Barriers to Early Recognition of Child Abuse and Neglect Among Pediatric Nurses

Introduction

Pediatric nurses occupy a distinctive position in the identification of child abuse and neglect, given their frequent, close, and repeated contact with children and caregivers across inpatient, emergency, and ambulatory settings, often preceding and extending beyond the point of physician evaluation (Lines et al., 2020; Fraser et al., 2010). Early recognition is clinically consequential: delayed identification of abusive injury has been associated with recurrent and escalating harm, and prompt recognition is a prerequisite for the protective, medical, and social service interventions that follow (Jenny et al., 1999; Thorpe et al., 2014). Despite this, prior survey and qualitative literature has consistently documented a gap between clinical suspicion and formal recognition or reporting among nurses and other frontline clinicians, suggesting that suspicion alone is an insufficient predictor of appropriate action (Flaherty et al., 2008; Lines et al., 2020).

Existing literature has identified a range of candidate barriers to recognition and reporting, spanning individual knowledge and training gaps, the genuine clinical ambiguity of many presentations of possible abuse or neglect, institutional and workflow-related constraints, and interpersonal or emotional factors such as reluctance to jeopardize the caregiver relationship or uncertainty about the consequences of a report (Flaherty et al., 2008; Van Haeringen et al., 1998; Jones et al., 2008). However, this literature has more often examined individual barriers in isolation or within physician-predominant samples, with comparatively less work directly comparing the relative weight of these barrier domains within nursing practice specifically, or examining how prior training exposure relates to both perceived barriers and actual recognition and reporting behavior within the same sample.

Clarifying which barriers are most prominent among pediatric nurses, and whether structured training is associated with meaningfully lower barriers and higher reporting behavior, has direct implications for how health systems prioritize limited continuing-education and workflow-redesign resources. The purpose of this cross-sectional survey study was to examine the prevalence and relative ranking of perceived barriers to early recognition of child abuse and neglect among pediatric nurses, and to examine the association between these barriers, prior maltreatment-recognition training, and self-reported recognition and reporting behavior.

Methods

Design. This study used a cross-sectional, self-administered survey design distributed electronically to eligible nurses across a single multi-site regional health system.

Setting and participants. Eligible participants were registered nurses providing direct clinical care to pediatric patients (age 0–17 years) in inpatient, emergency department, or ambulatory pediatric settings within the health system, with at least six months of pediatric clinical experience. Of 480 eligible nurses invited by health-system email, 312 completed the survey (65.0% response rate), with data collection occurring over a six-week period in 2023.

Measures. The Barriers to Recognition and Reporting Scale (BRRS) is a 22-item, validated self-report instrument assessing perceived barriers to recognizing and reporting suspected child abuse and neglect, rated on a 1–5 scale, organized into four subscales: knowledge/training barriers, clinical ambiguity barriers, institutional/workflow barriers, and interpersonal/emotional barriers (Jones et al., 2008, adapted). Clinical confidence in recognizing possible maltreatment was assessed using a single 1–5 self-rating item. Participants additionally reported whether they had received prior structured maltreatment-recognition training (defined as a dedicated training module, workshop, or competency requirement beyond general orientation content), whether they had ever formally reported suspected maltreatment, and, if applicable, whether they had ever suspected but not reported maltreatment, along with the reason for not reporting, selected from a fixed list with an open-text option.

Statistical analysis. Mean BRRS item and subscale scores were calculated and ranked. Differences in clinical confidence and subscale scores between trained and untrained nurses were examined using independent-samples t-tests. The association between prior training and having ever made a report of suspected maltreatment was examined using multivariable logistic regression adjusting for years of pediatric experience and practice setting, yielding an adjusted odds ratio. Reasons for suspecting but not reporting were summarized descriptively as the proportion of applicable respondents selecting each reason, with respondents permitted to select more than one. A two-sided p value of less than .05 was considered statistically significant.

