss of participants from the time of the educational intervention to the post-education assessment, the intervention was successful in showing that CHILD ABUSE RECOGNITION/DOCUMENTATION education is of key importance in increasing staff awareness of abuse in both the clinical and 15 nonclinical settings. Interpretation The post-education assessment demonstrated that the clinical staff who participated in the educational intervention had significantly fewer barriers to reporting suspected abuse following the intervention, and obtained an increased knowledge in topics related to maltreatment injuries, which Walsh and Jones (2015) reported as possible reasons that healthcare workers were unlikely to report suspected abuse. Participants agreed with the findings of Christian (2015) that distinguishing abusive injuries from accidental injuries is one of the most difficult challenges that they may face, although it is also one of the most important challenges. It was anticipated from the results of the pre education needs assessment that the education sessions would be well attended; the intervention site explained that the resulting decrease in clinical staff participation at the education sessions was possibly a result of this education not being a requirement of their clinical staff. After evaluation of the identifying data collected in the pre education assessment, no specific job positions, department, or participant age indicated a likelihood of participating in the education sessions. The educational intervention did require the intervention site to pay the participating employees for their attendance in the one-hour education sessions. The benefits to the intervention site may be minimal, but there is the potential to improve the overall health and well being of the children who live within the community that is served by this site, making this a cost efficient intervention. The employees who were in attendance at the educational sessions were overwhelmingly receptive of the education; they showed interest in the topic of child maltreatment, and asked questions that were pertinent to the topics being presented. The CHILD ABUSE RECOGNITION/DOCUMENTATION intervention facility was quite receptive to participating in this educational intervention. They 16 provided helpful support staff, a comfortable room, and the electronic equipment needed for presentation of the educational information. Limitations Specific limitations to the generalizability of this educational intervention include the implementation at a small intervention site, with only a small portion of employees choosing to participate in all aspects of the intervention. Presenting this quality improvement intervention at a larger clinical site, with an attendance requirement, may show an impact on the statistical significance of the data. In the case of this intervention, the statistical significance was impacted by the small sample size. Those who attended the education sessions were asked if they had completed the preeducation needs assessment at the time of the education. In an attempt to increase the likelihood of completion of all required steps within this quality improvement project, if participants had not done so already, the needs assessment was completed prior to beginning the education session. After seeing the small numbers of attendees at the education session on the first day and realizing the possible impact of these numbers on the data, the project lead requested that a reminder of the education sessions be e-mailed to employees, which was helpful only for those who were at the clinical site and were able to check e-mail prior to the education sessions on the final day. The facility representative also offered to announce the education overhead for staff who were onsite on the final day to encourage attendance, which was successful as this was the most highly attended session. Participants were requested at the education sessions to complete the post education assessment that which was scheduled to be sent four weeks after the education. After realizing CHILD ABUSE RECOGNITION/DOCUMENTATION 17 that post-assessment response was slow over the holiday, the project lead extended the time for assessment submission, and repeated e-mail requests to those who had not completed this step. Although the size limitation was significant, it is thought that had the sample size been larger, this