Child Abuse Reporting Barriers: Iranian Nurses' Experiences.

BACKGROUND: Although in many countries child abuse reporting is mandated, Iranian nurses report abused cases voluntary. Some of the cases are reported to the police and others are referred to welfare organizations or other non-governmental organizations. Absence of a uniform reporting system along with a lack of legal support in the specific cultural context of Iran has resulted challenges for the reporters of child abuse.
OBJECTIVES: The aim of this study was to explore the Iranian nurses' experiences of reporting child abuse as well as to explore the existing barriers. PATIENTS AND METHODS: A qualitative study with conventional content analysis was conducted to explore the barriers of reporting child abuse. Individual interviews between 30 and 45 minutes in duration were conducted with a purposive sample of 16 nurses with direct experience of dealing with children who had been abused. Graneheim and Lundman's method was used for data analysis.
RESULTS: The data were classified to five themes including "knowledge deficit", "previous unpleasant experiences about child abuse reporting", "ethical challenges"," legal challenges" and "cultural beliefs".
CONCLUSIONS: According to the findings, enhancement of nurses and public knowledge about child abuse, legal issues and jurisprudence along with legislation of clear and simple laws, are mandatory to protect abused children in Iran.

1. Background

Most of the time and in many health care systems, nurses are the first professionals that encounter abused children and their families (1). Reporting of child abuse in many countries is mandated (2) therefore public and professional awareness of this phenomenon is high. Enhanced awareness about recognition and protection of abused children along with the legal force for reporting this human adverse event has led nurses to enter a complex world and encounter many unanswered questions and emotional or ethical challenges (3). Although facing these challenges is natural yet it should not result in irresponsibility of nurses about this issue because child protection is a significant nursing role. The adverse effects of child maltreatment have been studied for many years and in light of such investigations, we are aware of the long term health consequences such as mental disorders, drug abuse, suicide attempts, sexually transmitted infections, risky sexual behavior, chronic diseases, and other physical health outcomes in adulthood (4). In such a situation, nurses commit themselves to protect abused or neglected children. It is something about their professional and social responsibility and not only about the legal force because even knowing their legal responsibilities medical staff may report child abuse erratically (5, 6). Based on the same argument, even in countries where reporting child abuse is not mandated, nurses seek the best ways to protect these oppressed victims. In Iran the welfare of children has been concerned for years and government and public institutions are trying to provide services for abused children and their families. Reporting child abuse and neglect is not mandated in Iran and also there is no uniform strategy for such situations. Some of the abused cases report to the police and other cases refer to welfare organizations. Although there has been no investigation about the true range of child abuse reporting by Iranian nurses, yet considering the context, it is possible that many cases are and will be missed. In addition, reporting abused cases is not without challenges because of the social and cultural context and also religious beliefs in Iran.

2. Objectives

The aim of this study was to explore Iranian nurses’ experiences about reporting child abuse and the challenges of this process.

3. Patients and Methods

3.1. Design

A qualitative design with conventional content analysis was used. Content analysis is a qualitative analytical method through which data are summarized, described and interpreted. It is used to identify main themes from the data and is appropriate for examining experiences and attitudes toward a particular subject (7).

3.2. Data Collection

The purposive sample included participants who were interested to attend the study and had direct experience of dealing with children who had been abused and had referred to hospitals and other medical centers. Participants were selected among those who were key informants and could provide insight into the research questions. The first participant was selected from one pediatric hospital. She was a nurse who had worked for several years on child abuse prevention and was selected because she was a key informant in this field and was very eager to participate in this study. The other participants were selected from various hospitals and other medical centers based on findings of each previous interview. The researchers tried to select participants based on their diversity on demographic and activities in the field of child maltreatment. This was done to ensure maximum variation and to obtain more extensive data. Participants comprised 16 nurses with Bachelors, Master’s and PhD degrees in nursing. They were invited to participate in this study from various hospitals and medical centers in Tehran, Iran. No one refused to participate in this study. After explanation of the objectives, all invited nurses participated in the study with passion and enthusiasm. They believed that the results of this study will be useful for health policymakers to decide about the reporting of child abuse and also it is a way to help abused children. They perceived some challenges and difficulties in reporting child abuse and were searching ways to solve these perceived problems. Thus no participant dropped out of the study. The only exclusion criterion in this study was unwillingness of participants to continue the study. Data were collected via individual face to face in depth semi structured interviews and if needed, these sessions were followed by telephone interviews. These interviews began with a general question about the phenomenon. The main questions in all interviews were: “what are your experiences of dealing with child abuse cases in your shifts” and “what do you do when you encounter an abused child during your shift?”. Depending on the participant’s answers, the interview moved towards more detailed questions. In two cases we held a second face-to-face interview because we needed more information about the issues that had been raised in the first interview. Depending on the participants’ preferences interviews were conducted in hospitals or their homes and each session lasted 30 - 45 minutes. All interviews were audiotaped. The data were collected between October 2012 and September 2013.