Results

Of 312 responding nurses (Table 1), 53.8% reported having received prior structured maltreatment-recognition training beyond general orientation content, and 64.4% reported having formally reported suspected maltreatment at least once during their career. Among all respondents, the highest-ranked individual barrier items and subscale-level scores are shown in Figure 1.

Comparing trained and untrained nurses, those with prior structured maltreatment-recognition training reported significantly higher clinical confidence and significantly lower barrier subscale scores across all four BRRS subscales, as shown in Figure 2.

In multivariable logistic regression adjusting for years of pediatric experience and practice setting, prior structured training was independently associated with having ever formally reported suspected maltreatment (adjusted odds ratio 2.87, 95% CI 1.64–5.02, p < .001). Among the 130 nurses (41.7% of the sample) who reported having suspected but not reported maltreatment on at least one occasion, the distribution of self-reported reasons is shown in Figure 3.

Discussion

In this cross-sectional survey of pediatric nurses across inpatient, emergency, and ambulatory settings, the most highly ranked barriers to early recognition of child abuse and neglect were diagnostic ambiguity in distinguishing possible abuse from an alternate clinical explanation and uncertainty about where the threshold for reporting lies, rather than a general lack of awareness that maltreatment is a clinical concern. This pattern is consistent with prior literature suggesting that many barriers operate not at the level of whether a nurse is willing to act, but at the level of whether a given presentation is interpreted as meeting a threshold requiring action (Flaherty et al., 2008; Van Haeringen et al., 1998).

The finding that nurses with prior structured maltreatment-recognition training reported significantly higher clinical confidence, significantly lower barrier scores across all four subscales, and were independently more likely to have ever formally reported suspected maltreatment, is consistent with, and extends, prior evidence supporting the effectiveness of structured training interventions for improving clinician recognition of child maltreatment (Narayan et al., 2017; Louwers et al., 2010). The consistency of the training association across both attitudinal measures (confidence, perceived barriers) and a behavioral measure (reporting history) strengthens the interpretation that the association reflects a genuine training effect rather than a difference limited to self-perception.

The reasons cited by nurses who suspected but did not report maltreatment further reinforce the threshold-uncertainty finding: uncertainty that the presentation met the reporting threshold and fear of being incorrect were the two most commonly cited reasons, each substantially more common than concerns about the caregiver relationship or retaliation. This suggests that interventions targeting diagnostic clarity, for example, structured decision-support tools or clearly defined institutional criteria for when a concern should prompt formal evaluation, may address a larger share of missed recognition than interventions focused primarily on interpersonal or emotional barriers alone, though both categories of barrier were present in this sample and likely interact in practice.

Several limitations should be considered. This study relied on self-reported barriers and self-reported recognition and reporting history rather than an objective, chart-audited measure of actual missed cases, and self-report may be subject to social desirability bias, particularly regarding sensitive behaviors such as failing to report a suspicion. The cross-sectional design precludes causal inference regarding the direction of the association between training and reporting behavior; it is possible that nurses more inclined toward vigilance in this area were also more likely to seek out training. Finally, this study was conducted within a single regional health system, and the relative ranking of barriers may differ in settings with different institutional reporting infrastructure, patient populations, or baseline training requirements.

Future research should incorporate objective outcome measures, such as chart-audited concordance between documented clinical findings and formal evaluation or reporting, to complement self-reported barrier and behavior data, and should evaluate specific training and workflow interventions, such as structured decision-support tools targeting the reporting-threshold barrier identified here, using pre-post or controlled designs. Extension of this survey approach to additional clinical roles, including advanced practice providers and physicians, and to additional health systems with differing institutional reporting infrastructure, would help clarify which barriers are broadly generalizable versus setting-specific. Taken together, these findings suggest that expanding structured, recurring maltreatment-recognition training and clarifying institutional reporting thresholds and processes represent priority targets for improving early recognition of child abuse and neglect in pediatric nursing practice.

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