education intervention would have yielded an increased number of statistically significant results based on the improvements that were seen throughout the analysis. Conclusions Based on the feedback, which was received onsite at the education sessions; the information presented was relevant to all who attended, and was anticipated to be useful in improving their ability to recognize possible abusive injuries. The long-term implications of this education include the prevention of the long-term negative physical and emotional consequences related to child maltreatment, such as post-traumatic stress disorder (PTSD), aggression, explosive responses, depression, and suicidal ideation as identified by the AAP (2008). The results showed improvements in most areas assessed, so there is the potential for greater success if this intervention were to be implemented in additional sites, including those areas impacted the most by abuse such as those in proximity to military health facilities, areas with high rates of poverty and substance abuse, and rural areas (Maguire-Jack & Font, 2016; Miyamoto, et. al, 2014; Rabenhorst, McCarthy, Thomsen, Milner, Travis & Colasanti, 2015; Raitasalo & Holmila 2017). The next steps for this quality improvement intervention include the possibility of seeking additional sites that would be interested in implementing child abuse education for their clinical staff members. The needs assessment will be adjusted to fit their specific needs and educational level. The educational intervention will then be implemented to increase staff knowledge, and evaluation will be conducted to determine the intervention success. Additional CHILD ABUSE RECOGNITION/DOCUMENTATION content experts could also be sought to provide input into the assessment tool and educational 18 interventions. Finally, validation of the assessment tool could have a significant impact upon its use in future intervention sites. CHILD ABUSE RECOGNITION/DOCUMENTATION References 19 American Association of Pediatrics (AAP). (2008). Understanding the behavioral and emotional consequences of child abuse. Pediatrics, 122(3), 667-673. doi: 10.1542/peds.2008-1885 Christian, C. W. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), 1337-1354. doi: 10.1542/peds.2015-0356 Fang, X., Brown, D. S., Florence, C. S. & Mercy, J. A. (2011). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36, 156-165. doi: 10.1016/j.chiabu.2011.10.006 Ho, G. W. K., Gross, D. A. & Bettencourt, A. (2017). Universal mandatory reporting policies and the odds of identifying child physical abuse. American Journal of Public Health, 107(5), pp. 709-716. doi: 10.2105/AJPH.2017.303667 Iniguez, K. C. & Stankowski, R. V. (2016). Adverse childhood experiences and health in adulthood in a rural population-based sample. Clinical Medicine & Research, 14(3-4), 126-137. doi: 10.3121/cmr.2016.1306 Maguire-Jack, K. & Font, S. A. (2016). Intersections of individual and neighborhood disadvantage: Implications for child maltreatment. Children and Youth Services Review, 72, 44-51. doi: 10.1016/j.childyouth.2016.10.015 Miyamoto, S., Dharmar, M., Boyle, C., Yang, N. H., Macleod, K., Rogers, K., Nesbitt, T. & Marcin, J. P. (2014). Impact of telemedicine on the quality of forensic sexual abuse examinations in rural communities. Child Abuse & Neglect, 38, 1533-1539. http://dx.doi.org/10/1016/j.chiabu.2014.04.015 CHILD ABUSE RECOGNITION/DOCUMENTATION 20 Quorum Health Resources. (2016). Memorial Hospital of Sweetwater County: Economic Impact Analysis. Retrieved from https://www.sweetwatermemorial.com/Uploads /Files/Downloads/MHSC%20Economic%20Impact%20Report%20-%2010.27. 16.pdf Rabenhorst, M. M., McCarthy, R. J., Thomsen, C. J., Milner, J. S., Travis, W. J. & Colasanti, M. P. (2015). Child maltreatment among U.S. Air Force parents deployed in support of Operation Iraqi Freedom/Operation Enduring Freedom. Child Maltreatment, 20(1), 6171. doi: 10.1177/1077559514560625 Raitasalo, K. & Holmila, M. (2017). Parental substance abuse and risks to children's safety, health and psychological development. Drugs: Education, Prevention and Policy, 24(1), 17-22. doi: 10.1080/09687637.2016.1232371 Sweetwater Memorial. (2017). Our hospital. Retrieved on October 27, 2017 from http://www.sweetwatermemorial.com U. S. Census Bureau. (2015). American fact finder. Retrieved from https://factfinder .census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF U. S. Department of Health and Human Services (HHS). (2015). Child maltreatment 2015. Retrieved from https://www.acf.hhs.gov/sites/default/files/cb/cm2015.pdf UT Health Science Center. (2015). Star Model. Retrieved on July 1, 2017 from http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp Walsh, W. A. & Jones, L. M. (2015). Factors that influence child abuse reporting: A survey of child-serving professionals. Crimes Against Children Research Center. Retrieved from http://www.unh.edu/ccrc/pdf/Final%20Reporting%20 Bulletin%20Professional%20Perceptions.pdf 21 CHILD ABUSE RECOGNITION/DOCUMENTATION Table 1 Questions Levels I am comfortable in my ability to recognize child physical abuse Strongly Disagree Pre Post Total 2 (18.18%) 0 (0%) 2 (9.09%) Disagree 1 (9.09%) 0 (0%) 1 (4.55%) Unsure 5 (45.45%) 1 (9.09%) 6 (27.27%) Agree 3 (27.27%) 9 (81.82%) 12 (54.55%) P Value 0.020 Strongly Agree 0 (0%) 1 (9.09%) 1 (4.55%) ______________________________________________________________________________________________________________________________ I am familiar with the mandate to report child maltreatment in my state Strongly Disagree 2 (18.18%) 0 (0%) 2 (9.09%) Disagree 0 (0%) 0 (0%) 0 (0%) Unsure 0 (0%) 0 (0%) 0 (0%) Agree 3 (27.27%) 6 (54.55%) 9 (40.91%) 0.230 Strongly Agree 6 (54.55%) 5 (45.45%) 11 (50%) ______________________________________________________________________________________________________________________________ I am familiar with my state's child abuse and neglect reporting hotline Strongly Disagree 2 (18.18%) 0 (0%) 2 (9.09%) Disagree 0 (0%) 0 (0%) 0 (0%) Unsure 4 (36.36%) 1 (9.09%) 5 (22.73%) Agree 3 (27.27%) 5 (45.45%) 8 (36.36%) 0.179 Strongly Agree 2 (18.18%) 5 (45.45%) 7 (31.82%) ______________________________________________________________________________________________________________________________ I am familiar with the process of photo documenting injuries related to suspected child abuse ** P values calculated using Fisher's Exact Test Strongly Disagree 2 (18.18%) 0 (0%) 2 (9.09%) Disagree 4 (36.36%) 0 (0%) 4 (18.18) Unsure 1 (9.09%) 3 (27.27%) 4 (18.18%) Agree 2 (18.18%) 6 (54.55%) 8 (36.36%) Strongly Agree 2 (18.18%) 2 (18.18%) 4 (18.18%) 0.590 Table 2 22 CHILD ABUSE RECOGNITION/DOCUMENTATION What are your perceived barriers to reporting suspected maltreatment Answers Pre Post Total Limited knowledge of abuse Checked 7 (63.64%) 0 (0%) 7 (31.82%) Unchecked 4 (36.36%) 11 (100%) 15 (68.18%) Checked 4 (36.36%) 0 (0%) 4 (18.18%) Unchecked 7 (63.64%) 11 (100%) 18 (81.82%) Checked 3 (27.27%) 0 (0%) 3 (13.64%) Unchecked 8 (72.73%) 11 (100%) 19 (86.36%) Checked 1 (9.09%) 1 (9.09%) 2 (9.09%) Unchecked 10 (90.91%) 10 (90.91%) 20 (90.91%) Checked 4 (36.36%) 4 (36.36%) 8 (36.36%) Unchecked 7 (63.64%) 7 (63.64%) 14 (63.64%) Checked 0 (0%) 7 (63.64%) 7 (31.82%) Unchecked 11 (100%) 4 (36.36%) 15 (68.18%) Limited knowledge of child neglect Unfamiliar with how to report suspected maltreatment Unsure that reporting will help the child Fear of potentially making the maltreatment worse for the child None of the above * * This option was not available in the pretest ** P values calculated using Fisher's Exact Test P Value 0.004 0.090 0.214 1.0 1.0 0.004 23 CHILD ABUSE RECOGNITION/DOCUMENTATION Table 3 Question (correct answer bold) Answers Pre Post Totals P Value It is usually easy to distinguish between True 3 (27.27%) 3 (27.27%) 6 (27.27%) 1.0 accidental and non-accidental injury of a child False 8 (72.73%) 8 (72.73%) 8 (72.73%) ______________________________________________________________________________________________________________________________ The most common injury associated with child physical abuse is Broken bone 1 (9.09%) 0 (0%) 1 (4.55%) Bruising/soft tissue injury 6 (54.55%) 9 (81.82%) 15 (68.18%) Burn 0 (0%) 1 (9.09%) 1 (4.55%) 0.220 Head trauma 4 (36.36%) 1 (9.09%) 5 (22.73%) ______________________________________________________________________________________________________________________________ Which of the following types of fracture may be associated with abuse Spiral 6 (54.55%) 7 (63.64%) 13 (59.09%) Buckle 0 (0%) 0 (0%) 0 (0%) Transverse 1 (9.09%) 0 (0%) 1 (4.55%) 1.0 All of the above 4 (36.36%) 4 (36.36%) 8 (36.36%) ______________________________________________________________________________________________________________________________ Under what age does the AAP recommend a skeletal survey if abuse is