3.3. Data Analysis

For analysis of the data we used conventional content analysis informed by Graneheim and Lundman’s method (8). All content of the interviews were made into transcripts by the researchers immediately after each interview and each document was read several times to obtain a general insight of the participants’ statements. This process was guided by research questions and aims. After this step, the codes emerged and were reviewed to assess similarities, differences, properties and relationships. We did this in order to reach consensus regarding the central, unifying theme emerging from the data. The researchers extracted the meaningful units and merged codes to categorize and form the final themes. After 11 interviews the emerged codes were repetitive and no new code was emerged but the researchers continued the interviews for more confidence of saturation.

3.4. Rigor

Guba and Lincoln’s four criteria were used for judging the soundness of this qualitative research (7). To realize credibility and dependability, researches spend 12 months in the field and tried to understand the setting and the phenomenon. Triangulation of data sources was used and investigators invited various participants from various settings to take apart in this study. Maximum variation sampling through diversity in participants’ age, gender, shifts, work experiences, wards, medical settings, educational levels and managerial positions was used. Triangulation of researchers through presence of two researchers in a research team was done. Both researchers had work experiences in pediatric wards and had confronted child abuse cases several times. They both had experiences of reporting child abuse and its barriers and challenges. Along with these proceedings all transcribed interviews and codes were verified through peer debriefing and member checking. Researchers shared their ideas about codes, categories and themes and resolved the conflicts. Because of the sensitivity of the issue especially about its religious and cultural aspects the researchers discussed ambiguities with the participants and after reaching consensus, the participants’ codes and themes were verified or changed. Reinforcement strategies for transferability include describing the context and ensuring the representativeness of the data. Participants were selected from a diverse cultural, economic, academic and geographical status. Some of the nurses were working in deprived areas and others were working in rich regions. Nurses in this study were working at university and private hospitals, as well as urban and rural medical centers. Also researchers recorded and reported the study’s various processes to enable replication. All these processes helped the researchers ensure validity.

3.5. Ethical Considerations

Permission to conduct the study was obtained from the Ethics Committee of Tehran University of Medical Sciences. The code of ethical approval is 93/S/105/398. Study objectives were orally described to the participants prior to the study and they were assured of their anonymity and confidentiality. All questions about the research objectives and data gathering method (interview) were answered by the researchers. The researchers introduced themselves to the participants and their contact information (phone number and email address) was provided. Participants signed a written consent. They were assured that participation in this study was not mandatory and they were allowed to leave the research at any stage. The interview venue and time were agreed upon with the participants and before starting the interviews, researchers asked participants for permission to record the conversation. The results were made available upon request.

4. Results

The minimum clinical experience of the participants was five years. The participants’ age was between 25 and 55 and most of them had five to ten years of clinical experiences. The majority (61.3%) were female and 12% had additional academic degrees such as law, hospital management and religious jurisprudence. Furthermore, 47.12% were married and 35.9% had at least one child. 20.03% had managerial positions such as supervisory. Table 1 shows the demographic information of the participants.

Table 1.

Demographical Variables

Variables	Percentage, %
Gender
Female	61.3
Male	38.7
Age group, y
25 - 35	15.7
35 - 45	64.1
45 - 55	20.2
Marital status
Single	52.88
Married	47.12
Having children
Yes	35.9
No	64.1
Clinical experiences, y
5 - 10	59.3
10 - 15	27.6
15 - 20	9.1
20 - 25	4
Degree
Bachelors	64.1
Masters	28.9
PhD	7
Additional academic degrees
Yes	12
No	88
Managerial positions
Yes	20.03
No	79.9

After data analysis, 179 codes emerged from 179 meaning units. Furthermore, 123 codes were categorized into barriers. In this article we present the barriers and discuss them in detail. The participants’ experiences were classified into five themes. These were “knowledge deficit”, “previous unpleasant experiences about child abuse reporting”, “ethical challenges”, “legal challenges” and “cultural beliefs”. Approximately 28.5% of the codes were related to the knowledge deficit theme, 25.20% were related to the previous unpleasant experiences about child abuse reporting theme, 17% were related to the ethical challenges theme, 19.5% were related to legal challenges and 9.7% of codes were related to cultural challenges. The themes, categories and sub categories are mentioned in Table 2.

Table 2.

Themes, Categories and sub Categories

Theme	Categories	Sub-categories
Knowledge deficit	Knowledge deficit related to legislation	Inability to make decisions based on the law: (6 related codes)
		Insufficient knowledge about legislation: (9 related codes)
		Lack of legal education: ( 3 related codes)
	Knowledge deficit related to jurisprudence	Lack of recognition of religious issues: (7 related codes)
		Religious misconceptions about the tutelage of fathers: (5 related codes)
	Knowledge deficit related to child maltreatment	Inadequate education about the nature of child abuse: (3 related codes)
		Bewilderment in maltreatment diagnosis: (2 related codes)
Previous unpleasant experiences about child abuse reporting	Previous futile efforts	No complaints handling: (4 related codes)
		Experience of failure related to child abuse reporting: (5 related codes)
		Lack of legal protections in hospitals for reporters: (11 related codes)
	No penalty for abuser parent after reporting child abuse	No penalty for abuser parent after reporting child abuse: (7 related codes)
	Unpleasant experience of being threatened after reporting child abuse	Being questioned by doctors and managers: (2 related codes)
		Verbal threats: (2 related cod)
Ethical challenges	Uncertainty about the child’s future and the results of reporting	Absence of child protective services: (7 related codes)
		Un answered questions about the quality of care after child separation: (9 related codes)
	Feelings of guilt	Compassion for abuser parents: (1 related cod)
		Regret for doing something that is not clear: (4 related codes)
Legal challenges	Flaws in the legislation	Lack of enforcement strategies: (12 related codes)
		Lack of specific legal guidelines for health care: (8 related codes)
	Misinterpretation of the law	Lack of precise definitions of the rules in health care systems: (4 related codes)
Cultural beliefs	children as the father’s property	Incorrect definition of custody of children in public opinion: (12 related codes)

4.1. Knowledge Deficit

All participants stated that they did not have accurate information about child abuse and related legislation. “Knowledge deficit related to legislation”, “knowledge deficit related to jurisprudence” and “knowledge deficit related to child maltreatment” are categories representing the underlying factors of knowledge deficit.

“Knowledge deficit related to legislation” is one of sub-themes. Nurses were not alert about child abuse or child protection laws.

4.1.1. Participant No. 5

“In fact our knowledge about legislations is not sufficient. We have no insight in to laws. It is probable that most of us don’t know about child abuse laws. Even I am unsure about the existence of such laws in our country”.

Knowledge deficit related to jurisprudence was another issue stated by the participants. Child custody is an issue that is related to child abuse. It is a jurisprudence issue too. According to Iranian religious orders, fathers have the right of guardianship for their children of less than 18 years.

4.1.2. Participant No. 11

“Most of the laws in our country are influenced by our religious beliefs and thus jurisprudence is an important factor in this field. Most of us have no information about dynamic jurisprudence. We think that according to jurisprudence and religious beliefs, fathers' guardianship right is undisputed and they are free to do anything in regards to their children. However, this is not true”.

Knowledge deficit related to child maltreatment is another sub-theme that was expressed by the participants.

4.1.3. Participant No. 9

“Knowledge deficit related to child maltreatment is an important problem in our nursing system. Until now I had never noticed the extent of this issue. In fact I had seen children that were admitted to our ward yet I did not have sufficient knowledge and skills to diagnose maltreatment. I was not sure about the real signs of child abuse. We need to be trained in this regard”.

4.1.4. Participant No. 2

“Neglect has many definitions. We have very little information about this issue”

Some nurses declared that one of the barriers of reporting child abuse is their previous experience.