suspected 18 months 4 (36.36%) 2 (18.18%) 6 (27.27%) 2 years 3 (27.27%) 8 (72.73%) 11 (50%) 3 years 2 (18.18%) 0 (0%) 2 (9.09%) 0.186 4 years 2 (18.18%) 1 (9.09%) 3 (13.64%) ______________________________________________________________________________________________________________________________ The age of a bruise can be accurately True 7 (63.64%) 0 (0%) 7 (31.82%) 0.004 estimated or determined by its appearance False 4 (36.36%) 11 (100%) 15 (68.18%) ______________________________________________________________________________________________________________________________ Which of the following medical conditions can be mistaken for abuse Osteogenesis imperfect 3 (27.27%) 4 (36.36%) 7 (31.82%) Ehlers Danlos 1 (9.09%) 0 (0%) 1 (4.55%) Von Willebrand Disease 0 (0%) 0 (0%) 0 (0%) 1.0 All of the above 7 (63.64%) 7 (63.64%) 14 (63.64%) ______________________________________________________________________________________________________________________________ The mechanism of injury for a spiral fracture is Bending 0 (0%) 0 (0%) 0 (0%) Compression 0 (0%) 0 (0%) 0 (0%) Torsion 9 (81.82%) 9 (81.82%) 18 (81.82%) 1.0 All of the above 2 (18.18%) 2 (18.18%) 4 (18.18%) ______________________________________________________________________________________________________________________________ The most common cause of burn injury in young children, that present to the emergency department Hot solid object 1 (9.09%) 0 (0%) 1 (4.55%) Open flame 2 (18.18%) 1 (9.09%) 3 (13.64%) Scalding liquid 8 (72.73%) 10 (90.91%) 18 (81.82%) Caustic chemical 0 (0%) 0 (0%) 0 (0%) Electric current 0 (0%) 0 (0%) 0 (0%) 0.587 24 CHILD ABUSE RECOGNITION/DOCUMENTATION Table 3 continued Question (correct answer bold) Answers Pre Post Totals P Value Which of the following is NOT a red flag when assessing burns in children A delay in seeking care for a child who is burned 1 (9.09%) 0 (0%) 1 (4.55%) 0.106 The presence of other unexplained injuries 1 (9.09%) 0 (0%) 1 (4.55%) A burn that covers a large surface area 5 (45.45%) 2 (18.18%) 7 (31.82%) A child >5 years of age 4 (36.36%) 9 (81.82%) 13 (59.09%) ______________________________________________________________________________________________________________________________ When photo documenting exam findings from suspected child abuse, it is important to do which of the following Take a photo that demonstrates 0 (0%) the location of the finding in relation to the rest of the body 0 (0%) 0 (0%) Take a photo with a forensic scale or ruler showing the size of the finding 0 (0%) 3 (13.64%) 0 (0%) 0 (0%) 3 (27.27%) Take a photo of just the finding 0 (0%) alone 0.214 All of the above 8 (72.73% 11 (100%) 19 (86.36%) ______________________________________________________________________________________________________________________________ What is the most commonly cited trigger for abusive head trauma Poverty 0 (0%) 0 (0%) 0 (0%) Infant crying 8 (72.73%) 11 (100%) 19 (86.36%) Toilet training accidents 1 (9.09%) 0 (0%) 1 (4.55%) Misbehavior 2 (18.18%) 0 (0%) 2 (9.09%) * P values calculated using Fisher's Exact Test 0.214 25 CHILD ABUSE RECOGNITION/DOCUMENTATION Chart 1 I am comfortable in my ability to recognize child physical abuse 10 9 8 7 6 5 4 3 2 1 0 Pre-education Post-education Strongly Disagree Disagree Unsure Agree Strongly Agree Chart 2 I am familiar with the mandate to report child maltreatment in my state 7 6 5 4 Pre-education 3 Post-education 2 1 0 Strongly Disagree Disagree Unsure Agree Strongly Agree 26 CHILD ABUSE RECOGNITION/DOCUMENTATION Chart 3 I am familiar with my states child abuse and neglect reporting hotline 6 5 4 3 Pre-education Post-education 2 1 0 Strongly Disagree Disagree Unsure Agree Strongly Agree Chart 4 I am familiar with the process of photo documenting injuries related to suspected child abuse 7 6 5 4 Pre-education 3 Post-education 2 1 0 Strongly Disagree Disagree Unsure Agree Strongly Agree 27 CHILD ABUSE RECOGNITION/DOCUMENTATION Chart 5 What are your perceived barriers to reporting suspected maltreatment 8 7 6 5 4 3 2 1 Pre-education 0 Post-education Chart 6 Parametric Data on Knowledge Questions 12 10 8 Number correct pre-education 6 Number correct posteducation 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 28 CHILD ABUSE RECOGNITION/DOCUMENTATION Chart 7 Knowledge Assessment Questions Preassessment Postassessment Mean Standard Deviation 6.36 2.01 8.81 1.4 Statistically Significant; p = 0.0034