4.1.5. Participant No. 5

“Even when we reported to the police, nothing happened. They came and filled out their forms and left. They did not arrest the guilty parents. Especially in cases that fathers were at fault. This is probably because fathers are the children’s guardians and some may believe that fathers have the right for punishment. It is [reporting] a vain attempt. No one follows these cases. I see no point in it”

4.1.6. Participant No. 1

“I prefer to not interfere because last time that I reported to the police her father came to the hospital and made a scene. He threatened to kill me. I really had a close call. I don’t want to risk my neck”.

4.1.7. Participant No. 6

“Parents̛ reactions are not predictable. It is highly unlikely they react with respect. They are aggressive. Reporting child abuse in this situation is playing with fire”.

4.2. Ethical Challenges

“Uncertainty about child future and the results of reporting” and “feelings of guilt” are two important challenges that participants mentioned.

4.2.1. Participant No. 9

“The question is: “what happens when we report a case”? Whether this abused child will survive or not? We accuse parents to maltreatment. We get them into trouble. Now the child should come back to these wounded parents. From this moment on, we are not sure about nothings. I think it goes from bad to worse. This is outrageous. We drop children in this situation. No one support this child”.

4.2.2. Participant No. 14

When I report child abuse I am not sure about the result and I am not whether the child problem is solved or not?

4.2.3. Participant No. 1

“One question that must be answered is whether welfare centers are better than the child’s homes? Whether the situation of the child at welfare centers is worth their separation from parents and their family?”

Nurses discussed about feelings of guilt. According to the participant’s point of view ineffectual efforts to save an abused child through reporting was the most important reason for feeling guilty.

4.2.4. Participant No. 5

“When you are involved in reporting child abuse and you are not making any progress in it or when you reach an impasse, you as a nurse along with children and their families are harmed. I feel guilty”.

4.3. Legal Challenges

There are two sub-themes in this category: flaws in the legislation and misinterpretation of the law.

One issue that was noted by all the participants was “flaws in the legislation”. For instance reporting child abuse is not one of the nursing duties in Iran and there is no law to mandate nurses or other health professional staff to report child abuse. This means reporting child abuse is arbitrary and in many cases depends on the doctor’s opinion and preferences, because in Iranian health care system like many other health care systems, physicians have the responsibility of the medical team. On the other hand when we have no law dealing with this issue it is expected to not have any organized system to report child abuse.

4.3.1. Participant No. 6

“During the many years I have been working as a nurse I have not seen ministry impart a law for child abuse reporting. Reporting child abuse is not mandated. We report some of the diseases to the ministry. I have wondered why those diseases are important issues but child abuse is not? Although we all know about its bad consequences, we ignore it. Sometimes I think maybe they don’t realize the importance of this issue”.

4.3.2. Participant No. 4

“Assuming that I want to report these cases. Please tell me how I should do it? Is there any organization in our medical system for this issue? We need an expert system in this field. We have no expert staff or any referral system”.

4.3.3. Participant No. 2

“The trouble is that nurses have not authority and there is no law to support them in reporting child abuse. In our medical system nurses cannot do anything independently. According to current laws, doctors have the responsibility and authority. If they don’t want to report child abuse, we cannot do anything. Doctors have the final say and nurses have no voice. There is no law about it. If there was a law that mandates us to report child abuse many problems could be solved”.

There are some laws that must be reformed or clarified because they do not have a uniform perception and they could be misinterpreted easily. One of them is discharge against medical advice and father’s right to discharge the child when she/he is under 18 years old. According paragraph 2 of article 59 “Islamic penal code of the Islamic republic of Iran”, every legitimate medical action or operation, should be performed with approval of the patient, his/her parents or guardians or their legal representative. Such actions must be made with consideration of scientific, medical and governmental regulations. In emergency cases the approval is not necessary. This act allows parents to make decisions about their children’s discharge. On the other hand, according to Islamic penal code, fathers are children’s guardians and the misinterpretation starts from here. It is supposed that fathers have the right to do any things. For example they are free to make decisions to discharge their children against medical advice. In this study some of participants described their experiences about this issue. They told us in many cases fathers discharged their children without considering the child’s health status or doctor’s opinions. While as mentioned above any medical act must be done considering scientific, medical and governmental regulations, yet this is ignored and fathers as the child’s guardian discharge their child without attention to regulations.

4.3.4. Participant No. 11

“Note that one of our problems is the law of discharge against medical advice. Legally fathers or guardians or legal representative of children are responsible for signing the consent. Now consider a father who is a child abuser and has abused his child. If he doesn’t want his child to receive medical care, for any reason, he has the right to discharge his child because he is supported legally. However, this is not true and is an illusion. Legislators do not say fathers are free to do anything because they are the child’s guardians. We have encountered a big misinterpretation. It is law falsification”.

4.4. Cultural Beliefs

One of the challenges that our participants mentioned is cultural belief about fathers and their ownership of their children. In some subcultures children are the father’s property.

4.4.1. Participant No. P9

“One of our cultural beliefs is that children are the fathers’ properties. Therefore, fathers are free to do everything with their properties”.

Another myth in some subcultures is that parents can punish their children as part of upbringing.

4.4.2. Participant No. 8

“When I criticized her, she told me what should I do? How can I up bring him? I wondered and thought why this mother doesn’t understand the differences between child abuse and upbringing? Now, in a situation where some of the parents don’t know about these issues, is reporting child abuse the right action?”

5. Discussion

Five themes have emerged from the data of this study. The first theme was knowledge deficit. This theme consists of three categories: “knowledge deficit related to legislation”, “knowledge deficit related to jurisprudence” and “knowledge deficit related to child maltreatment”. Nurses mentioned that their knowledge about child abuse and related issues such as legislation and jurisprudence is insufficient. Because of the religious context in Iran, having insight to jurisprudence is an important factor. In the case of child abuse, which is related to issues such as guardians, having insight to jurisprudence will be more significant because according to our religious orders, fathers are the children’s guardians. On the other hand, legislation in our country is guided by religious orders and jurisprudence. Therefore reporting child abuse is affected by these elements. Herendeen et al. (2014) in their study acknowledging the significance of knowledge and its effect on reporting child abuse suggested that nurses need to be educated about this issue (9). According to Alvarez, Kenny, Donohue and Carpin (2004) lack of knowledge is a significant reporting child abuse barrier (3).

Another theme that emerged from our data was previous unpleasant experiences about child abuse reporting. Experiences of child abuse reporting have a significant role in nurses’ attitudes towards reporting. Nurse’s future practice about reporting child abuse is influenced by their reporting experiences. Nurses are apprehensive about reporting abused cases (10, 11). Therefore previous unpleasant experiences are a barrier to report child abuse. Not achieving desired results, being threatened and being afraid of parental reactions are the most important factors that made unpleasant experiences for the participants in this study. The nurses aim when reporting child abuse is to protect the abused children and this is their underlying belief in reporting child abuse (12) yet when there is no systematic reporting structure, it is clear that achieving this aim will be a dream. Feng, Chen, Wilk, Yang and Fetzer, 2009 claimed that child abuse reporters are not sure about their personal safety, and immunity is a main concern in this field (13). Fear of negative consequences is reported by child abuse reporters (3, 13).

The third theme is ethical challenges. “Uncertainty about the child’s future and the results of reporting” and “feelings of guilt” were the sub-themes. According Feng et al. (2012) nurses are uncomfortable with the uncertainty about the child's future and wish to do no harm because it isn’t always possible to change parent’s behavior and reporting child abuse is not effective in all cases (14). Jonsen, Siegler and Winslade, 2002 in their study indicated the ethical conflicts of child abuse reporting (15).

Another theme in this study was legal challenges, which consisted of “flaws in the legislation” and “misinterpretation of the law”. Reporting child abuse is not mandated in Iran and it is clear that child abuse reporters are not supported legally and the procedure of reporting is unorganized. By law, nurses as professionals have the right and responsibility to intervene in this field (12). To stop misinterpretation of the law medical professionals should be involved in the legislation process because their judgments and definitions of maltreatment can differ from the legal perspective (16).

Cultural beliefs were the last barrier mentioned by the participants. Culture is a complex issue and is influenced by many factors. Feng et al. (2009) discussed about the role of culture in child abuse reporting. Cultural issues in Taiwan are one of the barriers for which the mandatory child abuse reporting law doesn’t achieve its aims (13).

Reporting child abuse is a professional and systematic effort and protecting children and their families is its aim. Nurses should be educated and the public awareness about this issue should be improved. Nurses should improve their knowledge and information about legal, ethical and juridical fields. We need special organizations and specific and clear laws to protect abused children. The findings suggest that policy reform is needed. The existing law needs revision for clarity. Lack of protocols and guidelines about child abuse is obvious. It is time to create a safer world for our children.